Surgical Atlas of pediatric otolaryngology - part 9 potx

684 Surgical Atlas of Pediatric Otolaryngologyular or postauricular pedicled flap with staged take down, delayed by3-6 weeks Figure 29–6.. ♦ > 20% of defects require a cartilage graft in

Soft Tissue Surgery 681

Figure 29–3 Repair of lip defect

involving the commissure with

Estlander type flap Lip defect,

in this case due to neoplasm

resection Note flap design (A ).

Result after flap transposition

and mucosal advancement (B ).

(Reprinted with permission from

Renner GJ Reconstruction of

the lip In: Baker SR, Swanson

NA, editors Local flaps in facial

reconstruction St Louis:

Mosby; 1995 p 345–96.)

Figure 29–4 Repair of lip defect

not involving the commissure

using the Abbe flap Lip defect,

showing flap design (A ) Result

after flap transposition and

mucosal advancement with

pedi-cle intact (B ) Final result

follow-ing pedicle division, which is

delayed (C ) (Reprinted with

permission from Renner GJ.

Reconstruction of the lip In:

Baker SR, Swanson NA, editors.

Local flaps in facial

reconstruc-tion St Louis: Mosby; 1995

p 345–96.)

C

682 Surgical Atlas of Pediatric Otolaryngology

AURICULAR REPAIR

• The pinna is particularly susceptible to injury and avulsion The ular contour has little role in terms of hearing, so reconstruction isaimed at creating an inconspicuous unit

auric-• Fortunately, both ears are rarely seen simultaneously Consequently,exact symmetry of the ears has a lesser priority than preserving generalcontour and definition

• Auricular cartilage is elastic and covered by a thin layer of skin thatallows the irregular contours to be apparent This unique relationship isdifficult to recreate and every effort is made to preserve as much nativetissue as possible

• Chondritis of the ear can destroy a meticulous repair and cause cant deformity Consequently, all open injuries to the ear require sys-temic antibiotics with adequate cartilage penetration Quinolones areused frequently in adults, but are inappropriate for pediatric use because

signifi-of the potential for damage to structural cartilages

Auricular Hematomas

• Auricular hematomas should be incised and drained

• The hematoma usually exists between the perichondrium and cartilage,along the anterior and posterior surfaces, and must be fully expressed.Residual blood can devitalize the cartilage and result in a characteristicauricular deformity, ie, the “cauliflower ear”

• Incisions are placed along anatomic boundaries when possible

• A bolster dressing secured with through-and-through mattress suturesapplies pressure to the site to prevent re-accumulation

Lacerations

• Ear lacerations are closed in layers

• Cartilage is repaired with permanent or slowly absorbing monofilamentsuture

• Skin closure is performed with emphasis on everting the helical rim toprevent contracture A small Z-plasty can be created along the helicalrim to minimize the notching, but is rarely performed at the acute set-ting

• Cartilage edges that cannot be covered because of skin deficiencies aretrimmed to allow primary skin closure Even if the conservative trim-ming of cartilage creates a slightly smaller ear, it is rarely conspicuousand less important than risking chondritis

Cutaneous Defects

Isolated cutaneous defects of the auricle are unusual and more often arise

from resection of skin lesions Best results are generally achieved with a fullthickness skin graft, which preserves auricular height, definition, and ori-entation Helical rim defects are an exception, because of greater fibrofattytissue producing a “cookie bite” deformity after skin grafting

Soft Tissue Surgery 683

• The skin graft is readily harvested from the periauricular, lar, or upper eyelid areas

supraclavicu-• Perichondrium or the contralateral skin must be intact as the recipientbed When bare cartilage is exposed, it is often resected to create a vas-cularized wound bed

• A bolster dressing may be sewn in position to assure graft stability Whilethese dressings are often unnecessary in the face, the additional security

is welcome in children Through-and-through tacking sutures of

rapid-ly absorbing gut are helpful to maintain close apposition between thegraft and wound bed

Helical Rim Defects

• Isolated helical rim defects are managed according to their size.4,11

♦ < 20% of defects can be closed using helical rim advancement flaps(Figure 29–5)

♦ > 20% of defects may require a combination of wedge resection andhelical advancement Alternatively, one may create a tubed preauric-

Figure 29–5 Repair of small

heli-cal rim defect using advancement

flaps Scar to be excised and

inci-sion planning (A ) Advancement

flaps raised (B ) Advancing and

securing the flaps (C ) Final

clo-sure (D ) Note: Larger rim

defects may require small wedge

excision of scaphoid fossa to

allow closure of flaps (Reprinted

with permission from Quatela

VC, Cheney ML Reconstruction

of the auricle In: Baker SR,

Swanson NA, editors Local flaps

in facial reconstruction St Louis:

Mosby; 1995 p 443–80.

