Nghiên cứu kết quả phẫu thuật tạo hình thiểu sản vành tai nặng theo kỹ thuật nagata
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INTRODUCTION
Microtia is a congenital condition caused by the abnormal
development of the auricle during pregnancy to varying degrees, from
mildly abnormal structural part of the ear to severe. Microtia greatly
affects the aesthetic issue, which can even lead to inferiority complex
due to being stigmatized and shunned by people around them.
Therefore, these children need to get their ears corrected early to help
them integrate and improve their quality of life.
Currently in the world, there are some methods of ear
reconstruction: forming by autologous rib cartilage, shaping by artificial
materials or installing artificial ear canal. In that, forming ear flaps with
rib cartilage itself is still a reliable method, bringing long-lasting
aesthetic results. However, in Vietnam, there are still not many
researches on this method.
Therefore, we carry out this research project "Research on the
results of ear reconstruction surgery by Nagata technique" to:
Evaluate the results of ear reconstruction surgery by Nagata
technique.
1. The urgency
At the ENT hospital, every day there are microtia patients to visit,
consult and desire surgery so the need for ear reconstruction is great. In
the current methods in the world, the making of artificial materials has
just begun in Vietnam and prosthetic implant fitting has not been
conducted in Vietnam. However, these two methods are still expensive
compared to Vietnamese people and also have many disadvantages.
Only the method of using rib cartilage itself is most appropriate with the
advantage: the rib cartilage itself should not have a risk of graft
rejection, the results of long-term stable surgery, relatively high
aesthetic.
We chose the Nagata technique because it has the advantages: the
time and the number of surgeries are shortened, the reconstructed ear
looks more natural.
Because ear reconstruction is an extremely complex and
sophisticated technique, requires a well-trained and regularly operated
surgeon. We also hope that when conducting this topic, it will firstly
help Vietnamese doctors to master the technique and surgery on a
regular basis to improve the technique, reduce complications and help
patients to have good results in terms of aesthetics, improved
psychology as well as confidence in life.
2. New contributions of the thesis
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- Describe the clinical characteristics of patients with severe
microtia and accompanied malformations.
- Apply the modified Nagata tehnique (using the posterior auricular
fascia instead of the temporoparietal fascia flap) for patients with
microtia, so the surgery is suitable for Vietnamese people, achieve high
results and few complications.
3. The layout of the thesis:
- The thesis is presented with 110 pages including: 02 page
introduction, 31 pages overview, 20-page research objects and methods,
27-page research results, 27-page discussions, 1-page conclusions and
1-page proposal.
- The thesis has 33 tables, 03 charts, 12 pictures, including 89
references arranged in the order of appearance in the thesis.
CHAPTER 1: BACKGROUND
1.1. Embryology and anatomy of the auricle
1.1.1. Embryology
The outer ear consists of the auricle and ear canal, developing from
the mesenchymal layer of the first and second pharyngeal arch. The auricle
is made up of 6 auricular hillocks of His. At the 5th week of pregnancy, 3
hillocks arise from the mandibular arch (His 1,2,3) and the remaining 3
hillocks from the hyoid arch (His 4,5,6) opposite of the first pharyngeal
arch. Around the 12th week, 6 auricular hillocks converge together to
create a defined structure of the ear.
The aurilce is in the same shape as an adult by about the 18th
week. By 3 years it reaches 85% of adult size and the ear cartilage is
almost complete by 5 years of age, although it continues to grow until
about 9 years old, it reaches adult size. Microtia occurs when there is an
abnormal problem during the development of the auricle in the
embryonic period.
1.1.2. Anatomy
1.1.2.1. Appearance: includes components: the helix, antihelix, tragus,
antitragus, scapha, triangular fossa, concha and lobule.
1.1.3. Auricular anthropometry
The ears are located on either side of the head, related to the
temporomandibular joint and the parotid gland in the front, the mastoid
bone and the upper temporal region. The auricle is like 2 leaves with the
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free part opening behind, creating with the mastoid surface an angle of
about 20 - 30º (auricular- mastoid angle).
- Limit of normal auricle
+ Above: not higher than straight line crossing eyebrows.
+ Lower: not lower than the straight line across the nose.
+ The longitudinal axis of the auricle: is the straight line
connecting the highest peak of the auricle to the lowest point of the
lobule, this line is usually created with a vertical angle of 15 - 20º and
parallel to the axis of the nose bridge.
+ The anterior ear axis corresponds to the posterior edge of the
branch on the mandibule.
- Size of ears: average length of about 65mm long, 35 mm wide,
with length / width ratio ≈ 2/1.
1.2. Pathology of microtia
1.2.1. Epidemiological characteristics
- The incidence of microtia: ranges from 0.83 to 4.34 / 10,000
newborns, common among Asians, Pacific Islanders and Hispanic
people (Spain and Portugal).
- Microtia is predominant in men, right ear is more common than
left ear.
- Microtia may be isolated, or in combination with other
abnormalities, or may be part of the syndrome: OAVS system (OAVS:
Oculo-Auriculo-Vertebral Spectrum) with the most classic manifestation is
congenital Goldenhar syndrome or Klippel-Feil deformities.
1.2.2. Morphology of microtia
1.2.2.1. Morphological characteristics
About 70-90% of cases of microtia occur on one side with the
prominence in men and more often in the right ear than the left
Bilateral microtia: relatively rare with the ratio of about 0.05 ‰.
1.2.2.2. Classification of microtia:
There are many ways to classify microtia but the most popular
classification is Marx's (1926). He divided microtia into three
categories:
+ Type I: the ear is smaller than normal and still has most of its
normal structures (still with external ear canal).
+ Type II: the ear is missing 1-2 anatomical units of the ear canal
(without earlobe or helix), the external ear canal is blocked or narrow.
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+ Type III: the ear structure is only a small part of peanut,,
without external ear canal.
Later, Marx added Type IV: anotia: no auricle.
In this thesis, we classify III and IV as severe microtia which
require total ear reconstruction.
1.3. Ear reconstruction surgery
- Using autologous rib cartilage: featured with 2 techniques of
Brent and Nagata.
- Using artificial rib cartilage (MEDPOR or polyethylene)
- Prosthetic implant.
1.3.1. Ear reconstruction with autologous rib cartilage: a gold
standard surgery
1.3.1.1. Age of the patient
Brent thinks the age suitable for surgery is 6 years old. According
to Nagata, the appropriate age is 10 years or older, or when the chest
circumference> 60 cm
1.3.1.2. Four- stage technique of Brent:
- Stage 1: Haversting of rib cartilage, constructing the framework,
and inserting the framework in the pocket subcutaneously at the
reconstructed ear location.
- Stage 2: Lobule transposition.
- Stage 3: Elevation of the reconstructed ear with a skin graft to
create the auriculocephalic sulcus.
- Stage 4: Tragal construction, conchal excavation, and
simultaneous contralateral otoplasty
1.3.1.3. Two- stage technique of Nagata:
Stage 1: harvesting of the costal cartilages, fabrication of the three-
dimensional cartilage framework (3-D frame) and the grafting of the 3-
D frame to its proper anatomical location.
+ Step 1: Creating an auricle template (similar to Brent technique).
+ Step 2: Haversting the ipsilateral rib cartilage. Perichondrium is
preserved to avoid chest deformity after surgery. The cartilage pieces
are sewn together with a special type of steel thread.
+ Step 3: Implanting the framework in the pocket subcutaneously
at the reconstructed ear location.
+ Step 4: Lobule transposition and tragus reconstruction.
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Stage 2: At least 6 months after stage 1.
- Get the additional piece of cartilage (banked under the thoracic
skin during the first stage)
- Take a free flap from groin with an appropriate size.
- Elevate the framework.
- Place the semilunar cartilage, fixed by the posterior auricular
fascia.
- Using a thickness skin graft to cover posterior auricular area.
* Advantages:
1. The time and the number of surgeries are shortened.
2. The reconstructed ears look more natural
* Defect:
1. The risk of lobule necrosis is higher (due to the lack of blood
vessels).
2. The chest is weak (due to the large number of cartilage taken).
3. The risk of hair loss on the scalp.
1.3.1.4. Symptoms
- Complications at the chest
* Early complications - Perforation of the pleura: - Pneumothorax:
- Hematoma: caused by occlusion, slipping drainage in the chest.
* Late complications - Thoracic deformity: - Bad scars, keloid
scars, hypertrophic scars:
- Complications at the ear
* Early complications - Necrosis of skin flap covered with
framework - Hematoma, condensation: caused by occlusion, closed
drainage - Infection: - Cartilage inflammation: causing necrosis,
deformed framework , affecting aesthetic results. – Ischemia when
lobule transposition.
* Late complications
- Bad scars, hypertrophic scars, keloid scars.
- Changes in the morphology of the cartilage framework:
+ Errors in the position (right) of the ear,
+ Changes in skin color.
+ Change in the size of the framework.
+ Loss of the anatomy details.
