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DR. AKASHA AMBAR
PGT-2 PLASTIC SURGERY
BVH BAHAWALPUR
MICROTIA
ANATOMY & EMBRYOLOGY
 At 5 weeks of gestation
 1st branchial cleft
 Dorsal end of 1st(mandibular) & 2nd (hyoid)
branchi...
EMBRYOLOGY (1ST BRANCHIAL ARCH)
ANATOMY & EMBRYOLOGY
ANATOMY & EMBRYOLOGY
24 mm
IMPORTANT CONSIDERATIONS OF EAR
 Ear development with age
 66% of adult size at birth
 85% of adult size at 3 years
 9...
NERVE SUPPLY OF AURICLE
Arnold’s nerve (a branch of the vagus nerve):
Inferior bony canal, posterosuperior cartilaginous c...
NERVE SUPPLY OF AURICLE
Post surface: GAN & Lesser occipital nerve
BLOOD SUPPLY OF AURICLE
BLOOD SUPPLY OF AURICLE
MUSCLES OF EAR
 Extrinsic
 Auricularis anterior(vii)
 Auricularis superior(vii)
 Auricularis posterior(GAN)
 Intrinsi...
LYMPHATIC DRAINAGE
 Preauricular L.N
 Anterior & superior wall of EAM,tragus
 Infraauricular L.N
 Helix, inferior wall...
TANZER CLASSIFICATION OF AURICULAR
DEFECTS
 1. Anotia
 2. Complete hypoplasia(microtia)
 With atresia of EAM
 Without ...
MICROTIA
 Small ear(varies from anotia to small ear vestige)
 Male female ratio is 2:1
 Right to Left to Bilateral Rati...
CLASSIFICATION OF MICROTIA
 Nagata classification:
 Lobule type
 Only ear remnant & malpositioned lobule
 Conchal type...
GRADING OF MICROTIA (AGUILAR)
 Three grades:
 Grade I: all anatomic subunits present but
misshaped
 Grade II: anatomic ...
HISTORY OF MICROTIA RECONSTRUCTION
 Gillies 1st one to use rib cartilage from cadaver or
parents
 Dr. Tanzer 1959: 1st a...
SURGICAL PLANNING
 Surgery Timing:
 Dr. Brent considered 6 years of age
 Nagata operated at age 10 when rib cartilages ...
SURGICAL METHODS
 Autogenous reconstruction
 Composite Autogenous/Alloplastic reconstruction
 Prosthetic reconstruction
AUTOGENOUS RECONSTRUCTION
 Brent technique
 4 stages:
 1. making & placing rib cartilage auricular framework
 2. Repos...
BRENT TECHNIQUE
 Four staged technique adapted from tanzer’s 6
staged technique
 Stage I: fabrication of the auricular f...
STAGE 1: FABRICATE AURICULAR FRAMEWORK
 Template of normal ear(if unilateral) or parent’s ear(if bilateral) on XRAY
FILM ...
upper border of 6th cartilage preserved,to prevent subsequent chest deformity. Floating
cartilage used for helix.To produc...
Preoperative marking& indicating the desired location of
the framework (solid line) and the extent of the dissection
neces...
POSTOPERATIVE MANAGEMENT
 Vaseline impregnated gauze packed into convulsions
 Apply bulky,non compressive dressing
 as ...
STAGE 2: LOBULAR TRANSPOSITION
 Performed at least 3 months later to the previous
surgery
 Inferiorly based rotation flap
skin overlying the lower ear region has
been loosened and slid under the elevated
framework’s tip to surface the “floor”
b...
STAGE 3:ELEVATION OF AURICLE
 Incision few mm away from helical rim
 Framework elevated
 For projection, position a wed...
STAGE 4: CONCHAL DEEPENING & CREATING
TRAGUS
 Composite skin-catilage graft from posterior aspect of
contralateral (norma...
BRENT TECHNIQUE MODIFICATIONS
 Laser treatment of hair before auricular reconstruction
 Creating tragus with the main fr...
