Nagata Method Research Articles

Splicing of Helix Framework in Modified Nagata Method Stage I for Auricle Reconstruction in Patients With Insufficient 8th Rib Cartilage.

The 8th rib cartilage was sometimes insufficient to construct a complete external helix in ear reconstruction for microtia. The aim of this study was to investigate the splicing technique of 8th rib cartilage in modified Nagata method stage I. Between September 2022 and May 2023, 231 consecutive patients with microtia underwent auricular reconstruction with modified Nagata method stage I. Thirty-four patients with insufficient 8th rib cartilage were screened out by three-dimensional (3D) computed tomography preoperatively, who were included in the study prospectively. The 8th rib was spliced to create the external helix when fabricating the ear framework in the stage I surgery for the 34 patients. The median duration of follow-up was 12.1 months (8-15 months). There were no perioperative complications in our study. During follow-up, all patients had satisfying outcomes, with no inward collapse, displacement, or absorption of the spliced external helix. The splicing point was not obvious. It was safe and effective to splice the 8th rib cartilage for external helix of the cartilage framework in ear reconstruction for microtia.

Salvage of Extensive Skin Graft Necrosis After Auricle Reconstruction by Using Modified Nagata Method.

Extensive skin graft necrosis after auricle reconstruction surgery is a thorny problem for plastic surgeons. Four unilateral microtia patients were enrolled for extensive skin graft necrosis after ear elevation surgery. Early debridement and daily dressing changes were important for preoperative preparation. Surgical treatments involved local flaps and secondary split-thickness skin graft. After 3 to 12 months of follow-up, clear surface structures and obvious auricular sulcus were shown in all 4 patients. No cartilage exposure, skin necrosis, healing impairment, or other complications were found. We attribute the cause of extensive skin graft necrosis to subcutaneous hematoma. Local skin flaps and split-thickness skin grafting can be effective treatments for such situations. The use of temporoparietal fascial flap is unnecessary when poor graft survival is caused by subcutaneous hematoma.

Secondary ear reconstruction based on the Nagata method after unsatisfactory microtia surgery outcomes

Follow-up studies on auricular reconstruction procedures have reported postoperative complications; some of which can only be reversed with revision surgery. This study aims to provide a feasible surgical strategy based on the Nagata method for patients requiring secondary revision and verify mid-term aesthetic outcomes. Secondary auricular reconstructions based on the Nagata method were performed on seven patients seeking secondary revision between 2017 and 2021. Scores of a five-point Likert scale and artificial intelligence ratings based on convolutional nerve networks were used as outcome measures. Five patients underwent complete two-stage ear reconstruction, and the other two patients underwent the first-stage microtia procedure only. Few complications were observed, except in Case 4; this patient required an additional minor surgery after frame exposure 6 weeks after the first-stage procedure. All revised ears showed clear anatomical structures, and all patients were satisfied with the aesthetic results. Statistical analysis showed a significant increase in postoperative versus preoperative scores by convolutional neural network models (p<0.05). Cases 5 and 6, which involved projection surgeries only, had decreased artificial intelligence appearance scores postoperatively. After adequate preoperative evaluation, secondary auricle reconstruction based on the Nagata method can achieve reliable aesthetic outcomes with few complications. ClinicalTrials.gov ID: NCT05604456.

A Two-Flap Combination for Auricular Elevation in Microtia Reconstruction.

The aims of this study were to describe and evaluate the effectiveness of combined flaps, a modification of the Nagata technique, for providing a reasonable projection for reconstructed auricles. The authors modified the Nagata method for covering the cartilage block by introducing a new combined flap technique, including the temporoparietal skin flap and retroauricular flap. The authors compared the shape, size, and position of the reconstructed ear to the opposite ear, and we evaluated postoperative complications and patient satisfaction levels. They verified the effectiveness of the combined flap by assessing flap necrosis, skin color, thickness, hair in the auricular area, and scars. A total of 38 consecutive patients (39 ears) with microtia, aged 6 to 34 years, underwent reconstruction using the modified method and were followed up for 33.6 months on average. The reconstructed auricle's shape was well defined, with 41.0% having good and 15.4% having excellent results. Most cases achieved good and acceptable levels in size, position, medial longitudinal axis angle, and auriculocephalic angles, and 79.9% of patients/their families were satisfied. The authors observed no cases of flap necrosis or hypertrophic scarring, and there were low rates of flap complications, such as unmatched skin color (7.7%), unacceptable thickness (5.1%), or hair and stretch marks (10.3%). The modified method's reconstructed ear achieved stable projection, symmetric appearance, and obvious anatomical landmarks with high patient satisfaction. The combined flap method showed certain advantages: high survival rate, less skin contrast, no hypertrophic scars, and fewer complications. Therapeutic, IV.

