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• W2602435784 abstract "The Brent technique for microtia repair was first published in 1974 and developed from principles espoused by Tanzer. This process involves careful meticulous planning with creation of preoperative templates. The surgical reconstruction involves 4 stages. Stage 1 is started as early as 6 years of age with harvest of a contralateral costal cartilage and subdermal placement through an anterior auricular incision. Additional stages involved creation and inset of a lobule, elevation of the auricle and creation of a posterior sulcus and grafting of a tragus and deepening of the conchal bowl. Long-term outcomes are successful with this technique with minimal incidence of infection, extrusion, and hematoma. These cartilage constructs grow simultaneously with the patient and the unaffected ear. The Brent technique for microtia repair was first published in 1974 and developed from principles espoused by Tanzer. This process involves careful meticulous planning with creation of preoperative templates. The surgical reconstruction involves 4 stages. Stage 1 is started as early as 6 years of age with harvest of a contralateral costal cartilage and subdermal placement through an anterior auricular incision. Additional stages involved creation and inset of a lobule, elevation of the auricle and creation of a posterior sulcus and grafting of a tragus and deepening of the conchal bowl. Long-term outcomes are successful with this technique with minimal incidence of infection, extrusion, and hematoma. These cartilage constructs grow simultaneously with the patient and the unaffected ear. Sustainable ear reconstruction is paramount in children with microtia. Adherence to a set of basic principles is critical to success in this reconstructive endeavor. Patients who are noted to have microtia should be referred for evaluation and counseling by 12 months of life, then seen annually until reaching the optimal surgical age of at least 5 years of age. This visit should include review of family history and physical examination looking for any associated branchial arch deformities, facial asymmetry, deficits in facial animation, and deformity in dental occlusion. If necessary, referral to genetics counseling should be initiated. Audiology testing should be implemented. The ear reaches about 60% of its adult size by 12 months of age1Krimmel M. et al.Three-dimensional normal facial growth from birth to the age of 7 years.Plast Reconstr Surg. 2015; 136: 490e-501eCrossref PubMed Scopus (15) Google Scholar and 90% by 9 years of age. The reconstruction is generally scheduled for between 6 and 8 years of age to optimize rib growth and minimize psychological harm from embarrassment due to the child’s microtia. By this age, children are often aware of their smaller ear and may have experienced bullying or teasing. The surgery may need to be postponed until the child is older if the opposite normal ear is large and the child is small, as there will not be adequate rib cartilage initially.2Brent B. Auricular repair with autogenous rib cartilage grafts: Two decades of experience with 600 cases.Plast Reconstr Surg. 1992; 90: 355-374Crossref PubMed Google Scholar Preoperative planning starts with creation of a film pattern based on the opposite normal ear, which is then reversed (Figure 1). This is made several millimeters smaller in all dimensions to allow for the extra thickness created by the skin draped over the cartilage framework. If the patient has bilateral microtia, it is critical to note the hairline position. Smaller ears should be planned to limit the proximity of the hairline to the new ear construct. If a unilateral microtia ear is paired with a larger unaffected ear, making it more likely to have hair over the ear, a smaller construct is formed and the normal ear is later reduced in size to match. The position of the new ear is also marked preoperatively, noting the unaffected ear’s position in relation to the lateral canthus, lobule position, and relationship to the nose. In patients with hemifacial microsomia, the normal ear’s upper pole position is used as a guide for height in place of the lateral canthus as it is unreliable and too close to the eye.3Brent B. Chapter 7: Reconstruction of the Ear.in: Neligan P. Plastic Surgery. Elsevier Saunders, London2013: p187-p225Google Scholar If bony repairs are planned, or bone anchors needed, these should be delayed until after the first stage of auricle construction has healed. If done first, they must be approached through separate scars outside of the proposed auricular site. Historically, early treatment options