NAGATA TECHNIQUE
 Two staged technique
 Age usually10 years
 Complex framework
 5 blocks of cartilage
 base block fro...
NAGATA STAGE 1
 Cartilage harvested; 5 blocks
 Framework carved & secured with stainless steel
suture
 Nagata incision
...
STAGE 2: AURICLE ELEVATION
 Cartilage block banked under skin(1st stage)
 Carved into a crescent wedge, placed into the
...
CARTILAGE HARVEST COMPLICATION
 Tears in pleura
 Minor leak
 After taking the cartilage graft, if leak
found/pneumothor...
OTHER RECONSTRUCTIVE OPTIONS
 Single stage reconstruction
 Tissue expanders
 Osteointegrated prosthesis
 Stick on pros...
SINGLE STAGE RECONSTRUCTION
 Predominantly used for partial deformities
 Helix formation,lobule formation
 Results are ...
TISSUE EXPANDERS
 Hata & Umeda
 tissue expansion followed by reconstruction of ear in
single stage by using expanded ski...
PROSTHESIS
 Osseointegrated(titanium) implant prosthesis
 Stick on silicon prosthesis
OSSEOINTEGRATED PROSTHESIS
OSSEOINTEGRATED PROSTHESIS
 Indications:
 Failed autogenous reconstruction & no enough tissue left
for secondary reconst...
MEDPORE ALLOPLASTIC IMPLANT
 Reinish introduced the technique
 Prefabricated porous polyethylene implant
 Excellent bio...
PROCEDURE STAGES:
 In the 1st stage:
 Medpore implant soaked into a betadine solution
 its pieces are affixed with caut...
PROCEDURE STAGES:
 In 2nd stage:
 Tragus formation
 Deepening of concha
SILASTIC ALLOPASTIC IMPLANT
 Silicon implants investigated by CRONIN & OHMORI
 Best results initially
 Disappointing lo...
TISSUE ENGINEERING
 Developing biocompatible, tissue-engineered auricle
 closely mimicking the normal anatomy of the pat...
THANK YOU
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  1. 1. DR. AKASHA AMBAR PGT-2 PLASTIC SURGERY BVH BAHAWALPUR
  2. 2. MICROTIA
  3. 3. ANATOMY & EMBRYOLOGY  At 5 weeks of gestation  1st branchial cleft  Dorsal end of 1st(mandibular) & 2nd (hyoid) branchial arches  6 mesenchymal proliferations(hillocks of His)  1st arch  Hillocks 1(tragus),2(crus of helix) & 3(helix)  2nd arch  Hillocks 4 & 5 (antihelix) & 6 lobule  Lower neck position  ascends with mandible development  adult position by 20th week
  4. 4. EMBRYOLOGY (1ST BRANCHIAL ARCH)
  5. 5. ANATOMY & EMBRYOLOGY
  6. 6. ANATOMY & EMBRYOLOGY 24 mm
  7. 7. IMPORTANT CONSIDERATIONS OF EAR  Ear development with age  66% of adult size at birth  85% of adult size at 3 years  95% of adult size at 6 years  Normal height of ear: 5.5-6.5cm  Posterior vertical inclination is 5-30 degree  Vertical angle parallel or within 15 degree of nasal dorsum  Distance from lateral canthus to helical root: 65-67mm  Helical rim protrudes 1.5-2cm from mastoid with 15-20 degree protrusion angle
  8. 8. NERVE SUPPLY OF AURICLE Arnold’s nerve (a branch of the vagus nerve): Inferior bony canal, posterosuperior cartilaginous canal & corresponding segments of the tympanic membrane, cymba concha. posterosuperior bony EAC is innervated by branches of the facial nerve.