Auricular Reconstruction in Adult Patients With Unprepared Congenital Microtia

From January 2015 to January 2021, auricular reconstruction was performed in 38 adult patients (39 ears) of congenital microtia based on autologous costal cartilage. The whole procedure was divided into 2 stages: stage I, the individualized framework carved with autologous costal cartilage was inserted into subcutaneous pocket in the mastoid region; then, the earlobe was transposed backward; and stage II, ear elevation, harvesting the retroauricular fascial flap to cover the support scaffold and closing the defect with free skin graft, was performed. All patients successfully underwent ear reconstruction. The follow-up time ranged from 3 months to 3 years. Infection occurred in 1 patient. The ear frameworks were partially broken at the helix in 4 cases. Retroauricular graft skin survival was poor in 1 patient. Retroauricular hypertrophic scars occurred in 2 cases. Bad projection of the reconstructed ear occurred in 1 case. Totally 38 patients were satisfied with the results. According to the physiological characteristics of the costal cartilage and skin soft tissues of adult patients, improvements are made to details based on the Nagata's method, so that the adult patients with microtia can obtain satisfactory surgical results.

Management Strategy of Local Subcutaneous Effusion After Auricle Reconstruction.

Microtia is a severe congenital malformation of the external ear, and auricular reconstruction is still a challenge for plastic surgeons because of the complicated procedures and rare conditions. This study aimed to describe the location of subcutaneous effusion after auricular reconstruction and explore the clinical efficacy of the indwelling needle puncture drainage method in the treatment of local subcutaneous effusion. From January 2017 to December 2019, 1240 patients (1296 affected sides) who underwent auricular reconstruction using autogenous cartilage framework in the Plastic Surgery Hospital of Chinese Academy of Medical Science and Peking Union Medical College were selected. The local subcutaneous effusion occurred within 5 days after the drainage tube was removed, and the indwelling needle was used for puncture and drainage in the postoperative treatment. A total of 55 patients had subcutaneous effusion after the operation, including 24 cases with Nagata's method and 31 cases with the expanded single-flap method. One patient showed no obvious reduction after puncture and drainage by indwelling needle and improved after the secondary operation. Two patients had slight cartilage absorption. The remaining patients had good results. The method of the indwelling needle for puncture and drainage is easy to operate. The problem of local subcutaneous effusion after auricular reconstruction can be solved and good efficacy can be obtained.

Treatment effect of hemifacial dysplasia by injecting transplantation of autologous tissue in the second stage surgery for total auricle reconstruction