CHAPTER 2: SUBJECTS AND METHODS OF THE STUDY
2.1. Subjects
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2.1.1. Selection criteria:
- Patients diagnosed with congenital severe microtia (type III, IV
according to Marx) underwent ear reconstruction by Nagata technique
at ENT Hospital.
- Patient has full participation in 2 stages of surgery.
- Having complete medical records.
- Follow- up after 2nd stage at least 6 months.
- Agree to join the research.
2.1.2. Exclusion criteria - Patient had surgery at another hospital;. -
Patients were operated without Nagata technique- Patient was not
followed-up at least once after 2 nd stage of surgery for 6 months. -
Patients do not agree to participate in the research.
2.1.3. Sample size: Because microtia is a rare disease, we selected a
convenient sample size. In fact, in the 3 years from 2016 to 2019, we
screened all 32 eligible patients for the study. In which, 15 patients
were retrospective and 17 patients were prospective.
2.2. Methods
2.2.1. Study design: clinical intervention study, before-after control.
2.2.3. Research location: Esthetic and Plastic Surgery Department -
ENT Hospital.
Research period: within 3 years from 2016 to 2019.
2.2.4. The main evaluation parameters
2.2.4.1. Before surgery: age and gender
- Family history:
- The position of microtia: 1 or 2 sides, left or right.
- External ear canal: narrow or completely blocked.
- Accompanied malformations:
- Features of normal ear: Length, width, the distance between
helix-lateral canthus, the distance of ear from mastoid bone, the
auricular- mastoid angle.
- Number of surgeries:
- Hospital stay of each time:
- Time between 2 stages:
2.2.4.2. After surgery
- Early and late complications of 1 st stage at the chest, at the
location of the reconstructed ear.
- Managing complications
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- Aesthetic results of the ear in various aspects: were evaluated
after 4 follow-up times: 2 times after stage 1, 2 times after stage 2; Each
visit is at least 3 months apart.
+ Location: position, the distance between helix-lateral canthus,
the distance helix- mastoid, the auricular- mastoid angle, the ear axis.
+ Size: length, width
+ Shape (13 anatomical details)
+ Other characteristics: ear thickness, skin color, unwanted hair, scar.
- Satisfaction level of the patient:
2.3. Steps to proceed
2.3.1. Designing samples of research records, collecting data -
Develop a sample medical record to collect data.
- Select patients according to the set criteria.
- Explain the patient agrees to participate in the study and sign a
commitment to agree to participate in the study.
- Condut patient information collection according to the sample case:
- Administrative part: recording full name, age, gender, address,
phone contact, hospital registration number, research record number to
contact and evaluate after surgery.
- For retrospective patients: retest according to the information in
the sample medical records at the beginning of the study. All
retrospective patients have only completed stage 1 of the surgery, so we
proceeded to conduct research at stage 2.
- For prospective patients: pre-surgery clinical examination: fully
record in detail the morphological characteristics of the microtia ear.
2.3.2. Planning the surgery:
- Use a piece of X-ray film to draw hightlights key structure of the
normal ear: For patients with bilateral microtia, we use a sample ear that
matches the face of the patient (sample ears have 3 sizes: big, medium
and small).
- Locate the reconstructed ear:
- Draw the shape and size of the ear canal to prepare for
reconstruct at the position of the microtia ear, mark with an indelible
marker pen or pump methylene blue pole at the top and bottom of the
ear, the ear axis.
- Locate the donor site at the ipsilateral chest.
- Photographing patients before surgery.
2.3.3. Ear reconstruction by Nagata: includes 2 stages:
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2.3.3.1. Stage 1: Create a 3D cartilage framework with the ipsilateral rib
cartilage, lobule transposition and tragus reconstruction.
Step 1: Take rib cartilage: Often use rib cartilage 6, 7, 8, 9 to
sculpting cartilage framework. Specifically: take a block of rib cartilage
6, 7 to create the basic frame, take the whole rib cartilage 8.9 to the
adjacent section with the rib, preserve the perichondrium. Bury the
excess cartilage pieces under the chest skin for 2 nd stage. Sculpte the rib
cartilage into the details of the normal ear, stitching to fix the details
with steel thread.
Step 3: Create a skin pocket: Redefine the ear landmarks: ear axis,
highest and lowest points. Create skin pockets by undermining
postauricular scalp area to a specified size, not too wide, not too tight.
Control the bleeding carefully.
Step 4: Implant the cartilage framework into the skin pocket:
Implant the cartilage framework beneath the skin corresponding to the
location of the reconstructed ear that was located in step 1. Turn the
earlobes into position and reconstruct the tragus.
Step 5: Closed drainage - close the skin pocket - wound bandage:
Put 2 closed drains, apply antibiotic- light compress.
Follow up after surgery:
+ At the chest: Bleeding, hematoma: drainage usually withdrawn
after 24 hours; pneumothorax.
+ At the location of the ear: Keep negative pressure of drains.
Evaluate skin color: pink or hematoma, purple, black, necrotic ....
Observe if the main anatomical details are clear, whether the new ear in
right place.
2.3.3.2. Stage 2: Elevate the cartilage framework: after 1 st stage at least
6 months. Take a piece of cartilage waiting at 1 st stage. Take a thickness
skin graft in the groin area. Cut the skin behind on the cartilage
framework 5mm from the atrial edge of the cartilage, all the way to the
scales behind the ears. Elevate the cartilage framework up and forward,
reposition the ear if needed. Place the semilunar cartilage padding on
the cartilage frame, cover and fix by posterior auricular fascia, collating
so that it is proportional to the opposite side. Fixed stitching of skin
grafts on the back of the framework. Fixation with bolster.
Follow up after surgery: - After surgery, patients are given
antibiotics, analgesic, anti- imflamation. - Examining to detect and
handle complications: infections, skin flap, regular observation of flap
color ... - Bolster is removed after 5-7 days.
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2.3.4. The corrective surgery
After 2nd stage surgery, depending on the surgical results on the
shape, size and position of the reconstructed ear, there may be
corrective surgery for perfection:
- Correction of hypertrophic or keloid scars.
- Edit unclear anatomical details, misalignment.
- Edit the auricular- mastoid angle.
2.3.4.1. Evaluate general results after surgery
- Assessing the results of 1st stage surgery: with the following
criteria:
+ At the chest:
0 points: for each of the following criteria: Bleeding requires
intervention after surgery; drainage of pleura, necrotic infection with
necrotic, non-healing scar.
1 point: for each of the following criteria: Bleeding must intervene
during surgery; pleural suture, edema, no infection.
2 points: for each criterion: No bleeding; no punctured pleura,
good scars.
+ At the ear:
0 point for each criterion: Closed drainage is lost, open to be sewn
or continuous aspiration; hematoma; infected surgical incisions, scarred
necrosis; skin flap necrosis > 1cm; chondritis cartilage destruction.
1 point for each criterion: leaked drains must be applied with
antibiotic grease; Hematoma requires no intervention; wound without
infection, no necrosis; skin flap necrosis <1cm; no cartilage destruction.
2 points for each criterion: no slip, open drainage; no hematoma;
good scars; No necrotizing flap skin; No chondritis.
Based on this scale, individual points will be calculated at the chest
the location of the reconstructed ear and dividing the surgical results
into 4 levels:
-At the chest: Poor: <3 points; Average: 3 points; Good: 4-5
points; Very good: 6 points.
- Reconstructed ear: Poor: > 5 points; Average: 5-7 points; Good:
7-9 points; Very good: 10 points.
Evaluation of late results: The evaluation time is every 3 months
after surgery with the following criteria:
+ At the chest:
0 points for each of the following criteria: Scar bulge; chest
deformity;
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1 point for each criterion: bad scar; chest deformity;
2 points for each criterion: normal scars; no chest deformity;
+ At the ear :
0 points for each criterion: Clear skin color; the ear is very thick,
with unwanted hair need to cut regularly; keloids.
1 point for each criterion: Slightly different skin color; slightly
thicker ears; There is less hair not to cut periodically; bad scars.
2 points for each of the following criteria: Skin color equivalent;
Equivalent thick ears, no unwanted hair; normal scar.
Based on this scale, individual points will be calculated at the site
of taking rib cartilage, the location of the ear shape and dividing the
surgical results into 4 levels:
-At the chest: Poor: <2 points; Average: 2 points; Good: 3 points;
Very good: 4 points.
-At the reconstructed ear: Poor: < 4 points; Average: 4-5 points;
Good: 6-7 points; Very good: 8 points.
- Aesthetic results about position and size of reconstructed ear:
difference from the healthy side:
0 points for each criterion: Length, width> 10mm; misaligned ear
axis; high or low ear position> 10mm; auricular- mastoid angle > 20o;
distance between helix- mastoid> 10mm; distance between helix- lateral
canthus > 10mm.
1 point for each criterion: Length, width 5-10mm; ear axis less
deviated; auricular- mastoid angle 10 ͦ -20o; distance between helix-
mastoid 5- 10mm; distance between helix- lateral canthus 5- 10mm.
