Reconstructive Plastic Surgery For Auricular Defects

Objective – To improve the results of surgical treatment of various defects of the auricle by improving the methods of otoplasty. Material and Methods - The study included patients with acquired traumatic defects and III degree inborn folded auricle. The work was carried out in the Department of Plastic and Reconstructive Microsurgery of the State Institution " RSSPMCS named after Academician V. Vakhidov" for the period from 1990 to 2020. In general, the comparative analysis of the results included 38 patients in the main group, among them in 13 (34.2%) cases there were defects with extension to the central part of the auricle, 15 (39.5%) patients with III degree deformity of the auricle (folded auricle), as well as in 9 cases - marginal defects of the auricle and in 1 case a patient with a total traumatic defect. The comparison group included 28 patients, 16 (57.1%) - defects with extension to the central part of the auricle and 12 (42.9%) patients with III degree deformity of the auricle. Accordingly, the effectiveness of the proposed otoplasty method for ear defects was assessed according to two categories of pathologies - defects with extension to the central part of the auricle and grade III ear deformity (folded auricle). The average age in the main group was 22.4 ± 1.3 years, in the comparison group 19.4 ± 1.9 years. Results - Improved methods of reconstruction of an amputated but preserved auricle, with a peripheral defect of the auricle, with a folded auricle, and reconstructive otoplasty with defects with the capture of the central parts of the auricle are proposed. In total, complications developed in 8 (29.6%) patients in the There was also a statistically significant difference in the number of additional plastic surgery stages performed for the complications noted above (criterion χ 2 = 4.305; df = 1; p = 0.039). The average duration of surgery in the comparison group for all stages of reconstructive otoplasty was 220.7 ± 2.7 minutes, and in the main group after 2-stage otoplasty according to the proposed method - 189.5 ± 1.9 minutes (t-criterion = -9 , 60; p <0.05). Conclusion - The improved method of otoplasty in case of grade III defects or deformities of the auricle made it possible to reduce the overall incidence of complications from 29.6% to 7.1%, and to reduce the need for repeated reconstructive interventions from 22.2% to 3.6%, which, in general, led to a decrease in the period of complete rehabilitation from 4.4 ± 0.1 to 3.7 ± 0.1 months. of the results.


INTRODUCTION
Defects and deformities of the auricle of inborn and acquired etiology are a common pathology of the maxillofacial region, and the number of patients with this problem is increasing every year [1][2][3]. In the population, deformities of the auricle are found in 20% of the population. The incidence of inborn malformations of the auricle is 3.5: 1000 newborns, and are distinguished by a variety of their variants. With the birth rate in the Republic of Uzbekistan 22.1 per 1000 population, up to 2400 children are born with anomalies in the development of the auricle per year. The multifactorial nature of isolated cases of the disease is assumed, however, to this day the etiological issue of anomalies in the development of the auricle remains unresolved, therefore, the number of children born with such defects does not decrease [4,5].
In terms of the frequency of occurrence, acquired defects of the auricle are not inferior to congenital defects, and the treatment rate of patients for traumatic deformities and defects of the auricle is up to 42% of the total frequency of injuries of the maxillofacial region [6,7]. In most cases, damage to the auricle occurs as a result of domestic and industrial injuries. At the same time, regardless of the reasons that led to the loss of the outer ear, this defect is a serious aesthetic problem and, in addition to physical disability, affects the psychoemotional state of the patient, reduces the quality of life and can lead to social maladjustment, which is expressed in the limitation of social contacts, low self-esteem, anxiety and changes in personal attitudes and values. Surgical intervention in such cases is often the patient's last opportunity to return to a full life in society [8]. Today, there are many methods and original techniques for  [11].
The aim of this study was to improve the results of surgical treatment of various defects of the auricle by improving the methods of otoplasty.

MATERIAL AND METHODS
The study included patients with acquired traumatic defects, with the exception of patients with post-burn cicatricial transformation, since in these cases, as a rule, not only the reconstruction of the auricle, but also the plastic of the surrounding tissues was required. The work was carried out in the Department of Plastic and Reconstructive Microsurgery of the State Institution " RSSPMCS named after Academician V. Vakhidov" for the period from 1990 to 2020. Also, our study included patients with such an inborn defect as a III degree folded auricle. In general, the comparative analysis of the results included 38 patients in the main group, among them in 13 (34.2%) cases there were defects with extension to the central part of the auricle, 15 (39.5%) patients with III degree deformity of the auricle (folded auricle), as well as in 9 cases -marginal defects of the auricle and in 1 case a patient with a total traumatic defect. The comparison group included 28 patients, 16 (57.1%) -defects with extension to the central part of the auricle and 12 (42.9%) patients with III degree deformity of the auricle. Accordingly, the effectiveness of the proposed otoplasty method for ear defects was assessed according to two categories of pathologies -defects with extension to the central part of the auricle and grade III ear deformity (folded auricle). The average age in the main group was 22.4 ± 1.3 years, in the comparison group 19.4 ± 1.9 years.

Description of improved techniques for otoplasty for auricle defects.
In traumatic amputation of the auricle, replantation using microvascular anastomoses is the best option for surgery. However, the complexity of such an intervention is associated with the small diameter of the anastomosed vessels and the possible injury of the entire auricular zone. In this connection, engraftment of a completely amputated auricle often ends in an unsatisfactory result.

