© Borgis - New Medicine 3/2004, s. 69--70
Henryk Skarżyński1, Maciej Mrówka1, Paulina Młotkowska-Klimek1, Bożena Skarżyńska2
Assessment of total pinna reconstruction in the treatment of unilateral microtia
1International Centre of Hearing and Speech, Institute of Physiology and Pathology of Hearing,
Warsaw, Poland
Head: Prof. Henryk Skażyński MD, PhD
2Department of Anatomy, Medical University, Warsaw, Poland
Head: Prof. Bogdan Ciszek MD, PhD
Summary
Surgical reconstructive technique in the treatment of unilateral microtia was assessed. Twenty eight patients with unilateral microtia, aged 9 – 23 years underwent the procedure in the years 1999-2002. Brent and Nagata´s two-stage operating technique was used with our own modifications; its aim was to obtain/achieve auricular reconstruction by using the patient´s own rib cartilage.The second stage was performed at 6 months after the first stage of surgery. A total of 23 patients were operated using a two-stage operating technique; in 5 patients only the first step has been performed so far. In 22 out of 23 patients, operation proved to be a total success with fully reconstructed posterior auricular surfaces, functional for wearing glasses. Eighteen patients assessed the operative effect as remarkably good and 4 patients were fully satisfied with the reconstruction. Three patients had hypertrichosis due to a low hairline. In one case the treatment was not successful due to inflammatory necrosis of cartilage following the second-stage operation. The authors believe that this method provides very good therapeutic results, and may be useful and well-tolerated as a reconstructive technique.
Introduction
The icidence rate of congenital ear malformations is 1: 20 000, 1: 30 000 live births. They are due to transformation disorders in the mesoderm of the first and second branchial arches. The structures of the external and middle ear develop irrespectively of the inner ear structures (1). The degree of malformations range from minor to more complex. A visible deformity is a great psychological disadvantage for children´s parents and physicians. Recent advances in medical sciences have resulted in new treatments of such defects. Information on the advent of modern technologies in medicine also increases public awareness.
The treatment procedure of congenital ear malformations developed at the Institute of Physiology and Pathology of Hearing, Warsaw has been implemented over a few years. Patient qualification for the treatment is based on satisfying the following criteria:
– a unilateral defect
– normal hearing in the contralateral ear
– no previous history of surgical interventions
– the patient´s age allowing to obtain adequate amount of material for the reconstruction
– informed consent for the surgical procedure signed by the patient/ parents /guardian or care provider.
In view of the above criteria, 28 patients with unilateral deformity underwent surgery in the years 1999-2002, including the study group.
Material and Method
The material consisted of 28 patients aged 9-23 years who had unilateral microtia and normal hearing in the contralateral ear. Out of that number, 23 patients underwent the two-stage reconstruction; in the remaining five patients the first stage of operation was performed and at present they have been waiting for the second stage of the procedure to be accomplished.
The two-stage operating technique was based on Brent and Nagata´s method with our own modifications added (2, 3, 4, 5). The method consists of two stages, with a possibility to perform some minor corrections at the third stage of the procedure which include correction of the lobule position or other improvements.
The first stage of reconstruction consists of forming a cartilage framework with all the anatomical structures of the pinna. The contralateral pinna serves as an anatomical model for the surgeon. The cartilage for the framework is obtained from the cartilaginous portion of the branchial arch, and additionally from the 11th rib. Next, a skin pocket is prepared near the pinna location. This requires delicate and careful manipulation, so that the implanted framework could be supplied with blood and could heal properly. Hence, one of the main conditions to be satisfied: the site should be free from any previous surgical interventions, scarring, circulatory disorders. Any undeveloped cartilage fragments present at the site should be removed. Elements such as lobules are used even if their placement is not adequate.
The second stage of the operation is usually performed at 6 months later. Its main objective is to construct the posterior wall of the pinna by producing a groove behind it. This is accomplished by removing the posterior edge and moving the pinna backwards from the cranium. Skin deficiency on the posterior surface of the pinna is completed with a free skin graft obtained from the hair area. The skin graft has a good appearance, with adequate thickness, and it is grafted without hair.
Result
The treatment was completed in 23 out of 28 patients; the first stage was performed in the remaining 5 subjects. The patients were followed up for approximately from 1 to 3 years. Good results were achieved in 22 of 23 patients who had completed their treatment, which means that the pinna had healed, its anatomical features had been preserved, which allowed the patients to wear glasses. One of the important achievements is the patient´s acceptance of the appearance of the pinna. In the study group, 18 patients did not have any objections and assessed the result to be satisfactory; the 4 remaining patients assessed the results as unsatisfactory because of the presence of hair on the top of the ears. The hair was present there because of a low hairline at that side of the head; however, the problem may be easily solved by laser depilation. In one case, the surgical result was unsatisfactory due to the malformation of the upper part of the pinna, caused by necrosis of the cartilage framework following the second-stage operation. It was necessary to remove the necrotic cartilage, which resulted in the loss of the pinna.
After the first stage of the treatment, healing of the pinna in the remaining 5 patients had an uncomplicated course.
Discussion
Many surgical methods are available to accomplish reconstruction of the pinna. Multistage operative reconstruction does not provide final satisfactory results which might be approved by patients. Long-lasting multistage surgeries discourage patients, since long-term results are difficult to estimate. The correction technique used at our clinic seems to meet patients´ expectations. Brent (2) and Nagata´s (3) method of reconstruction has been recognized as the best worldwide. It has also been modified by many authors depending on their own experience (5). Discussions on details of the surgical technique seem to stem from the percentage of operations performed and effects obtained. Our experience, although moderate, has been gained over a very short time. The present study allows us to assess the results of the surgical technique employed, which, in turn, seems to confirm and justify the choice of both the qualification procedure and the surgical technique itself. They also confirm previous evaluation of satisfactory results obtained (6).
Conclusions
1. Patients´ approval of the results obtained indicates that the treatment technique was selected appropriately.
2. The results are reproducible, which confirms the accuracy of the technique employed, and is also crucial in the treatment of congenital defects.
3. Substantial experience of the surgical team allows them to improve the operative technique and obtain better results.
4. Patients´ interest and their persistence to undergo this type of surgical reconstruction confirms their approval of the treatment techniques employed.
Piśmiennictwo
1. Makowski A.: Wady wrodzone ucha. Otolaryngol. Pol. 1999; 53 (suppl. 30):474-475. 2. Brent B.: Auricular repair with autogenous rib cartilage grafts- two decades of experience with 600 cases. Plastic and Reconstructive Surgery 1992; 90(3):355-374. 3. Nagata S.: Total auricular reconstruction with a three-dimensional costal cartilage framework. Annales de Chirurgie Plastique et Esthetique 1995; 40(4):371-398. 4. Żarowski A., Skarżyński H., Miszka K., Somers T.: Wady wrodzone ucha. Cztery opscje leczenia chirurgicznego znacznych malformacji małżowiny i ucha środkowego. Otolaryngologia Polska 1999; 53 (suppl. 30):89-92. 5. Firmin F., Scand J.: Ear reconstruction in cases of typical microtia. Personal experience based on 352 microtic ear corrections. Plastic and Reconstructive Surgery 1998; 32:35-47. 6. Skarżyński H., Sommers Th., Żarowski A., Miszka K., Zawadzki R.: Technika chirurgicznej rekonstrukcji małżowiny usznej z chrząstki własnej pacjenta. Otolaryngologia Polska 1999; 53 (suppl. 30):92-95.