684 Surgical Atlas of Pediatric Otolaryngology

ular or postauricular pedicled flap with staged take down, delayed by3-6 weeks (Figure 29–6)

Composite Defects

• Larger composite defects, such as those involving the helical rim with the

antihelix and scaphoid fossa, are also treated based on their size.4,11

♦ < 20% of defects can be closed primarily after simple wedge or starexcisions

♦ > 20% of defects require a cartilage graft interposition with ricular flap coverage and delayed pedicle division

postau-• Composite grafts from the opposite ear can be utilized, but have

ques-tionable reliability and leave a significant donor site scar

Auricular Avulsions Partial avulsion

• Partial avulsions are re-anastomosed primarily (Figure 29–7)

• Tremendous vascular reserve allows many near complete avulsions tosurvive

• If only partial viability occurs, the result may still be better than whatcan be achieved secondarily

• The adjacent peri-auricular skin must not be interrupted, because

non–hair bearing skin may be essential in a future definitive lar reconstruction

auricu-Complete avulsion

Complete avulsion of the auricle is a perplexing problem with no clearmethod of repair that maintains consistent results There are several options:

• Primary anastomosis, with or without microvascular repair, has been

successful In general, the successful outcomes are found as ual case reports and the number of failed primary re-anastomoses isdifficult to find.12

individ-• The amputated auricle can be de-epithelized and banked in abdominal

fat for future use as a structural framework Unfortunately, the lage loses much of its form and is unable to support a vascularizedcutaneous flap More often, the banked cartilage is used only as smallonlay grafts to a definitive framework from costal cartilage

carti-• The pocket principle can be utilized The avulsed ear is dermabraded to

the dermal layer, re-attached primarily to the auricular stump, thenburied under a postauricular skin flap The buried period is only tran-sient and serves to maintain nutrients to the amputated cartilage untilvascular flow can be re-established through the primary anastomosis.Once the ear is delivered from the pocket, auricular skin is regenerat-

ed from the residual dermal elements and the postauricular skin isreplaced in toto.13

• The auricular stump can be closed primarily and the avulsed tissuediscarded with a delayed complete reconstruction using conventionalmicrotia repair techniques.14If there is significant trauma to the peri-auricular tissues, use of the temporoparietal fascia flap with costal car-tilage and a full thickness skin graft may be warranted.15

686 Surgical Atlas of Pediatric Otolaryngology

NASAL REPAIR

The pediatric nose is rarely injured due to its relative small size with respect

to the forehead and cheeks The mostly cartilage and soft tissue frameworkfurther contributes to decreased damage during trauma by impartinggreater elasticity When they occur, however, nasal injuries present someunique challenges:

• Cosmetically, the nose has a central position where small scars and tle asymmetries are readily detected

sub-• The juvenile nose assumes the adult proportion and shape during

puber-ty and disruption of the growth centers can significantly impact thisdevelopment

• Successful repair is predicated on a functional result with preservation ofnormal nasal physiology and patency

Nasal injuries must be viewed as a potential three-layered problem withdiligent assessment of the cutaneous tissue, cartilaginous framework, andmucosal lining Each layer requires meticulous and independent repair

Cutaneous Defects

• Lacerated skin edges are closed primarily in a separate layer

• Avulsion of nasal skin is managed initially with conservative measures,but a definitive repair often requires a small transposition flap

• When electing to treat conservatively with second intention healing, onemust anticipate some degree of wound contracture and be wary of dis-tortion to the alar rim

Cartilaginous Framework Injuries

• The nasal septum must be evaluated for a hematoma, even if sedation ortopical anesthesia with vasoconstriction is necessary

1 Septal hematomas are typically bilateral, occurring in the potentialspace between the perichondrium and cartilage

2 Untreated hematomas can devascularize the cartilage, leading to tilage absorption or septal perforation In addition to the physiologicdisturbance this causes, it may impact nasal growth and dorsal pro-jection The result is a persistent juvenile nose with a saddle deformi-

car-ty and nasal obstruction

3 All hematomas must be drained and the mucoperichondrial flaps apposed with absorbable sutures, packing, or splints In the child, thisrequires general anesthesia

re-• Cartilage lacerations should be meticulously re-approximated with

per-manent or slowly absorbing monofilament suture

• Cartilage deficits are replaced using existing avulsed cartilage or conchal

cartilage grafts Avulsed cartilage may be a precious source of autologousmaterial

• Injuries to the alar lobule and nasal sidewall may occur without cartilageviolation, but repair with soft tissue alone will result in nasal obstruc-

Soft Tissue Surgery 687

tion A cartilage graft may need to be placed in a nonanatomic location

to protect against future collapse

Mucosal Injuries

• Lacerations of the intranasal mucosa must be specifically repaired Leftalone, they will heal through second intention but not before somedegree of wound contracture with possible notching along the alar rim

or vestibular stenosis Once this has occurred, the surgical repair is nificantly more challenging

sig-• Tissue loss intranasally is a challenging problem that requires a secondepithelial flap for repair While this is usually done at a later stage, onemust not delay too long lest permanent contracture, distortion, andstenosis occur There are many options for reconstituting the internallining, and the surgeon should be facile with several options.16