2 points for each of the following criteria: Length, width <5mm;
good ear axis; high or low ear position <5mm; auricular- mastoid angle
< 10 ͦ; distance between helix- mastoid < 5mm; distance between helix-
lateral canthus < 5mm.
-Sorting aesthetic results on ear position, size: Poor: <6 points;
Average: 6-8 points; Good: 9-11 points; Very good: 12 points.
-Aesthetic results about the reconstructed ear: based on 13
anatomical details according to Mohit Sharma: each detail 1 point: crus
of helix, upper 1/3rd of helix, middle 1/3rd of helix, lower 1/3rd of helix,
superior and inferior crus of antihelix, middle part of antihelix,
antitragus, tragus, lobule, scaphoid fossa, triangle fossa, cymba concha,
cavum concha.
- Sort by Mohit Sharma: Poor: 1-5 points; Average: 6-8 points;
Good: 9-11 points; Very good: 12-13 points.
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-The level of patient satisfaction: divided into 5 levels: Completely
dissatisfied; Unsatisfied; Normal; Satisfied; Very satisfied.
2.3.5. Methods of analyzing and processing data: Data from research
records are coded and entered using EpiData data entry software 3.1.
Data analysis using SPSS 22.0 software.
2.3.6. Ethics in research: Patients are explained carefully about
surgical methods, possible risks. The study was approved by the Ethics
Commitee of Hanoi Medical University.
CHAPTER 3: RESULTS
3.1. Clinical characteristics of patients with severe microtia
3.1.1. Age at surgery
Comments: The age of the youngest patient is 7, the oldest age is
37. The average age is 16.1 ± 7.6; Most patients have surgery at the age
of 10 - 20 years old, there are 3 patients undergoing surgery under the
age of 10 and 5 patients over 20 years old.
3.1.2. Sex
Gender
Giới tính
34,4%
65,6%
Nam
Mal Female
Nữ
e
Figure 3.1. Gender distribution
Comment: Male: female ratio: 1.9: 1. The majority of patients are
male (65.6%), the remaining 11 patients are female, however this
difference is not statistically significant with p = 0.077.
Table 3.3. Side of microtia: Microtia is mainly on the right (20
ears), only 11 left ears and 1 patient has microtia on both sides.
However, this difference is not statistically significant with p = 0,106.
Figure 3.2. Malformations and syndromes: There are 13 patients
without any accompanied malformations. There were 19 patients with
inferior maxillofacial osteoarthritis attached (accounting for 59,4%).
There were 5 patients with mild congenital facial paralysis, there were 3
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patients with preauricular sinus, 2 patients with low set ear and 1 patient
with a macrostomia.
Table 3.5. Normal ear: The average length of the ear is 60.2 mm.
The average width of the ears is 30.6mm. The average of the auricular
mastoid angle is 19.1º. The distance between the helix- lateral canthus
is 75.6mm. The average distance of the auricular- mastoid is 19.1mm.
3.2. Ear reconstruction surgery results
Table 3.6. Number of surgeries: More than half of patients have to
undergo 3 surgeries, 1/3 patients only need to undergo 2 surgeries, 2
patients need 4 surgeries and 1 patient need 5 surgeries. The average
number of surgeries is 2.75.
Figure 3.3. Average number of treatment days: the longest is 26
days. The longest treatment day in 1st stage is in patients with necrosis
of the skin flap, which causes exposed cartilage and prolonged
hospitalization.
Table 3.7.Time between 2 stages of surgery: Most patients have
surgery 2nd stage after 1 year, 4 patients undergo surgery after 1 year - 2
years, only 1 patient underwent surgery for 2nd stage after 6 months.
3.2.4. Complications of surgery
3.2.4.1. Complications at the chest
Table 3.8. Early complications at the chest: During 1 st stage of the
surgery, we did not experience complications of bleeding, pleural
perforation or infection but only pleural perforation in 6 cases (18.2%),
It is mainly a hole <1cm in diameter.
Table 3.9. Late complications at the chest: 26/33 cases without any
complications. No patients with chest deformity. There were 7 patients
with bad scars, of which 6 patients had hypertrophic scars, only 1
patient had keloid.
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Table 3.10. Early complications at the reconstructed ear
Complications n %
Hematoma 2 6,1
Infections 3 9,1
Necrosis of skin flap 1 3,0
Uncomplicated 27 81,8
Total 33 100
Comment:
In the 1st stage of surgery, the majority of patients (27/33 ears) had no
complications. At the reconstructed ear in 1 st stage of surgery, there
were 2 patients with hematoma, 3 patients with infections and 1 patient
suffered from skin flap necrosis.
Table 3.11. Late complications at the reconstructed ear: The
majority of patients (29 out of 33 cases) had no complications.
However, there were 2 patients with hypertrophic scars and 2 patients
with keloid.
3.2.4.3. Complications at the inguinal skin site
- Early complications: 100% of patients do not experience early
complications at the inguinal skin site such as: hematoma, infection.
Table 3.12. Late complications at the site of inguinal skin: Most
patients do not have any complications (27/33 cases), 5 cases have
hypertrophic scars and 1 case of keloid scars.
Table 3.13. Total of bad scars at 3 locations: In 33 reconstructed
ears, in 3 locations the number of bad scars was 17 (17.2%). In which,
reconstructed ear area were 4 cases, chest area was 7 cases and groin
area was 6 cases. Of the 17 bad scars, most are hypertrophic (13/17),
with only 4 keloid.
Table 3.14. Management of bad scars: In 17 bad scars, 6 cases
were left untreated, 7 scars were intra lesion injected with
costicosteroids and 4 cases: surgery and injections.
3.2.5. Reconstructed ear characteristics
Table 3.15. Morphology: The average length of the ear is 58.3 mm.
The average width of the ears is 29.6 mm. The average angle of auricular-
mastoid is 16.7º. The distance between the helix- lateral canthus is 75.6
mm. The average distance of the auricular- mastoid is 19.1 mm.
Table 3.16. Difference in ear length compared to healthy side.
20/33 cases in which the length of the reconstructed ear is most
different from the healthy ear below 5mm.
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12/33 cases in which the length of the reconstructed ear to be 5-10
mm different from the normal ear.
In only 1 case, the length of the reconstructed ear was different
from the healthy ear> 10mm.
Table 3.17. Difference in ear width compared to healthy side
In 26/33 cases, the width of the reconstructed ear was much
different from the normal ear below 5mm.
7/33 cases in which the width of the reconstructed ear is 5-10 mm
different from the normal ear shape.
There is no case where the width of the ear shape is different from
the healthy ear> 10mm. The difference in ear width is less than the
length. This difference is mostly smaller, that is, the reconstructed ear is
usually smaller than the good ear.
Table 3.18. The angle of the auricular- mastoid compared to the
healthy side: The angle through examinations is almost unchanged,
most only differ below 100. Only 1 patient had a 10-200 difference.
Table 3.21. The position of the ear examinations: The high and low
position of the ear through examinations is unchanged (or only changes
below 5mm). Nearly ½ of the ears are same level with the right ear, one
fifth of the ears are higher and one third of the ears are lower than the good.
Table 3.22. Axis of the reconstructed ear through examinations: On
the 1 st and 2nd examinations, the axis is the same: there are 18 ears on
the right axis, 7 ears on the front axis and 8 ears on the rear axis. On the
3rd anf 4th examination 3 and 4 the axis was similar and improved: there
were 22 right ear axes, 4 ear deviated front axis and 7 ear rear axis
deviation.
Table 3.23. Ear thickness through examinations: Ear thickness is
the same across the visits, only 7/33 ear thickness is equivalent to
healthy ear, and the rest (26/33 ears) are all thicker than healthy ears.
No ears are too thick compared to healthy ears.
Table 3.24. Skin color: Through examinations, most skin are the
same color with the surrounding skin, only 1 ear has a different skin
color than the surrounding skin.
Table 3.25. Unwanted hair condition in the skin flap: 1/3 of the
patients have unwanted hair in the skin flap, while 2/3 of the patients have
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no unwanted hair. In the case of hair flap there are many different levels:
hair on the front, the hair is extreme on the helix, more hair, less hair
Table 3.26. How to treat unwanted hair in skin flap: Among 11 patients
with hair in skin flap, 5 patients did not handle anything, while 6 patients had
to have periodic haircuts, none of them had laser hair removal.
3.2.12. Characteristics of anatomy details
Table 3.27. Frequency of anatomy details
N Details Total details / 33 %
1 Crus of helix 30 90,9
2 Upper 1/3rd of helix 32 96,9
3 Middle 1/3rd of helix 31 93,9
4 Lower 1/3rd of helix 30 90,9
5 Superior and inferior crus of antihelix 18 54,5
6 Middle part of antihelix 24 72,7
7 Antitragus 21 63,6
8 Tragus 26 78,8
9 Lobule 32 96,9
10 Scaphoid fossa 30 90,9
11 Triangle fossa 15 45,4
12 Cymba concha 12 36,4
13 Cavum concha 33 100
Comment: Among the 13 anatomical details, the detail observed,
which appeared most in all ears was the cavum concha (100%). Details
appear at least, less than a quarter of cases are triangular fossa with a
frequency of 45.4%. The details with high frequency of succession are:
Upper 1/3rd of helix and earlobe (96.9%); Middle 1/3 rd of helix (93.9%);
crus of helix, lower 1/3rd of helix , scaphoid fossa (90.9%). The details
that appear less are: 78.8% tragus; middle part of antihelix 72.7%;
superior and inferior crus of antihelix are opposite to 54.5%.
