[Chondrogenesis of adipose derived stem cells induced by misshapen auricular chondrocytes from microtia in vitro].

OBJECTIVE: To investigate the effects of the misshapen auricular chondrocytes from microtia in inducing. METHODS: Human ADSCs at passage 3 and misshapen chondrogenesis of human adipose derived stem cells (ADSCs) in vitro. auricular chondrocytes at passage 2 were harvested and mixed at a ratio of 7:3 as experimental group (group A, 1.0 x 10(6) mixed cells). Misshapen auricular chondrocytes or ADSCs at the same cell number served as control groups (groups B and C, respectively). All samples were incubated in the centrifuge tubes. At 28 days after incubation, the morphological examination was done and the wet weight was measured; the content of glycosaminoglycan (GAG) was detected by Alcian blue colorimetry; the expressions of collagen type II and Aggrecan were determined with RT-PCR; and HE staining, toluidine blue staining, Safranin O staining of GAG, and collagen type II immunohistochemical staining were used for histological and immunohistochemical observations. RESULTS: At 28 days after incubation, all specimens formed disc tissue that was translucent and white with smooth surface and good elasticity in groups A and B; the specimens shrank into yellow spherical tissue without elasticity in group C. The wet weight and GAG content of specimens in groups A and B were significantly higher than those in group C (P < 0.05), but no significant difference was found between groups A and B in the wet weight (t = 1.8203, P = 0.0687) and in GAG content (t = 1.8614, P = 0.0627). In groups A and B, obvious expressions of collagen type II and Aggrecan mRNA could be detected by RT-PCR, but no obvious expressions were observed in group C; the expressions in groups A and B were significantly higher than those in group C (P < 0.05), but no significant difference was found between groups A and B in collagen type II mRNA expression (t = 1.4576, P = 0.1449) and Aggrecan mRNA expression (t = 1.5195, P = 0.1286). Mature cartilage lacunas and different degrees of dyeing for the extracellular matrix could be observed in groups A and B; no mature cartilage lacunas or collagen type II could be observed in group C. The expression of collagen type II around cartilage lacuna was observed in groups A and B, but no expression in group C; the gray values of groups A and B were significantly lower than that of group C (P < 0.01), but no significant difference was found between groups A and B (t = 1.6615, P = 0.0970). CONCLUSION: Misshapen auricular chondrocytes from microtia can induce chondrogenic differentiation of human ADSCs in vitro.

[Ear reconstruction after rupture of postauricular expanded flap].

OBJECTIVE: To summarize the principles of ear reconstruction after rupture of postauricular expanded flap. METHODS: The rupture of the postauricular expanded flap was graded as I-IV degree. For flap rupture of I and II degree, the ear reconstruction was performed immediately with autogenous cartilage framework. For flap rupture of III degree, topical and systemic treatment should be done to relieve the redness and swelling. Then the ear reconstruction was performed. For flap rupture of IV degree, the expanded postauricular flap was smoothened. Ear reconstruction was performed 3 months later. RESULTS: There were 67 cases with flap rupture, including 43 cases as I and II degree, 17 cases as III degree and 7 cases as IV degree. Ear reconstruction with autogenous cartilage framework was performed in 43 cases, with Medpor framework in 17 cases. Flap smoothing and secondary ear reconstruction with autogenous cartilage framework was performed in 7 cases. The results were satisfactory with complications in 4 cases (7%), which resolved after treatment. Primary healing was achieved in all the patients. CONCLUSIONS: Good result could be achieved in ear reconstruction, even after flap rupture. Proper treatment should be adopted according to the rupture degree.

[Experimental research on DNA methylation profile in congenital microtia].

