RU2808380C1 - Method of one-stage reconstruction of the auricle - Google Patents

Abstract

FIELD: medicine; maxillofacial; reconstructive; plastic surgery.

SUBSTANCE: invention is intended for use as a one-stage reconstruction of the auricle. The preparation of the bed in the projection of the future auricle is carried out simultaneously with the collection and formation of a cartilaginous rib autograft. After hydropreparation of the soft tissues of the appendage and the temporo-parietal region, an incision is made along the edge of the skin appendage on the right. The skin is mobilized over the anterior and posterior surfaces of the rudiment. The vestigial cartilage is isolated and removed. Next, in the temporo-parietal region and the scalp, the incision is extended in a Y-shape with a total length of up to 15 cm. After this, three triangular skin-fat flaps are mobilized, partly sharp, partly bluntly, and the wound is tamponed. A cartilaginous rib autograft is taken synchronously, a linear incision 4 cm long is made on the chest in the projection of the VII rib parallel to the costal arch, the cartilaginous part of the VIII rib is isolated using blunt and sharp dissection to its border with the bone tissue, the cartilaginous part of the VII–VI ribs is isolated in the same way with the obligatory inclusion of synchondrosis, dimensions corresponding to previously made templates, the wound is sutured in layers. Next, using the obtained fragments of the cartilaginous part of the ribs, with the help of carving technique, the base of the auricle frame is formed, which is positioned in a previously prepared bed, covered with flaps of the temporoparietal fascia on the inner and outer surfaces, the appendage is dissected and the auricle is formed. Next, using sharp and blunt dissection using electrocoagulation in cutting mode, a flap of temporoparietal fascia size 7 × 7 cm is mobilized, flipped onto the cartilaginous frame, the relief of the anterior surface of the auricle is formed and fixed to the inner surface of the skin appendage. After this, a skin strip up to 2 mm thick is taken from the anterior surface of the thigh or posterior surface of the buttocks, fixed over a flap of the temporoparietal fascia on the anterior-posterior surface of the auricle, and a drainage with active aspiration is installed along the edge of the skin appendage into the wound, which is removed on the 4–5th day after the surgery.

EFFECT: method allows to simultaneously restore the cartilaginous frame and soft tissue cover of the auricle, achieving a high aesthetic result by restoring all elements of the auricle in one stage.

1 cl, 4 dwg, 2 ex

Description

This invention relates to medicine, namely to maxillofacial, reconstructive, plastic surgery and can be used for one-stage reconstruction of defects of the auricle in case of injury or microtia.

There is a known method for multi-stage reconstruction of the auricle with microtia by dissecting the skin in the area of the rudiment of the auricle, removing cartilaginous rudiments with the simultaneous introduction of a simulated frame of rib cartilage into the resulting cavity. The second stage involves moving the dystopic lobe. The third stage involves retracting the formed frame and creating the ear-head angle (behind-the-ear fold) using split autologous grafts. The fourth stage is to form the concheal fossa. (TanzerR.C.: Totalreconstructionoftheexteenalcar. Plast. Reconstr. Surg. 23:1, 1959).

The disadvantage of this method is the multi-stage nature of surgical treatment and the long waiting period for results in case of donor damage in the amount of cartilaginous rib autografts and split autodermal grafts.

There is another known method of two-stage otoplasty, where at stage I, rudimentary cartilage is removed and an expander is positioned in the resulting skin bed for the purpose of dermatension. Dosed stretching of the skin continues for 1-1.5 months. Next, at stage II, the auricle frame is formed using cartilaginous autografts, which are covered with a superficial and deep layer of the temporal fascia on the feeding pedicle. The outer surface of the frame is covered with skin stretched using an expander, and the inner surface is covered with a split skin flap from the inner surface of the shoulder. (Patent for invention No. 2111731 C1, IPC A61F 11/00, published on May 27, 1998. Vissarionov V.A., Chirkova E.A., Myshakov D.V.)

The disadvantage of this method is the multi-stage nature of surgical treatment; the skin defect, despite the installation of an expander, is eliminated using split autodermal grafts. Mobilization of the deep layer of the temporal fascia is technically difficult; its area (1 cm above the zygomatic arch) cannot fully eliminate the defect in the anterior surface of the formed frame, taking into account the reduction of the flap and the lack of its mobility.

