The Effect of Auricular Graft Donor Site on Morbidity and Cosmetic Appearance in Cartilage Tympanoplasties.

OBJECTIVES: The aim of the present study was to compare the postoperative morbidity and cosmetic results between the use of the scapha and the use of the tragus as the auricular cartilage graft donor site in patients who had undergone cartilage tympanoplasty. The fascia graft was used as the control. MATERIALS AND METHODS: The patient's visual symmetry, cosmetic satisfaction, and anthropometric measurements were studied to objectively evaluate the cosmetic condition. The formation of skin scar changes, pigmentation changes, and sensory changes as clinical criteria were compared. RESULTS: A total of 234 patients and their 257 operated ears were included in the study. Forty prospectively operated ears with preoperative findings were also included. All patients (100%) felt that their results were good, as indicated by the visual analog scale, and the anthropometric ear measurements used to reinforce the data showed no significant differences between the groups. A significant difference with respect to clinical sensory changes was found between the groups only in patients undergoing unilateral surgery via the retro auricular approach (p<0.05). There was no difference between the scapha and tragus groups with respect to scar formation or skin pigmentation change. CONCLUSION: Neither scapha nor tragus use for graft retrieval led to dissatisfaction or cosmetic problems in the postoperative period. Sensory changes in the skin on clinical evaluation were less common in patients in whom the scapha donor site was preferred than in cases in which the tragus was used.

Developing a xenograft model of human vasculature in the mouse ear pinna.

Humanised xenograft models allow for the analysis of human tissue within a physiological environment in vivo. However, current models often rely on the angiogenesis and ingrowth of recipient vasculature to perfuse tissues, preventing analysis of biological processes and diseases involving human blood vessels. This limits the effectiveness of xenografts in replicating human physiology and may lead to issues with translating findings into human research. We have designed a xenograft model of human vasculature to address this issue. Human subcutaneous fat was cultured in vitro to promote blood vessel outgrowth prior to implantation into immunocompromised mice. We demonstrate that implants survived, retained human vasculature and anastomosed with the circulatory system of the recipient mouse. Significantly, by performing transplants into the ear pinna, this system enabled intravital observation of xenografts by multiphoton microscopy, allowing us to visualise the steps leading to vascular cytoadherence of erythrocytes infected with the human parasite Plasmodium falciparum. This model represents a useful tool for imaging the interactions that occur within human tissues in vivo and permits visualization of blood flow and cellular recruitment in a system which is amenable to intervention for various studies in basic biology together with drug evaluation and mechanism of action studies.

Engineering of scaffold-free tri-layered auricular tissues for external ear reconstruction.

OBJECTIVES: Current strategies for external ear reconstruction can lead to donor site morbidity and/or surgical complications. Tissue-engineered auricular tissues may provide readily available reconstructive materials that resemble native auricular tissue, which is composed of a cartilaginous region sandwiched between two perichondrial layers. We previously developed scaffold-free bi-layered auricular tissues, consisting of a perichondrial layer and a cartilaginous layer, by cultivating chondrocytes and perichondrial cells in a continuous flow bioreactor. Here, we aimed to improve construct properties and develop strategies to engineer tri-layered auricular constructs that better mimic native auricular tissue. STUDY DESIGN: Experimental study. METHODS: Different concentrations of insulin-like growth factor (IGF)-1 and insulin were supplemented during bioreactor culture to determine conditions for engineering bi-layered constructs. We also investigated two methods of engineering tri-layered constructs. Method 1 used Ficoll separation to isolate perichondrial cells, followed by the seeding of isolated perichondrial cells onto the opposing side of the bi-layered constructs. Method 2 involved the growth of the bi-layered constructs in osteogenic culture medium. RESULTS: The combination of 10 nM IGF-1 and 100 nM insulin led to increased collagen content in the engineered bi-layered constructs. For developing tri-layered constructs, method 2 yielded thicker constructs with better mechanical and biochemical properties compared to method 1. In addition, the presence of the perichondrial layers protected the engineered constructs from tissue calcification. CONCLUSION: Auricular tissues with a biomimetic microstructure can be created by growing chondrocytes and perichondrial cells in a continuous flow bioreactor, followed by cultivation in osteogenic medium. LEVEL OF EVIDENCE: NA Laryngoscope, 129:E272-E283, 2019.

Repair of Anterior Ear Defects Using Transcartilage Island Pedicle Flaps.