Features of the reconstruction of an amputated but preserved auricle.
Operation stages: Stage I -placement of the cartilaginous framework in a well-vascularized bed of the ear region (14 days after injury) (Fig. 1).
Stage II -lifting the previously implanted auricle with the skin. Plastic surgery behind the ear with a split skin graft (3 months after the first stage) (Fig. 2 Thus, the most acceptable method of plastic surgery for marginal (peripheral) defects of the auricle is the use of a pediatric fascial flap behind the ear. In all cases (9 patients), good aesthetic results were obtained.

Improvement of the method of reconstructive otoplasty with a folded auricle.
One of the most difficult inborn deformities of the auricle for reconstruction is the folded auricle (grade III deformity). To improve the functional and aesthetic results of otoplasty with this defect of the auricle, an improved method of reconstructive otoplasty has been proposed. The method includes restoration of the missing part of the auricle from the framework of the autologous cartilage implanted in the behind-the-ear region. In particular, at the first stage, the missing part of the auricle is formed from the autocostal cartilage and, after being sewn into the defect, is implanted into the behind-the-ear region. Three months later, the second stage is performed, which includes lifting the previously implanted framework together with the skin and performing the final plastic surgery.
The proposed method is carried out as follows.
The operation is performed under intravenous anesthesia in combination with local infiltration anesthesia, in two stages. In contrast to the prototype method, at the first stage, a frame made of autocostal cartilage, prepared according to the size of the defect, was used with sculptural revision of the missing parts of the auricle ( Fig. 7 and 8). The upper part of the ear cartilage is fixed in the correct position to the temporal fascia. After fixing the cartilaginous frame in the defect of the auricle, it is immersed in the subcutaneous pocket of the ear region ( Fig. 9 and 10). Two thin drainage tubes are placed under the frame and behind it, connected to a vacuum system, which is removed on the fifth day after the operation.
The next stage of the operation is performed three months after the first operation as the microcirculation recovers and the edema subsides. At the same time, the implanted part of the auricle is separated from the tissues of the head and the space behind the ear is formed. The implantation of a spacer from the remnant cartilage is also performed to create a normal protrusion angle of the auricle. The defect in the posterior surface of the ear frame is closed with a split skin graft (Fig. 11). Thus, the choice of the method of surgery with a folded auricle should be based on a clear definition of the anatomical defect and on the measurement of differences in the size of the altered and normal ear. Due to the parameters of the defect with a folded auricle of the III degree, reconstruction requires the use of a cartilaginous frame. Accordingly, the use of a frame defect prepared in size from autocostal cartilage with sculptural refinement makes it possible to obtain clear aesthetically acceptable contours of the missing parts of the auricle. In turn, the use of a cartilaginous support makes it possible to obtain a normal "protrusion" angle of the reconstructed auricle. The improved method was used in the reconstruction of a III degree folded auricle in 15 cases.
Reconstructive otoplasty for defects involving the central parts of the auricle. If the defect of the auricle captures not only the curl, but also the central parts, then reconstructive otoplasty can also be carried out using a frame made of autocostal cartilage according to the proposed method. In these cases, the operation is performed in two stages. At the first stage, the autocostal cartilage is harvested and the missing part of the auricle is fabricated according to the template taken from the healthy auricle. The fabricated frame is implanted in the behind-the-ear region (Fig. 12-15).
The At the second stage, after 3 months, the previously implanted framework is lifted with the final plasty. According to the improved method of plastic surgery in two stages using a cartilaginous framework was performed in 13 cases.

RESULTS
In total, complications developed in 8 (29.6%) patients in the comparison group and 2 (7.1%) in the main group (Table 1).  In total, 6 (22.2%) additional stages of otoplasty were performed in the comparison group: 2 (7.4%) in cases of violation of the normal protrusion of the formed auricle, 2 (7.4%) in cases of the formation of an unnatural skin fold, 1 (3, 7%) in case of violation of the contour of the curl and antihelix and 1 more (3.7%) -in the case of recurrence of pronounced deformity of the auricle (Table 2), in the main group an additional stage of surgery was required only in 1 (3.6%) case the formation of an unnatural fold of skin. There was also a statistically significant difference in the number of additional plastic surgery stages performed for the complications noted above (criterion χ2 = 4.305; df = 1; p = 0.039).   The duration of the hospital period (Table 5) in aggregate for all stages of reconstructive otoplasty in the comparison group was 10.1 ± 0.2 days, which was significantly longer than in the main group, where this indicator was 9.0 ± 0.2 days (t-test = -3.86; p <0.05). The summary data on the duration of all stages of reconstructive otoplasty for defects or deformities of the auricle of the III degree are shown in Fig. 16  The most acceptable method of plastic surgery for marginal (peripheral) defects of the auricle is the use of a skin-fascial flap behind the ear on the leg. In all cases (9 patients), good aesthetic results were obtained.
The choice of the method of surgery with a folded auricle should be based on a clear definition of the anatomical defect and on the measurement of differences in the size of the altered and normal ear. Due to the parameters of the defect with a folded auricle of the III degree, reconstruction requires the use of a cartilaginous frame.
The use of a frame made of autocostal cartilage with sculptural refinement, prepared according to the size of the defect, allows obtaining clear aesthetically acceptable contours of the missing parts of the auricle. In turn, the use of a cartilaginous support makes it possible to obtain a normal "protrusion" angle of the reconstructed auricle.
An improved method of otoplasty for grade III auricle defects or deformities made it possible to reduce the overall complication rate from 29.6% to 7.1% (χ2 = 4.672; df = 1; p = 0.031), and to reduce the need for repeated reconstructive interventions from 22, 2% to 3.6% (χ2 = 4.305; df