The one-stage reconstruction of the auricle we offer allows us to achieve a high aesthetic result in one stage of the operation, using out-of-the-box tissues.

The technical result is achieved by the fact that the frame of the auricle is formed using cartilaginous costal autografts of the VI, VII, VIII ribs, which are positioned in the prepared bed after removal of rudimentary cartilages. The skin appendage is used as an earlobe, and a flap of the temporoparietal fascia covers the cartilaginous frame from the inner and outer surfaces. Split autodermal grafts from the buttock or thigh replenish the skin of the anterior and posterior surfaces of the auricle. Thus, a high aesthetic result is achieved in 1 stage of the operation.

The technical result is achieved as follows.

Marking is done with a solution of brilliant green along the edge of the skin appendage, then in a Y-shape in the temporo-parietal region. Hydropreparation of soft tissues at the level of subcutaneous fat with 0.9% physiological solution with the addition of 1.0 ml adrenaline solution in a ratio of 400:1 with a total volume of 50-80 ml. An incision is made along the edge of the skin appendage, followed by mobilization of the skin over the rudiment, with its further removal. Further, in the temporo-parietal region, the incision is extended in a Y-shape in the scalp with a total length of up to 15 cm. Next, by mobilizing 3 triangular skin-fat flaps, the wound is packed with gauze pads with aminocaproic acid. A cartilaginous rib autograft is simultaneously collected through a linear incision with a total length of up to 4 cm on the chest in the projection of the VII rib. After isolation and resection of the cartilaginous part of the VIII rib to its border with the bone part, they begin to isolate the cartilaginous part of the VII-VI ribs, the dimensions corresponding to the previously made templates, with the obligatory inclusion of synchondrosis. From a fragment of the VIII rib we form a helix and antihelix. A C-shaped base of the auricle frame is formed from a fragment of the VII-VI ribs. By fixing the cartilaginous elements with a metal thread, the formed frame of the auricle is positioned in a previously prepared bed, where the appendage in its lower pole is dissected and serves to form the auricle (Figure 1). Next, using acute dissection by electrocoagulation in cutting mode, a flap of temporoparietal fascia measuring 7*7 cm was mobilized, which was overturned onto a cartilaginous frame and fixed to the inner surface of the skin appendage with a 5-0 monocryl thread. (Figure 2, 3), using a dermatome, split autodermal grafts from the anterior surface of the thigh up to 2 mm thick cover the anterior-posterior surface of the auricle and are fixed along the edge of the skin appendage with a 5-0 prolene thread. (Figure 4).

Example 1

Patient I. (14 years old) is being treated at the clinic with a diagnosis of second degree microtia on the right. From the anamnesis: the disease is congenital. No surgical treatment was performed.

At the time of examination, the patient has underdevelopment of the right auricle, which is halved in size, deformation of the helix, antihelix, the external auditory canal is preserved, and hearing is preserved. The skin has physiological coloration and performs facial expression tests in full. The opening of the mouth is not limited.