BACKGROUND: Surgical reconstruction of the anterior surface of the ear (concha, antihelix, scapha, and triangular fossa) is complicated by the paucity of mobile local skin. OBJECTIVE: This is a retrospective study of the transcartilage island pedicle flap for reconstruction of surgical defects of the anterior ear. METHODS AND MATERIALS: Two hundred thirty-two Mohs micrographic surgery defects were included in the study. The technique involves circumferential incision of the flap in the postauricular sulcus, transfer of the flap to the anterior ear through a surgically created cartilage slit, suturing of the flap on the anterior surface of the ear, and repair of the secondary postauricular defect. Preoperative, intraoperative, and postoperative details of each case were tabulated and analyzed. RESULTS: The mean defect size was 1.9 × 1.5 cm. Complications included flap edema (n = 6, 2.6%), postoperative bleeding (n = 4, 1.7%), partial thickness flap necrosis (n = 2, 0.9%), pinning back of the ear (n = 2, 0.9%), and central flap dimpling (n = 2, 0.9%). There was 1 acute staphylococcal abscess and 1 sterile abscess that developed 13 months postoperatively. All complications resolved with medical or surgical management. CONCLUSION: Transcartilage island pedicle flaps may be considered for single-stage surgical reconstruction of defects involving the anterior ear.

The Occipital Artery-Based Fascial Flap for Ear Reconstruction.

BACKGROUND: The temporoparietal fascia flap is frequently used in ear reconstruction. When the temporoparietal fascia flap is unavailable, options for primary or secondary salvage reconstruction are limited. In these patients, an inferiorly based occipital artery fascia transpositional flap is a good alternative for soft-tissue coverage over a framework. This article describes the use of the occipital artery fascia flap for ear reconstruction in conjunction with a porous polyethylene framework. METHODS: The authors included all patients who underwent occipital artery fascia flap surgery with a porous polyethylene framework for ear reconstruction performed by the first author from 1992 to 2017. RESULTS: A total of 83 patients received an occipital artery fascia flap: 24 for primary microtia reconstruction and 59 for revision or salvage of unsatisfactory results. All had contraindications for temporoparietal fascia flap use: prior use, flap injury from previous surgery, trauma, inappropriate flap location, or inadequate flap perfusion. Twelve patients (14 percent) developed occipital artery fascia flap complications (infection or necrosis) and underwent further revision to achieve satisfactory results. CONCLUSIONS: Given the paucity of reported techniques for large-scale auricular salvage/revision, the authors offer a versatile option that remains available when other conventional flaps are unavailable. The occipital artery fascia flap may be used with either alloplastic or autologous frameworks. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Posterior auricular muscle patch graft for exposed orbital implant.

The purpose of this article is to describe a surgical technique to repair an exposed orbital implant by posterior auricular muscle autograft. A retrospective review was conducted of four patients with an exposed orbital implant that were treated with a posterior auricular muscle graft. Four patients received posterior auricular muscle patch graft to the exposed orbital implant. The donor site healed with minimal scarring and remained well hidden. The graft incorporated fully into surrounding orbital tissue with no recurrent exposure at average of 13 month follow-up. The posterior auricular muscle autograft is a viable technique for repairing an exposed orbital implant.

Tissue engineering the human auricle by auricular chondrocyte-mesenchymal stem cell co-implantation.

Children suffering from microtia have few options for auricular reconstruction. Tissue engineering approaches attempt to replicate the complex anatomy and structure of the ear with autologous cartilage but have been limited by access to clinically accessible cell sources. Here we present a full-scale, patient-based human ear generated by implantation of human auricular chondrocytes and human mesenchymal stem cells in a 1:1 ratio. Additional disc construct surrogates were generated with 1:0, 1:1, and 0:1 combinations of auricular chondrocytes and mesenchymal stem cells. After 3 months in vivo, monocellular auricular chondrocyte discs and 1:1 disc and ear constructs displayed bundled collagen fibers in a perichondrial layer, rich proteoglycan deposition, and elastin fiber network formation similar to native human auricular cartilage, with the protein composition and mechanical stiffness of native tissue. Full ear constructs with a 1:1 cell combination maintained gross ear structure and developed a cartilaginous appearance following implantation. These studies demonstrate the successful engineering of a patient-specific human auricle using exclusively human cell sources without extensive in vitro tissue culture prior to implantation, a critical step towards the clinical application of tissue engineering for auricular reconstruction.

Reconstruction of Orbital Floor With Auricular Concha.