Table 3.28. Rating points according to Mohit
Sharma
Score n %
≤5 0 0
6-8 4 12,1
9-11 23 69,7
≥12 6 18,2
16
Total 33 100
Comment: No ears have less than 5 details.
There are 4 ears with 6 - 8 details.
There are 23/33 ears with 9 - 11 details.
And especially there are 6 ear with 12-13 details of anatomy.
3.2.13. Evaluate the overall results
3.2.13.1. Early results of surgery
Table 3.29. Assessing the early results of surgery: The majority of
the ear lobes (27/33) have very good results with no complications at
the chest and reconstructed ear. There were 6 patients with good results
with minor complications of the reconstructed ear or rib cartilage such
as pleural perforation, hematoma. No patients had poor results.
3.2.13.2. Late results of surgery:
Table 3.30. Assess the late outcome of surgery
At the chest: Better results at the reconstructed ear. 78,8% achieved
good results because there were no patients with chest deformity and
beautiful scars; There were 6 patients achieved good results ie there
were hypertrophic scars or keloids in the chest area. At the
reconstructed ear: very good results with 7 patients, 3 patients with
good results, 12 patients with satisfactory results. And especially 1
patient with poor results
3.2.13.3. Aesthetic results about the position and size of the ears
Table 3.31. Evaluating aesthetic results about ear position, size
The majority of ears (81.8%) had good location and size results,
which were relatively similar and well balanced for healthy ears.
Especially 1 ear has very good results. There were 5 ears that achieved
results ie either the ear size was not commensurate with the good ear, or
the ear position was not in balance with the healthy ear. No ears had
poor results.
3.2.13.4. Aesthetic results on anatomical details:
Table 3.32. Evaluating aesthetic results of ear anatomy: 23 out of
33 ears have 9 ÷ 11/13 details of the ear, ie having relatively enough
shape of the ear. Having 6 ears with 12/13 details. Only 4 ears have
only 6 ÷ 8 details, none has less than 6 details. As a result, the shape of
the ear is mainly good and very good (29/33 ears) for 87.9%. No ears
have poor results.
Table 3.33. Satisfaction level of patients: The majority of patients
were satisfied and very satisfied with the reconstructed ear, accounting
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for 78.1% (25/32 patients), only 21.9% of patients were normal with
surgical results.
CHAPTER 4: DISCUSS
4.1. Clinical characteristics of patients with severe microtia
4.1.1. Age
In our study, most of patients had surgery mainly between the ages of
10-20 years old. This is a very suitable age for Nagata technique because at
this time, the rib has grown enough to take the necessary amount of rib
cartilage and the quality of rib cartilage has not been reinforced.
However, there are 5 patients over 20 because they did not have
the economic conditions for surgery at a young age. Therefore, we
recommend that the formation of the ear cartilage with rib cartilage
should be done best around the age of 10.
According to the 4th International Ear Reconstruction Congress
with the participation of 31 surgeons, the age is agreed for surgery is
from 8-10 years old.
According to Im, 72% of surgeons believe that surgery at a later
age will have better aesthetic results.
According to Li (2018), the standard that patients can have surgery
is > 120cm height, chest circumference > 55 cm.
4.1.2. Sex
All studies of microtia is male predomiant disease except for one
study by Zhu (2000) that found no difference between the sexes, it is
not explained in detail.
4.1.4. Location
Microtia is mainly on the right, accounting for 62.5%, only 34.4%
has left ear and 1 patient has on both sides. This is also consistent with
the clinical characteristics of microtia more commonly on the right than
on the left. According to Ly Xuan Quang, among 38 patients with 50%
had right ear, 47.4% had left ear and there was 1 patient with both ears,
according to Brent, a total of 1200 cases was 58.2% had right ear ,
32.4% had left ear and 9.4% had both ears, according to Kawanabe this
rate is 65.2% and 34.8 respectively. However, the reason why microtia
is more common on the right is that no studies have mentioned it.
4.1.6. The malformation and accompanied syndrome
There were 19 patients with hemifacial microsomia, accounting for
57.6%, higher than Brent's study of 36.5%, Zhang's study was 44%. Thus,
the majority of patients with hemifacial microsomia. This problem poses the
need plastic surgegy so that the face is symmetric so that the reconstructed
ear can become more balanced. The surgery helps to symmetry the face for
18
better results. This is the expectation of many parents as well as patients, it
also affects the level of satisfaction of the patient.
4.1.7. Normal ear charateristics
Our results are relatively consistent with Vietnamese results in
terms of length and width. There are currently no studies evaluating the
angle auricular- mastoid, the distance between helix- lateral canthus, the
distance auricular- mastoid.
4.2. Reconstructed ear results
4.2.1. Number of surgeries
The average number of surgeries per patient is 2.75. Most of the
following surgeries are corrected for ear details or fistula surgery.
Although the Nagata technique consists of only 2 stages of surgery,
in fact it is only 2 major surgeries. In addition, after 2 surgeries, there
will be a number of small corrective surgeries.
According to Constatine, the average number of surgeries is 4.88
times, higher than our study. According to the summary at the
International Ear Reconstruction Congress in 2007, 61% of surgeon
operated 3 times, 29% of surgeon operated twice for ear reconstruction.
4.2.3. The time between 2 stages
Over time we have mastered the technique and the first patients to
be completely operated by Vietnamese surgeons who have had stage 2
surgery are 6 months.
According to Ly Xuan Quang, 71.8% of patients had the 2 nd stage
after 6-12 months. According to the 4 th International Ear Reconstruction
Congress, 71% of patients had the 2nd stage after 6-12 months.
4.2.4. Complications of surgery
4.2.4.1. Complications at the chest:
- Early complications: There are 6 cases of pleural perforation, of
which most are holes <1cm in diameter. Of which 5 patients were
pleural suture and 1 patient was pleural drainage, follow-up and
withdrawal after 24 hours. Our pleural perforation rate of 18.2% is
higher than most studies. According to Long (2013), the rate of pleural
perforation was 12.75%. According to Chauhan (2011), this rate is
3.7%, according to Dashan (2008) this rate is 0%, according to
Kawanabe (2006) is 0.37%. According to Kawanabe, the rate of pleural
perforation is low because they do not remove perichondrium.
According to Thomson, this rate is 22% due to perichondrium remove.
Our research also carried out the preservation of perichondrium,
but it may be because our technique is not good, surgery is not done
19
regularly, so the rate of pleural perforation is high. This is one thing that
needs to be learned from our research.
- Late complications: In our study, there were no patients with
chest deformities. This is also consistent with Kawanabe's study: 0/273
cases, Avelar: 0/146 cases.
According to Kawanabe, Avelar's cause of chest deformity is not
due to the amount of rib cartilage removed, but because the
perichondrium is not preserved. Because Nagata technique still needs to
take 4 rib cartilage 6,7,8,9 in the 1 st stage without any patients with
chest deformity in 273 patients. The proportion of bad scars is generally
21.2%, relatively high compared to other authors. This can be explained
by racial factors, as judged by Wolfram and Yotsuyanagi, black people
are at a higher risk of forming bad scars than whites.
4.2.4.2. Complications at the reconstructed ear:
- Early complications: At the reconstructed ear at the 1 st stage of
the surgery, there were 2 patients with hematoma, 3 patients with
infections and 1 patient with skin flap necrosis. 2 patients with
hematoma are due to slipped drainage, open should conduct continuous
suction, but still cause hematoma and although mild. Drainage is also a
key to the success of surgery: because it reduces the dead space
between the skin and the framework -> avoids hematoma and
congestion so it is necessary to close the skin incision. Three out of 32
patients (9.4%) had a mild infection, which was characterized by a red,
inflamed ear ring. Patients who are exchanging or adding antibiotics are
stable. According to Firmin (2010) the infection rate was 6/930 cases
(0.65%), the cause is usually from the outer ear canal caused by
Pseudomonas bacteria. According to Long (2013) this rate is 0.9%.
However, in our study, only 1 patient had skin flap necrosis
(3.0%), According to Firmin (1998), the rate was higher, 13.9%.
According to Long (2013), the rate is lower than 0.16%.
Learning from this complication, we see an important role in
creating skin pockets at the location of the microtia . Skin pockets
should be removed not too thick to avoid seeing the anatomical details
but not too thin, which will lead to malnutrition and skin necrosis.
- Late complications:
After 2 stages, 2 patients had hypertropic scars and 2 patients with
keloid scars. According to Cho (2007), 3 out of 125 patients had keloids in
the reconstructed ear. So we can see the bad scarring rate of our study is
much higher.
