Autologous Ear Reconstruction Research Articles

Assessment of Patients’ Satisfaction after Reconstruction of Unilateral Microtia Using Modified Questionnaire Form

Abstract Background Microtia is a rare and severe craniofacial abnormality that impairs newborns' appearance. The most favored treatment for microtia is regarded as autologous ear reconstruction. Patient satisfaction is paramount element in improvement of surgical outcomes. Most studies depended on medical stuff reviews for reconstruction. Aim of the Work Thus, this study aims to help define items that individual’s own satisfaction is based on. Patients and Methods In this cross sectional study, 44 patients, 28 females and 16 males ; with unilateral microtia underwent autologous ear reconstruction using costal cartilage graft were selected. Bilateral cases and Anotia types were excluded.6th to 8th costal cartilage were harvested in the 1st stage to shape the framework. Elevation was done in the 2nd stage. Satisfaction was recorded using a questionnaire form 4 months postoperatively. Results All patient were satisfied with their surgery and never regret doing it. Helix and lobule get higher satisfaction rates than those for antihelix and concha. Conclusion Helix and lobule of reconstructed auricle get the highest level of satisfaction while antihelix and concha still need more continuous work and follow up to enhance their aesthetic outcome.

Validating a New Surgical Gouge for Autogenous Ear Reconstruction During Simulated Microtia Workshops

Autologous ear reconstruction remains a gold standard surgical technique for the treatment of external ear deformities. This highly technical procedure requires experience, an understanding of aesthetic principles, and a surgical approach that can consistently produce optimal results. As an experienced microtia surgeon having trained under Dr Satoru Nagata, the senior author has emphasized the importance of appropriate surgical tools during this procedure. Here, we present results of a novel surgical handle and gouge meant to optimize complex cartilage carving. The senior author regularly holds microtia workshops to help train individuals around the United States. During 2 of such workshops held in 2022, participants were given access to both the standard, commercially available surgical gouge as well as a prototype of a novel surgical gouge developed by the authors. Participants were then given a Likert-scale survey to assess their subjective feedback for both tools. Twenty-seven total participants completed the postworkshop survey. Cumulatively, the results demonstrated that participants rated the custom gouge significantly higher than its counterpart (4.2 versus 3.2, P<0.001). They also had a significantly higher likelihood of using the custom gouge again (4.1 versus 3.2, P=0.023). The custom gouge designed by the senior author demonstrated higher subjective ratings when compared with what is currently available on the market. This serves as a primary validation study that demonstrates feasibility for further assessment in a true operative setting.

Comparative evaluation of low-cost 3D scanning devices for ear acquisition

Autologous ear reconstruction is a surgical procedure performed in the case of defects of the outer ear in which the malformed anatomy is reconstructed with autologous cartilage tissue and often involves the use of surgical guides modelled from a digital reconstruction of the ear anatomy. To obtain such three-dimensional anatomy, traditional imaging methods, which are expensive and invasive, can be replaced by professional 3D scanners or low-cost commercial devices. In this context, this paper focuses on the evaluation of two devices for the acquisition of the outer ear, the Intel® RealSense D405™ (stereo camera) and the TrueDepth camera of the iPhone® 13 (structured light camera), proposing a comparison based on four parameters: accuracy, precision, deviation range and point-to-point distance, in order to assess their usability in the medical field, and in particular in the context of autologous ear reconstruction. The results show that, despite significantly different handling of the raw data, the performance of the two devices is comparable: average accuracy is 0.76 mm for the D405 and 0.95 mm for the iPhone 13, average precision is 0.071 mm for the D405 and 0.065 mm for the iPhone 13, average range of deviation is 3.12 mm for the D405 and 3.64 mm for the iPhone 13.

Remaining microtia tissue as a source for 3D bioprinted elastic cartilage tissue constructs, potential use for surgical microtia reconstruction.

The absence of ears in children is a global problem. An implant made of costal cartilage is the standard procedure for ear reconstruction; however, side effects such as pneumothorax, loss of thoracic cage shape, and respiratory complications have been documented. Three-dimensional (3D) printing allows the generation of biocompatible scaffolds that mimic the shape, mechanical strength, and architecture of the native extracellular matrix necessary to promote new elastic cartilage formation. We report the potential use of a 3D-bioprinted poly-ε-caprolactone (3D-PCL) auricle-shaped framework seeded with remaining human microtia chondrocytes for the development of elastic cartilage for autologous microtia ear reconstruction. An in vivo assay of the neo-tissue formed revealed the generation of a 3D pinna-shaped neo-tissue, and confirmed the formation of elastic cartilage by the presence of type II collagen and elastin with histological features and a protein composition consistent with normal elastic cartilage. According to our results, a combination of 3D-PCL auricle frameworks and autologous microtia remnant tissue generates a suitable pinna structure for autologous ear reconstruction.

