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Archive for the ‘ear reconstruction’ Category

OR Snapshots – Microtia Rib Graft Ear Reconstruction

Friday, December 23rd, 2016

 

The ear is composed of two basic structures, cartilage and skin. The cartilage component of the ear is considerable as only the earlobe is not supported by it. The cartilage is solely responsible for the very complex shape of the ear with its many hills, valleys, ridges and curves that are seen externally. How it gets this shape is an embryological marvel as six hillocks fuse in utero to ultimately create what we see as the external ear.

While cartilage supports all the convexities and concavities of the ear, its most important contribution is to its elevations or convexities. (helical rim, superior and inferior crus, antihelix, tragus and antitragus) Cartilage can be removed from any of the concave areas and the shape of the ear would not change. This is well known from the common harvesting of ear cartilage in rhinoplasty from the concha, the largest ear concavity which looks the same both before and after graft harvest.

rib-graft-microtia-ear-reconstruction-dr-barry-eppley-indianapoliosThe greatest illustration of the role of cartilage in the shape of the ear is in microtia reconstruction. For children born with parts or all of the external ear missing, the traditional ear reconstruction method is done with rib cartilage. Portions of ribs 6, 7, and 8 are used to create a cartilage ear framework for insertion under the skin. In making his ear framework the complete concept of the ‘hills and valleys’ of the ear must be artistically created by carving and assembling the pieces of rib cartilage. The eventual shape of the ear is seen many months after surgery as the overlying skin shrinks into and around its cartilage shape.

Of all the shaping procedures that are done in plastic surgery throughout the body, making an ear out of rib cartilage in microtia reconstruction certainly qualifies as a sculpting surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Fat Grafting for the Stiff Medpor Ear Recconstruction

Wednesday, September 28th, 2016

 

Microtia is a congenital condition where all or major parts of the ear are missing. Two methods of microtia reconstruction have evolved using either one’s own ribs or through the use of a synthetic framework. Autologous microtia reconstruction is done to using portions of the cartilaginous #7, 8 and 9 ribs to create the base framework of the ear. Alloplastic microtia reconstruction uses a synthetic performed ear framework made of a Medpor material that is simultaneously covered by a vascularized temporal fascial flap. Such ear reconstructions are usually done around ages 6 to 8 years old.

medpor-ear-framework-dr-barry-eppley-indianapolismedpor-ear-framework-back-side-dr-barry-eppley-indianapolisBoth microtia ear reconstruction methods have their own unique advantages and disadvantages. The Medpor ear reconstruction framework offers the advantages of a well-shaped preformed ear framework and the avoidance of a donor rib scar and harvest site. Because it is a stiff material, however, it can feel fairly rigid. The rigidity of the wedge on the back part of a Medpor ear framework, which allows it to have good projection from the side of the head, can be a source of ear stiffness and rigidity.

medpor-ear-framework-reduction-dr-barry-eppley-indianapolismedpor-ear-reconstruction-fat-grafrt-dr-barry-eppley-indianapolisTo reduce the rigidness of a Medpor ear reconstruction, the wedge on the back part of the ear framework can be shaved down from an incision on the back of the ear. This is then filled with a dermal-fat graft placed into the space where the wedge of Medpor material was removed. Some slight projection of the ear reconstruction may be lost but the ear will have some flexibility when pressed on.

While many rib graft microtia reconstructions need projection and a more rigid graft placed behind it, a synthetic framework often needs the opposite. The preformed framework provides good projection but at the expense of ear stiffness. The ear is made of flexible cartilage that springs in and out and that is a feature that a plastic material can not do.

Dr. Barry Eppley

Indianapolis, Indiana

Surgical Correction of the Constricted Ear Deformity

Monday, May 30th, 2016

 

One of the major types of congenital ear deformities is that of the constricted ear. It is estimated that it represents about 10% of all congenital ear deformities. It is a variable ear deformity that has been described by multiple classification systems (e.g. Tanzer, Cosman, Ngata) with associated surgical strategies based on its classification. The numerous classification systems can be confusing and it is not easy to always define what type of surgery is best for the variable presentations in which the constricted ear is seen.

