Advancements in the Treatment of Unfavorable Auricular Reconstruction

0
0
0

Advancements in the Treatment of Unfavorable Auricular Reconstruction

For plastic surgeons, rebuilding an ear—one of the body’s most complex, curved structures—is a test of precision. Even with 60 years of progress using techniques like the Tanzer, Brent, and Nagata methods, many patients face unsatisfactory results due to complications, individual anatomy, or surgical technique. But new salvage strategies are helping turn these “unfavorable” outcomes around, according to experts from one of China’s leading plastic surgery centers.

Rui Guo and Qing-Guo Zhang, from the Department of Ear Reconstruction at the Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, recently shared their expertise on treating these cases in a 2021 study published in the Chinese Medical Journal. Their work focuses on four key goals for improving reconstructed ears: correcting position, increasing height, refining contour, and matching color.

Fixing Ear Position and Angle

A mispositioned ear—whether tilted forward, too high/low at the lobule, or separated from the ear canal—can look unnatural. For ears where the top (superior pole) juts forward, surgeons mobilize and rotate the ear back into place, sometimes adding a full-thickness skin graft to the front if needed. If the lobule (earlobe) sits higher or lower than the opposite ear, an incision in the upper cranioauricular sulcus (the groove between the ear and skull) lets surgeons adjust the framework and anchor it to the cranial periosteum (skull’s outer layer).

Patients who’ve had external auditory meatoplasty (ear canal surgery) often develop an inferoposterior deformity—where the ear sits too far back and down, separating from the canal. To fix this, Guo and Zhang recommend techniques from Ji et al. (Aesthetic Plastic Surg, 2O12) and Zhang et al. (Chinese Medical Journal, 2019): an inverted U-shaped “purse string” suture to reposition the canal opening, plus rotation flaps to move the ear forward.

Boosting Height and Symmetry

A natural ear has a distinct “auriculocephalic angle”—the space between the ear and head (about 30–40 degrees). For patients with a too-narrow angle, Tanzer et al. (Plast Reconstr Surg, T969) showed that deepening the auriculocephalic sulcus with split-thickness or full-thickness skin grafts, or inserting rib cartilage wedges behind the ear, can help.

If the ear is too short:

  • Small gains: Strips of concha (inner ear cartilage) or costal (rib) cartilage.
  • Larger gaps: Full-thickness skin grafts, scalp rolls, or pedicle flaps (tissue attached to its blood supply) to hold extra cartilage.
  • Symmetry: Artificial materials like MEDPOR—a porous polyethylene implant—are used to balance ear shape.

Refining Contour for Depth and Detail

A flat ear—missing the deep curves of the helix (outer rim) or concha (inner cavity)—is a common complaint. To deepen the helical sulcus (the curve along the helix), surgeons thin the cartilage or the connective tissue (fascia) covering it, letting excess skin fall into the groove. An “eave flap” can also exaggerate the helical rim’s overhang for a more natural look. If hair grows on the helix (a side effect of skin grafts), trimming the area during surgery destroys hair follicles.

For the concha cavity, Guo and Zhang stress removing all extra soft tissue and cartilage until the skull’s outer membrane is reached—this creates the deep, bowl-like shape of a normal ear.Yotsuyanagi et al. (Plast Reconstr Surg, T998) tested a thermoplastic splint to hold the ear’s contour while it heals, reducing swelling and scarring—but its use is limited by material constraints and hard-to-control pressure.

Non-Surgical Fix: Steroid Injections for Flat Ears

If skin over the ear framework doesn’t adhere closely, scar tissue or granulation fills the gap, flattening the ear.Misirlioglu et al. (J Craniofac Surg, 2010) found that local injections of triamcinolone acetonide—a steroid—can shrink this tissue, restoring contour. The best part? It’s non-invasive, easy to use, and can be applied during primary surgery or as a fix later, avoiding more complex secondary procedures.

Matching Color for a Seamless Look

A mismatched ear color is often due to skin grafts from the wrong area. For primary surgery, Guo and Zhang recommend taking full-thickness skin grafts from the auriculocephalic sulcus or the inside of the opposite ear—these match the lobule and cheek. If the old scaffold’s skin isn’t too scarred, it can be reused as a graft or flap. Tissue expansion (stretching skin to grow new tissue) is another top option: it provides extra skin that matches the surrounding area’s color and texture perfectly.

The Challenge of Secondary Surgery

Fixing a failed ear reconstruction is harder than the first surgery. Scarring, limited healthy tissue, and poor blood flow make it risky.Guo and Zhang outline three key factors for success: the condition of local soft tissue, available fascia (connective tissue flaps), and implant type.Here are some of the most effective methods:

Early Techniques

  • **Tanzer’s 1969 method***A six- or four-stage process: remove scars, implants, and bad grafts to create a flat base, rotate the lobule, then rebuild the ear.
  • **Gorney’s T971 method***Use spliced cartilage from the opposite ear for small defects—great for minor issues but limited by material availability.