  9. 9. NERVE SUPPLY OF AURICLE Post surface: GAN & Lesser occipital nerve
  10. 10. BLOOD SUPPLY OF AURICLE
  11. 11. BLOOD SUPPLY OF AURICLE
  12. 12. MUSCLES OF EAR  Extrinsic  Auricularis anterior(vii)  Auricularis superior(vii)  Auricularis posterior(GAN)  Intrinsic  Tragicus,antitragicus,  helicis major,helicis minor,  oblique and transverse muscles
  13. 13. LYMPHATIC DRAINAGE  Preauricular L.N  Anterior & superior wall of EAM,tragus  Infraauricular L.N  Helix, inferior wall of EAM  Mastoid L.N  Concha, antihelix
  14. 14. TANZER CLASSIFICATION OF AURICULAR DEFECTS  1. Anotia  2. Complete hypoplasia(microtia)  With atresia of EAM  Without atresia of EAM  3. Hypoplasia of middle 3rd of auricle  4. Hypoplasia of superior 3rd of auricle  Constricted (lop/cup) ear  Cryptotia  Hypoplasia of entire superior 3rd  5. Prominent ear
  15. 15. MICROTIA  Small ear(varies from anotia to small ear vestige)  Male female ratio is 2:1  Right to Left to Bilateral Ration is 6:3:1  Location may vary (sup. or inf.)  Occurs in 1 in every 6000 births  High in asians  Associated with maternal teratogenic drugs (isotretinoin,thallidomide,tranquillizers)effects,1st trimester rubella infection,congenital anomalies in treacher collins syndrome,hemifacial microsmia,middle ear defects,facial nerve defects, associated with cleft palate/lip, and other anomalies.
  16. 16. CLASSIFICATION OF MICROTIA  Nagata classification:  Lobule type  Only ear remnant & malpositioned lobule  Conchal type  Ear remnant,malpositioned lobule,concha(with or without meatus) tragus,antitragus & incisura intertragica  Small conchal type  Ear remnant,malpositioned lobule,small indentation without proper concha  Anotia  No or only minute ear remnant  Atypical microtia  combination of defects not fitting in above categories
  17. 17. GRADING OF MICROTIA (AGUILAR)  Three grades:  Grade I: all anatomic subunits present but misshaped  Grade II: anatomic subunits either deficient or absent  Grade III: classic “peanut ear” and anotia
  18. 18. HISTORY OF MICROTIA RECONSTRUCTION  Gillies 1st one to use rib cartilage from cadaver or parents  Dr. Tanzer 1959: 1st article on auricular reconstruction with autogenous rib cartilage, 6 stages procedure  Dr. Brent 1974: 4 stages procedure,foremost authority on auricular reconstruction  Dr. Nagata 1985: 2 staged procedure  Firmin modified Nagata technique
  19. 19. SURGICAL PLANNING  Surgery Timing:  Dr. Brent considered 6 years of age  Nagata operated at age 10 when rib cartilages are sufficiently developed (confirmed with x-ray)  Otologic surgery(canaloplasty) is in general planned after the auricular reconstruction surgery  If bony work 1st,scars should be peripheral to proposed auricular site  Autogenous cartilage is gold standard
  20. 20. SURGICAL METHODS  Autogenous reconstruction  Composite Autogenous/Alloplastic reconstruction  Prosthetic reconstruction
  21. 21. AUTOGENOUS RECONSTRUCTION  Brent technique  4 stages:  1. making & placing rib cartilage auricular framework  2. Repositioning ear lobule  3. Elevation of reconstructed auricle & retroauricular sulcus creation  4. Tragus formation and deepening of concha  Nagata technique  2 stages:  Combination of brent stages 1,2 & 4 in single stage  And 3rd stage of brent
  22. 22. BRENT TECHNIQUE  Four staged technique adapted from tanzer’s 6 staged technique  Stage I: fabrication of the auricular framework with contralateral costal cartilage (6,7 & 8)  A piece of cartilage for helical rim is taken from a first floating rib through same incision  Stage II: lobule transposition  Stage III: framework elevation  Stage IV: tragus reconstruction & conchal excavation  At 6 years of age  All surgeries minimum 3 months apart
  23. 23. STAGE 1: FABRICATE AURICULAR FRAMEWORK  Template of normal ear(if unilateral) or parent’s ear(if bilateral) on XRAY FILM or plastic sheet  Decrease size of template by few millimeters(3-4mm) to accommodate for skin cover thickness  Harvest two blocks of costal cartilage from:  ribs 6-8 contralateral to microtic ear and a floating rib  Base formed by synchondrosis of ribs 6 & 7  Helical rim from floating rib  Pieces attached with 4-0 nylon suture  Place framework in subcutanous pocket made via small vertical incision posterior to ear vestige  Extra piece of cartilage banked in chest incision or retroauricular scalp  2 suction drains  one behind the framework & other below the framework  Left for 5 days  Avoid pressure & bolster dressings
  24. 24. upper border of 6th cartilage preserved,to prevent subsequent chest deformity. Floating cartilage used for helix.To produce acute flexion of helix, cartilage warped in desired direction by thinning it on its outer surface.Helix affixed to main block with horizontal mattress sutures of 4-0 nylon; knots placed on framework’s undersurface.