Autologous Ear Reconstruction and 3D Printing, an Innovative Hybrid Surgical-engineering Reconstructive Approach for Custom-made Ear Models: Our Experience

Background: Microtia is a congenital anomaly of the ear. We present an innovative technique using a 3D personalized framework that could simplify and standardize the sculpting phase, thanks to reverse engineering and additive manufacturing techniques. Methods: Three-dimensional models were realized by T3Ddy, a joint laboratory between the department of industrial engineering and Meyer Children’s Hospital. Data were obtained retrospectively and included patient demographics, primary diagnosis, side of the affected ear, microtia classification, surgical time, length of hospitalization, type of skin approach and framework, complications, aesthetic results, and level of satisfaction using specific questionnaires. Data are reported as median and IQR. Results: A total of 17 children (female gender: four) underwent auricular reconstruction surgery with autologous cartilage in our center, between 2019 and 2022. Median age at surgery was 14 years [interquartile range (IQR), 13–17], and the median hospitalization length was 5 days (IQR, 3–5). Median surgical time was 420 minutes (IQR, 406–452). Complications occurred in four patients out of 19 procedures, with a complication rate of 21%. Aesthetic results were satisfactory in all cases. Conclusions: The three-dimensional models allow for an intuitive and precise approach. Having developed specific models for each component of the framework, we aimed to improve the aesthetic result and simplify the surgical intervention, guaranteeing a standardized yet personalized experience for each patient. The interprofessional partnership is fundamental to achieving this result.

G-ear: a user-friendly tool for assisted autologous ear reconstruction.

The major breakthroughs in the fields of reverse engineering and additive manufacturing have dramatically changed medical practice in recent years, pushing for a modern clinical model in which each patient is considered unique. Among the wide spectrum of medical applications, reconstructive surgery is experiencing the most benefits from this new paradigm. In this scenario, the present paper focuses on the design and development of a tool able to support the surgeon in the reconstruction of the external ear in case of malformation or total absence of the anatomy. In particular, the paper describes an appositely devised software tool, named G-ear, which enables the semi-automatic modeling of intraoperative devices to guide the physician through ear reconstruction surgery. The devised system includes 3D image segmentation, semi-automated CAD modelling and 3D printing to manufacture a set of patient-specific surgical guides for ear reconstruction. Usability tests were carried out among the surgeons of the Meyer Children's Hospital to obtain an assessment of the software by the end user. The devised system proved to be fast and efficient in retrieving the optimal 3D geometry of the surgical guides and, at the same time, to be easy to use and intuitive, thus achieving high degrees of likability.

Systematic Review of Medpor Versus Autologous Ear Reconstruction.

Ear reconstruction is 1 of the most technically challenging sub-specialties of craniofacial and reconstructive plastic surgery. The reconstructive ear must not only fulfil the requirement of being aesthetically pleasing but must also have good vascularity with a low complication rate. Several ear reconstructive techniques have been developed such as the autologous ear reconstruction technique using costal cartilage and ear reconstruction with high-density porous polyethylene or Medpor (Porex Surgical, Inc, College Park, GA). Autologous ear reconstructive techniques have advantages of durability and low infection rates however are associated with poorer aesthetic outcomes such as poor projection of the ear. Medpor has advantages of a more consistent three-dimensional definition without the need to harvest costochondral cartilage and create a donor site. However, due to its alloplastic material properties, Medpor has historically been reported as having a higher rate of extrusion and infection. This is the first systematic review to compare the outcomes of both techniques. The 6 studies that were reviewed were analyzed against 3 evaluative criteria: aesthetic outcome, complication rate, and convenience of intervention. This is so a comprehensive, evidence-based decision can be made by the surgeon and patient when ear reconstruction is required. The results showed heterogeneity in data and a lack of detailed descriptions of the assessment for aesthetic outcomes and convenience, hence were inconclusive. The results however showed that there were more complications with Medpor framework with 15% of total cases resulting in either extrusion or infection compared to 2% of autologous ear reconstruction framework.