Orbital floor fractures of varying sizes commonly occur after orbital injuries and remain a serious challenge. Serious complications of such fractures include enopthalmos, restriction of extraocular movement, and diplopia. There is a dearth of literature that can be applied widely, easily, and successfully in all such situations, and therefore there is no consensus on the treatment protocol of this pathology yet. Autogenous grafts and alloplastic and allogenic materials with a wide variety of advantages and disadvantages have been discussed. The value of preoperative and postoperative ophthalmological examination should be standard of care in all orbital fracture patients. An ideal reconstructed orbital floor fracture should accelerate the restoration of orbital function with acceptable cosmetic results. Management parameters of orbital fractures such as timing of surgery, incision type, and implant materials, though widely discussed, remain controversial. In this study, 55 patients with orbital floor fractures surgically reconstructed with conchal cartilage grafts between 2008 and 2014 were retrospectively evaluated. Complications and long-time follow-up visit results have been reported with clinical and radiographic findings. The aim of this study was to present the authors' clinical experiences of reconstruction of blow-out fractures with auricular conchal graft and to evaluate the other materials available for use.

The Versatile Posterior Auricular Fascia in Secondary Rhinoplasty Procedures.

BACKGROUND: Secondary rhinoplasty often involves the addition of autogenous graft material to add volume, structure, support and to camouflage cartilage and bone grafts. A variety of fascias have been used to camouflage, wrap and give "fill" in secondary rhinoplasty. The posterior auricular fascia is a source of material ideal for such purposes, and its quantity, anatomical structure and ease of harvest with minimal donor site morbidity make it a versatile and attractive autogenous graft. METHODS: The clinical records of patients receiving autogenous posterior auricular fascial grafts were reviewed. There were two main uses of this graft material, one was to cover the tip reconstruction in secondary rhinoplasties under thin tip skin. This is a camouflage graft. The second use is for fill and augmentation, especially for the nasal dorsum and as an interpostitional graft between the dorsum and the tip. CONCLUSION: The posterior auricular fascial graft has many potential uses in secondary rhinoplasties and is readily harvested as a generous graft concurrent to conchal cartilage harvest and with a concealed scar behind the ear. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Reconstruction of Congenital Isolated Alar Defect Using Mutaf Triangular Closure Technique in Pediatric Patients.

Congenital isolated alar defects are extremely rare, occurring in approximately 1 in 20,000 to 40,000 live births. The patients are presented here of 2 pediatric patients operated on for congenital isolated alar defect. The reconstruction of congenital isolated alar defects was made in a 3-layered fashion. The skin defects were covered using the Mutaf triangular closure technique in which 2 cutaneous local flaps are designed in an unequal Z-plasty manner. Conchal cartilage graft was used between the skin and mucosal closure to replace the missing part of the lower lateral cartilage in these patients. The early results were promising in Patient 1, but sufficient improvement was detected in the alar cartilage postoperative follow-up period in Patient 2. Hence, this patient required revision 1 to 2 years postoperatively. This technique provides excellent aesthetic and functional results, except for this problem in Tessier 2 cleft patients. The use of the Stair step flap technique with Mutaf triangle closure technique achieved cosmetically and functionally excellent results in the reconstruction and repair of a large, irregular, narrow cleft, in the inadequate rotation of the lateral part of the lower lateral cartilage. However, because of this problem, evaluation of the long-term follow-up of patients is necessary.

Reconstruction of Full-Thickness Eyelid Defects Following Malignant Tumor Excision: The Retroauricular Flap and Palatal Mucosal Graft.

Treatment of malignant periorbital tumors requires radical resection of the tumor, which can result in the creation of major eyelid defects. Reconstruction of such defects with satisfactory restoration of function and aesthetic appearance is difficult. The present patient series describes the satisfactory outcomes achieved with a new surgical approach using a retroauricular flap and palatal mucosal graft. The authors reviewed 19 patients of eyelid defects created upon resection of malignant periorbital tumors between 1994 and 2012. Upon confirmation of the defect size, the eyelid defect was repaired with a palatal mucosal graft. Then a retroauricular flap was prepared at the postauricular region and the flap was used to cover the skin defect. In 1 patient, serious venous congestion of the flap occurred. After emergency surgery, the epidermis of the flap died, but the base of the flap survived. Thus, dermatoplasty was repeated. One-fourth of the flap died in 1 patient with an upper eyelid defect near the inner canthus, and after dressing of the wound, dermoplasty was repeated. No complications occurred in the other 17 patients, and satisfactory results were achieved.Thus, using a retroauricular flap, the authors can obtain good aesthetic results in the reconstruction of eyelids defect including the inner and external canthus. The color and texture of the retroauricular flap are similar to those of the eyelid, and scar contracture has a minimal effect.

Penetrating sclerokeratoplasty and autologous pinnal cartilage and conjunctival grafting to treat a large limbal melanoma in a dog.