In the clinic, after preoperative preparation, a one-stage reconstruction of the right auricle was performed. First, markings were made with a solution of brilliant green along the edge of the skin appendage on the right, then in a Y-shape in the temporo-parietal region. Next, hydropreparation of the soft tissues of the appendage and temporo-parietal region at the level of subcutaneous fat was carried out with a physiological solution of 0.9% with the addition of a solution of adrenaline 1.0 ml in a ratio of 400:1 with a total volume of 80 ml. An incision was made along the edge of the skin appendage on the right, 20 mm long, using sharp and blunt dissection, the skin was mobilized over the anterior and posterior surfaces of the rudiment, then the rudimentary cartilage was isolated and removed. After this, in the temporo-parietal region in the scalp, the incision is extended in a Y-shape, with a total length of 13 cm. Next, 3 triangular skin-fat flaps are mobilized, partly sharp and partly bluntly, and the wound is packed with gauze pads with aminocaproic acid. A cartilaginous rib autograft is collected at the same time. After preliminary marking with brilliant green and hydropreparation of the soft tissues of the chest area with saline solution with the addition of 1.0 ml adrenaline solution. in a ratio of 400:1 with a total volume of 30 ml, a linear incision of 4 cm is made in the projection of the VII rib parallel to the costal arch. Using blunt and sharp dissection, linear incisions were made layer by layer to the cartilaginous part of the VI, VII, VIII ribs. After isolation and resection of the cartilaginous part of the VIII rib to its border with the bone part, they begin to isolate the cartilaginous part of the VII-VI ribs, the dimensions corresponding to the previously made templates, with the obligatory inclusion of synchondrosis. We insert drainage into the wound with active aspiration. The wound is sutured layer by layer with vicryl thread, and an intradermal suture is placed on the skin with 5-0 prolene thread. Next, using the carving technique, we form a helix and antihelix from a fragment of the VIII rib. A C-shaped base of the auricle frame is formed from a fragment of the VII-VI ribs. By fixing the cartilaginous elements with a metal thread, the formed frame of the auricle is positioned in a previously prepared bed. The appendage in its lower pole is dissected and serves to form the earlobe and position the lower pole of the formed frame. Next, using the method of acute dissection by electrocoagulation in the cutting mode, a flap of temporoparietal fascia measuring 7*7 cm was mobilized, which was tilted onto the cartilaginous frame to form the relief of the anterior surface and fixed to the inner surface of the skin appendage with a 5-0 monocryl thread. After intradermal hydropreparation with saline solution with the addition of 1.0 ml adrenaline solution in a ratio of 400:1 with a total volume of 80 ml. Using a dermatome, a strip of skin 2 mm thick is taken from the anterior surface of the thigh, which is fixed over a flap of the temporoparietal fascia on the anterior-posterior surface of the auricle and fixed along the edge of the skin appendage with a 5-0 Prolene thread. Drainage with active aspiration is supplied to the wound. Modeling turunda with dimexide solution with the addition of physiological solution in a ratio of 1:4, ac. Bandage. Ac. Chest bandage. Legius bandage on the anterior - lateral surface of the thigh, ac. bandage. The drains were removed on the 4th day. The sutures were removed on the 10th day after surgery. No postoperative complications were identified.

Example 2

Patient Ya. (9 years old) is being treated at the clinic with a diagnosis of “III degree microtia on the right, condition after canaloplasty.” From the anamnesis: the disease is congenital. The formation of the ear canal is completed.

At the time of examination, the patient has underdevelopment of the right auricle, which is represented by rudimentary cartilage and skin appendages, the external auditory canal is formed, and hearing is reduced. The skin has physiological coloration and performs facial expression tests in full. The opening of the mouth is not limited.

In the clinic, after preoperative preparation, a one-stage reconstruction of the right auricle was performed.

Marking is done with a solution of brilliant green along the edge of the skin appendage on the right, then in a Y-shape in the temporo-parietal region. We carried out hydropreparation of the soft tissues of the appendage and the temporo-parietal region at the level of subcutaneous fat with a physiological solution of 0.9% with the addition of a solution of adrenaline 1.0 ml in a ratio of 400:1 with a total volume of 70 ml. A 15 mm long incision was made along the edge of the skin appendage on the right, the skin was mobilized using sharp and blunt dissection over the anterior and posterior surfaces of the rudiment, and the rudimentary cartilage was isolated and removed. Next, in the temporo-parietal region in the scalp, the incision was extended Y-shaped in the scalp, with a total length of 15 cm. Next, 3 triangular skin-fat flaps were mobilized, partially sharp and partially blunt, and the wound was packed with gauze pads with aminocaproic acid. A cartilaginous rib autograft was collected at the same time. After preliminary marking with brilliant green and hydropreparation of the soft tissues of the chest area on the right with saline solution with the addition of 1.0 ml adrenaline solution. in a ratio of 400:1 with a total volume of 30 ml, then a linear incision of 3.5 cm was made in the projection of the VII rib parallel to the costal arch. Using blunt and sharp dissection, linear incisions were made layer by layer to the cartilaginous part of the VI, VII, VIII ribs. After isolating and resection of the cartilaginous part of the VIII rib to its border with the bone part, we began to isolate the cartilaginous part of the VII-VI ribs with the obligatory inclusion of synchondrosis, dimensions corresponding to the previously made templates. Drainage with active aspiration was inserted into the wound. The wound was sutured in layers with 4-0 Vicryl thread, and an intradermal suture was placed on the skin with 5-0 Prolene thread. Next, using the carving technique, a helix and antihelix were formed from a fragment of the VIII rib. A C-shaped base of the auricle frame was formed from a fragment of the VII-VI ribs. By fixing the cartilaginous elements with a metal thread, the formed frame of the auricle is positioned in a previously prepared bed. The appendage in its lower pole is dissected and serves to form the earlobe and position the lower pole of the formed frame. Next, using acute dissection by electrocoagulation in cutting mode, a flap of temporoparietal fascia measuring 7*7 cm was mobilized, flipped onto a cartilaginous frame to form a relief of the anterior surface, and fixed to the inner surface of the skin appendage with a 5-0 monocryl thread. After intradermal hydropreparation with saline solution with the addition of 1.0 ml of adrenaline solution in a ratio of 400:1 with a total volume of up to 80 ml, using a dermatome, a 2 mm thick skin strip was taken from the posterior surface of the buttock, which was fixed over a flap of the temporoparietal fascia on the anteroposterior surface auricle and along the edge of the skin appendage with 5-0 prolene thread. Drainage with active aspiration was inserted into the wound. Modeling turunda with dimexide solution with the addition of physiological solution in a ratio of 1:4, ac. bandage. Ac. Chest bandage. Legius bandage on the anterior - lateral surface of the thigh, ac. bandage. The drains were removed on the 5th day. The sutures were removed on the 10th day after surgery. No postoperative complications were identified.