were less than optimal and did not have long-term efficacy. Tanzer4Tanzer R.C. Total reconstruction of the external ear.Plast Reconstr Surg Transplant Bull. 1959; 23: 1-15Crossref PubMed Scopus (328) Google Scholar first described using the costal cartilage from 1-2 ribs to create a multipiece construct which allowed for ease of insertion and assembly and durability in a multistage process. His 10-year follow-up also showed that it withstood resorption with minimal complications.5Tanzer R.C. Total reconstruction of the auricle: A 10-year report.Plast Reconstr Surg. 1967; 40: 547-550Crossref PubMed Scopus (38) Google Scholar Tanzer6Tanzer R.C. Congenital deformities of the auricle.in: Converse J.M. Reconstructive Plastic Surgery. 2nd ed. WB Saunders, Philadelphia, PA1977Google Scholar also developed a classification system of microtia which has assisted in preoperative planning (Table).TableTanzer classification of auricular defectsI.AnotiaII.Complete hypoplasia (microtia)A.With atresia of external auditory canalB.Without atresia of external auditory canalIII.Hypoplasia of middle third of auricleIV.Hypoplasia of superior third of auricleA.Constricted (cup and lop) earB.CryptotiaC.Hypoplasia of entire superior thirdV.Prominent ear Open table in a new tab Dr Burt Brent presented and published his 4-stage technique for ear microtia reconstruction at the annual meeting of American Society of Plastic and Reconstructive Surgeons in 1973, building on previously published techniques, in particular on Tanzer’s body of work.7Brent B. Ear reconstruction with an expansile framework of autogenous rib cartilage.Plast Reconstr Surg. 1974; 53: 619-628Crossref PubMed Scopus (90) Google Scholar Brent aimed to minimize the steep learning curve and difficulty with outcome reproducibility with his new method. Despite first publishing this technique in 1974, it has not changed much over 3 decades. He has published multiple long-term follow-ups, closely scrutinizing his own outcomes. Once the patient is between 5 and 8 years of age, he or she is scheduled for the OR. X-ray film has already been used to create a template of the normal ear. The defective ear and the contralateral chest are prepped and draped into the field. An oblique incision is made above the sixth rib margin. The external oblique and rectus muscles are separated to expose the synchondrosis of the sixth, seventh, and eighth ribs. The sterilized film pattern, traced based on the unaffected opposite ear, is placed over the synchondrosis and used as a stencil. The helical rim is made separately from the cartilage of the first free floating rib (rib 9 or 10) which additionally aids in exposure of the synchondrosis of ribs 6 and 7 (Figure 2). Note the upper border of the sixth cartilage is preserved to help prevent subsequent chest deformity as the child grows.8Brent B. Technical advances in ear reconstruction with autogenous rib cartilage grafts: Personal experience with 1200 cases.Plast Reconstr Surg. 1999; 104: 319-334Crossref PubMed Scopus (311) Google Scholar Caution is needed during this harvest to (1) avoid disruption of the underlying pleura and creating a pneumothorax and (2) maintaining the upper and medial margin of the sixth rib synchondrosis to avoid a significant chest deformity. Using a #10, #11, and #15 scalpel blades and rounded wood carving chisels the cartilage framework is carved. It is important to exaggerate the helical rim and the details of the antihelical complex. Power tools should be avoided to minimize chondrocyte damage. If this is done in an adult, the framework may need to be thinned or can be done in one block due to its calcification.3Brent B. Chapter 7: Reconstruction of the Ear.in: Neligan P. Plastic Surgery. Elsevier Saunders, London2013: p187-p225Google Scholar Thinning and carving should be done on the inner surface to cause deliberate warping in a favorable direction and avoid damage to perichondrium on the outside.9Brent B. Microtia repair with autogenous rib cartilage grafts.Oper Techn Plast Reconstr Surgery. 