A four-year-old neutered male Labrador retriever presented to Portland Veterinary Specialists Ophthalmology Service for evaluation of a pigmented mass oculus sinister (OS) of approximately 4-month duration. Complete ophthalmic examination revealed a large, pigmented, raised, well-demarcated, epibulbar mass appearing to originate from the nasodorsal limbal region. The mass was smooth and roughly circular, extending approximately 4 mm into the sclera and 14 mm into the nasodorsal cornea. Gonioscopy directly under the mass was not possible due to mass size. The visible iridocorneal angle was normal. High-resolution B-scan ultrasound showed mass extension to Descemet's membrane and deep sclera, but no intraocular invasion. Penetrating sclerokeratoplasty was performed followed by autologous pinnal cartilage and conjunctival grafting to repair the corneoscleral defect (20 mm x 19 mm) and to restore globe integrity and function. Histopathology confirmed the mass to be a benign limbal melanoma with complete excision. The surgery site healed without complication, and the pinnal cartilage became fully incorporated into the globe. Twelve months postoperatively, the patient remains visual with a normal intraocular and fundic examination. The pinnal harvest site on the right ear healed without complication. To the authors' knowledge, this is the first reported case of corneoscleral grafting using autologous pinnal cartilage. This may represent a viable alternative to other corneoscleral grafting procedures for large defects and is an attractive treatment option due to lack of host rejection, readily available source of donor cartilage, and provision of tectonic support to the globe.

Osteochondral articular defect repair using auricle-derived autologous chondrocytes in a rabbit model.

Hypothesizing that the implantation of non-articular (heterotopic) chondrocytes might be an alternative approach to support articular cartilage repair, we analyzed joint cartilage defect healing in the rabbit model after implantation of autologous auricle-derived (auricular) chondrocytes. Autologous lapine articular and auricular chondrocytes were cultured for 3 weeks in polyglycolic acid (PGA) scaffolds before being implanted into critical sized osteochondral defects of the rabbit knee femoropatellar groove. Cell-free PGA scaffolds and empty defects served as controls. Construct quality was determined before implantation and defect healing was monitored after 6 and 12 weeks using vitality assays, macroscopical and histological score systems. Neo-cartilage was formed in the PGA constructs seeded with both articular and auricular chondrocytes in vitro and in vivo. At the histological level, cartilage repair was slightly improved when using autologous articular chondrocyte seeded constructs compared to empty defects and was significantly superior compared to defects treated with auricular chondrocytes 6 weeks after implantation. Although only the immunohistological differences were significant, auricular chondrocyte implantation induced an inferior healing response compared with the empty defects. Elastic auricular chondrocytes might maintain some tissue-specific characteristics when implanted into joint cartilage defects which limit its repair capacity.

Sheep hemifacial and auricular transplantation models: an anatomic study.

INTRODUCTION: Currently, only a few large animal models, including swine, dog, and nonhuman primate, are described for composite face transplantation studies and the literature lacks reports on the large animal model of composite auricular transplantation. Large animal models offer better understanding of the immunological mechanisms and major histocompatibility complex characterization and, for this reason, are preferred to the small animal models for the assessment of new immunosuppressive tolerance induction protocols. Thus, the aim of this study was to demonstrate feasibility of dissection and exploration of vascular territories of the hemifacial and auricle transplantation models in the sheep cadavers. MATERIALS AND METHODS: Ten cadaver sheep heads were studied. The vascular territories of the composite hemifacial flap and composite auricle flap were defined by anatomical dissection. Methylene blue staining and laser-assisted indocyanine green angiography using SPY Elite System were used for vascular territories assessment. RESULTS: The dissection of cadaver sheep heads confirmed that the hemifacial flap and auricle flap can be raised on the same pedicle consisting of the common carotid artery and jugular vein. An adequate vascular network was observed in the flaps after injection of methylene blue dye via the arterial pedicle. Laser-assisted indocyanine green angiography identified vascular territories of the hemifacial and auricular vascular network. CONCLUSIONS: We described a new hemifacial and an auricular transplantation models in the sheep cadavers and have confirmed presence of the adequate vascular network as demonstrated by the laser-assisted angiography. This study introduces 2 new large animal models into the armamentarium of vascular composite allotransplantation.

