Auricular repair with autogenous rib cartilage grafts: two decades of experience with 600 cases

The purpose of this paper is twofold: to present a sound approach to auricular construction using methods that have evolved through two decades of my personal experience with 600 cases and to discuss pertinent information I have gleaned from a questionnaire sent to my operated patients. This series comprises 546 completed ears in 500 microtia patients (46 bilateral) and 75 completed ears in acquired deformities. Follow-up ranges from 1 to 17 years. Major complications such as infection, hematoma, or skin loss with cartilage exposure occurred in only 1.6 percent of cases and were limited to the perioperative period of 12 days. None have occurred in the last 9 years (481 frameworks). This paper describes the evolution and rationale for my current management of total ear repair and covers preoperative planning, how to fabricate the rib cartilage framework, how to modify the framework for specific deformities, and how to cover the framework, i.e., how to assess and use local skin and vestiges or when to supplement the coverage by recruiting fascial flaps or using tissue expansion. When considering fascial flaps, patient selection was found to be particularly important because of long-term effects on the donor scalp; expansion was found to be most useful intraoperatively. This paper also covers how to manage the hairline, how to stage the surgery, when to combine procedures, and how to manage bilateral microtia in a team approach. The survey revealed that autogenous cartilage frameworks grow, are durable, retain their detail over the years, and withstand trauma well. More than 40 severe traumas occurred in surgically constructed ears, and all healed without incident. Ears constructed in young patients generally grew to keep pace with the opposite normal side; 41.6 percent actually overgrew by several millimeters. Emotional and psychological benefits were universal, and patient satisfaction was high. Among patients who were classified as "severely affected" by the original deformity, 100 percent were pleased with the result. When considered "moderately disturbed" by the microtic defect and operated on by age 14, 95.5 percent of patients were satisfied with the surgical repair; 83.3 percent of adolescents between the ages of 15 and 20 who did not consider themselves "severely affected" by the deformity were pleased with the outcome, and the rest were "undecided."