Objective: To observe the treatment effect of hemifacial dysplasia by injecting transplantation of autologous dermis and fat granules in the second stage surgery for total auricle reconstruction. Methods: From March 2013 to March 2018, 57 patients with unilateral microtia and mild-to-moderate hemifacial dysplasia were divided into concurrent treatment group (32 cases, including 13 females and 19 males and aged 6-33 years old with an average age of 12.5 years) and traditional treatment group (25 cases, including 10 females and 15 males and aged 6-21 years old with an average age of 11.3 years) according to the different surgical methods. Modified Nagata method of auricular reconstruction was chosen, in the second stage surgery (cranial ear angle plasty), patients in concurrent treatment group received the treatment of hemifacial dysplasia with autologous dermal and fat injection transplantation at the same time; Patients in traditional treatment group only received cranial ear angle plasty. Statistical analysis of the two groups of patients was carried out for the average operation time, the average length of hospital stay, the incidence of common complications and postoperative satisfaction rate. SPSS 21.0 software was used for statistical analysis. Results: The mean operation time of the concurrent treatment group (282.0±3.4)min was longer than that of the traditional treatment group (243.0±3.1)min, and the difference was statistically significant (t=9.884, P<0.05). There were no statistically significant differences in the average length of stay between the the concurrent treatment group (9.4±0.3)d and the traditional treatment group(9.5±0.2)d, t=0.256, P>0.05. There were no statistically significant differences in the incidence of common surgical complications between the concurrent treatment group (12.5%, 4/32) and the traditional treatment group(12.0%, 3/25), χ2=0, P>0.05. Postoperative satisfaction rate of the concurrent treatment group(90.6%, 29/32) was significantly higher than that of the traditional treatment group(56.0%, 14/25), the difference was statistically significant (χ2=9.081, P<0.05). Conclusions: Auricular reconstruction with treatment of hemifacial dysplasia should not significantly increase the average length of stay and the incidence of common complications compared with auricular reconstruction alone. Although the operation time is slightly extended, the scheme of concurrent treatment can reduce the times of operations, save medical resources and increase the satisfaction rate of patients.

Commentary on "Comparison of Two Surgical Epilation Procedures Based on the Nagata Method in All Degrees of Low Hairline Microtia" by Wang et al.

Commentary on "Comparison of Two Surgical Epilation Procedures Based on the Nagata Method in All Degrees of Low Hairline Microtia" by Wang et al.

Severe Eczema Followed by Microtia Reconstruction.

Sir: In microtia reconstruction, it is typical to use the costal cartilages harvested from the patient himself or herself.1 After the surgery, hematoma, infection, exposed cartilage, skin, and cartilage necroses are commonly encountered.2 Clinically, auricle eczema is a common skin disease. In some severe cases, it is characterized by itches, erythema, papules, and herpes on and around the auricle or blister concentration with blurred edge, erosion, and scars which ooze easily. If infection worsens, pustules or pus scabs will be visible.3 A 9-year-old patient was admitted to ear reconstruction center for microtia repair. Nagata method was performed, the no. 7, 8, and 9 left side costal cartilages were harvested and then fixed by titanium wire. Twenty days after the surgery, itch and erythema appeared on the reconstructured auricle, and then gradually spread to the skin around it. Two days later, papules were visible on and around the reconstructured auricle and papulo-vesicle concentrated and oozed easily with blurred edge and erosion (Fig. 1). The initial treatment was normal saline wash and loratadine 5 mg qd P.O.4 Fourteen days later, local skin lesions around the reconstructured auricle fully recovered. Three months later when the patient showed no more symptoms of skin lesions, Nagata phase 2 was performed. Twelve months (Fig. 2) after the surgery, the recurrence of eczema was not reported in the patient follow-up.Fig. 1.: Papules appeared on and around the reconstructured auricle.Fig. 2.: The final shape of the reconstructured auricle 12 mo after the surgery of Nagata phase 2.According to “Guidelines for the diagnosis and treatment of eczema” issued by Chinese Society of Dermatology in 2011, the exact mechanisms of eczema are unclear.5 Eczema in certain area after auricle reconstruction is rare. In this case, it may be related to skin allergy caused by local iodophor disinfection after the surgery.6 Clinically, the skin on and around the reconstructured auricle becomes itchy, and in most cases, erythema, papules, and exudate are visible. In severe cases, it may lead to infection of the reconstructured auricle, cutaneous necrosis, and cartilage exposure. Regular treatment of eczema is usually applied, including taking antiallergic drugs, applying histamine antagonists and steroid hormone as well as local physical therapy. Clinically, it often recurs after stopping using drugs. As for prevention, it is suggested patient avoid eating or touching allergens, avoid perspiring and keep the skin clear and dry.5 Timely treatment are needed if abnormal itch occurs or the characteristic of the skin changes. Through timely treatment, the patient in this case is satisfied with the final shape of the reconstructured auricle. But long-term of follow-up is needed in case of recurrence. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Auricular reconstruction of congenital microtia by using the modified Nagata method: Personal 10-Year experience with 1350 cases