Nasal Avulsion

• Nasal avulsions are fortunately rare but less resilient than those of theear Nevertheless, the amputated segments are generally replaced andclosed primarily

• Graft enhancement with hyperbaric oxygen17or medicinal leeches may

be helpful

688 Surgical Atlas of Pediatric Otolaryngology

PERIORBITAL REPAIR

Injuries to this region should prompt a consultation with the ogist, particularly when there is hyphema, diplopia, enophthalmos, exoph-thalmos, hypophthalmos, globe injury, diminished acuity, or penetration ofthe orbital septum as evidenced by prolapsing orbital fat The rudimentaryexamination should include visual acuity, pupillary function, range ofmotion, and a fluorescein stain for corneal abrasions

ophthalmol-Eyelid Injuries Eyelid anatomy

• The eyelid is uniquely devoid of subcutaneous fat and the orbicularisoculi is a thin layer of muscle fibers intimately applied to the deepsurface of the thin dermis (Figure 29–8).18

• Layered relations are important when exploring lid lacerations:

1 At the level of the upper lid margin, the sequential layers are skin,muscle, levator aponeurosis, tarsal plate, and conjunctiva

2 More superiorly, above the crease, the sequential layers are skin,muscle, orbital septum, orbital fat, levator aponeurosis, and con-junctiva

• The lower lid is retracted via a layer of fascia, which is acted on by theinferior rectus muscle This fascia is roughly analogous to the levatoraponeurosis, but does not require repair when injured

• The gray line is the transition from conjunctiva to squamous lium and analogous to the vermilion border of the lip The Meibo-mian glands are more internal and distinct from the gray line

epithe-Eyelid lacerations

• Repair of lid lacerations should focus on meticulous layered closure

and exact re-alignment of the gray line (Figure 29–9).19

• Tarsal plate injuries are repaired with 2-3 interrupted 6-0 polyglactinsutures through the anterior 2/3 of the plate The sutures should notpenetrate the posterior surface of the tarsus

• The conjunctiva is not repaired, but is held in apposition by the tarsalrepair This prevents abrasion of the cornea by the suture

• Levator aponeurosis can be evaluated by observing for appropriate lidretraction when the patient looks upward When clearly injured, thelevator aponeurosis should be repaired separately with interrupted 6-

0 polyglactin sutures The sutures are placed precisely at the cut gin of the levator to avoid bunching of the aponeurosis, which mayresult in lid retraction or lagophthalmos

mar-• Orbicularis oculi fibers are repaired using interrupted 6-0 polyglactinsutures

• Skin margins are traditionally closed with interrupted 6-0 silk suture,however, rapidly absorbing gut can be used

♦ The first suture is placed at the gray line and is left long for tion Sutures are placed on either side of the lash line, progressingaway from the lid margin

retrac-690 Surgical Atlas of Pediatric Otolaryngology

♦ The tails of the sutures nearest the lid margin are left long andsecured under the knot of the more distal skin sutures This tech-nique secures the ends away from the globe while leaving themlong enough for easy subsequent removal

Putter-Medial Periorbital Injuries

The medial periorbital region contains the medial canthal tendons andlacrimal system Injuries to this area must be explored with attention to therelative anatomy and possible disruption

Canthal anatomy

• Canthal tendons are fibrous bands from each end of the tarsal plateand orbicularis muscle that attach to the bone of the medial and lat-eral orbital walls (Figure 29–10)

• Medial and lateral canthal tendons separate into anterior and

Canthal tendon injury

• Repair of the canthal tendons is imperative to prevent ectropion,scleral show, canthal dystopia, and to maintain a normal intercanthaldistance.19

• Sharply cut tendons can be primarily repaired with 6-0 nylon sutures

• Avulsed tendons must be re-attached to the periosteum or underlyingbone with permanent suture or wire

• The keystone principle of reattaching canthal tendons is tion Securing the lateral tendon a few millimeters posterior andsuperior to their anatomic attachment sites provides for a good out-come after gravity and tension exert their effects

over-correc-Figure 29–11 Stent of the

supe-rior lacrimal canaliculus into the

• The puncta are dilated with lacrimal probes and cannulated with theends of a single piece of 0.94 mm silicone tubing (Figure 29–11)

• The ends are then identified in the wound and passed into the tive proximal canalicular stumps after dilation

respec-• The ends of the tubing are passed into the lacrimal sac and directedinferiorly through the nasolacrimal duct and into the nose

• The ends are retrieved from the inferior meatus and tied in a knotwith tails long enough for later retrieval

• The tubing is removed after 3-4 months

Eyebrow Injuries

• Brow injuries are often discounted, but there are a few points that assistwith repair

• The brow should never be shaved

• Any incisions should be made oblique and parallel to the direction of thehair shafts and follicles