OBJECTIVE: To screen for abnormal methylation in CpG islands and CpG sites through whole genome of congenital microtia to identify their associated genes. To discuss the relationship between abnormal methylation level of genes and the etiology of congenital microtia. METHODS: Residual ear cartilage of 50 patients with microtia was collected with ear cartilage of 34 patients without ear malformations as control. Nimblegen CpG promoter array was chosen to screen the 28,226 CpG islands in the whole genome of both experimental and control groups. The genes with differential methylated CpG islands were selected. SpectroCHIP array was chosen to detect the methylation level of each CpG site in abnormal methyletion CpG islands of both experimental and control groups. The CpG sites with differential methylation level were selected. RESULTS: There were 36 CpG islands with differential methylated level in whole genome between experimental group and control group, among which 29 CpG islands were connected with 29 named genes. In the abnormal methylated CpG islands of COL18A1, MYH14, RBMY1A1 and ZIC3, 6 differentially methylated CpG sites were found with statistical significance. The methylation level of these 6 CpG sites in experimental group and control group were COL18A1_2_CpG_170.9783 +/- 0.0235 and 0.9526 +/- 0.0589; MYH14_CpG_170.9600 +/- 0.0414 and 0.9284 +/- 0.0655; RBMY1A1_1_CpG_3.40.9966 +/- 0.0055 and 0.9914 +/- 0.0069; RBMY1A1_1_CpG_130.9648 +/- 0.0118 and 0.9757 +/- 0.0127; ZIC3_3_CpG_150.0867 +/- 0.0212 and 0.0543 +/- 0.0399; ZIC3_2_CpG_270.3775 +/- 0.1816 and 0.472 3 +/- 0.0439. CONCLUSIONS: The DNA methylation profile of the entire genome is initially established. The abnormal methylated CpG islands of COL18A1, MYH14, RBMY1A1 and ZIC3 might be related to the pathogenesis of microtia.

[Ear reconstruction for microtia with craniofacial deformities].

OBJECTIVE: To investigate the methods and effectiveness of ear reconstruction for the microtia patients with craniofacial deformities. METHODS: Between July 2000 and July 2010, ear reconstruction was performed with tissue expander and autogenous costal cartilages in 1 300 microtia patients with degree II+ hemifacial microsoma, and the clinical data were reviewed and analyzed. There were 722 males and 578 females, aged 5 years and 8 months to 33 years and 5 months (median, 12 years and 2 months). The expander was implanted into the retroauricular region in stage I; ear reconstruction was performed after 3-4 weeks of expansion in stage II; and reconstructed ear reshaping was carried out at 6 months to 1 year after stage II in 1 198 patients. RESULTS: Of 1 300 patients, delayed healing occurred in 28 cases after stage II, healing by first intention was obtained in the other 1 272 cases, whose new ears had good position and appearance at 1 month after stage II. After operation, 200 cases were followed up 1-9 years (mean, 3 years). One case had helix loss because of trauma, and 1 case had the new ear loss because of fistula infection. At last follow-up, the effectiveness were excellent in 110 cases, good in 65 cases, and fair in 23 cases with an excellent and good rate of 88.4%. CONCLUSION: It is difficulty in ear reconstruction that the reconstructed ear is symmetrical to the contralateral one in the microtia patients with degree II+ hemifacial microsoma. The key includes the location of new ear, the fabrication of framework, and the utilization of remnant ear.

[Sectional anatomical analysis of auricular and middle ear malformation in patients with microtia].

OBJECTIVE: To analyze the sectional anatomical features of auricular and middle ear malformation in patients with microtia so as to improve the clinical classification and the instruction of surgery. METHODS: From Jun. to Dec. 2009, 36 cases with microtia were selected in the center of auricular reconstruction in Plastic Surgery Hospital, including 22 cases of unilateral microtia and 14 cases of bilateral microtia. 22 patients with unilateral microtia were studied with the contralateral healthy ears as controls. Spiral CT was performed for high-resolution scan of the temporal bone. The coronal, sagittal and 3D reconstruction images were created with Mimic software. Several distances and degrees were measured. RESULTS: The patients were classified by Max classification. The anteroposterior diameter and the vertical diameter of tympanic cavity were (7.75 +/- 1.92) mm and (14.66 +/- 4.75) mm for type I; (6.17 +/- 2.56) mm and(14.35 +/- 5.12) mm for type II; (6.31 +/- 3.40) mm and (9.97 +/- 4.36) mm for type III (P = 0.001). The mastoid pneumatization degree for type I, II, III were 13.33%, 13.64%, 30.77% in sclerotic type, 13.33%, 18.18%, 7.69% in diploe type, 0, 9.09%, 38.46% in composite type, 73.33%, 59.09%, 23.08% in pneumatic type (chi2 = 24.11, P = 0.002). The cover of fenestra vestibuli by facial nerve was 21.43%, 47.62%, 54.55% (chi2 = 23.44, P = 0.002) for type I, II, III. There was a statistical difference between the microtia group and the control group. CONCLUSIONS: According to the Max classification, the middle ear malformation changed along the auricular malformation. The anatomical variations was complicated in type II microtia, which should be sub-classified.

[Application of bi-pedicled frontal expanded flap for cervical cicatricial contracture].