BackgroundTotal auricular reconstruction is currently one of the most challenging plastic surgery procedures. Herein, we present our 10-year experience with 1350 cases of ear reconstruction by using Nagata method with necessary improvement. MethodsFactors related to ear reconstruction, namely, remnant ear, mastoid skin, adjacent scalp, rib cartilages, normal ear, and mastoid process, were carefully evaluated before operation. An individualized design and precise framework fabrication were performed for each patient. Necessary modifications in fabricating base frame, helix, tragus, and antihelix were introduced to achieve a stable and individualized framework. These efforts also reduced the quantity of cartilage required for ear reconstruction. ResultsFollow-up time ranged from 1 month to 5 years, and 1217 (90.1%) patients were satisfied with the reconstructed ears, which showed appropriate color, texture, size, and location. The modifications made conferred a harmonious and individualized contour of the reconstructed ears. Incidence of all complications such as hematoma, skin necrosis, and framework absorption was very low. ConclusionsBased on preoperative assessment, individualized design, and precise sculpting, a harmonious and individual auricle with detailed anatomical structures was achieved by using our modified Nagata method in which a stable and sophisticated framework can be fabricated with less cartilage requirement.

Tragus formation during concha-type microtia repair using a chondrocutaneous island flap.

Formation of an ideally-shaped tragus remains one of the most challenging issues during staged tragus reconstruction in microtia patients. The authors describe a new method used to treat a unique case of concha-type microtia in which the 10-year-old male patient had only a portion of pre-existing cartilage at the tragus site. An anomalous skin lump was also present. During the initial stages of the reconstruction, the two-stage Nagata method was used for surgical correction of the microtia. An autologous rib cartilage graft was used to form the ear framework. A temporoparietal fascia flap was also constructed. Remnant skin tags and anomalous cartilage that accompany microtia are usually removed during microtia repair. However, the cartilage and skin lump were preserved during the reconstruction. The skin lump was later used to form a vascularized chondrocutaneous island flap that supplemented the portion of cartilage during tragus formation. The result was a new tragus that was satisfactorily improved in both size and shape. Patients with concha-type microtia may benefit from the use of this new method for tragus formation.

The Retrograde Transposition of the Remnant Earlobe in Patients With Low-Set Microtia.

During auricle reconstruction, lobular transposition has become a routine technique applied by most of surgeons. But to some low-set remnant ears, it is difficult to manipulate the conventional lobule transposition method in clinical application. In this article, the authors introduce a method to retrogradely transpose the remnant ear with the the ratio of length:width of the lobular flap being 4-5:1. The lobule transposition could be applied during the first stage of Nagata method or the third stage using expansion method. The authors take the superior part of the remnant ear as the pedicle and make the incision at the middle and inferior parts of the remnant ear to form the lobular flap. Then the inferior lobule is rotated posteriorly and superiorly to cover the rear end of the framework and to form the inferior part of helical rim. The results of the reconstructed auricles are satisfactory with aesthetic natural earlobes and the location of the reconstructed ear is symmetric to the contralateral ear. The authors believe that to the 2% to 5% patients with low-set microtia, this is a good way to make use of remnant ear for the purpose of a real earlobe.

The application of medpor and split-thickness skin graft in formation of cranioauricular sulcus during auricular reconstruction with Nagata method

To investigate the application of medpor and split-thickness skin graft in formation of cranioauricular sulcus during auricular reconstruction with Nagata method. The first stage operation was fulfilled according to the Nagata two-stage method which involves fabrication and grafting of the costal cartilage framework. The second-stage ear elevation operation was undertaken 6 months later to form the cranioauricular sulcus. Split-thickness skin was taken from temporal and accipital area. After releasing the auricular framework and transplanting C shaped medpor at the rear side of framework, the temporaparietal fascia flap was transferred to cover postauricular medpor and framework. Then the split-thickness skin graft was implant on the fascia surface. From July 2010 to August 2012, 20 cases (22 ears) were treated. Partial necrosis of temporaparietal fascia flap and framework exposure happened in 1 case. Successful ear reconstruction was achieved in other cases with satisfactory cranioauricular sulcus during the follow-up period of 6-18 months (average, 13 months). The application of medpor and split-thickness skin graft in the ear elevation of Nagata method for auricular reconstruction for microtia can achieve satisfactory results. It not only avoids the obvious scar in the donor site due to harvesting full-thickness and intermediate-thickness skin, but also reduces chest trauma due to harvesting costal cartilage.