The effect of carbon dioxide therapy on composite graft survival

PURPOSE: To investigate the effect of carboxytherapy in auricular composite grafts in rabbits. METHODS: An experimental study was conducted using 20 rabbits randomly assigned to a treatment group of carboxytherapy or a control group of saline solution. In each ear, a circular graft with 1.5 cm or 2 cm of diameter was amputated and reattached. Animals underwent carbon dioxide or saline injection four times during the experiment. We analyzed clinical evolution of the animals, grafts survival, histopathology features and histomorphometry of collagen. RESULTS:The treated group had a significantly lower weight gain (p=0.038). Histopathology was not significantly different between groups. There was an increase in amount of collagen in 2 cm grafts submitted to carbon dioxide therapy (p=0.003). Carboxytherapy didn't influence graft survival rate for 1.5 cm grafts or 2 cm grafts (p=0.567 and p=0.777, respectively). CONCLUSIONS:Carbon dioxide therapy increased the amount of collagen in 2 cm grafts. CO2 was not significantly different from saline infusion on composite grafts survival, but this study suggests that there is a mechanical effect caused by distension which favored graft survival.

The effect of carbon dioxide therapy on composite graft survival.

PURPOSE: To investigate the effect of carboxytherapy in auricular composite grafts in rabbits. METHODS: An experimental study was conducted using 20 rabbits randomly assigned to a treatment group of carboxytherapy or a control group of saline solution. In each ear, a circular graft with 1.5 cm or 2 cm of diameter was amputated and reattached. Animals underwent carbon dioxide or saline injection four times during the experiment. We analyzed clinical evolution of the animals, grafts survival, histopathology features and histomorphometry of collagen. RESULTS: The treated group had a significantly lower weight gain (p=0.038). Histopathology was not significantly different between groups. There was an increase in amount of collagen in 2 cm grafts submitted to carbon dioxide therapy (p=0.003). Carboxytherapy didn't influence graft survival rate for 1.5 cm grafts or 2 cm grafts (p=0.567 and p=0.777, respectively). CONCLUSIONS: Carbon dioxide therapy increased the amount of collagen in 2 cm grafts. CO2 was not significantly different from saline infusion on composite grafts survival, but this study suggests that there is a mechanical effect caused by distension which favored graft survival.

[Reconstruction of the lower third of the ear with a Crikelair flap]. / Reconstruction du tiers inférieur de l'auricule par lambeau de Crikelair.

Amputation of the lower third of the ear includes full thickness earlobe defects. Earlobe reconstruction depends on the covering and scaffold technique used. The Crikelair cervical skin flap is one of the available techniques for reconstruction. We discuss its assets and drawbacks by comparing it with alternative procedures.

The auricle's cavum conchae composite graft in nasal reconstruction.

BACKGROUND: Autologous transplants consisting of skin and cartilage, so-called composite grafts (CGs), are useful in nasal reconstruction of multilayered defects. A CG from the auricle's cavum conchae serves both functional and esthetic demands. This article outlines the indications and the requirements of the CG, making special considerations to improve wound healing, and discusses our results in consideration with recent publications. METHODS: A retrospective case-control study assessing the functional and esthetic long-term results in the donor and recipient site is presented. RESULTS: Between 2005 and 2011, 91 patients received differently sized CGs of the auricle for nasal reconstruction. In 85/91 cases the donor site defect was closed using a retroauricular pedicled island flap. Six of 91 defects were closed primarily. Indications were multilayered defects of the nasal vestibule, the nasal floor, the inner nasal valve, and the lateral sidewall. The main indication for surgery was skin malignancies. One of 91 major and 14/91 minor complications were observed. Seventy-seven of 91 patients received a custom-made prosthesis to prevent stenotic scarring. The 2.5-year follow-up showed excellent results of stability and shape at the donor and recipient site. CONCLUSION: The auricular inner lining CG is a versatile and reliable autologous transplant, which is ideal for multilayered nasal reconstruction because of easy harvesting, little donor site morbidity, and its convex shape. Septal splints and custom-made prosthesis secure healing and prevent stenotic scarring.

Free concha flap for sensitive nasal reconstruction using the infraorbital artery and nerve as a recipient vessel and a recipient nerve.

Free auricular flap transplantation is one of the treatments for nasal reconstruction. This report presents a case of nasal reconstruction where the infraorbital artery was used as a recipient vessel, and the infraorbital nerve as a recipient sensory nerve. A 75-year-old female underwent resection of malignant melanoma of the right nasal ala. A free ear concha flap was used for the reconstruction. The facial artery could not be found intraoperatively; instead, the infraorbital artery was identified and anastomosed with the posterior auricular artery. The great auricular nerve was coapted with the infraorbital nerve. The results of the sensory examination were the same as those of the unaffected side. This procedure not only achieves a good aesthetic outcome, but also restores sufficient sensory function.