INTRODUCTION
Microtia is a congenital condition caused by the abnormal
development of the auricle during pregnancy to varying degrees, from
mildly abnormal structural part of the ear to severe. Microtia greatly
affects the aesthetic issue, which can even lead to inferiority complex
due to being stigmatized and shunned by people around them.
Therefore, these children need to get their ears corrected early to help
them integrate and improve their quality of life.
Currently in the world, there are some methods of ear
reconstruction: forming by autologous rib cartilage, shaping by artificial
materials or installing artificial ear canal. In that, forming ear flaps with
rib cartilage itself is still a reliable method, bringing long-lasting
aesthetic results. However, in Vietnam, there are still not many
researches on this method.
Therefore, we carry out this research project "Research on the
results of ear reconstruction surgery by Nagata technique" to:
Evaluate the results of ear reconstruction surgery by Nagata
technique.
1. The urgency
At the ENT hospital, every day there are microtia patients to visit,
consult and desire surgery so the need for ear reconstruction is great. In
the current methods in the world, the making of artificial materials has
just begun in Vietnam and prosthetic implant fitting has not been
conducted in Vietnam. However, these two methods are still expensive
compared to Vietnamese people and also have many disadvantages.
Only the method of using rib cartilage itself is most appropriate with the
advantage: the rib cartilage itself should not have a risk of graft
rejection, the results of long-term stable surgery, relatively high
aesthetic.
We chose the Nagata technique because it has the advantages: the
time and the number of surgeries are shortened, the reconstructed ear
looks more natural.
Because ear reconstruction is an extremely complex and
sophisticated technique, requires a well-trained and regularly operated
surgeon. We also hope that when conducting this topic, it will firstly
help Vietnamese doctors to master the technique and surgery on a
regular basis to improve the technique, reduce complications and help
patients to have good results in terms of aesthetics, improved
psychology as well as confidence in life.
2. New contributions of the thesis
2
- Describe the clinical characteristics of patients with severe
microtia and accompanied malformations.
- Apply the modified Nagata tehnique (using the posterior auricular
fascia instead of the temporoparietal fascia flap) for patients with
microtia, so the surgery is suitable for Vietnamese people, achieve high
results and few complications.
3. The layout of the thesis:
- The thesis is presented with 110 pages including: 02 page
introduction, 31 pages overview, 20-page research objects and methods,
27-page research results, 27-page discussions, 1-page conclusions and
1-page proposal.
- The thesis has 33 tables, 03 charts, 12 pictures, including 89
references arranged in the order of appearance in the thesis.
CHAPTER 1: BACKGROUND
1.1. Embryology and anatomy of the auricle
1.1.1. Embryology
The outer ear consists of the auricle and ear canal, developing from
the mesenchymal layer of the first and second pharyngeal arch. The auricle
is made up of 6 auricular hillocks of His. At the 5th week of pregnancy, 3
hillocks arise from the mandibular arch (His 1,2,3) and the remaining 3
hillocks from the hyoid arch (His 4,5,6) opposite of the first pharyngeal
arch. Around the 12th week, 6 auricular hillocks converge together to
create a defined structure of the ear.
The aurilce is in the same shape as an adult by about the 18th
week. By 3 years it reaches 85% of adult size and the ear cartilage is
almost complete by 5 years of age, although it continues to grow until
about 9 years old, it reaches adult size. Microtia occurs when there is an
abnormal problem during the development of the auricle in the
embryonic period.
1.1.2. Anatomy
1.1.2.1. Appearance: includes components: the helix, antihelix, tragus,
antitragus, scapha, triangular fossa, concha and lobule.
1.1.3. Auricular anthropometry
The ears are located on either side of the head, related to the
temporomandibular joint and the parotid gland in the front, the mastoid
bone and the upper temporal region. The auricle is like 2 leaves with the
3
free part opening behind, creating with the mastoid surface an angle of
about 20 - 30º (auricular- mastoid angle).
- Limit of normal auricle
+ Above: not higher than straight line crossing eyebrows.
+ Lower: not lower than the straight line across the nose.
+ The longitudinal axis of the auricle: is the straight line
connecting the highest peak of the auricle to the lowest point of the
lobule, this line is usually created with a vertical angle of 15 - 20º and
parallel to the axis of the nose bridge.
+ The anterior ear axis corresponds to the posterior edge of the
branch on the mandibule.
- Size of ears: average length of about 65mm long, 35 mm wide,
with length / width ratio ≈ 2/1.
1.2. Pathology of microtia
1.2.1. Epidemiological characteristics
- The incidence of microtia: ranges from 0.83 to 4.34 / 10,000
newborns, common among Asians, Pacific Islanders and Hispanic
people (Spain and Portugal).
- Microtia is predominant in men, right ear is more common than
left ear.
- Microtia may be isolated, or in combination with other
abnormalities, or may be part of the syndrome: OAVS system (OAVS:
Oculo-Auriculo-Vertebral Spectrum) with the most classic manifestation is
congenital Goldenhar syndrome or Klippel-Feil deformities.
1.2.2. Morphology of microtia
1.2.2.1. Morphological characteristics
About 70-90% of cases of microtia occur on one side with the
prominence in men and more often in the right ear than the left
Bilateral microtia: relatively rare with the ratio of about 0.05 ‰.
1.2.2.2. Classification of microtia:
There are many ways to classify microtia but the most popular
classification is Marx's (1926). He divided microtia into three
categories:
+ Type I: the ear is smaller than normal and still has most of its
normal structures (still with external ear canal).
+ Type II: the ear is missing 1-2 anatomical units of the ear canal
(without earlobe or helix), the external ear canal is blocked or narrow.
4
+ Type III: the ear structure is only a small part of peanut,,
without external ear canal.
Later, Marx added Type IV: anotia: no auricle.
In this thesis, we classify III and IV as severe microtia which
require total ear reconstruction.
1.3. Ear reconstruction surgery
- Using autologous rib cartilage: featured with 2 techniques of
Brent and Nagata.
- Using artificial rib cartilage (MEDPOR or polyethylene)
- Prosthetic implant.
1.3.1. Ear reconstruction with autologous rib cartilage: a gold
standard surgery
1.3.1.1. Age of the patient
Brent thinks the age suitable for surgery is 6 years old. According
to Nagata, the appropriate age is 10 years or older, or when the chest
circumference> 60 cm
1.3.1.2. Four- stage technique of Brent:
- Stage 1: Haversting of rib cartilage, constructing the framework,
and inserting the framework in the pocket subcutaneously at the
reconstructed ear location.
- Stage 2: Lobule transposition.
- Stage 3: Elevation of the reconstructed ear with a skin graft to
create the auriculocephalic sulcus.
- Stage 4: Tragal construction, conchal excavation, and
simultaneous contralateral otoplasty
1.3.1.3. Two- stage technique of Nagata:
Stage 1: harvesting of the costal cartilages, fabrication of the three-
dimensional cartilage framework (3-D frame) and the grafting of the 3-
D frame to its proper anatomical location.
+ Step 1: Creating an auricle template (similar to Brent technique).
+ Step 2: Haversting the ipsilateral rib cartilage. Perichondrium is
preserved to avoid chest deformity after surgery. The cartilage pieces
are sewn together with a special type of steel thread.
+ Step 3: Implanting the framework in the pocket subcutaneously
at the reconstructed ear location.
+ Step 4: Lobule transposition and tragus reconstruction.
5
Stage 2: At least 6 months after stage 1.
- Get the additional piece of cartilage (banked under the thoracic
skin during the first stage)
- Take a free flap from groin with an appropriate size.
- Elevate the framework.
- Place the semilunar cartilage, fixed by the posterior auricular
fascia.
- Using a thickness skin graft to cover posterior auricular area.
* Advantages:
1. The time and the number of surgeries are shortened.
2. The reconstructed ears look more natural
* Defect:
1. The risk of lobule necrosis is higher (due to the lack of blood
vessels).
2. The chest is weak (due to the large number of cartilage taken).
3. The risk of hair loss on the scalp.
1.3.1.4. Symptoms
- Complications at the chest
* Early complications - Perforation of the pleura: - Pneumothorax:
- Hematoma: caused by occlusion, slipping drainage in the chest.
* Late complications - Thoracic deformity: - Bad scars, keloid
scars, hypertrophic scars:
- Complications at the ear
* Early complications - Necrosis of skin flap covered with
framework - Hematoma, condensation: caused by occlusion, closed
drainage - Infection: - Cartilage inflammation: causing necrosis,
deformed framework , affecting aesthetic results. – Ischemia when
lobule transposition.
* Late complications
- Bad scars, hypertrophic scars, keloid scars.
- Changes in the morphology of the cartilage framework:
+ Errors in the position (right) of the ear,
+ Changes in skin color.
+ Change in the size of the framework.
+ Loss of the anatomy details.
CHAPTER 2: SUBJECTS AND METHODS OF THE STUDY
2.1. Subjects
6
2.1.1. Selection criteria:
- Patients diagnosed with congenital severe microtia (type III, IV
according to Marx) underwent ear reconstruction by Nagata technique
at ENT Hospital.