A rapid prototyping approach for custom training of autologous ear reconstruction

Autologous ear reconstruction is the preferred treatment in case of partial or total absence of the patient external ear. This kind of surgery can be really challenging since precise replication of complex three-dimensional structure of the ear is crucial to provide the patients with aesthetically consistent reconstructed anatomy. Therefore, the results strongly depends on the “artistic skills” of the surgeon who is in charge to carry out a three-dimensional sculpture, which resembles the shape of a normal ear. In this context, the definition of a preoperative planning and simulation process based on the patient's specific anatomy may help the surgeon in speeding up the ear reconstruction process and, at the same time, to obtain better results, thus allowing a superior surgical outcome. In the present work the main required features for performing an effective simulation of the ear reconstruction are identified and a strategy for their interactive design and customization is devised with the perspective of a semi-automatization of the procedure. In detail, the paper provides a framework which start from the acquisition of 3D data from both a healthy ear of the patient (or, if not available e.g. due to bilateral microtia of the ear of one of his parents or from a template) and of costal cartilage. Acquired 3D data are properly processed to define the anatomical elements of the ear and to find, using nesting-based algorithms, the costal cartilage portions to be used for carving the ear itself. Finally, 3D printing is used to create a mockup of the ear elements and a prototype of the ear to be reconstructed is created. Validated on a test case, the devised procedure demonstrate its effectiveness.

A Single Surgeon's Experience of Starting a New Ear Reconstruction Service in the UK.

Autologous ear reconstruction is known as one of the most difficult types of reconstruction to perform in plastic surgery. Very rarely is a trainee exposed to the level of complexity and variety of cases they will treat as a sole care provider in a tertiary care setting. This is because the learning curve is steep and those few surgeons that already perform ear reconstruction are limited in what technical experience they can offer trainees due to the plethora of factors competing against the surgeon. These include patient expectations, level of experience, length of anesthetic and accountability for results and complications. For this reason, once a plastic surgeon is nominated to provide autologous ear reconstruction, they face the daunting prospect of not only performing what is a very complex surgery with a very steep learning curve but also the judgment of their patients and colleagues. This paper charts the endeavors of the senior author to provide a service over the last 5 years. It will hopefully provide insight and context on setting up a service, dealing with complications, patient and peer expectations, and finally acknowledgment from both alike as experience is gained and excellence is reached.

Modification of the cartilaginous framework for autologous ear reconstruction: Construction of a stable complete ring framework with grander highs and lows

Successful microtia reconstruction involves fabrication of a framework with well-defined ear subunits. Tragal definition and deep conchal bowl are key elements to produce a natural well-defined and contoured ear. We describe a modification in the cartilage framework with the purpose of increasing framework stability, tragal definition and conchal bowl depth. The tragus is placed on two cartilaginous bars (L-shaped), which are fixed to the framework base block creating a complete ring. These increase tragal projection and conchal depth. The tragus is carved angled posteriorly to have a shadowing effect on the absent auditory canal. Aesthetic outcome was assessed, at least 6 months after the second stage, on a 5-point ordinal scale (1-5) using the scoring system published in the UK microtia care standards and agreed on by the International Society for Auricular Reconstruction (ISAR). A total of 406 auricular reconstructions were performed in 363 patients (206 right, 114 left, 43 bilateral). After excluding cases who did not have second stage and those without complete photographs, 290 cases were assessed. The described modification in the framework carving was performed in 255 ears out of these 290 ears. The mean aesthetic score before and after the modification was 2.4 and 3.09 respectively for the tragus (p < 0.001), 2.2 and 2.95 for the intertragal notch (p < 0.001) and 2.77 and 3.49 for the concha (p < 0.001). This technical refinement has resulted in increased permanence and definition of the tragus and deeper and more aesthetic concha.

A novel ear elements segmentation algorithm on depth map images

The growing interest in the auricular anatomy is due to two different strands of research: 1) in the medical field it is associated with autologous ear reconstruction, a surgery adopted following trauma or congenital malformations; 2) in surveillance and law enforcement the ear is used for human detection and recognition. Alternative systems of ear analysis can be differentiated for the type of input data (two-dimensional, three-dimensional or both), for the type of acquisition tools (3D scanner, photographs, video surveillance, etc.) and finally for the adopted algorithms. Although the segmentation and recognition of the ear from the face is a widely discussed topic in literature, the detection and recognition of individual anatomical elements has not yet been studied in depth. To this end, this work lays the foundation for the identification of the auricular elements through image processing algorithms. The proposed algorithm automatically identifies the contours of the main anatomical elements by processing depth map images. The algorithm was tested qualitatively and quantitatively on a dataset composed of 150 ears. The qualitative evaluation was performed with the collaboration of medical staff and the quantitative tests were performed using manually annotated ground truth data.