• Brow continuity is essential in order to be inconspicuous; it may be essary to excise incomplete avulsions and re-align edges of the brow

nec-• Brow defects can often be repaired using opposing advancement flaps ofthe remaining brow (Figure 29–12)

694 Surgical Atlas of Pediatric Otolaryngology

PAROTID DUCT REPAIR

Posterior cheek lacerations require exploring the parotid duct Duct injury

is suspected when firm massage of the gland fails to produce clear salivafrom Stensen’s duct, and is confirmed when saliva, or an orally placed ductprobe, is visible in the cheek wound More often, duct continuity is assuredwhen clear saliva is expressed intraorally following massage Prior to milk-ing, the gland visualization should be optimized, because there is usually asingle opportunity to obtain salivary flow even when the duct is intact

Duct Laceration

• The intraoral papilla is dilated with lacrimal probes and a 16-20 gaugesilastic catheter is inserted to cannulate the distal duct segment Alter-natively, No 9 polyethylene tubing or a large nylon suture may be used

FACIAL NERVE REPAIR

Injury to the facial nerve is suspected in any laceration of the lateral face,and nerve integrity must be documented before sedating the child or infil-trating local anesthetics

• Management of facial paresis is conservative and significant recovery can

be anticipated Complete paralysis, however, should be specifically

doc-umented and ideally photographed

• Nerve injuries in the central face are not explored, because of small

neur-al fibers and significant arborization Injuries located posterior or laterneur-al

to a vertical line from the lateral canthus warrant consideration forexploration

• Although not a true surgical emergency, the wound is cleaner during theacute stage and the distal segments can be identified via neural stimula-tion for up to 72 hours following injury

Soft Tissue Surgery 695

Anatomy

• The facial nerve arises from the stylomastoid foramen deep to the ule of the ear and courses anteriorly and then superiorly to enter the sub-stance of the parotid gland at the base of the tragal cartilage

lob-• Arborization occurs in a variable manner within the parotid

• The branches emerge from the anterior border of the gland, continueforward into the midface immediately deep to the superficial muscularaponeurotic system (SMAS), and innervate the muscles of facial expres-sion from the undersurface

parotidec-• Crushed nerve ends should be freshened with a sharp razor blade orscalpel Trimming the ends at a 45˚ angle improves regrowth of axons ofthe proximal end into the neural tubule of the distal segment

• The identified ends are anastomosed under magnification with 3 or 4simple sutures (9-0 or 10-0 nylon) through the epineurium A fewsutures must be placed through the surrounding tissues to relieve tensionfrom the neural anastomosis

• If the proximal stump cannot be identified and the surgeon is not pared to perform a superficial parotidectomy, the distal stump should betagged with a colored permanent suture in the adjacent soft tissue forfuture identification

pre-SCAR REVISION

Most unacceptable scars can be revised to yield a more inconspicuousresult Pediatric scar revisions are unique in that they significantly involvethe parents, whose desires and expectations may be unrealistic and differfrom the patient’s Discussions of scar revisions should always be put in

terms of scar improvement and not scar removal, and several requirements

must be met prior to surgical intervention:

1 The scar must be allowed time to mature

2 The patient and parents should be over the initial emotional reaction ofthe trauma and have had the opportunity to adjust and accept the facialdisfigurement This allows for a more realistic outlook on potential out-comes and expectations

3 Cooperation and motivation of the child is imperative for diligentwound care, sun protection, and avoidance of even minor trauma dur-ing the healing phase

4 As with any cosmetic procedure, if the anticipation is indirect ment in social life, school performance, etc, the surgeon is destined tohave an unhappy patient

improve-696 Surgical Atlas of Pediatric Otolaryngology

Indications and Timing

• Linear scars greater than 2 cm long and 2 mm wide can often beimproved

• A straight and lengthy scar is often noticeable because similar facial lines

do not normally exist Breaking the scar into shorter segments of ent orientations is beneficial

differ-• Scars that are of excessive width will improve with a simple excision

• Revision is often warranted for scars that are poorly oriented to faciallines, distort normal anatomic landmarks, or have contracted andformed webs.21

Simple Excision

Some scars may improve with just a direct excision and primary closure,especially when they are relatively short, ie, less than 2 cm, and are alignedwell with facial lines, but are either wide or have an irregular contour Ten-sion free closure and good soft tissue techniques are paramount for optimalresults

• Incisions are made in the margin of normal tissue immediately eral to the scar

periph-• Slight beveling away from the scar will facilitate skin edge eversion ing closure

dur-• The deep layer of scar is left in place, which often serves to support thenew scar and prevent depression and contraction

• The skin margins are undermined and closed in a layered fashion

Serial Excision

Very broad scars, or benign lesions in which complete excision would bedifficult to close primarily, can be excised serially

• The scar is removed with serial excisions in multiple stages

• Each stage is delayed by 2-3 months to allow for maturation and cent tissue expansion

adja-• In the initial stages, all incisions are made within the scar to prevent

dam-age to healthy skin

• The final stage is a complete excision and can be closed with broken lineclosure if indicated