Constricted Ear Reconstruction with Rib Graft Insertion Dr Barry Eppley Indianapolis Constricted Ear Reconstruction with Rib Grarft Dr Barry Eppley IndianapolisIn the May 2016 issue of Plastic and Reconstructive Surgery, a paper was published entitled ‘Classification and Algorithmic Management of Constricted Ear: A 22-Year Experience’. Over 160 ears that had a lidded helix, compressed scapha and triangular fossa and an overall cuplike appearance were used as the clinical material for the study. The authors classification system uses a antihelical tubing test and a scapha-helix push test. By these two methods four types of contricted ear are identified. Type 1 constricted ears can be treated by an antihelical tubing procedure using horizontal mattress sutures placed on the backside of the ear. A type 2 constricted ear was treated by  tumbling concha-cartilage flap combined with a mastoid hitch suture. In type 3 constricted ears an antihelical wrapping technique using a free floating rib cartilage graft was used. In type 4 constricted ears where a shortage of helix exists, a helical expansion technique using a rib graft and preauricular and scapha skin flaps was used.

Based on their experience the authors have evolved to the following concepts for the constricted ear. First, waiting to age 12 or older allows for better results. Second, the existing cartilage framework was not sectioned but rolled and grafted to prevent unnatural shapes. Third, rib grafts are better than ear cartilage grafts for helical expansion. Lastly, the protruding part of the constricted ear is often overlooked and needs to be corrected by mattress sutures and/or mastoid hitch sutures.

The constricted ear and microtia have some overlap in their features. What separates them surgically is that in the constricted ear the existing cartilage framework is maintained and cartilage and soft tissue flaps are added to it. In microtia, the existing framework is unusable and has to be replaced. This paper provides an effective surgical strategy for the constricted ear that allows for a single stage correction without removal of any of the existing ear framework

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Macrotia Ear Reduction

Sunday, December 6th, 2015

 

Background: The embryology and development of the human ear is a marvel in not only its complexity but how well it works most of the time. It is created by the merging of six separate tissue segments (hillocks) in utero that create the recognizable ear that is a collection of various ridges and valleys. But due to its complex shape the ear is prone to a wide variety of congenital anomalies of which microtia is the most severe.

macrotiaThe opposite of microtia is macrotia where the ear is abnormally large. Unlike microtia where various parts of the ear are either missing or deformed, in macrotia the ear components are normal but bigger than desired. The ear is usually felt to be large primarily because it is vertically long. Various parts of the ear may be bigger than normal but usually the upper and lower thirds of the ear are what is too long.

The average height of the ear, as measured from the bottom of the lobule to the top of the upper helix, is in the range of 60 to 65mms. (average of 63mms) While they are some slight differences in these measurements between men and women, they are not all that different. (around 5% or less) The average length of the earlobe is around 18mms or about 1/3 of the total ear height.The average height of the pinna or cartilaginous portion of the ear, calculated by subtracting the earlobe height from the total ear height, was around 45mms.

Case Study: This 27 year male had ears that he felt were too big (long) as well as stuck out. He had seen other plastic surgeons but they only wanted to fix the protruding aspect of them. His total ear height was 76mms with an earlobe length of 24mms.

Vertical Ear Reduction result intraop Dr Barry Eppley IndianapolisUnder local anesthesia with infiltration around the base of his ear, three specific ear reshaping procedures were done. The earlobe was vertically reduced by 6mms with a helical rim excision technique. The upper third of the ear was reduced by 7mms using  scaphal excision of cartilage and outer skin with a helical rim reduction. (scapha-helical rim flap) Lastly ear was set back with concha-mastoid sutures from a postauricular incision. At the end of the procedure the total ear height was 65mms.

Macrotia ear reduction is done by reducing the height of the ear from the top (scapha-helical reduction) and bottom (earlobe reduction) simultaneously. Correction of any ear protrusion can be safely done during macrotia reduction surgery.

Highlights:

  1. Macrotia is an aesthetically abnormal enlargement of the ear that is most manifest in the vertical dimension.
  2. Macrotia ears usually have a combined increased height of the upper ear and longer earlobe.

3) Macrotia ear reduction surgery is done by an upper ear scapha-helical reduction flap and a helical rim earlobe reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Burn Ear Reconstruction Options

Saturday, August 29th, 2015

 

Ear reconstruction is challenging and is put to the test when portions of the ear are lost from a burn injury. Burned ears present with a unique situation due to the pattern of ear loss. Almost always the external auditory canal and the cartilaginous tragus and portions of the antihelix may remain. But the outer helix and earlobe are often lost due to the greater exposure of the outer framework of the ear to the heat source.