A computer-aided strategy for preoperative simulation of autologous ear reconstruction procedure

Autologous ear reconstruction is the preferred treatment in case of partial or total absence of the external ear. The surgery can be very challenging to perform and the aesthetic result highly dependent on the surgeon’s “artistic skills”. In this context a preoperative planning and simulation phase based on the patient’s specific anatomy may result crucial for the surgical outcome. In this work, starting from a case study, the elements necessary for an effective simulation are identified and a strategy for their interactive design and customization is devised with a perspective of a semi-automatization of the procedure.

Autologous Ear Reconstruction: Towards a Semiautomatic CAD-based Procedure for 3D Printable Surgical Guides

Autologous Ear Reconstruction: Towards a Semiautomatic CAD-based Procedure for 3D Printable Surgical Guides

Validity and reliability of three-dimensional costal cartilage imaging for donor-site assessment and clinical application in microtia reconstruction patients: A prospective study of 22 cases.

This study assesses the ability to reconstruct costal cartilage images by using three-dimensional visualisation software (Mimics) based on semi-automated segmentation algorithm and to investigate its reliability and validity with an anthropometric analysis. Observational prospective study. Plastic surgery department of a tertiary hospital. Twenty-two microtia patients who underwent autologous ear reconstruction. Preoperative thoracic computed tomography data were processed to Mimics software for three-dimensional costal cartilage imaging. The length, width, thickness and volume of the 9th costal cartilages were calculated from these images and compared with the direct measurements (DM) obtained intraoperatively. The intra-examiner reliability and inter-examiner reliability were high in terms of all four measurements (intraclass correlation coefficients, ICC: 0.876-0.984). There were no significant differences between image-based anthropometry and DM in the linear measurements except for the volume (P<.05). The mean volume calculation error of Mimics was -0.08±0.13mL. No correlation was found between the anthropometric variables and the absolute errors (P>.05). Furthermore, Bland-Altman plots were used to evaluate the agreement between the two methods. Despite a very small error was found in volume calculation, Mimics software was accurate and reliable in linear calculation. Three-dimensional costal cartilage imaging was found to be an efficient tool for morphological evaluation of costal cartilages. We believe that with the application of individualised cartilage models based on three-dimensional printing, the use of customised ear framework carving will be practicable in surgical training.

Refinements in autologous ear reconstruction: descriptive surgical technique and experience of 400 consecutive cases at a tertiary referral center in the UK

Ear reconstruction for microtia is a great challenge in plastic surgery. Autogenous costal cartilage has remained the material of choice for framework fabrication. We describe our preferred technique and provide several refinements which have been developed over years to improve the outcome and minimize complications, based on experience with 406 cases. Esthetic outcome scoring was performed by evaluating all subunits of the reconstructed ears as well as the overall integration of the ear with the face (15 esthetic parameters). These were graded, using a 5-point ordinal scale from 1 (very poor) to 5 (very good). The course of improvement of the overall esthetic score was assessed using one-way ANOVA test with Bonferroni post hoc analysis. The overall complication rate was 15%. Wire extrusion was the most common (12.8%). The rate of revision procedures was 11.8%. The helix and concha had the highest esthetic score (3.4 each). The overall esthetic score was 3.2 on average. The overall score showed statistically significant improvement after the first 50 cases (p = 0.02) and another increase after performing 250 cases. The difference between the esthetic score of the first and the last subgroup of cases is highly significant (p < 0.001). Autologous ear reconstruction is a complex surgery with inevitable learning curve. Undertaking an adequate training is advised to achieve pleasing results. Having a regular high volume case load is essential to achieve significant improvement in outcomes. The goal of having nationally designated ear reconstruction units is highly recommended. Level of evidence: Level IV, therapeutic study.

Autologous Ear Reconstruction for Microtia Does Not Result in Loss of Cutaneous Sensitivity.