Z-Plasty

A Z-plasty is a double triangle interposition flap that can be used to

length-en or re-orilength-ent scars It is perhaps most useful to elongate existing scars thathave contracted and become a small web or caused distortion of adjacentstructures.22

• The central limb is oriented in the axis of excessive tension This is

usual-ly the pre-existing scar, which can be excised concurrentusual-ly (Figure 29–13)

• The lateral limbs are of identical length to the central limb and extendfrom the ends of the central limb at angles of ≤60˚ or less This shouldresult in parallel arms

698 Surgical Atlas of Pediatric Otolaryngology

Broken Line Closures

Long straight or curvilinear scars are very noticeable because the course ispredictable and easily followed Therefore, scar excision with broken lineclosure can create an irregular pattern with better camouflage A W-plasty is

a rapid and effective means of converting a straight line to a jagged one withsmall limbs that can be better oriented along facial lines (Figure 29–14)

• The scar is excised

• Skin margins are evenly undermined

• Interlocking mini-flaps are created using a No 11 scalpel perpendicular

to the skin surface

♦ Each limb of the pattern should be at least 2-3 mm to avoid a widescar appearance.23

♦ Individual flaps should not exceed 4-5 mm in any surface dimension

♦ A geometric broken line closure (Figure 29–15) is preferable for verylong scars, because a long W-plasty creates a recognizable repeatingpattern Although more challenging and time consuming, a geomet-ric broken line closure creates an irregular pattern and can providemaximal camouflage

• The broken line closure is closed in layered fashion

Dermabrasion

Scars with subtle surface irregularities may have conspicuous shadowingfrom small step-offs, which may often be improved by dermabrasion.Abrading skin and scar to the level of the papillary dermis allows theepithelium to regenerate from the deeper adnexal structures in the reticu-lar dermis The desired result is a more subtle transition of color and sur-face from the surrounding skin to the scar Individuals with darker skin,hormonal changes due to pregnancy or exogenous replacement, or a histo-

ry of oral herpes are prone to excessive pigmentary changes and scarringduring healing.24

• Local anesthesia, either topical or infiltration, is used Young childrenusually require a general anesthesia

• A powered hand piece with a 5-10 mm wide diamond abrasive fraise isused to create a controlled superficial injury

• Injury is limited to the papillary dermis, because injury to the reticulardermis damages adnexal structures and increases scarring

• Multiple delayed sessions and prolonged maturation may be required foroptimum results

• Dermabrasion can be an important adjunct to other techniques such asbroken line closures

• Diligent wound care is imperative during the postoperative period,being sure to maintain cleanliness and moisture Hydrogen peroxide isavoided due to cellular toxicity and delayed healing

700 Surgical Atlas of Pediatric Otolaryngology

9 Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg1974;27:93–7

10 Renner GJ Reconstruction of the lip In: Baker SR, Swanson NA, editors Local flaps in facialreconstruction St Louis: Mosby; 1995 p 345–96

11 Quatela VC, Cheney ML Reconstruction of the auricle In: Baker SR, Swanson NA, editors.Local flaps in facial reconstruction St Louis: Mosby; 1995 p 443–80

12 McDowell F Successful replantation of a severed half ear Plast Reconstr Surg 1971;48:281–3

13 Mladick RA, Horton CE, Adamson JE, Cohen BI The pocket principle: a new technique forthe reattachment of a severed ear part Plast Reconstr Surg 1971;48:219–23

14 Brent B Technical advances in ear reconstruction with autogenous rib cartilage grafts:

person-al experience with 1200 cases Plast Reconstr Surg 1999;104:319–34

15 Park SS, Wang TD Temporoparietal fascial flap in auricular reconstruction Facial Plast Surg1995;11:330–7

16 Park SS, Cook TA Reconstructive rhinoplasty Facial Plast Surg 1997;13:309–16

17 McClane S, Renner G, Bell PL, et al Pilot study to evaluate the efficacy of hyperbaric oxygentherapy in improving the survival of reattached auricular composite grafts in the NewZealand white rabbit Otolaryngol Head Neck Surg 2000;123:539–42

18 Ellis E, Zide MF Surgical approaches to the facial skeleton Baltimore: Williams & Wilkins;1995

19 Leone CR Jr Periorbital trauma Int Ophthalmol Clin 1995;35:1–24

20 Putterman AM Cosmetic oculoplastic surgery: eyelid, forehead, and facial techniques 3rd ed.Philadelphia: WB Saunders; 1999

21 Koopman CF Wound healing and scar revisions in the pediatric patient In: Smith JD, sted RM, editors Pediatric facial plastic and reconstructive surgery New York: Raven Press;

The goal of microtia surgery is to provide the patient with an auricularappearance that is sufficiently close to normal in order that no attentionwill be attracted to the ear Options include