Auricular reconstruction for microtia with modified Nagata method

To investigate a method for total reconstruction of auricle. 90 patients (101 ears) with congenital microtia underwent two-stage operations for auricular reconstruction. The first stage involved fabrication and grafting of autologous costal cartilage, removing the remnant ear cartilage, embedding the framework into local flap of the mastoid region, transferring the remnant ear lobule flap to link to the inferior framework. The second stage was creating an auriculocephalic sulcus. The reconstruction was performed 4 - 12 months after the first surgery. Skin incision was made 5 mm lateral side of the posterior margin of the auricle. The ear framework carrying a thick ear fascia was separated from the side of the head, the frames of the costal cartilage banked at the first operation were harvested, shaved and transplanted to the posterior wall of the concha with sutures; adjust stand position and angle, so that made the ear shape, position, axis, close to the healthy ear, and auriculocephalic angle was slightly larger than the contralateral ear. Two random flap was designed with superior on the root of the helix and in the inferior-posterior direction of the inferior mastoid area, two flapes were elevated and transplanted to posterior auricular sulcus to cover the grafted cartilage. Skin graft was performed in the remaining raw surface. A total of 90 patients were operated, all of 101 constructed ears achieved satisfied or near satisfied shapes. Five cases of partial skin flap necrosis were caused by pedicle impairment. Exposure of cartilage framework happened in two cases. The auriculocephalic sulcus of four cases diminished after the second stage operation. Three month to two-year follow-up of 67 patients showed that the reconstructed ears were satisfied with the results, including good shapes and steady auriculocephalic angles. The method is a simple, safe and reliable method for total aural reconstruction.

A New Method for the Second-Stage Auricular Projection of the Nagata Method: Ultra-Delicate Split-Thickness Skin Graft in Continuity with Full-Thickness Skin

A New Method for the Second-Stage Auricular Projection of the Nagata Method: Ultra-Delicate Split-Thickness Skin Graft in Continuity with Full-Thickness Skin

Reconstruction of Segmental Acquired Auricular Defects

The 2-stage Nagata method for auricular reconstruction in patients with microtia is a widely accepted technique. We have modified this technique into a single-stage procedure for the reconstruction of acquired segmental auricular defects. A prospective analysis was made of the senior author's first 20 consecutive cases over a 4-year period (February 2004 to February 2008). The mean age of patients in our series was 34 years (range, 17-59 years). There were 15 males and 5 females; 13 were right-sided and 7 were left-sided segmental auricular defects. Five patients had had previous auricular reconstruction including local flaps and grafts. Costal cartilage harvest was ipsilateral to the defect in all cases. All 20 patients underwent a single-stage modification of the Nagata technique. Mean duration of surgery was 8.56 hours (range, 5.5-11.5 hours). Mean hospital stay was 7.6 days (range, 4-19 days). Mean time from initial surgery to a satisfactory completion of treatment was 21 months. Overall, a low complication rate and high patient satisfaction were observed in this series. We believe the single-stage modified Nagata technique offers consistent high-quality results in the treatment of acquired segmental auricular defects. All patients undergoing autologus ear reconstruction need to be assessed in a multidisciplinary setting and should be offered all other options for treatment.

A New Method for the Second-Stage Auricular Projection of the Nagata Method: Ultra-Delicate Split-Thickness Skin Graft in Continuity with Full-Thickness Skin

Staged auricular reconstruction remains mainstream among the various techniques of microtia reconstruction using autogenous costal cartilage. The initial stage involves fabrication and implantation of the cartilage framework, followed by projection of the reconstructed auricle in the second stage. During the projection stage, the line of incision is usually made close to the helical rim, from the superoanterior margin of the helical rim to the region of the lobule. Generally, a fascial flap is raised and covered over a cartilage block to project the auricle, and a skin graft is inset over the raw surface of the newly created postauricular sulcus. The authors developed a new refinement for the second-stage auricular projection, whereby the skin cover for the raw surface over the posterior aspect of the auricle and the postauricular sulcus is an ultra-delicate split-thickness skin graft raised in continuity with the full-thickness skin over the anterior aspect of the auricle. Incorporation of this new technique has minimized the visibility of suture lines and improved the appearance of the superior otobasion. In addition, the dimension of the skin cover required can be designed with greater precision. Postoperative outcomes using this new technique for auricular projection have been more than satisfactory. More favorable results that carry less surgical stigma can now be achieved in auricular reconstruction using this new modification of Nagata's two-stage method.