Maintenance of the external auditory canal and the surrounding cartilage is always beneficial in ear reconstruction as these ear areas can be the hardest structures to surgically recreate. But the burnt tissue around the remaining stump of the ear, which has usually been skin grafted, poses a dilemma for outer ear framework reconstruction. The skin is not pliable and can not be used/elevated to provide any skin coverage over a helical cartilage reconstruction.

Burned Ear Reconstruction with Rib Graft result Dr Barry Eppley IndianapolisThere are two methods to create the necessary skin coverage for burn ear reconstruction. The most common is the use of a tissue expander as a first stage procedure. The surrounding skin grafted/burned skin can be slowly expanded directly over where the recreated helix will be. Once adequately expanded a cartilage graft can be used to make the helix and placed under the expanded. The key here is slow tissue expansion to prevent breakdown of the scarred skin.

Burn Ear Reconstruction 2  result Dr Barry Eppley IndianapolisThe second approach is to use the scarred skin around the ear stump as a pedicled skin flap. The raised skin is rolled onto itself and cartilage grafted underneath it. This will require that a skin graft be done to cover the area left raw from where the skin flap was raised.

There is also a third approach where an ear cartilage framework is covered by a pedicled temporal fascial flap. This requires of course an intact temporal artery pedicle which may or may not be present. The fascial flap covers the framework and is then skin grafted.

The burn ear deformity presents a different reconstructive challenge than that of congenital microtia for example. It suffers from poor quality surrounding skin cover and thus requires a different strategy for providing soft tissue coverage over a cartilage framework reconstruction.

Dr. Barry Eppley

Indianapolis, Indiana

Simultaneous Stahl’s Ear and Constricted Ear Corrections

Thursday, July 30th, 2015

There are numerous types of congenital ear deformities. The constricted ear represents a tightness of the ear like a cinch around the outer helix of the ear which makes it smaller and often folded somewhat onto itself. The Stahl’s ear deformity, also known as a Vulcan or Spock ear, has a cartilage fold that can cause a pointed malformation in the upper part of the ear. Both types of ear deformities are uncommon but are even more rare when they occur together.

In the July 2015 issue of the International Journal of Plastic Reconstructive and Aesthetic Surgery, an article appeared in print entitled ‘ Surgical Correction of Constricted Ear combined with Stahl’s Ear’. Over a seven year period, the authors had 19 patients with constricted ear with Stahl’s ear, most of whom had it on just one side. They were surgically treated by a technique that consisted of an initial double Z-shaped skin incision made on the back side of the ear with the entire layer of cartilage cut parallel to the helix traversing the third crus to form a fan-shaped cartilage flap. The superior crus of the antihelix were shaped by folding the cartilage rim. The cartilage of the abnormal third crus was made part of the new superior crus of the antihelix and the third crus was eliminated.

Postoperative assessment of the ear reconstructions based on symmetry, helical stretch, successful elimination of the third crus, the auriculo-cephalic angle, and the substructure of the reshaped ears. All reconstructions were rated as excellent to good without any complications seen. This study shows that even the rarest of congenital ear deformities can be successfully treated with the proper surgical technique.

In the human ear the bifurcated Y-shaped superior and inferior crus is a major component of its upper half. In Stahl’s ear deformity an aberrant crus usually replaces the superior crus, crossing the scaphoid fossa from the site of the normal bifurcation of the antihelix posteriorly towards the helix which gives it an abnormal J-shape. A surgical technique to correct Stahl’s ear deformity can be done by a Z-plasty to the incision to lengthen the skin on the posterior surface, together with making use of the aberrant crus to reconstruct the superior crus without reducing the ear size using horizontal mattress sutures. This is achieved by posterior scoring and suturing without any cartilage excisions which converts the J antihelix into a Y antihelix.

Adding the constricted ear problem to the Stahl’s ear raises the stakes in terms of reconstructive difficulty. The tightness of the skin and shortage of cartilage necessitates the need to release the constricted cartilage into a fan shape and use Z patterned incisions on the back of the ear.

Dr. Barry Eppley

Indianapolis, Indiana

Lop Ear Deformity Reconstruction with Rib Graft

Sunday, June 7th, 2015

 

The shape of the ear is incredibly complex and it is a miracle that the ear is properly formed as often as it does. But when it does not become adequately shaped there are many possibilities for its deformity. One such category of congenital ear deformity is that of the constricted ear. This is where the outer rim of the ear is smaller than it should be or tightened…much like that of a cinch around a waistband.

lop eqar beforeOne form of a constricted ear deformity is that of the lop ear or lidding deformity. Like the well known lop eared rabbit, this is where the top half of the ear folds over onto itself. This is due to a deficiency of natural cartilage or normal cartilage stiffness in the upper third of the ear involving the scapha, superior crus and triangularis fossa. Without this support the superior helix folds over causing a marked decrease in vertical ear height as well.