• Auricular repair with rib augmentation The results of rib augmentation

are consistent and reliable, such that children need no longer bedeprived of the surgical option of auricular correction The trade-off for

an improved auricular appearance by rib reconstruction is a linear scarover the contralateral lower chest and a donor skin graft site

• Bone-anchored titanium implant with prosthetic auricle.8 Advantagesinclude fewer surgeries with less morbidity and a realistic pinna appear-ance at arm’s length Disadvantages include artificial feel of the ear, theneed for strict hygiene in a child, a lifetime of replacement protheses,unsightly appearance of the anchoring site with the prosthesis removed,and generally, older age requirement for initial placement

• Transfer of contralateral conchal bowl cartilage and postauricular skin.9

Advantages include fewer surgeries with less morbidity and a normalfeeling pinna Disadvantages include a result that is somewhat smallerthan the normal ear, and that mastering this technique is a formidabletask for the surgeon

• Nonsurgical options The patient may elect to simply cover the ear with

long hair

• Potential option In the future, tissue engineering might evolve

suffi-ciently for actual patient use.10,11

Anxious parents of a newborn with microtia should be counseled that successful surgicalcorrection of a severely malformed auricle is possible.1–7Conventional repair using rib car-tilage to augment the auricle is generally postponed until age 6-7 years Hearing assessment,however, is necessary soon after birth to determine if a normal-appearing contralateral earhears adequately When microtia is bilateral, a standard bone conduction hearing aidshould be placed as soon as possible

CH A P T E R 30

Roland D Eavey, MD

702 Surgical Atlas of Pediatric Otolaryngology

AURICULAR REPAIR OF MICROTIA Indications and Timing

• Microtia repair is indicated for severe auricular congenital malformation

• Surgery is postponed until age 6-7 years to ensure a sufficient volume ofcartilaginous rib, and to allow a symmetric reconstruction when the con-tralateral ear is nearly normal adult size

• Auricular reconstruction for microtia should always precede repair of ear

canal atresia (see Chapter 8) so that the regional skin coverage is notviolated

• Measurements from the normal ear are used in reconstructing themicrotic ear (Figure 30–2)

• Note the position of each lobule viewed en face (Figure 30–3); themicrotic lobule lies more superiorly

Figure 30–1 Preoperative

mea-surements of a normal

contralat-eral ear Relationship of the

superior auricle to the brow (A).

Distance from the lateral

can-thus to the auricle (B) Distance

from the lateral canthus to the

lobule (C) Axis of the auricle

relative to the nasal dorsum (D).

Vertical height of the auricle (E).

704 Surgical Atlas of Pediatric Otolaryngology

• Create a template from the normal ear using an X-ray film and a

mark-er (Figure 30–4) For bilatmark-eral microtia, an ear design template for rib

reconstruction can be created from the ear of a family member

• Examine for other potential facial asymmetry and facial nerve malfunction

• Evaluate the child’s overall size (the child should be at least 6 years of ageand preferably older) Evaluate the size of the contralateral cartilaginousribs by palpation Check for possible trauma to the ribs or a congenitalmalformation that could require use of ipsilateral ribs

Procedure Overview

• The repair involves at least three stages: (1) rib harvest, (2) lobule position, and (3) creation of a functional postauricular sulcus A fourthstage, to add a tragus or to perform a contralateral “otoplasty” of the nor-mal auricle, is needed occasionally

trans-• Repair of bilateral microtia is staged efficiently The initial ear receives a

rib graft at the first operation At the next operation, the second earreceives the rib graft and the previously grafted ear undergoes the lobulerotation simultaneously, and so on

• Microtia repair is surprisingly well tolerated The first stage (rib harvest) isthe most painful; usually 2 nights of hospitalization are required because

of discomfort and drainage requirements All other hospital stays areshorter

Figure 30–4 An X-ray film

template is created from the

normal ear.

Auricular Repair for Microtia 705

STAGE 1: RIB HARVEST Preparation

• The contralateral chest is prepared with an iodine solution; those ribshave a curvature that is favorable for reconstruction Towels are placedwith a square window sufficiently generous to harvest several cartilagi-nous ribs from the lower costal margin Injection of local anesthesia andepinephrine is optional

• Simultaneously, the ear site is prepped with an iodine solution No localinjection should be used The area is shielded with three towels; a clearplastic drape permits a view of the face

Procedure Rib harvest

• Make a linear incision (approximately 5 cm) over the lower tralateral ribs (Figure 30–5)

con-• Identify and retract (do not divide) the rectus abdominus muscle.6

• Isolate three lower cartilaginous ribs:

1 Use the film template, and place it over two ribs connected at thesynchondrosis to select for the base of the framework A thirdfloating rib is to be used for the helix

2 Cut the ribs cleanly at the costochondral junction Remove withthe perichondrium (see Figure 30–5)

3 A fourth rib (floating) can be harvested more caudad as needed

Figure 30–5 Rib harvest procedure.