1994; 1: 69-76Crossref Scopus (6) Google Scholar This outer perichondrium facilitates adherence and subsequent nourishment from the surrounding auricle pocket tissue. Once the antihelical construct and helical rim are carved, the helical rim should be attached to the framework body with 4-0 clear nylon, which is preferred over the originally described stainless steel wire suture to minimize extrusion (Figure 3).8Brent B. Technical advances in ear reconstruction with autogenous rib cartilage grafts: Personal experience with 1200 cases.Plast Reconstr Surg. 1999; 104: 319-334Crossref PubMed Scopus (311) Google Scholar The recipient pocket should then be developed through a small preauricular incision at the posterior aspect of the auricular vestige. A subcutaneous pocket is raised, ensuring the overlying skin is thick enough to provide an adequate vascularized covering for the framework. The subdermal vascular plexus should be preserved as the skin is dissected with great care from the native cartilage remnant, which should be subsequently discarded. The pocket is then extended 1-2 cm circumferentially beyond the projected framework markings (Figure 4). Epinephrine can be used for the initial incision but should otherwise be avoided as it is critical to note blanching when insetting the cartilage to avoid skin necrosis. The hairline should be displaced just behind the new framework rim and the incision is to remain anterior.4Tanzer R.C. Total reconstruction of the external ear.Plast Reconstr Surg Transplant Bull. 1959; 23: 1-15Crossref PubMed Scopus (328) Google Scholar Meticulous hemostasis should be achieved before insetting the cartilage construct into the pocket. Using 2 silicone catheters, the skin is coaptated to the framework by means of vacuum tube suction.3Brent B. Chapter 7: Reconstruction of the Ear.in: Neligan P. Plastic Surgery. Elsevier Saunders, London2013: p187-p225Google Scholar One to two silicone catheters are placed under the construct, and the outer end placed into a rubber topped vacuum tube, which is monitored for changes in drainage characteristics.2Brent B. Auricular repair with autogenous rib cartilage grafts: Two decades of experience with 600 cases.Plast Reconstr Surg. 1992; 90: 355-374Crossref PubMed Google Scholar The hairline can be lower in microtia. It is better to have hair cover the cartilage construct then to place the construct too low. If it covers only the helix and the upper scapha, then electrolysis can be implemented as it preserves normal skin. If it covers the upper one-third of the pinna, electrolysis can be attempted but a skin graft may ultimately be necessary. If the hair will cover one-half or more of the ear and especially if the pocket is already tight, a temporalis fascial flap should be elevated to cover the superior cartilage. An inverted T incision is made to expose the temporoparietal fascia and then elevated with an inferior pedicle to transpose it over the superior cartilage and then skin grafted. A postoperative dressing made of Vaseline gauze and bulky noncompressive gauze is applied to minimize skin flap necrosis. The drainage should be monitored closely. This is continued until the vaccutainers or bulb contain only drops of serosanguinous drainage, usually by postoperative day 5. Protective dressings are continued for 10-14 days. Close monitoring by the medical team and patient are crucial to notice early signs of infection of vascular compromise. Brent discussed concerns he held for the amount of anesthesia exposure required for this procedure due to the extensive detail and time required for carving the cartilage construction. To minimize this, he has an assistant close the chest wall deformity while the cartilage is carved. He reports this can help bring the operative time down to around 3 hours.9Brent B. Microtia repair with autogenous rib cartilage grafts.Oper Techn Plast Reconstr Surgery. 1994; 1: 69-76Crossref Scopus (6) Google Scholar During his initial description, Brent also reported on the use of refrigeration and banking the cartilage in the abdomen as a means of staging the cartilage reconstruction. This is followed by later insetting under local within 24-48 hours. His experimental models were without infection several months later. Ultimately, practical techniques call for banking extra cartilage under the chest incision or the scalp just posterior to the main pocket in the event that additional cartilage is needed later. The later location seems to provide better blood supply to the banked cartilage and is easier to retrieve during a later stage procedure. The lobule transposition should be done after the cartilage framework has healed at least 4-6 months from stage one to ease in positioning. A narrow inferiorly based triangular flap is developed from the remnant lobule and rotated from a superior or inferior orientation to an anterior or posterior one. The skin overlying the inferior cartilage construct can be removed to receive the transposed lobule and create a continuous helical contour. The lobule is then wrapped around the inferior cartilage construct ensuring circumferential vascularized tissue contact on the cartilage. If no lobule is present initially as with anotia, the lobule should be created as (Figure 5). During the third stage, the auricle