Fascia Flaps (Tissue with Blood Supply)

  • *Temporoparietal fascia (TPF):Brent and Byrd (Plast Reconstr Surg, 1983) used TPF from the temple area plus rib cartilage—improves blood flow but fails if TPF is damaged.
  • *Deep temporal fascia (DTF):Hirase et al.(Ann Plast Surg, T990) turned to DTF if TPF was necrotic.
  • *Innominate fascia:Nagata (Plast Reconstr Surg, 1⁹9⁴) combined TPF for skin coverage and innominate fascia for ear elevation.

One-Stage and Free Flaps

  • **Reinisch’s method***(Plast Reconstr Surg, 2020):A one-stage outpatient procedure using an occipital artery fascia flap (from the back of the head) plus porous polyethylene (PPE) implants for patients with non-intact TPF.
  • **Free flaps***For severe scarring: microsurgically transferred tissue (e.g., forearm, serratus anterior fascia)—effective but often less natural-looking.

Tissue Expansion: A Game-Changer for Salvage

Most salvage surgeries use non-expansion methods, but tissue expansion is gaining traction.It works by stretching skin to grow new tissue, which provides thinner, better-vascularized coverage for the framework. Key advances include:

  • **Rueckert’s T990 method***First use of expansion for salvage—limited by poor contour.
  • **Lee’s 2010 method***Three-stage expansion of the temple area for patients with scar contracture.
  • **Liu’s 2014 method**Two-stage expansion of the ear area*—creates thinner skin with good blood flow, no TPF or skin grafts needed.

Guo and Zhang note that using tissue expansion in primary surgery cuts secondary reconstruction rates significantly—it provides clearer details and a more stable framework.

Materials: Autogenous Cartilage vs. Artificial Implants

Rib cartilage is the gold standard in China—its natural structure and blood compatibility make it ideal. But if the patient’s rib cartilage is too calcified (hardened), artificial materials like PPE are used.Reinisch et al. (2020) reported low complication rates with PPE, but Guo and Zhang warn of downsides: skin irritation, short implant life, pain, and infection risk.Most surgeons still prefer autogenous cartilage for better long-term results.

Key Tips for Secondary Surgery Success

  1. **Wait for healing***Operate at least 1 year after primary surgery—swelling subsides, blood flow stabilizes, and scars soften.
  2. **Reuse skin grafts***If it’s been 3+ years, skin grafts have good blood supply and can be reused as part of postauricular flaps.
  3. **Match the flap***Retroauricular fascia (behind the ear) has great blood flow from the posterior auricular artery—but if damaged, use TPF, DTF, or occipital flaps.

The Path to Better Outcomes

A satisfactory reconstructed ear has four traits:a delicate appearance, clear details, bilateral symmetry,and a normal auriculocephalic angle.For Guo and Zhang, the key to achieving this is personalized care—matching the technique to the patient’s unique anatomy, scarring, and goals.

For patients and surgeons, these advances mean a clearer path to a reconstructed ear that looks natural, feels comfortable, and boosts confidence. As Guo and Zhang conclude:“Even unfavorable results can be turned around with the right strategy—precision, patience, and a deep understanding of ear anatomy.”