- Patient has full participation in 2 stages of surgery.
- Having complete medical records.
- Follow- up after 2nd stage at least 6 months.
- Agree to join the research.
2.1.2. Exclusion criteria - Patient had surgery at another hospital;. -
Patients were operated without Nagata technique- Patient was not
followed-up at least once after 2 nd stage of surgery for 6 months. -
Patients do not agree to participate in the research.
2.1.3. Sample size: Because microtia is a rare disease, we selected a
convenient sample size. In fact, in the 3 years from 2016 to 2019, we
screened all 32 eligible patients for the study. In which, 15 patients
were retrospective and 17 patients were prospective.
2.2. Methods
2.2.1. Study design: clinical intervention study, before-after control.
2.2.3. Research location: Esthetic and Plastic Surgery Department -
ENT Hospital.
Research period: within 3 years from 2016 to 2019.
2.2.4. The main evaluation parameters
2.2.4.1. Before surgery: age and gender
- Family history:
- The position of microtia: 1 or 2 sides, left or right.
- External ear canal: narrow or completely blocked.
- Accompanied malformations:
- Features of normal ear: Length, width, the distance between
helix-lateral canthus, the distance of ear from mastoid bone, the
auricular- mastoid angle.
- Number of surgeries:
- Hospital stay of each time:
- Time between 2 stages:
2.2.4.2. After surgery
- Early and late complications of 1 st stage at the chest, at the
location of the reconstructed ear.
- Managing complications
7
- Aesthetic results of the ear in various aspects: were evaluated
after 4 follow-up times: 2 times after stage 1, 2 times after stage 2; Each
visit is at least 3 months apart.
+ Location: position, the distance between helix-lateral canthus,
the distance helix- mastoid, the auricular- mastoid angle, the ear axis.
+ Size: length, width
+ Shape (13 anatomical details)
+ Other characteristics: ear thickness, skin color, unwanted hair, scar.
- Satisfaction level of the patient:
2.3. Steps to proceed
2.3.1. Designing samples of research records, collecting data -
Develop a sample medical record to collect data.
- Select patients according to the set criteria.
- Explain the patient agrees to participate in the study and sign a
commitment to agree to participate in the study.
- Condut patient information collection according to the sample case:
- Administrative part: recording full name, age, gender, address,
phone contact, hospital registration number, research record number to
contact and evaluate after surgery.
- For retrospective patients: retest according to the information in
the sample medical records at the beginning of the study. All
retrospective patients have only completed stage 1 of the surgery, so we
proceeded to conduct research at stage 2.
- For prospective patients: pre-surgery clinical examination: fully
record in detail the morphological characteristics of the microtia ear.
2.3.2. Planning the surgery:
- Use a piece of X-ray film to draw hightlights key structure of the
normal ear: For patients with bilateral microtia, we use a sample ear that
matches the face of the patient (sample ears have 3 sizes: big, medium
and small).
- Locate the reconstructed ear:
- Draw the shape and size of the ear canal to prepare for
reconstruct at the position of the microtia ear, mark with an indelible
marker pen or pump methylene blue pole at the top and bottom of the
ear, the ear axis.
- Locate the donor site at the ipsilateral chest.
- Photographing patients before surgery.
2.3.3. Ear reconstruction by Nagata: includes 2 stages:
8
2.3.3.1. Stage 1: Create a 3D cartilage framework with the ipsilateral rib
cartilage, lobule transposition and tragus reconstruction.
Step 1: Take rib cartilage: Often use rib cartilage 6, 7, 8, 9 to
sculpting cartilage framework. Specifically: take a block of rib cartilage
6, 7 to create the basic frame, take the whole rib cartilage 8.9 to the
adjacent section with the rib, preserve the perichondrium. Bury the
excess cartilage pieces under the chest skin for 2 nd stage. Sculpte the rib
cartilage into the details of the normal ear, stitching to fix the details
with steel thread.
Step 3: Create a skin pocket: Redefine the ear landmarks: ear axis,
highest and lowest points. Create skin pockets by undermining
postauricular scalp area to a specified size, not too wide, not too tight.
Control the bleeding carefully.
Step 4: Implant the cartilage framework into the skin pocket:
Implant the cartilage framework beneath the skin corresponding to the
location of the reconstructed ear that was located in step 1. Turn the
earlobes into position and reconstruct the tragus.
Step 5: Closed drainage - close the skin pocket - wound bandage:
Put 2 closed drains, apply antibiotic- light compress.
Follow up after surgery:
+ At the chest: Bleeding, hematoma: drainage usually withdrawn
after 24 hours; pneumothorax.
+ At the location of the ear: Keep negative pressure of drains.
Evaluate skin color: pink or hematoma, purple, black, necrotic ....
Observe if the main anatomical details are clear, whether the new ear in
right place.
2.3.3.2. Stage 2: Elevate the cartilage framework: after 1 st stage at least
6 months. Take a piece of cartilage waiting at 1 st stage. Take a thickness
skin graft in the groin area. Cut the skin behind on the cartilage
framework 5mm from the atrial edge of the cartilage, all the way to the
scales behind the ears. Elevate the cartilage framework up and forward,
reposition the ear if needed. Place the semilunar cartilage padding on
the cartilage frame, cover and fix by posterior auricular fascia, collating
so that it is proportional to the opposite side. Fixed stitching of skin
grafts on the back of the framework. Fixation with bolster.
Follow up after surgery: - After surgery, patients are given
antibiotics, analgesic, anti- imflamation. - Examining to detect and
handle complications: infections, skin flap, regular observation of flap
color ... - Bolster is removed after 5-7 days.
9
2.3.4. The corrective surgery
After 2nd stage surgery, depending on the surgical results on the
shape, size and position of the reconstructed ear, there may be
corrective surgery for perfection:
- Correction of hypertrophic or keloid scars.
- Edit unclear anatomical details, misalignment.
- Edit the auricular- mastoid angle.
2.3.4.1. Evaluate general results after surgery
- Assessing the results of 1st stage surgery: with the following
criteria:
+ At the chest:
0 points: for each of the following criteria: Bleeding requires
intervention after surgery; drainage of pleura, necrotic infection with
necrotic, non-healing scar.
1 point: for each of the following criteria: Bleeding must intervene
during surgery; pleural suture, edema, no infection.
2 points: for each criterion: No bleeding; no punctured pleura,
good scars.
+ At the ear:
0 point for each criterion: Closed drainage is lost, open to be sewn
or continuous aspiration; hematoma; infected surgical incisions, scarred
necrosis; skin flap necrosis > 1cm; chondritis cartilage destruction.
1 point for each criterion: leaked drains must be applied with
antibiotic grease; Hematoma requires no intervention; wound without
infection, no necrosis; skin flap necrosis <1cm; no cartilage destruction.
2 points for each criterion: no slip, open drainage; no hematoma;
good scars; No necrotizing flap skin; No chondritis.
Based on this scale, individual points will be calculated at the chest
the location of the reconstructed ear and dividing the surgical results
into 4 levels:
-At the chest: Poor: <3 points; Average: 3 points; Good: 4-5
points; Very good: 6 points.
- Reconstructed ear: Poor: > 5 points; Average: 5-7 points; Good:
7-9 points; Very good: 10 points.
Evaluation of late results: The evaluation time is every 3 months
after surgery with the following criteria:
+ At the chest:
0 points for each of the following criteria: Scar bulge; chest
deformity;
10
1 point for each criterion: bad scar; chest deformity;
2 points for each criterion: normal scars; no chest deformity;
+ At the ear :
0 points for each criterion: Clear skin color; the ear is very thick,
with unwanted hair need to cut regularly; keloids.
1 point for each criterion: Slightly different skin color; slightly
thicker ears; There is less hair not to cut periodically; bad scars.
2 points for each of the following criteria: Skin color equivalent;
Equivalent thick ears, no unwanted hair; normal scar.
Based on this scale, individual points will be calculated at the site
of taking rib cartilage, the location of the ear shape and dividing the
surgical results into 4 levels:
-At the chest: Poor: <2 points; Average: 2 points; Good: 3 points;
Very good: 4 points.
-At the reconstructed ear: Poor: < 4 points; Average: 4-5 points;
Good: 6-7 points; Very good: 8 points.
- Aesthetic results about position and size of reconstructed ear:
difference from the healthy side:
0 points for each criterion: Length, width> 10mm; misaligned ear
axis; high or low ear position> 10mm; auricular- mastoid angle > 20o;
distance between helix- mastoid> 10mm; distance between helix- lateral
canthus > 10mm.
1 point for each criterion: Length, width 5-10mm; ear axis less
deviated; auricular- mastoid angle 10 ͦ -20o; distance between helix-
mastoid 5- 10mm; distance between helix- lateral canthus 5- 10mm.