  25. 25. Preoperative marking& indicating the desired location of the framework (solid line) and the extent of the dissection necessary {dotted line)
  26. 26. POSTOPERATIVE MANAGEMENT  Vaseline impregnated gauze packed into convulsions  Apply bulky,non compressive dressing  as vacuum system already providing skin coaptation  pressure is contraindicated  Vacuum tubes are changed every 4-6 hours or when tube is one third full  drains stay in place for 5 days until few drops of serosanginous discharge  Avoiding sleeping on operation side  return to routine light activities after two weeks  Postoperative complications:  Hematoma, infection, skin flap necrosis, framework exposure or extrusion
  27. 27. STAGE 2: LOBULAR TRANSPOSITION  Performed at least 3 months later to the previous surgery  Inferiorly based rotation flap
  28. 28. skin overlying the lower ear region has been loosened and slid under the elevated framework’s tip to surface the “floor” beneath it. connective tissue has been carefully preserved over the cartilaginous tip
  29. 29. STAGE 3:ELEVATION OF AURICLE  Incision few mm away from helical rim  Framework elevated  For projection, position a wedge of cartilage in retroauricular sulcus (banked in 1st brent stage)  Cartilage wedge coverage  with a occipitalis facia turnover “book flap  With temporoparietal facial flap  Retroauricular scalp advanced upto the sulcus  Post. aspect of auricle is skin grafted  FTSG from groin or abdomen  NAGATA used second chest surgery for this wedge of cartilage to avoid banking it
  30. 30. STAGE 4: CONCHAL DEEPENING & CREATING TRAGUS  Composite skin-catilage graft from posterior aspect of contralateral (normal)concha  A piece of full thickness skin graft behind the opposite normal lobule  J or L shaped incision  Main limb of J at proposed posterior tragal margin  Crook of J representing intertragal notch  Extra soft tissue beneath incision excised  Composite graft in vertical position & FTSG placed in the floor  Concha deepened by excavating subcutaneous tissue
  31. 31. BRENT TECHNIQUE MODIFICATIONS  Laser treatment of hair before auricular reconstruction  Creating tragus with the main framework in stage 1  Floating cartilage for helical rim  2nd strut arching around for tragus,antitragus & intertragal notch  Tip of the strut affixed to crus of helix by horizontal mattress suture with nylon  Modified Kirkham Method:  In bilateral microtia; anteriorly based conchal flap folded on itself
  32. 32. NAGATA TECHNIQUE  Two staged technique  Age usually10 years  Complex framework  5 blocks of cartilage  base block from synchrondrosis, one free floating rib for helix, one tragus/antitragus block, one antihelix/triangular fossa block, wedge piece for 2nd stage  Framework placement into the skin pocket, lobule rotation and deepening of concha with tragus creation in 1st stage  auricle elevated in next stage with sulcus formation
  33. 33. NAGATA STAGE 1  Cartilage harvested; 5 blocks  Framework carved & secured with stainless steel suture  Nagata incision  Different from brent  Designed so medial skin of ear lobule is incorporated into conchal lining  Pocket dissected leaving a caudal pedicle intact near lobule  Lobule transpositioned caudally  Framework placed in pocket  Deepening of concha with tissue excision
  34. 34. STAGE 2: AURICLE ELEVATION  Cartilage block banked under skin(1st stage)  Carved into a crescent wedge, placed into the sulcus after elevating the reconstructed auricle  Cartilage piece coverage with TP fascia flap with skin graft on post aspect of auricle  Superior results  High rate of perilobular skin necrosis(14%)  High risk of cartilage extrusion as multiple wire sutures