The advantage of this method is its cosmetic effect, which is achieved by forming all elements of the frame using the carving technique using cartilaginous rib autografts, maintaining the relief of all elements of the auricle by covering with a thin sheet of temporoparietal fascia, as well as thin autodermografts. The use of a temporoparietal fascia flap allows the operation to form the auricle to be performed in one stage, which significantly reduces the patient’s rehabilitation time. The method does not require expensive materials and equipment, donor damage does not worsen the patient’s quality of life, and the operation time increases by 40 minutes.

Claims (1)

A method for one-stage reconstruction of the auricle using cartilaginous rib autografts, a flap of the temporoparietal fascia and autodermal grafts, including the isolation and removal of rudimental cartilage, the formation of a rigid frame of the auricle, as well as the integumentary tissues of the postauricular fold, characterized in that the preparation of the bed in the projection of the future auricle carried out simultaneously with the collection and formation of a cartilaginous rib autograft - after hydropreparation of the soft tissues of the appendage and temporo-parietal region, an incision is made along the edge of the skin appendage on the right, the skin is mobilized over the anterior and posterior surfaces of the rudiment, the rudimentary cartilage is isolated and removed, then in the temporo-parietal region and the scalp, the incision is extended in a Y-shape with a total length of up to 15 cm, after which three triangular skin-fat flaps are mobilized partly sharp, partly bluntly, the wound is tamponed, a cartilaginous rib autograft is simultaneously collected on the chest in the projection of the VII rib parallel to the costal a linear incision 4 cm long is made in the arch, the cartilaginous part of the VIII rib is isolated using blunt and sharp dissection to its border with the bone tissue, the cartilaginous part of the VII-VI ribs is isolated in the same way with the obligatory inclusion of synchondrosis, dimensions corresponding to previously made templates, the wound is sutured layer by layer , then from the obtained fragments of the cartilaginous part of the ribs, using the carving technique, they form the base of the auricle frame, which is positioned in a previously prepared bed, covered with flaps of the temporoparietal fascia from the inner and outer surfaces, the appendage is dissected and the auricle is formed, then using the sharp and blunt dissection by electrocoagulation in the cutting mode, a flap of temporoparietal fascia measuring 7x7 cm is mobilized, flipped onto the cartilaginous frame, the relief of the anterior surface of the auricle is formed and fixed to the inner surface of the skin appendage, after which a skin strip is taken from the anterior surface of the thigh or the posterior surface of the buttocks up to 2 mm thick, fix it over the flap of the temporoparietal fascia on the anterior-posterior surface of the auricle and along the edge of the skin appendage, a drainage with active aspiration is installed in the wound, which is removed 4-5 days after the operation.