While the lop ear can be easily folded back up into an upright position manually, it will not so easily stay that way for it lacks structural support to remain so. Thus simple cartilage suturing, like that in a setback otoplasty (ear pinning), will not usually work or will only have short term shape retention. Cartilage grafting is usually need to provide the support or ‘framework’ for ear shape retention.

Lop Ear Reconstruction with Rib Graft Insertion Dr Barry Eppley IndianapolisLop Ear Reconstruction with Rib Grarft Dr Barry Eppley IndianapolisThe cartilage graft can be easily harvested from the tail end of the one of free floating ribs. (numbers 9 or 10) Only a 2 to 2.5 cm length of rib graft is needed that is carved to a curved shape with the perichondrium removed from the convex side. The rib graft is inserted behind the ear through a postauricular incision after a pocket has been made and the entire folded cartilage exposed. The ear is then folded back and the rib graft placed between the folded sides and sutured into place. This provides a stable construct for the ear to heal in its new shape.

The severe lop ear deformity is best reconstructed with a small rib graft. This ensures the ear will heal in an upright position without risk of a recurrent fold over due to inadequate cartilage support.

Dr. Barry Eppley

Indianapolis, Indiana

Novel Method of 3D Ear Fabrication and Reconstruction

Thursday, February 21st, 2013

 

Fabrication of various body parts has been in evolution for years involving tissue growth biologies and various biomaterial technologies. The latest innovation in this process is that of 3D printing, specifically creating a 3D-printed artificial ear. From the laboratories of Cornell University in New York, work has been published online of this new method of creating a bioengineered ear replacement. Such fabrications would be useful in in children born with incomplete or no ears (microtia) and in those who have lost part of all of their ear from an accident or cancer.

These bioengineered ears were made from a digital 3D image of an intact ear which was fed into a 3D printer to produce an ear-shaped mold. This mold was then injected with a gel material composed of living ear cells from a cow and collagen. Out of the mold comes an instant ear ready for implantation after the implanted cells created a cartilaginous ear in the shape of the mold. The whole process takes about three months, most of which is spent creating the cartilage in the mold after implantation in the backs of rats. Ultimately human cartilage cells must be used for this to transition into clinical plastic surgery use.

How are ears currently made or reconstructed? The options are to either use a prefabricated ear made out of a plastic material (Medpor) or to shape it out of the patient’s own ribs. The use of the patient’s ribs is almost always better long-term but does require a painful postoperative harvest site and a tedious fabrication process that takes an experienced plastic surgeon to do it.Taking the cartilaginous ribs 6, 7 8 and making an ear framework for implantation is a true work of art that takes several hours to do.

Once implanted, an autologous rib framework can create a reasonable looking ear whose final external appearance depends on the quality if the overlying skin. In somes cases, tissue expansion is done before implantation of the rib framework. In others it may be covered by a temporalis fascial flap and skin graft if not enough good skin exists over it. Either way, rib grafts can be successfully used for any type of ear reconstruction.

It is easy to see how a 3D ear created by printing a replica of the patient’s normal ear and grown to this shape after being implanted in a mold has tremendous potential. It would save hours of operative time and the harvesting of the patient’s own ribs. This is not the first time that ears have been grown in the backs of rats and has been done as long as a decade ago. But the 3D printing process and the improvements in cell growth technologies make it likely that that this method of ear reconstruction will transition to human in the near future.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Rib Graft Reconstruction of the Avulsed Ear

Thursday, February 3rd, 2011

Background:  One of the most challenging of all plastic surgery procedures of the face is ear reconstruction. Microtia, or congenital absence of the external, is the most extreme challenge when it comes to making an ear essentially from scratch. A more common, although not less challenging, is that of partial ear reconstruction.

Whether it be from an automobile accident, a sharp edged instrument or even a bite wound, the loosely attached and flexible cartilage of the ear and its attached skin is relatively easy to avulse or be amputated. Loss of part or all of the ear cartilage, while not life-threatening, is nonetheless disfiguring and very psychologically disturbing.