2 points for each of the following criteria: Length, width <5mm;
good ear axis; high or low ear position <5mm; auricular- mastoid angle
< 10 ͦ; distance between helix- mastoid < 5mm; distance between helix-
lateral canthus < 5mm.
-Sorting aesthetic results on ear position, size: Poor: <6 points;
Average: 6-8 points; Good: 9-11 points; Very good: 12 points.
-Aesthetic results about the reconstructed ear: based on 13
anatomical details according to Mohit Sharma: each detail 1 point: crus
of helix, upper 1/3rd of helix, middle 1/3rd of helix, lower 1/3rd of helix,
superior and inferior crus of antihelix, middle part of antihelix,
antitragus, tragus, lobule, scaphoid fossa, triangle fossa, cymba concha,
cavum concha.
- Sort by Mohit Sharma: Poor: 1-5 points; Average: 6-8 points;
Good: 9-11 points; Very good: 12-13 points.
11
-The level of patient satisfaction: divided into 5 levels: Completely
dissatisfied; Unsatisfied; Normal; Satisfied; Very satisfied.
2.3.5. Methods of analyzing and processing data: Data from research
records are coded and entered using EpiData data entry software 3.1.
Data analysis using SPSS 22.0 software.
2.3.6. Ethics in research: Patients are explained carefully about
surgical methods, possible risks. The study was approved by the Ethics
Commitee of Hanoi Medical University.
CHAPTER 3: RESULTS
3.1. Clinical characteristics of patients with severe microtia
3.1.1. Age at surgery
Comments: The age of the youngest patient is 7, the oldest age is
37. The average age is 16.1 ± 7.6; Most patients have surgery at the age
of 10 - 20 years old, there are 3 patients undergoing surgery under the
age of 10 and 5 patients over 20 years old.
3.1.2. Sex
Gender
Giới tính
34,4%
65,6%
Nam
Mal Female
Nữ
e
Figure 3.1. Gender distribution
Comment: Male: female ratio: 1.9: 1. The majority of patients are
male (65.6%), the remaining 11 patients are female, however this
difference is not statistically significant with p = 0.077.
Table 3.3. Side of microtia: Microtia is mainly on the right (20
ears), only 11 left ears and 1 patient has microtia on both sides.
However, this difference is not statistically significant with p = 0,106.
Figure 3.2. Malformations and syndromes: There are 13 patients
without any accompanied malformations. There were 19 patients with
inferior maxillofacial osteoarthritis attached (accounting for 59,4%).
There were 5 patients with mild congenital facial paralysis, there were 3
12
patients with preauricular sinus, 2 patients with low set ear and 1 patient
with a macrostomia.
Table 3.5. Normal ear: The average length of the ear is 60.2 mm.
The average width of the ears is 30.6mm. The average of the auricular
mastoid angle is 19.1º. The distance between the helix- lateral canthus
is 75.6mm. The average distance of the auricular- mastoid is 19.1mm.
3.2. Ear reconstruction surgery results
Table 3.6. Number of surgeries: More than half of patients have to
undergo 3 surgeries, 1/3 patients only need to undergo 2 surgeries, 2
patients need 4 surgeries and 1 patient need 5 surgeries. The average
number of surgeries is 2.75.
Figure 3.3. Average number of treatment days: the longest is 26
days. The longest treatment day in 1st stage is in patients with necrosis
of the skin flap, which causes exposed cartilage and prolonged
hospitalization.
Table 3.7.Time between 2 stages of surgery: Most patients have
surgery 2nd stage after 1 year, 4 patients undergo surgery after 1 year - 2
years, only 1 patient underwent surgery for 2nd stage after 6 months.
3.2.4. Complications of surgery
3.2.4.1. Complications at the chest
Table 3.8. Early complications at the chest: During 1 st stage of the
surgery, we did not experience complications of bleeding, pleural
perforation or infection but only pleural perforation in 6 cases (18.2%),
It is mainly a hole <1cm in diameter.
Table 3.9. Late complications at the chest: 26/33 cases without any
complications. No patients with chest deformity. There were 7 patients
with bad scars, of which 6 patients had hypertrophic scars, only 1
patient had keloid.
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Table 3.10. Early complications at the reconstructed ear
Complications n %
Hematoma 2 6,1
Infections 3 9,1
Necrosis of skin flap 1 3,0
Uncomplicated 27 81,8
Total 33 100
Comment:
In the 1st stage of surgery, the majority of patients (27/33 ears) had no
complications. At the reconstructed ear in 1 st stage of surgery, there
were 2 patients with hematoma, 3 patients with infections and 1 patient
suffered from skin flap necrosis.
Table 3.11. Late complications at the reconstructed ear: The
majority of patients (29 out of 33 cases) had no complications.
However, there were 2 patients with hypertrophic scars and 2 patients
with keloid.
3.2.4.3. Complications at the inguinal skin site
- Early complications: 100% of patients do not experience early
complications at the inguinal skin site such as: hematoma, infection.
Table 3.12. Late complications at the site of inguinal skin: Most
patients do not have any complications (27/33 cases), 5 cases have
hypertrophic scars and 1 case of keloid scars.
Table 3.13. Total of bad scars at 3 locations: In 33 reconstructed
ears, in 3 locations the number of bad scars was 17 (17.2%). In which,
reconstructed ear area were 4 cases, chest area was 7 cases and groin
area was 6 cases. Of the 17 bad scars, most are hypertrophic (13/17),
with only 4 keloid.
Table 3.14. Management of bad scars: In 17 bad scars, 6 cases
were left untreated, 7 scars were intra lesion injected with
costicosteroids and 4 cases: surgery and injections.
3.2.5. Reconstructed ear characteristics
Table 3.15. Morphology: The average length of the ear is 58.3 mm.
The average width of the ears is 29.6 mm. The average angle of auricular-
mastoid is 16.7º. The distance between the helix- lateral canthus is 75.6
mm. The average distance of the auricular- mastoid is 19.1 mm.
Table 3.16. Difference in ear length compared to healthy side.
20/33 cases in which the length of the reconstructed ear is most
different from the healthy ear below 5mm.
14
12/33 cases in which the length of the reconstructed ear to be 5-10
mm different from the normal ear.
In only 1 case, the length of the reconstructed ear was different
from the healthy ear> 10mm.
Table 3.17. Difference in ear width compared to healthy side
In 26/33 cases, the width of the reconstructed ear was much
different from the normal ear below 5mm.
7/33 cases in which the width of the reconstructed ear is 5-10 mm
different from the normal ear shape.
There is no case where the width of the ear shape is different from
the healthy ear> 10mm. The difference in ear width is less than the
length. This difference is mostly smaller, that is, the reconstructed ear is
usually smaller than the good ear.
Table 3.18. The angle of the auricular- mastoid compared to the
healthy side: The angle through examinations is almost unchanged,
most only differ below 100. Only 1 patient had a 10-200 difference.
Table 3.21. The position of the ear examinations: The high and low
position of the ear through examinations is unchanged (or only changes
below 5mm). Nearly ½ of the ears are same level with the right ear, one
fifth of the ears are higher and one third of the ears are lower than the good.
Table 3.22. Axis of the reconstructed ear through examinations: On
the 1 st and 2nd examinations, the axis is the same: there are 18 ears on
the right axis, 7 ears on the front axis and 8 ears on the rear axis. On the
3rd anf 4th examination 3 and 4 the axis was similar and improved: there
were 22 right ear axes, 4 ear deviated front axis and 7 ear rear axis
deviation.
Table 3.23. Ear thickness through examinations: Ear thickness is
the same across the visits, only 7/33 ear thickness is equivalent to
healthy ear, and the rest (26/33 ears) are all thicker than healthy ears.
No ears are too thick compared to healthy ears.
Table 3.24. Skin color: Through examinations, most skin are the
same color with the surrounding skin, only 1 ear has a different skin
color than the surrounding skin.
Table 3.25. Unwanted hair condition in the skin flap: 1/3 of the
patients have unwanted hair in the skin flap, while 2/3 of the patients have
15
no unwanted hair. In the case of hair flap there are many different levels:
hair on the front, the hair is extreme on the helix, more hair, less hair
Table 3.26. How to treat unwanted hair in skin flap: Among 11 patients
with hair in skin flap, 5 patients did not handle anything, while 6 patients had
to have periodic haircuts, none of them had laser hair removal.
3.2.12. Characteristics of anatomy details
Table 3.27. Frequency of anatomy details
N Details Total details / 33 %
1 Crus of helix 30 90,9
2 Upper 1/3rd of helix 32 96,9
3 Middle 1/3rd of helix 31 93,9
4 Lower 1/3rd of helix 30 90,9
5 Superior and inferior crus of antihelix 18 54,5
6 Middle part of antihelix 24 72,7
7 Antitragus 21 63,6
8 Tragus 26 78,8
9 Lobule 32 96,9
10 Scaphoid fossa 30 90,9
11 Triangle fossa 15 45,4
12 Cymba concha 12 36,4
13 Cavum concha 33 100
Comment: Among the 13 anatomical details, the detail observed,
which appeared most in all ears was the cavum concha (100%). Details
appear at least, less than a quarter of cases are triangular fossa with a
frequency of 45.4%. The details with high frequency of succession are:
Upper 1/3rd of helix and earlobe (96.9%); Middle 1/3 rd of helix (93.9%);
crus of helix, lower 1/3rd of helix , scaphoid fossa (90.9%). The details
that appear less are: 78.8% tragus; middle part of antihelix 72.7%;
superior and inferior crus of antihelix are opposite to 54.5%.