706 Surgical Atlas of Pediatric Otolaryngology

• Repair the pleura, if entered, with a pursestring suture, which is ened as a suction tube is removed

tight-• Close the incision, without a drain, using absorbable subcutaneoussuture A long-acting local anesthesia block can be used Place a ster-ile dressing

• Obtain an intraoperative chest X-ray to check for a pneumothorax

Framework Creation

• Clean the adherent muscle attachments

• Use a No 10 blade to shave perichondrium and cartilage off the ing rib on what will be the exterior surface of the helix The rib willcurl, which facilitates creating a helix (Figure 30–6) Preserve theperichondrium on the inner curve

float-• Place the film template on the upper two ribs with the sis Carve around the template with a scalpel to create the shape of theauricle (Figure 30–7)

synchondro-• Suture the helix (lower free rib) to the base (upper two ribs of the chondrosis) using a 4-0 clear nylon suture (Figure 30–8)

syn-♦ The sutures must purchase the perichondrium for strength

♦ Place the knot on the framework undersurface, not on the cartilagesurface that will be adjacent to the skin

Figure 30–6 Creation of a helix.

Shaving the perichondrium and

cartilage on one side of the rib

allows the rib to curl.

708 Surgical Atlas of Pediatric Otolaryngology

• Draw the outline of the fossa triangularis and the scaphoid fossa Use

a scalpel and septal gouge to carve these areas to create realistic tours (Figure 30–9)

con-• Keep the cartilage moist

Skin pocket preparation

• Place the template over the malformed ear Using preoperative surements, locate and outline the correct position

mea-• Create a 2-3 cm vertical pre-auricular incision (Figure 3–10) Avoidthe superficial temporal artery A scalp incision can also be used as analternative

• Remove the malformed cartilage of the auricle Do not remove thefatty tissue or the skin

• Elevate the skin pocket The plane should be an extension of the skindepth already existing over the malformed cartilage During dissection,the scissors tips should be slightly visible, tenting the skin (Figure 30–11)

• Apply pressure for hemostasis; the pocket dissection can be bloody

• Insert the framework and check the measurements

• Insert two suction drains and close the incision with a running lene suture (Figure 30–12) Tiny skin fenestrations are closed with a6-0 mild chromic suture

Pro-• Apply a mastoid dressing

Figure 30–9 Carving of the scapha, fossa triangularis, and antitragus features.

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Postoperative Care

• Manage rib area pain as necessary with patient-controlled anesthesia

• The suction drains require an hourly change of red-topped vacuumtubes that are displayed in a test tube rack to monitor drainage

• The mastoid dressing is changed daily, or at the surgeon’s discretion,when the patient is discharged from the hospital

• Discharge the patient on postoperative day 2 or 3, depending on theamount of drainage and pain

• Suture removal is performed at 7-10 days No new dressings are necessary

STAGE 2: LOBULE TRANSPOSITION Preparation

• The malformed ear is prepared with an iodine solution

• An adherent transparent plastic drape is placed anteriorly in the towelwindow to permit a view of face

Procedure

• The microtic ear usually has a lobule-like appendage located anterior to

the normal anatomic position (Figure 30–13A) Mark the area of

exci-sion, as well as the area for transfer, over the lower area of the framework

• Remove the skin over the framework Preserve the subcutaneous nective tissue over the framework

con-• Elevate the lobule-like remnant, retaining the inferior pedicle Rotate

the remnant posteriorly to the lower framework (Figure 30–13B).

• Trim the skin and fat until a realistic lobule contour is achieved

• Close the sites without drains, using Prolene sutures The donor site may

be closed with a small graft of skin obtained from the recipient site

• A sterile mastoid dressing is applied

Postoperative Care

• Pain is managed with acetaminophen

• This stage can be handled as ambulatory surgery at the surgeon’s discretion

• The mastoid dressing and sutures are removed after 1 week

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STAGE 3: SEPARATION FROM THE HEAD AND CREATION OF A FUNCTIONAL POSTAURICULAR SULCUS

Procedure

• Obtain a skin graft

♦ One technique is to use a dermatome to harvest skin (18/2000-inchthickness) from the ipsilateral buttock Place a sterile dressing on thedonor site

♦ Alternatively, the author prefers an elliptical full thickness graft,approximately 10 x 5 cm, harvested from over the lumbar spine area,using primary closure to mimic spine surgery in a location that thepatient cannot see The graft is then thinned with a scalpel and scis-sors until translucent and flexible

• Incise the skin along the helical rim to the depth that preserves

connec-tive tissue over the cartilage (Figure 30–14A) The incision placement

depends on the zone of hair-bearing skin The region of hair-bearingskin can be diminished if the patient undergoes preoperative laser hairremoval

• Elevate the framework and preserve the thin layer of subcutaneous

con-nective tissue over the cartilage (Figure 30–14B) Create a sulcus under

approximately two-thirds of the framework

• Retract the scalp skin away from the framework Attach the skin graft to

the superior edge of the skin (Figure 30–14C) Pull the skin over the

perimeter of the framework and tuck it medially under the framework

to create a rounded helical contour Trim excess skin graft

• Apply remainder of the skin graft to the side of the head (see Figure

30–14C).