I have seen ear amputations present numerous times with the avulsed ear segment in hand (or someone else’s hand) with the understandable hope that it may be able to be reattached. This is rarely possible although there is no harm in making an attempt if it is not overly crushed or mutilated, which it often is. Unless the ear is in fairly pristeen condition, it is better to close the wound and let it heal for six months before embarking on ear reconstruction efforts.

Case Study: This 18 year-old female presented in the emergency room from a rollover automobile accident on the night of her high school prom. The avulsed ear segment was brought in by the ambulance crew but it was completely crushed and unusable. She was taken to the operating room where her ear wounds were closed.

Six months later she presented for ear reconstruction. Initially tissue expansion was planned as the first stage prior to rib graft placement but she needed to complete her ear reconstruction as possible. (she was enrolling the military)

In her definitive one-stage ear reconstruction, the first step is to make a template of the opposite ear and transpose it to the amputated ear site to get the right shape and orientation of the reconstruction.

Rib grafts were then harvested using the confluence of rib numbers 6 and 7 as well as number 8 to make the helix. These were then carved and put together to make a framework for the ear reconstruction. This creates a complex framework of concavities and convexities which mimic those of the natural ear.

Because of her tight scar and skin coverage over where a rib graft reconstruction was to be placed, a temporoparietal fascial vascularized flap was planned. This was raised to be large enough to turn down and cover the full extent of the rib graft.

The rib graft is then placed and the temporoparietal flap used to provide vascularized coverage over it. A split-thickness skin graft, harvested from a non-hair bearing area, is then placed over it and meticulously sutured down. A compressive dressing is applied afterwards over drains placed underneath the cartilage framework.

The skin graft went on to have a 100% take over the combined rib graft and fascial flap. There remained a slight pigmentation difference in the skin graft from that of her natural ear and neck skin.

Case Highlights:

1)      External ear reconstruction from partial or total amputation injuries is best done with rib cartilage when significant portions of the framework are missing.

 

2)      Due to scarring and skin loss, more skin has to be created to produce an ample and supple skin cover over the rib graft. This is most commonly and easily done with tissue expanders which makes it a staged reconstruction approach.

 

3)       A one-stage ear reconstruction approach can be done using a temporoparietal fascial flap and split-thickness skin graft coverage. 

Dr. Barry Eppley

Indianapolis, Indiana

The Architecture of Ear Plastic Surgery

Wednesday, April 2nd, 2008

The ear may be quite small, measuring only about 5 cms in height and 3 cms in width, but it has the most complex anatomy of any facial component. Its many ridges and convolutions comprised only of cartilage (and the overlying skin), surrounding the ear hole, give it a distinct shape that is uniquely recognizeable as an ear. But within its complex geometries lie some basic architecture that guides how otoplasty (ear pinning) or ear reconstructive surgery is done.
On a simplistic level, the ear is three levels or tiers. An amphitheatre that encircles a central stage if you will. The outer or top layer is the outer rim of the ear known as the helix and it sits the highest. (farthest away from the side of the head) The next step down is an inner rim or antihelix which parallels the helix for the most part but at a lower level. And the final step down into the hole, so to speak, is the bowl or concha. Understanding the three tiers or levels of the ear is to understand how to surgically change it.
In otoplasty, often called ‘pinning back the ears’, the anithelix is missing. (the fold is not there) So to move the ears back, the cartilage from behind is sewn closer together to make an antihelix or antihelical fold, thus moving the helix and ear back closer to the head. How snug or loose these shaping sutures are placed determines how close the ear sits to the side of the head. In some cases of protruding ears, the bowl or concha is also too big. So the concha from behind may be cut down in size by cutting out a wedge or sewn directly back, this also moving the ear back. Since otoplasty is mainly about shaping the cartilage with sutures, this is why it is a simple and fairly quick operation…but with a very powerful visual effect.
Conversely, ear reconstruction can be quite complex. In children born with much or all of their ear missing (known as microtia), complex cartilage grafting must be done. This often involves taking rib cartilages, putting them together, and carving out an ear framework. And how is the framework pieced together and carved? Based on the three-tier principle of ear architecture! Helix, antihelix, and concha.While ear reconstruction is multiple stages and is not based solely on the cartilage framework that is put under the skin, it all begins with a well-fabricated cartilage framework. Onto that are finer details of the lobule and other shaping procedures (more minor) which are done later.

Dr Barry Eppley
Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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