Table 3.28. Rating points according to Mohit
Sharma
Score n %
≤5 0 0
6-8 4 12,1
9-11 23 69,7
≥12 6 18,2
16
Total 33 100
Comment: No ears have less than 5 details.
There are 4 ears with 6 - 8 details.
There are 23/33 ears with 9 - 11 details.
And especially there are 6 ear with 12-13 details of anatomy.
3.2.13. Evaluate the overall results
3.2.13.1. Early results of surgery
Table 3.29. Assessing the early results of surgery: The majority of
the ear lobes (27/33) have very good results with no complications at
the chest and reconstructed ear. There were 6 patients with good results
with minor complications of the reconstructed ear or rib cartilage such
as pleural perforation, hematoma. No patients had poor results.
3.2.13.2. Late results of surgery:
Table 3.30. Assess the late outcome of surgery
At the chest: Better results at the reconstructed ear. 78,8% achieved
good results because there were no patients with chest deformity and
beautiful scars; There were 6 patients achieved good results ie there
were hypertrophic scars or keloids in the chest area. At the
reconstructed ear: very good results with 7 patients, 3 patients with
good results, 12 patients with satisfactory results. And especially 1
patient with poor results
3.2.13.3. Aesthetic results about the position and size of the ears
Table 3.31. Evaluating aesthetic results about ear position, size
The majority of ears (81.8%) had good location and size results,
which were relatively similar and well balanced for healthy ears.
Especially 1 ear has very good results. There were 5 ears that achieved
results ie either the ear size was not commensurate with the good ear, or
the ear position was not in balance with the healthy ear. No ears had
poor results.
3.2.13.4. Aesthetic results on anatomical details:
Table 3.32. Evaluating aesthetic results of ear anatomy: 23 out of
33 ears have 9 ÷ 11/13 details of the ear, ie having relatively enough
shape of the ear. Having 6 ears with 12/13 details. Only 4 ears have
only 6 ÷ 8 details, none has less than 6 details. As a result, the shape of
the ear is mainly good and very good (29/33 ears) for 87.9%. No ears
have poor results.
Table 3.33. Satisfaction level of patients: The majority of patients
were satisfied and very satisfied with the reconstructed ear, accounting
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for 78.1% (25/32 patients), only 21.9% of patients were normal with
surgical results.
CHAPTER 4: DISCUSS
4.1. Clinical characteristics of patients with severe microtia
4.1.1. Age
In our study, most of patients had surgery mainly between the ages of
10-20 years old. This is a very suitable age for Nagata technique because at
this time, the rib has grown enough to take the necessary amount of rib
cartilage and the quality of rib cartilage has not been reinforced.
However, there are 5 patients over 20 because they did not have
the economic conditions for surgery at a young age. Therefore, we
recommend that the formation of the ear cartilage with rib cartilage
should be done best around the age of 10.
According to the 4th International Ear Reconstruction Congress
with the participation of 31 surgeons, the age is agreed for surgery is
from 8-10 years old.
According to Im, 72% of surgeons believe that surgery at a later
age will have better aesthetic results.
According to Li (2018), the standard that patients can have surgery
is > 120cm height, chest circumference > 55 cm.
4.1.2. Sex
All studies of microtia is male predomiant disease except for one
study by Zhu (2000) that found no difference between the sexes, it is
not explained in detail.
4.1.4. Location
Microtia is mainly on the right, accounting for 62.5%, only 34.4%
has left ear and 1 patient has on both sides. This is also consistent with
the clinical characteristics of microtia more commonly on the right than
on the left. According to Ly Xuan Quang, among 38 patients with 50%
had right ear, 47.4% had left ear and there was 1 patient with both ears,
according to Brent, a total of 1200 cases was 58.2% had right ear ,
32.4% had left ear and 9.4% had both ears, according to Kawanabe this
rate is 65.2% and 34.8 respectively. However, the reason why microtia
is more common on the right is that no studies have mentioned it.
4.1.6. The malformation and accompanied syndrome
There were 19 patients with hemifacial microsomia, accounting for
57.6%, higher than Brent's study of 36.5%, Zhang's study was 44%. Thus,
the majority of patients with hemifacial microsomia. This problem poses the
need plastic surgegy so that the face is symmetric so that the reconstructed
ear can become more balanced. The surgery helps to symmetry the face for
18
better results. This is the expectation of many parents as well as patients, it
also affects the level of satisfaction of the patient.
4.1.7. Normal ear charateristics
Our results are relatively consistent with Vietnamese results in
terms of length and width. There are currently no studies evaluating the
angle auricular- mastoid, the distance between helix- lateral canthus, the
distance auricular- mastoid.
4.2. Reconstructed ear results
4.2.1. Number of surgeries
The average number of surgeries per patient is 2.75. Most of the
following surgeries are corrected for ear details or fistula surgery.
Although the Nagata technique consists of only 2 stages of surgery,
in fact it is only 2 major surgeries. In addition, after 2 surgeries, there
will be a number of small corrective surgeries.
According to Constatine, the average number of surgeries is 4.88
times, higher than our study. According to the summary at the
International Ear Reconstruction Congress in 2007, 61% of surgeon
operated 3 times, 29% of surgeon operated twice for ear reconstruction.
4.2.3. The time between 2 stages
Over time we have mastered the technique and the first patients to
be completely operated by Vietnamese surgeons who have had stage 2
surgery are 6 months.
According to Ly Xuan Quang, 71.8% of patients had the 2 nd stage
after 6-12 months. According to the 4 th International Ear Reconstruction
Congress, 71% of patients had the 2nd stage after 6-12 months.
4.2.4. Complications of surgery
4.2.4.1. Complications at the chest:
- Early complications: There are 6 cases of pleural perforation, of
which most are holes <1cm in diameter. Of which 5 patients were
pleural suture and 1 patient was pleural drainage, follow-up and
withdrawal after 24 hours. Our pleural perforation rate of 18.2% is
higher than most studies. According to Long (2013), the rate of pleural
perforation was 12.75%. According to Chauhan (2011), this rate is
3.7%, according to Dashan (2008) this rate is 0%, according to
Kawanabe (2006) is 0.37%. According to Kawanabe, the rate of pleural
perforation is low because they do not remove perichondrium.
According to Thomson, this rate is 22% due to perichondrium remove.
Our research also carried out the preservation of perichondrium,
but it may be because our technique is not good, surgery is not done
19
regularly, so the rate of pleural perforation is high. This is one thing that
needs to be learned from our research.
- Late complications: In our study, there were no patients with
chest deformities. This is also consistent with Kawanabe's study: 0/273
cases, Avelar: 0/146 cases.
According to Kawanabe, Avelar's cause of chest deformity is not
due to the amount of rib cartilage removed, but because the
perichondrium is not preserved. Because Nagata technique still needs to
take 4 rib cartilage 6,7,8,9 in the 1 st stage without any patients with
chest deformity in 273 patients. The proportion of bad scars is generally
21.2%, relatively high compared to other authors. This can be explained
by racial factors, as judged by Wolfram and Yotsuyanagi, black people
are at a higher risk of forming bad scars than whites.
4.2.4.2. Complications at the reconstructed ear:
- Early complications: At the reconstructed ear at the 1 st stage of
the surgery, there were 2 patients with hematoma, 3 patients with
infections and 1 patient with skin flap necrosis. 2 patients with
hematoma are due to slipped drainage, open should conduct continuous
suction, but still cause hematoma and although mild. Drainage is also a
key to the success of surgery: because it reduces the dead space
between the skin and the framework -> avoids hematoma and
congestion so it is necessary to close the skin incision. Three out of 32
patients (9.4%) had a mild infection, which was characterized by a red,
inflamed ear ring. Patients who are exchanging or adding antibiotics are
stable. According to Firmin (2010) the infection rate was 6/930 cases
(0.65%), the cause is usually from the outer ear canal caused by
Pseudomonas bacteria. According to Long (2013) this rate is 0.9%.
However, in our study, only 1 patient had skin flap necrosis
(3.0%), According to Firmin (1998), the rate was higher, 13.9%.
According to Long (2013), the rate is lower than 0.16%.
Learning from this complication, we see an important role in
creating skin pockets at the location of the microtia . Skin pockets
should be removed not too thick to avoid seeing the anatomical details
but not too thin, which will lead to malnutrition and skin necrosis.
- Late complications:
After 2 stages, 2 patients had hypertropic scars and 2 patients with
keloid scars. According to Cho (2007), 3 out of 125 patients had keloids in
the reconstructed ear. So we can see the bad scarring rate of our study is
much higher.