Firm elevation of the reconstructed auricle with a retroauricular fascial flap wrapping an EH (a mixture of epoxide acrylate malelic and hydroxyapatite) composite wedge

Nagata's two-stage methods for ear reconstruction of congenital microtia have been widely used. In this study, we present another option to the second stage in Nagata's method. After the implanted auricle was separated from the bed, instead of using a temporoparietal fascial flap to wrap a cartilage wedge, we developed a new alternative using the retroauricular fascial flap wrapping an EH (a mixture of epoxide acrylate malelic and hydroxyapatite) composite wedge. In addition, it is quite often that, from a frontal view in the Chinese population, the upper and lower parts of the auricle are more prominent than the middle part. We designed an EH composite wedge with a special shape to obtain a firm elevation. Between July 2005 and June 2007, 117 patients underwent this operation; and the follow-up period ranged from 6 to 24 months, postoperatively. Among the 117 cases, the wedge was exposed only in one patient and hypertrophic scars were detected in two cases. Among the rest of the patients, there were no complications such as breakdown, exposure or infection. All the patients had satisfactory ear projection. This technique has the advantages of being straightforward and time saving. It is possible to create a firm elevation and to preserve the temporoparietal fascial flap and superficial temporal vessels for possible use in case of traumatic or secondary ear reconstruction in the future. Meanwhile, we clearly demonstrated that the EH composite wedge is a suitable material in the second stage of the reconstruction of the auricle.

The elevation of the constructed auricle with a temporoparietal fascial flap wrapping a resorbable plate

During the second stage reconstruction of the auricle in patients with microtia, we modified Nagata's method and two technical improvements were possible. After the implanted auricle was separated from the bed, we harvested the temporoparietal fascial flap through helical rim incision instead of incising the temporal scalp. So the surgical scar over the temporal region was avoided. Thereafter, a costal cartilage wedge was carved and grafted to the posterior aspect of the conchal region to get a firm projection. But in cases of unavailable costal cartilage wedge graft, we used a resorbable plate composed of polylactic and polyglycolic acid as a substitute for the former so that we could create firm elevation and sufficient ear projection. Between June 2002 and May 2004, 28 patients underwent this operation with the temporoparietal fascial flap and resorbable plating system. There was no complication resulting from our technique. It was possible to create firm elevation and good frontal projection even if there was no available cartilage wedge. Additionally, by harvesting the temporoparietal fascia through helical rim incision, we avoid creating additional scars on the scalp.

Vascular supply of the subcutaneous pedicle of Nagata's method in microtia reconstruction

Nagata's method is a two-stage method for total ear reconstruction in patients with microtia. In the first stage of this procedure, mastoid flap and posterior lobule flap are elevated with a subcutaneous pedicle. However, contribution to the vascular supply by this pedicle has been controversial. We investigated the presence or absence of apparent vessels in the subcutaneous pedicle in 14 primary cases of microtia in the first stage operation. In all cases some vessels were included in the pedicle. In lobular and small concha type microtia, the vessels originated from the parotid fascia or aponeurotic tissue behind the remnant cartilage. In concha type microtia, apparent vessels could be preserved by including the perichondrium of the conchal cartilage. These findings suggest that the mastoid and posterior lobule flaps or W-shaped flap in Nagata's first stage operation are actually the perforator-based flaps. The source vessel of the perforators seemed to be the posterior auricular artery because of its location although further dissection was not performed in order not to damage the vascular supply. The presence of the vessels can augment the blood supply of not only W-shaped flaps but also the skin flap cephalad to them. By confirming the preservation of the perforators in the subcutaneous pedicle the surgeon may be able to trim the covering skin more safely.