construct is elevated from the head to create projection. This should only be attempted once edema has markedly improved and the auricular details have become well defined. An incision is made several millimeters’ peripheral to the neoauricle and the cartilage is lifted from its bed, maintaining connective tissue on the posterior aspect of the cartilage and some over the fascia and periosteum of the bony floor. The posterior scalp is then undermined and advanced toward the new sulcus and anchored to the underling fascia. This limits the skin graft size needed and advances the hairline making the skin graft less visible from lateral visualization. If the neoauricle needs more lateral projection, a wedge of rib cartilage can be placed behind the elevated ear but must be covered with a tissue flap to allow for skin graft take. This can be done with a turnover book flap of occipitalis fascia from behind the ear.10Brent B. Microtia repair with rib cartilage grafts: A review of personal experience with 1000 cases.Clin Plastic Surg. 2002; 29: 257-271Abstract Full Text Full Text PDF PubMed Scopus (177) Google Scholar A full-thickness skin graft is then harvested at from the abdomen or groin crease and sutured in place, and secured with a tie over bolster (Figure 6).2Brent B. Auricular repair with autogenous rib cartilage grafts: Two decades of experience with 600 cases.Plast Reconstr Surg. 1992; 90: 355-374Crossref PubMed Google Scholar The final stage of the Brent reconstruction involves creation of a tragus and external canal along with conchal excavation and any final symmetry adjustments needed. A J-shaped incision is made in the anticipated conchal region with the main limb placed at the proposed posterior tragal margin and the crook of the J at the new intertragal notch. A soft tissue flap is developed with excessive tissue sharply excised to deepen the conchal floor. A composite graft from the anterolateral conchal surface of the normal ear is harvested. This can also help any prominence noted in the opposite ear to create frontal symmetry. If the nonaffected concha is normal and the ear projection is equal, a retro-auricular skin graft is harvested to graft this area. If there is bilateral microtia, then a small piece of rib cartilage can be fabricated and attached to the original cartilage construct in stage 1 (Figure 7). Additional methods include development of an anteriorly based rolled conchal flap used to recreate the tragus. Kirkham described elevating this flap and then rolling it onto itself to both deepen the concha and create the tragus simultaneously. The donor site is then skin grafted.11Kirkham H.L. The use of preserved cartilage in ear reconstruction.Ann Surg. 1940; 111: 896-902Crossref PubMed Google Scholar Long-term follow-up has revealed a low incidence of complications and maintenance of the majority of the size of the cartilage constructs.10Brent B. Microtia repair with rib cartilage grafts: A review of personal experience with 1000 cases.Clin Plastic Surg. 2002; 29: 257-271Abstract Full Text Full Text PDF PubMed Scopus (177) Google Scholar These results are also reproducible by other surgeons with practice and mastery of the technique.12Osorno G. A 20-year experience with the Brent technique of auricular reconstruction: Pearls and pitfalls.Plast Reconstr Surg. 2007; 119: 1447-1463Crossref PubMed Scopus (36) Google Scholar If the pleura is violated, it is important to look for a leak. If a full tear is noted, a rubber catheter should be inserted through the pleural opening and the pleura tear repaired in a purse string fashion. The rubber tubing should be attached to suction, the lungs expanded with positive pressure and the catheter rapidly withdrawn. This should be attempted while the costal cartilage is shaped to save anesthesia time. A postoperative X-ray should be obtained if there is any concern intraoperatively or postoperatively for a pneumothorax.3Brent B. Chapter 7: Reconstruction of the Ear.in: Neligan P. Plastic Surgery. Elsevier Saunders, London2013: p187-p225Google Scholar Meticulous hemostasis is the best means of prevention. Close examination of drainage and the ear construct especially during the first 10 days is paramount. If a hematoma does develop, the patient must be taken back to the operating room immediately to evacuate it. The suction drainage is not adequate at that point. Without rapid recognition and surgical evacuation, skin necrosis and warping of the cartilage construct will follow. Local erythema, edema, slightly elevated fluctuance, drainage or any of a combination of these will manifest in the presence of an early post-op infection. If noted, an irrigation