Microtia Reconstruction - Stage 1-2

Timing

• • a

Preparation 

• • OnQ pain pump

    • .1-.2% Ropivicaine (400 ml) 2-4 ml/hour

  • Trace template of normal ear on surgical visor

    • • Use template to trace templates for:

        • Baseplate

        • Tragus - Antitragus 

        • Antihelix - the helix is whatever specimen remains 

  • Mark chest

    • 1% Lidocaine with 1:100,000 Epinephrine

  • Mark ear

    • .25% Bupivicaine 

Procedure

• • Preserve subcutaneous pedicle in the conchal bowl to prevent anterior flap necrosis 

OP NOTE:

Right grade 3 lobular microtia

Right costal cartilage from ribs 7-10 harvested

Two drains placed in postauricular hairline

Three cartilage pieces banked in right temporal hairline

Procedure in Detail:

The patient was brought into the operating room and placed supine on the table. General anesthesia was administerd and the patient underwent endotracheal intubation. The bed was turned 180 degrees. The planned incision sites were drawn over the right chest and right ear. 1% lidocaine with 1:100,000 epinephrine were infiltrated into the chest site and posterior to the `ear site. The patient was prepped and draped in a sterile fashion.

A 3cm horizontal incision was made with the 15 blade in the right chest over rib 7. Subcutaneous fat and muscle were dissected with Bovie cautery until the rib cartilage was encountered. Starting with rib 8, the intercostal muscle and fascia were dissected from the costal cartilage with Bovie cautery, and the cartilage was removed adjacent to the bony junction with 15 blade. The same was performed for ribs 6,7, and 9, of which 6 and 7 which were taken as one piece. Hemostasis was achieved with bipolar. The wound was irrigated and a valsalva was performed, revealing no air leak.  The wound was closed with 4-0 Polysorb deep sutures in layered fashion, and a 5-0 Biosyn skin in interrupted subcuticular fashion. An OnQ pump catheter was placed into the wound bed through a separate skin insertion prior to closure.  Skin glue was applied with steristrip on top. The OnQ pump catheter was secured to the abdomen with a Tegaderm dressing.

The ear was addressed simultaneously as the cartilage harvest. The incision was made with 15 blade across the lobule and in a periauricular fashion. Subcutaneous fat was raised with fine tipped scissors and curved tenotomy. Care was taken to preserve a pedicle in the planned conchal bowl. Two 10 Fr round drains were placed in the wound, exiting in the postauricular hairline. One drain site was noted to have brisk venous flow and was removed, hemostasis was achieved with bipolar, surgicel, and oversewn with 4-0 chromic. New postauricular drain placed. Hemostasis obtained with bipolar

Care was then turned to carving the cartilage grafts. The baseplate of the auricle was sculpted from the synchondrosis of the 6th and 7th rib with a 15 blade and a 3 mm cutting drill to recreate the base of the helix, antihelix, and antitragus. The 8th free rib cartilage was used to form the rim of the helix. The free 9th rib was used to fashion the antihelix and split to form the superior and inferior crus. The cartilage piece was used to fashion a U-shaped frame for the tragus and antitragus. Additional cartilage pieces were used to create a buttress for the tragus. The cartilage pieces were assembled with 4-0 and 5-0 Maxon sutures in horizontal mattress fashion (see intra-op photos).

The reconstructed ear was implanted into the skin of the right ear. The drains were placed on suction to vacuum the skin to the cartilage. The skin was closed with 5-0 polysorb and 5-0 chromic deep sutures and 6-0 Fast sutures in running and interrupted fashion for the superficial skin.

The three remaining cartilage grafts were banked over the temporal hairline through a 2 cm incision.  The wound was closed with a running 4-0 Plain suture.  

The drains were placed to bulb suction. Puddy was applied to the ear to maintain contours. A glasscock dressing was placed over the reconstructed ear.

Care was turned back to anesthesia, and the patient was extubated in the OR. He was brought to PACU in stable condition.

Post-op

• • Medications 

    • Augmentin x 1 week 

    • Analgesic 

  • Follow up

    • RTC 1 week 

    • Glasscock dressing x 1 week

      • The only use at night for the next 6 weeks, use foam tape on anterior aspect to secure to face 

    • 2 bulb suction drains (***) x 1 week - DO NOT take off suction

      • Tape to chest on mesentery

    • Remove OnQ pump from chest

    • May also remove ear mold or leave on for an additional 1 week 

High-Yield

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Links

• • External anatomy illustration 

  • eMedicine article Microtia

  • UTMB grand rounds Microtia Reconstruction

  • http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312152/pdf/sps25257.pdf