• Apply a bolster and mastoid dressing

Postoperative Care

• Provide pain management with acetaminophen and perhaps a narcotic

• A dressing is left on the donor site

• The patient will be in the hospital overnight

• A sterile mastoid dressing and the bolster are left in place for 1 week

• After the bolster has been removed, instill antibiotic topical drops intothe sulcus for 3 weeks

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STAGE 4: OPTIONAL CREATION OF THE TRAGUS OR CONTRALATERAL OTOPLASTY

Procedure (conventional)

• A crescent-shaped composite cartilage graft with postauricular skin isharvested from behind the contralateral ear This provides a furtheropportunity to complete the symmetry by tailoring the normal ear

• A J-shaped incision is created in the reconstructed ear

• The cartilage is inserted under the preauricular skin

• A small skin graft with a bolster is applied to the interior raw surface

• Alternative procedures can be performed depending on anatomical cumstances Given excess rib at the first stage, a neotragus can be creat-

cir-ed from rib spanning the helical root to lobule area In other patients,the malformed cartilaginous remnant with overlying skin can be con-toured into a tragus Controlateral ear cartilage without attached skincan be used These techniques are favoured by the author

Sequellae

• If an infection occurs despite perioperative antibiotics, incision anddrainage are performed if the skin envelope is fluctuant Antibiotics arecontinued until the soft tissue is normal

• Skin breakdown, when it occurs, usually is located over the helix superiorly

antero-♦ Observe for skin breakdown, and allow to demarcate

♦ The skin may epithelialize if the area is small To promote epithelialization, use antibacterial ointment for several weeks anddebride the underlying cartilage to a fresh white substance if cartilagesloughs

re-♦ If re-epithelialization does not occur, either a bilobed scalp flap or atemporalis fascia flap is needed to cover the cartilage and provide askin graft bed At times, hyperbaric oxygen can be considered if theskin appears dusky but has not broken down

• A hypertrophic scar may occur

Auricular Repair for Microtia 715

Figure 30–15 Postoperative appearance following removal of the suture.

con-11 Eavey RD [Discussant for article reference #10] Plast Reconstr Surg 1997;100:303–4

• The parts of the cartilage of the auricle that are prominent on the rior surface will be depressions on the posterior surface, and vice versa.For example, the fossa triangularis on the anterior surface is the emi-nentia triangularis on the posterior surface.

ante-• The angle between the scapha and concha is produced by the antihelix

matura-• Caution should be exercised when recommending otoplasty if the child

is known to form keloids, or has a severe and extensive deformity of theauricle that involves more than just the antihelix

A prominent ear, or prominauris, is the abnormal protrusion of the auricle, which is mostcommonly caused by a poorly developed antihelix or an absent antihelical fold The goal ofotoplasty is to reconstruct a normally appearing antihelix in which the superior crus of theantihelix is rounded and smooth, not sharp The procedure described below fulfills thisgoal, and is a modification of the otoplasty technique originally described by Becker.1,2

Otoplasty for the Prominent Ear 719

• When the child has a unilateral moderate-to-severe deformity and thecontralateral ear appears normal, naturally, only the deformed ear should

be operated on However, when the contralateral ear has even a milddeformity, a bilateral otoplasty should be performed to ensure postoper-ative symmetry of the ears

Anesthetic Considerations

• The procedure in children is performed under general endotrachealanesthesia; however, in some adolescents, the operation can be carriedout with only local infiltrative anesthesia with the aid of intravenousanalgesia

• The postauricular skin is infiltrated with 1% lidocaine containing1:100,000 epinephrine for hemostasis

Preparation of the Patient and Ears

• Prior to surgery, photographs are obtained that show the full head andears of the patient Frontal, posterior, and both right and left sidesshould be included These photographs can then be compared withpostoperative ones usually obtained 6 months after the operation

• Following the usual preoperative sterilization of the auricle, the ear isdraped

♦ When both ears are to be operated on, both can be prepared anddraped; however, care should be taken not to fold the first auricle for-ward toward the face when the contralateral ear is being operated on

♦ During bilateral surgery, the surgeon should not repeatedly turn thepatient’s head from side to side, because movement of the endotra-cheal tube may traumatize the subglottis

• Cotton pledgets can be placed into the external auditory canal to vent blood from entering and forming a clot, which, when present inthe postoperative period, can be troublesome to both the surgeon andthe patient

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emi-Figure 31–3 The pinna folded

back into desired position to

esti-mate the amount of redundant

postauricular skin to be excised.

Figure 31–4 An elliptical

por-tion of skin to be excised is

out-lined with methylene blue and

injected with local anesthetic

agent.