Atypical Microtia Correction with Multiple Z-Plasties
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Op Dr Saffet ÖRS Microtia is a congenital malformation characterized by total or partial absence of the whole auricle or any of its components, varying from a small auricle to the total absence (anotia). There may be associated atresia of the external auditory meatus. The most common microtia, 60 percent of total cases, is lobule type. The others are the small concha with lobule (10 percent), scapha type without concha (9 percent), and the lobule type and concha type of the first and second branchial arch syndrome (4 percent, 5 percent). Facial palsy of the eyelid or lip is observed in 10.4 percent, especially in particular types such as the concha type of the first and second branchial syndrome or the concha only type (1). The frequency varies in different parts of the world between 0.4 and 5.5/10,000 newborns (2). The unilateral form is present in 81.5 of the cases, more frequently on the right side. Sixty three percent of the affected are males. 47.4 % of the patients are isolated malformation and 52.6 % are associated with other malformations (2). There are several methods suggested by different authors for lobule type (3-5). But there is still no commonly accepted standard methods for other types. Here we present a case of atypical microtia with normally shaped concha and lobule which cannot be classified by Fukuda classification, and describe an alternative method for the treatment of congenital atypical microtia using multiple Z-plasties. Case report A 6 year-old boy admitted for the right prominent ear and left microtia (Figure 1) . Lobule and helix of the left ear were intact. Vertically the length of the left ear was approximately the same as the right ear, whereas the transverse length was %20 lesser. Periphery and upper part of the conchal cavity was covered by cartilage and skin web. There was a fissure straight to conchal cavity over the web. An operation was carried out to correct this atypical case with small scapha and the atresia of the ear canal and the undeveloped antihelix and tragus. The right prominent ear was also repaired at the same time. In the left ear, two Z-plasties were performed at the level of upper and below the anterior side. A double opposing Z-plasty was performed in the posterior side. Two Z-plasties were performed on the apex of web and the base of web (Figure 2). All Z-plasties were limited to skin. After Z-plasty flaps were lifted, the remaining conchal cartilage was sliced full thickness from the center of concha to periphery. Preserving a distance of 5 mm from distal side, each cartilage segment was fixed to the base of concha with permanent sutures. Cartilage grafts were placed in front of the sutures. These grafts were formed antihelix. Tragus was formed with a piece of cartilage at the center of two Z-plasties at the anterior side. After suturing the flaps, the operation was completed. Tragus, concha scapha, antihelix, and triangular fossa could be well defined after this operation. The patient was followed 3 years in the postoperative period. After this long period all components were continued to be well defined in the left ear. (Figure 3). Discussion Standard method with acceptable results is well described in the literature for the correction of classic lobule type microtia (3-5). Concha-type microtia, scapha-type microtia, severely constricted ear, or even total earlobe defect, numerous corrective methods for each defect have been introduced (2,6-9). Atypical auricular deformities are more difficult to correct than the classic one. The amount and the shape of the skin and the cartilage within the auricular remnant are different in each case. A patient with a sizable auricular remnant expects better results than the one with a smaller remnant of lobule-type microtia. Concha-type and scapha-type microtia is representative deformity requiring construction of the upper and middle auricles. If the difference is similar to the size of the concha of normal auricle, the framework is constructed with a combination of contralateral conchal cartilage and costa cartilage or with a combination of contralateral conchal cartilage and septal cartilage (10). In the middle and upper auricular deformities such as a concha-type or a scapha-type microtia, a cranially based postauricular skin flap and lower mastoid fascial flap covered over the framework (10). For upper auricular deformities such as microtia representing lop-ear deformity (10), a narrow cranially based postauricular skin flap (Grotting) (11) and upper mastoid fascial flap are used (11). For lower auricular deformities such as total absence of the ear lobe, a cranially based skin flap and lower mastoid fascial are utilized. Two kinds of cranially based postauricular skin flaps have been reported in the literature. Grotting (11) used a narrow cranially based postauricular skin flap for the correction of small upper auricular defects. Crikelair (12) used a broader cranially based postauricular skin flap for moderate size upper auricular defects. For the correction of concha-type or scapha type microtia, most surgeons use methods of framework fabrication similar to the methods they use for lobule-type microtia. Fukuda and Yamada (1), Brent (3,4), and Nagata (5,8,9) presented their methods of manipulating the remnant cartilage in their framework fabrication. All tecniques may result in conspicuous long scars in infraauricular, retroauricular and donor regions. There are many complications of auricle reconstruction such as flap necrosis, infections, and deformation of cartilage framework. Methods of atypical microtia reconstruction are different in each case. The Z-Plasty principle can be used to increase the length of the skin in desired direction. For example, it is useful to release scar contractures, especially in cosmetically sensitive areas to break up the appearance of a straight line or to release a contracture. Congenital skin webs (without auricle) can also be corrected with Z-Plasties (13). Circumferential scars are amenable to lenghtening using Z-Plasties, especially in constricting bands of the extremities. The lobule and external auditory atresia can be corrected with Z-Plasties in microtia (13,14). Except these two anomalies, Z-Plasty has not been used in microtia before. In our case, the result of Z-plasties seems to be excellent. The deformation of cartilage framework and auricle can develop in reconstructed microtia in long period. However, no deformation developed in our case at the end of the third year postoperatively. As a result, this microtia reconstruction method is simple, safe and does not contain any donor side morbidity. To the best of our knowledge, there has been no other similar case reported previously. References
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