Cutaneous sensitivity of microtia reconstruction has been sparsely documented. The purpose of this study was to evaluate whether there is a loss of cutaneous sensitivity following two-stage autologous ear reconstruction for unilateral microtia. A prospective study was performed including unilateral microtia patients who underwent two-stage autologous ear reconstruction performed by a single plastic surgeon between 2011 and 2016. Standardized sensory testing (i.e., temperature discrimination and Semmes-Weinstein monofilaments) was executed at 11 predefined anatomical points of the affected and unaffected ears preoperatively and at 6 and 12 months postoperatively. Thirty-eight patients were included. Affected and unaffected sides presented similar (all p > 0.05) preoperative cutaneous sensitivity. Most (72.7 percent) of the tested points showed (all p < 0.05) preservation or recovery of cutaneous sensitivity at 12 months postoperatively. When comparing the reconstructed ears with the unaffected ears, there was no significant difference (all p > 0.05) in most (72.7 percent) of the tested points, except (all p < 0.05) at those points involving the postauricular sulcus. There is a temporary cutaneous sensitivity loss after a two-stage autologous microtia reconstruction, which returned to similar preoperative sensitivity at 12-month follow-up, except in the postauricular sulcus. Therapeutic, IV.

Ear Reconstruction Simulation: From Handcrafting to 3D Printing.

Microtia is a congenital malformation affecting one in 5000 individuals and is characterized by physical deformity or absence of the outer ear. Nowadays, surgical reconstruction with autologous tissue is the most common clinical practice. The procedure requires a high level of manual and artistic techniques of a surgeon in carving and sculpting of harvested costal cartilage of the patient to recreate an auricular framework to insert within a skin pocket obtained at the malformed ear region. The aesthetic outcomes of the surgery are highly dependent on the experience of the surgeon performing the surgery. For this reason, surgeons need simulators to acquire adequate technical skills out of the surgery room without compromising the aesthetic appearance of the patient. The current paper aims to describe and analyze the different materials and methods adopted during the history of autologous ear reconstruction (AER) simulation to train surgeons by practice on geometrically and mechanically accurate physical replicas. Recent advances in 3D modelling software and manufacturing technologies to increase the effectiveness of AER simulators are particularly described to provide more recent outcomes.

A technique to aid minimal access harvesting in the second stage of autologous ear reconstruction.

A technique to aid minimal access harvesting in the second stage of autologous ear reconstruction.

Cartilage exposure following autologous microtia reconstruction: An algorithmic treatment approach✰

Successful reconstruction of microtia involves fabrication of a cartilaginous framework and provision of thin, durable, soft tissue cover. Vascular compromise of this skin envelope can lead to exposure of the underlying cartilage, resulting in cartilage resorption and distortion of the final form of the ear construct. We describe our algorithm for management of this complication. All patients who underwent autologous ear reconstruction by a single surgeon (NWB) from April 2006 to September 2012 were retrospectively reviewed to identify any that developed exposure of the underlying cartilage framework. Details related to timing, location, size and management of the cartilage exposure were collected. From a total of 230 autologous auricular reconstructions (median age at first stage, 11.4years), 15 exposures of the cartilage framework were identified. All exposures occurred following the first stage of reconstruction (mean of post-operative day 29, range, 7-86days). Large areas of exposure (> 10mm2) required surgical management, with debridement and coverage with either a cutaneous or fascial flap, depending on the location. Areas < 10mm2 were managed conservatively. All exposures were successfully treated with no adverse effects on the final aesthetic outcome. Cartilage exposure following autologous microtia reconstruction can be a devastating complication if not addressed in a prompt and effective manner. The management strategy we propose provides a concise algorithm to guide the treatment of cartilage exposure. Therapeutic, grade III.

Ear Reconstruction Using Autologus Costal Cartilage: A Steep Learning Curve.

Ear reconstruction is a challenging operation with a steep learning curve. In view of its rarity, attaining a high standard for new surgeons is extremely difficult. This study describes the author's experience of 53 ear reconstructions using costal cartilage for congenital and post-traumatic ear deformity. The author performed 53 autologous ear reconstructions for microtia and post-traumatic ear defect over a period of 5 years utilizing the two-stage technique popularized by Firmin in most of the cases. An assessment of complications, pattern of progress and aesthetic outcome of the reconstructed ears was carried out. There were 4 cases of partial skin necrosis. In early cases, deficiencies were seen in the proportions of the reconstructed ear and the quality of definition. Better shape and definition were evident as more surgical experience was gained. This occurred as a result of increased appreciation of the ear proportions and improved framework carving. The series demonstrates the early learning curve in microtia reconstruction and underlines the importance of appropriate training and case availability in achieving high-quality results in autologous ear reconstruction.