Zhicheng XU,Ruhong ZHANG,Qun ZHANG,Feng XU,Datao LI,Yiyuan LI,Xia CHEN

Department of Plastic and Reconstructive Surgery,Shanghai Jiao Tong University School of Medicine,Huangpu District,Shanghai 200011,China

ABSTRACT Significant improvements have been achieved in microtia reconstruction using an autogenous costal cartilage framework.However,complications such as skin necrosis and cartilage exposure often destroy the final contour of the reconstructed auricle.Local fascia flaps are commonly used in salvage surgery because of their reliability and satisfactory results.Here,we report the case of a 26-year-old woman with multiple skin necroses and cartilage exposure on day 21 after the first-stage microtia reconstruction.The exposure area was covered by a temporoparietal fascia flap as a single-stage procedure.The most essential subunits survived,and the esthetic concours were harmonious and natural at 12 months postoperatively.Temporoparietal fascia flaps are recommended as the surgical treatment for multiple skin necroses and cartilage exposure in microtia reconstruction.The axial-pattern temporoparietal fascia flap is reliable for salvage auricular reconstruction and ensures satisfactory results at long-term follow-up.

KEY WORDS Microtia;Cartilage exposure;Temporoparietal fascia flaps

INTRODUCTION

Autologous cartilage staged reconstruction for patients with microtia remains the most commonly adopted method by plastic surgeons to improve the appearance of the auricle[1-7].Significant improvements have been achieved in microtia reconstruction.However,various complications,including hematoma,infection,flap venous congestion,skin necrosis,cartilage exposure,and framework deformities,inevitably occur when performing the surgery.Thus,a proper strategy should be applied for the treatment of such complications and to minimize negative impacts.Local facial flaps are often recommended to salvage cartilage exposure because of their reliable and satisfactory results.Here,axial-pattern temporoparietal fascia flap (TPFF) and skin graft were used to cover the cartilage exposure caused by a complication of microtia reconstruction with an autogenous costal cartilage framework.

CASE PRESENTATION

Multiple skin necrosis and cartilage exposure occurred in a 26-year-old woman after the first stage of microtia reconstruction with autogenous costal cartilage (Fig. 1A-1B).Inappropriate size of the subcutaneous pedicle and continuous destruction of subcutaneous vascular networks due to uneven flap dissection were considered as the causes of such complications.Thereafter,the patient underwent a secondary repair operation to cover the wound with an axial-pattern TPFF and skin graft.

Fig.1 A patient with multiple skin necrosis and cartilage exposure was salvaged with a TPFF and skin graft from the scalp.(A) A 26-year-old woman presented with conchal-type microtia.(B) Skin necrosis and cartilage exposure around the antihelix and lower part of the helix were found on postoperative day 21.Red arrows showed locations of multiple skin necrosis and cartilage exposure.(C) The axial-pattern TPFF can readily elevate and cover the cartilage exposure.(D) A split-thickness skin graft from the scalp was used to cover the TPFF.(E) The TPFF and skin graft completely survived on postoperative day 5.(F) Postoperative oblique view at 12 months after the salvage operation.

The patient was operated under local anesthesia with lidocaine containing 1:100 000 epinephrine.Intraoperatively,debridement was performed,and necrotic tissue was removed.A zigzag incision line was marked on the scalp after Doppler examination,which confirmed the completeness of the superficial temporal artery.Then,an 8 cm × 9 cm TPFF containing the superficial temporal vessels was harvested to drape over the cartilage framework with a“pants-over-vest”closure to the defected skin without resistance (Fig.1C).Thereafter,the facial flap was covered with a 0.3 mm split-thickness skin from the scalp.The facial flap and skin graft were closed using 6-0 absorbable interrupted mattress sutures,and the donor site was closed with a 3-0 silk thread.When the dressing was removed on postoperative day 5,both the TPFF and skin graft survived completely (Fig.1D).No obvious hypertrophic scars or alopecia was observed at the recipient or donor site (Fig.1E).The most essential subunits survived,and the esthetic concours were harmonious and natural at 12 months postoperatively (Fig.1F).

DISCUSSION

Skin necrosis and cartilage exposure more frequently occur in Nagata’s method than in Brent’s or Firmin’s techniques.With regard to our methods that were primarily modified from Nagata’s technique,the percentage of skin necrosis and cartilage exposure occurrence was approximately 1.8%.With improved operational skills,including the critical steps of selecting the appropriate size of the subcutaneous pedicle and maintaining the integrity of subcutaneous vascular networks during flap dissection,we found that the occurrence of such phenomenon would decrease significantly.

For skin necrosis ＜10 mm2,conservative wound care and hyperbaric oxygen therapy (HBOT) were initiated.HBOT can accelerate venous revascularization and reduce skin flap necrosis and has been applied to salvage tissue ischemia after breast reconstruction[8],facial ischemia due to cosmetic filler injection[9],and ischemic facial flaps after the surgical repair of traumatic wounds[10].These mechanisms include amelioration of ischemic/reperfusion injury,oxygenation of ischemic tissues,reduction of edema,and promotion of angiogenesis and collagen maturation[11-12].

If the exposure area is ＞10 mm2,the surgical treatment methods differ according to the location[13].Axial-pattern TPFFs with at least one artery and one vein that traverse far on the most distal portion of the flap provide a large,thin,and pliable tissue and are always reliable for salvage auricular reconstruction[14].Cartilage exposure at any location,especially related to a large area of skin necrosis,multipoint cartilage exposure,or pericentral part of the auricle,including the antihelix,antitragus,and concha,can be covered by an axial-pattern TPFF.Safe elevation of the TPFF is a time-consuming procedure,and alopecia along the long incision line may be obviously observed in male patients with short hair.With regard to the wound at the edge,we find that the local random fascia flap,including the random-pattern temporal fascial flap at the upper part of the helix and the retroauricular fascia,also known as the ‘‘postauricular’’ or ‘‘superficial mastoid’’ fascia flap at the lower part of the helix[15],is adequately large to cover a comparatively small area of exposed cartilage at the edge of the framework.The procedure is time-saving and easier to handle with shorter incision lines and less conspicuous scars.Thus,the axial-pattern TPFF with a complete superficial temporal artery and vein could be maintained for future use.

With respect to multiple skin necrosis and cartilage exposure in this case,the axial-pattern TPFF is recommended to salvage the reconstructed auricle.It is also reliable for the treatment of severe complications and ensures satisfactory results at long-term follow-up.

FUNDING

This work was supported by the National Natural Science Foundation of China (no.81974291) and the Clinical Research Program of Shanghai Ninth People’s Hospital,Shanghai Jiao Tong University School of Medicine (JYLJ201914).

ETHICS DECLARATIONS

Ethics Approval and Consent to Participate

Ethical approval (ID:2016-135-T84) was obtained from the Ethics Committee of Shanghai Ninth People’s Hospital,Shanghai Jiao Tong University School of Medicine.All participants provided written informed consent before study enrolment.

Consent for Publication

All the authors have consented to the publication of this article.

Competing Interests

The authors declare that they have no competing interests.The authors state that the views expressed in the article are their own and not the official position of the institution or funder.

AUTHORS’ CONTRIBUTIONS

ZC X participated in the operation and wrote the manuscript.RH Z is the corresponding author who conducted the surgery and instructed the study.Q Z and F X are surgical assistants during the surgery.YY L,DT L,and X C completed the patient follow-up.All authors have read and approved the manuscript.