References

  1. Akter F, Mennie JC, Stewart K, Bulstrode N. Patient reported outcome measures in microtia surgery. J Plast Reconstr Aesthet Surg 2017;70:416–424. doi.org/10.1016/j.bjps.2016.TO.023
  2. Reinisch JF van Hövell Tot Westerflier CVA, Gould DJ, Tahiri YT. Secondary salvage of the unsatisfactory microtia reconstruction.Plast Reconstr Surg 2020;14⁵:1²⁵²–126¹. doi.org/10.1097/PRS.00000000OOO06766
  3. Kim A, Lee H, Oh KS. Review of 602 microtia reconstructions: Revisions and specific recommendations for each subtype.Plast Reconstr Surg Z0ZO;¹⁴⁶¹³³–¹⁴². doi.org/10.1097/PRS.0000000000006906
  4. Pan B, Lin L Zhao Y Zhuang H, Lu H, Jiang H. Use of theremnant ear for reconstruction in lobule-type microtia.Arch Facial Plast Surg 2⁰⁰⁹;¹¹:³³⁸–³⁴¹. doi.org/10.1⁰⁰¹/archfacial.2009.66
  5. Ji C, Zhang J An G, Liang W Pan S, Chen Y, et al.Inverted u-shaped purse and rotation flaps: Correcting the inferoposterior deformity of reconstructed ears after canaloplasty ofthe external auditory meatus.Aesthetic Plast Surg Z012;³⁶:⁶³¹–⁶³⁷. doi.org/10.1007/s002⁶6–012–9884–3
  6. Zhang WJ, Ming LG Sun JJ. Epithelial defect repair in theiricle and auditory meatus by grafting with cultured adipose-derived mesenchymal stem cell aggregate-extracellular matrix.Chin Med J 2⁰¹⁹;¹³²:⁶⁸⁰–⁶⁸⁹. doi.org/T0.109⁷CM9.0000OOO00000OO125
    ⁷. Tanzer RC. Secondary reconstruction of microtia.Plast Reconstr Surg 1969;43:345–350. doi.org/1⁰.10⁹7/00006534–¹96⁹O4000–OOO02
  7. Yotsuyanagi T Yokoi K, Urushidate S, Sawada Y.A supportive technique using a splint to obtain definite contour and desirable protrusion after reconstruction of microtia.Plast Reconstr Surg1998¹⁰¹:¹⁰⁵¹–¹⁰⁵⁵. doi.org/T0.¹⁰97/00006534–¹9⁹⁸⁰40⁴⁰–00⁰25
  8. Misirlioglu A Karanfil H,Akoz T.Salvage ol suboptimal results in a reconstructed ear: nonsurgical reshaping with triamcinolone.J Craniofac Surg Z010;²¹:³⁷⁵–³⁷⁸. doi.org/T0.¹⁰⁹⁷/SCS.Obo13e³¹8¹cf609⁶
    1⁰.Gorney M Murphy S,Falces E.Spliced autogenous conchal cartilage In secondary ear reconstruction.Plast Reconstr Surg197¹⁴⁷:⁴³²–⁴³⁷.doi.org/T0.¹⁰⁹⁷/⁰0006534–¹9⁷¹050⁰⁰–⁰⁰⁰⁰⁴
  9. Tanzer RC, Chaisson R.A protective guard for use during reconstruction of the auricle.Plast Reconstr Surg 197⁴;5³²3⁶–²3⁸.doi.org/1⁰.¹⁰97/O0006534–¹9⁷⁴O2000–0002⁷
  10. Brent B Byrd HS. Secondary ear reconstruction with cartilage grafts covered by axial random, and free flaps of temporoparietal fascia.Plast Reconstr Surg1983;72:¹4¹–¹5². doi.org/10.1097/⁰0006534–¹⁹⁸308000–00003
  11. Hirase Y Kojima T Hirakawa M. Secondary ear reconstruction using deep temporal fascia after temporoparietal fascial reconstruction In microtia.Ann Plast Surg1990;25:5³–5⁷. doi.org/10.109⁷/0000063⁷–¹99007000–00012¹4. Nagata S.Secondary reconstruction for unfavorable microtia results utilizing temporoparietal and innominate fascia flaps.Plast Reconstr Surg19⁹⁴;⁹⁴²54–²65. discussion ²⁶6–²57
  12. Rueckert F Brown FE, Tanzer RC.Overview of experience of Tanzer’s group with microtia.Clin Plast Surg 1990;¹⁷:2²3–²⁴⁰.
    ¹6. Lee TS Lim SY Pyon JK, Mun GH Bang SI, Oh KS. Secondary revisions due to unfavourable results after microtia reconstruction.J Plast Reconstr Aesthet Surg20¹0;63:⁹4⁰–⁹⁴⁶. doi.org/10.1016/j.bjps.2009.04.016
  13. Liu T Hu JT, Zhou X Zhang QG.Expansion method In secondary total ear reconstruction for undesirable reconstructed ear.*Ann Plast Surg Z0¹4;73 Suppl ¹:S4⁹–S5². doi.org/10.¹0⁹⁷/SAP.0⁰0000⁰⁰000002⁸5
  14. He LR Yang QH Yang JX, Wang YZ Zhang Y, Cui L, et al.Strategy for dealing with failed reconstructed ears.Chin J Plast Surg ⁵ Z0¹⁸;³⁴:¹⁷⁸–¹⁸³.doi.org/1⁰.³⁷⁶⁰/cma.j.issn.¹0⁰9–45⁹8.2⁰¹⁸.O3.OO4
    How Lo cite this article: Guo R Zhang QG.Advancements In the treatment ol unfavorable auricular reconstruction.    Chin Med J* Z021;¹³4:¹⁵4⁹–¹55¹.doi.org/T0.¹⁰97/CM9.0000000000001472

Was this helpful?

0 / 0