drain may be placed under the skin flap and a continuous antibiotic drip irrigation initiated. The antibiotic is adjusted based on initial culture sensitivities. This was employed early in Brent’s experience but he reports no additional acute infection after he implemented his suction drain system.3Brent B. Chapter 7: Reconstruction of the Ear.in: Neligan P. Plastic Surgery. Elsevier Saunders, London2013: p187-p225Google Scholar This is best prevented intraoperatively. If the pocket is inadequately sized and excess tension is noted, this pocket must be adjusted or the cartilage construct must be shaved down or both should be done. Avoiding damage to the subdermal plexus is critical. Additionally, tight bolster sutures can lead to later skin necrosis and should be avoided. Once skin necrosis is noted, aggressive treatment is needed. If it is a small localized ulcer, good local wound care can treat this, even with cartilage exposure as long as the area is continuously covered with ointment. If the region is larger though, the necrotic skin should be excised early and a local skin flap or small fascia flap with skin graft should be transposed to cover the cartilage construct and salvage it.2Brent B. Auricular repair with autogenous rib cartilage grafts: Two decades of experience with 600 cases.Plast Reconstr Surg. 1992; 90: 355-374Crossref PubMed Google Scholar This is often seen when the entirety of the sixth costal cartilage is harvested. This can be avoided by leaving the superior most portion of the rib in situ. Additionally, if the perichondrium is left completely intact, this optimizes the opportunity for regeneration of cartilage over time.13Kawanabe Y. Nagata S. A new method of costal cartilage harvest for total auricular reconstruction: Part I. Avoidance and prevention of intraoperative and postoperative complications and problems.Plast Reconstr Surg. 2006; 117: 2011-2018Crossref PubMed Scopus (84) Google Scholar Pain and clicking may also be noted. Contour deformities can be resolved utilizing spare cartilage left over from the ear framework harvest to reconstruct this area.14Uppal R.S. Sabbagh W. Chana J. Gault D.T. Donor-site morbidity after autologous costal cartilage harvest in ear reconstruction and approaches to reducing donor-site contour deformity.Plast Reconstr Surg. 2008; 121: 1949-1955Crossref PubMed Scopus (65) Google Scholar Harvesting cartilage at a later age can also limit the extent of the deformity.15Ohara K. Nakamura K. Ohta E. Chest wall deformities and thoracic scoliosis after costal cartilage graft harvesting.Plast Reconstr Surg. 1997; 99: 1030-1036Crossref PubMed Scopus (168) Google Scholar Tanzer noted through long-term follow-up that the cartilage construct grew similarly to the normal ear in height. When restricted growth occurred wit was minimal, by 1-2 mm compared to the nonaffected side. This was not affected by age of reconstruction.16Tanzer R.C. Microtia: A long-term follow-up of 44 reconstructed auricles.Plast Reconstr Surg. 1978; 61: 161Crossref PubMed Scopus (143) Google Scholar In Brent’s early follow-up, he noted that in patients 5-10 years old with a minimum of 5-year follow-up, 48% of constructed ears grew at an even pace with the opposite ear, 42% grew several millimeters larger and 10% lagged behind.2Brent B. Auricular repair with autogenous rib cartilage grafts: Two decades of experience with 600 cases.Plast Reconstr Surg. 1992; 90: 355-374Crossref PubMed Google Scholar Brent acknowledges that advancements in tissue engineering will hopefully eliminate the need for costal cartilage harvest.10Brent B. Microtia repair with rib cartilage grafts: A review of personal experience with 1000 cases.Clin Plastic Surg. 2002; 29: 257-271Abstract Full Text Full Text PDF PubMed Scopus (177) Google Scholar Prefabricated bovine cartilage cells were grown in a lab, seeded onto a synthetic ear construct and implanted under the skin of a mouse.17Cao Y. Vacanti J.P. Paige K.T. Upton J. Vacanti C.A. Transplantation of chondrocytes utilizing a polymer-cell construct to produce tissue-engineered cartilage in the shape of a human ear.Plast Reconstr Surg. 1997; 100: 297-302Crossref PubMed Scopus (631) Google Scholar However, this would ultimately fail in clinical application. This is because the chondrocytes must be sufficiently regenerated from a small sample and the new construct must withstand pressure caused by the taut preauricular skin and fascia. Additional advancements are needed for this to be successful but it does create a promising future option for utilizing and modifying the Brent technique in the future." @default.
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