  35. 35. CARTILAGE HARVEST COMPLICATION  Tears in pleura  Minor leak  After taking the cartilage graft, if leak found/pneumothorax  place a rubber catheter into plueral cavity  Close the skin wound and ask anesthesiologist to give positive pressure ventilation, apply suction to catheter and draw immediately  Get CXR in sitting position on table if possible after removing the tube
  36. 36. OTHER RECONSTRUCTIVE OPTIONS  Single stage reconstruction  Tissue expanders  Osteointegrated prosthesis  Stick on prosthesis  Alloplastic reconstruction  Silastic implant  Medpore(porous polyethylene)  Tissue engineering
  37. 37. SINGLE STAGE RECONSTRUCTION  Predominantly used for partial deformities  Helix formation,lobule formation  Results are not comparable with multiple staged procedure  two flaps-single stage procedure converted into three staged procedure  (park 2000)
  38. 38. TISSUE EXPANDERS  Hata & Umeda  tissue expansion followed by reconstruction of ear in single stage by using expanded skin  no need of skin grafts  The disadvantages of this technique:  Not tolerable by children (painful)  Tissue expansion ;a separate stage  Not really a single staged procedure  Fibrous tissue around expander may affect contouring results
  39. 39. PROSTHESIS  Osseointegrated(titanium) implant prosthesis  Stick on silicon prosthesis
  40. 40. OSSEOINTEGRATED PROSTHESIS
  41. 41. OSSEOINTEGRATED PROSTHESIS  Indications:  Failed autogenous reconstruction & no enough tissue left for secondary reconstruction(autogenous or combined autogenous/allogenous)  Poor tissue due to cancer/radiation  Sever soft tissue/skeletal hypoplasia  Low or unfavorable hairline  Prosthesis needs change every 5 years  Expensive  Meticulous hygiene at skin-implant interface  Usually difficult to tolerate by children
  42. 42. MEDPORE ALLOPLASTIC IMPLANT  Reinish introduced the technique  Prefabricated porous polyethylene implant  Excellent biocompatibilty,stability,tissue integration & resistance to infection  Pore size 150 micrometer  allows soft tissue ingrowth & stability  Can be bent,carved & affixed to other pieces  Implant placed for auricle,still lobule transpositioned  A hearing aid device can be placed concurrently  Implant needs coverage with fascia in upper1/3rd, lower 2/3rd placed into skin pocket  Less extrusion rate than a silastic implant
  43. 43. PROCEDURE STAGES:  In the 1st stage:  Medpore implant soaked into a betadine solution  its pieces are affixed with cautery or nonabsorbable suture  Skin pocket formation  Upper part is covered with temporoparietal facia that is covered with skin graft  Lower part placed into pocket  Lobule transpositioned  Drains placement
  44. 44. PROCEDURE STAGES:  In 2nd stage:  Tragus formation  Deepening of concha
  45. 45. SILASTIC ALLOPASTIC IMPLANT  Silicon implants investigated by CRONIN & OHMORI  Best results initially  Disappointing long term outcomes  Minor trauma or abrasion causes implant failure  Implant extrusion/ resorption  Use has been discouraged Silastic Dacron auricle implant
  46. 46. TISSUE ENGINEERING  Developing biocompatible, tissue-engineered auricle  closely mimicking the normal anatomy of the patient-specific external ear and the complex mechanical behavior of native elastic cartilage  Can avoid the morbidity and poor aesthetic outcomes  typically associated with traditional reconstructions  3D image is taken, tansformed into a model,then making auricle from type 1 collagen through bovine chondrocytes  implanted subcutaneously into rats & harvested after 3 months
  47. 47. THANK YOU
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