OBJECTIVE: To investigate the therapeutic effect of bi-pedicled frontal expanded flap for cervical cicatricial contracture. METHODS: Tissue expanders were implanted under frontal muscle. After expansion, the frontal flaps were designed based on bilateral superficial temporal vessels and were transferred to the neck wound. The cervical spine movement and the mento-cervical angle was measured and analyzed by SPSS16.0 and t test. RESULTS: From September 2006 to May 2010, 7 patients were treated by this method. The range of active cervical movement was improved in all direction. The mento-cervical angle decreased from (152.7 +/- 1.9) to (90.7 +/- 2.2) degrees after operation. The patients were followed up for 5 months to 3 years with satisfactory result and no contracture recurrence. CONCLUSIONS: The bi-pedicled expanded frontal flap has a reliable blood supply and is very suitable for cervical cicatricial contracture with good functional and esthetic results, leaving less morbidity at donor site.

A 2-stage ear reconstruction for microtia.

OBJECTIVE: To introduce our 2-stage reconstruction of microtia method, which results in a natural-looking contour of the reconstructed ears, one of the most demanding challenges in facial plastic surgery. METHODS: In the first stage, the 3-dimensional cartilage framework is fabricated. The skin flap and retroauricular fascial flap are elevated in the mastoid area. Then the framework is wrapped by the fascial flap from behind and covered by the skin flap from front. In the second stage the crus, the tragus, and the conchal cavity are reconstructed. So almost all of the fine structures of ear are reconstructed. RESULTS: Sixty-eight patients ranging in age from 5 to 17 years had their ears reconstructed using our 2-stage method from January 1, 2006, to December 31, 2008. Forty-eight patients were boys, and 20 were girls. Unilateral microtia was present in 66 patients and bilateral microtia was present in 2 patients. The reconstructed ears had a 3-dimensional configuration, and the cranioauricular angle of the reconstructed ears was similar to that of the contralateral ear. CONCLUSIONS: Two-stage ear reconstruction is a simple and promising method for microtia. Furthermore, the complications are rare.

Seasonal variation in months of birth of patients with microtia in a Chinese population.

OBJECTIVE: Seasonality in months of births has been found in many congenital deformities, but little data are available in microtia, especially in a Chinese population. The aim of this study was to determine whether births of patients with microtia follow a seasonal pattern in a Chinese population. METHODS: Patients with microtia treated at the Plastic Surgery Hospital between 2009-03 and 2010-03 were investigated according to the months of births. Seasonal variations in months of births were analyzed by using χ(2) test. RESULTS: A total of 693 patients with microtia were included in the study. Birth time peaks occurred in autumn and winter, especially in October and March, compared with the nadir in the summer (P<0.05). The birth time peaks of male occurred in autumn and winter, especially in October, January and September. The birth time peaks of female occurred in spring and summer, especially in March. There was statistical difference in birth distribution in different months (P<0.05) or four seasons (P<0.05) between the two genders. There was no statistical difference in birth distribution on a monthly or seasonal basis by sides. CONCLUSIONS: The data indicate that there is a possible seasonality in months of births of patients with microtia in a Chinese population and a difference between the genders. This approach could be useful for the study of the etiology and pathogenesis of microtia.

A new method to correct Stahl's ear.

OBJECTIVE: Stahl's ear is a rare congenital auricular malformation in which an abnormal 'third crus' traverses the upper pole of the scapha. A number of different treatment options have been published to correct Stahl's ear deformity; however, none of them corrects all the variations perfectly. In this article, we describe our new method to correct this deformity. METHODS: To correct Stahl's ear and acquire a natural-looking appearance, a technique of cartilage scoring and a folding cartilage flap was used. The entire layer of the cartilage was cut through and the anterior skin covering the cartilage was dissected to the external border of the desired superior crus and antehelix to form a fan-shape flap. After scoring of the posterior surface of the cartilage, the cartilage flap was folded and sutured to the cartilage below to build the superior crus. RESULTS: Seventeen patients ranging in age from 9 to 46 years were operated upon using this technique. The ears that were created were of normal size and shape. All patients and their families were satisfied with the final result. There were no complications. CONCLUSION: We have developed a new method to correct Stahl's ear deformity. Outcomes of this technique on 17 patients suggest that our method is simple, effective and successful.

Individual earmuff during reconstruction of the auricle.

BACKGROUND: Auricular reconstruction represents one of the most demanding challenges in craniofacial surgery. But some of the complications may be stimulated by trauma or continuing pressures. Therefore, earmuff is important to the reconstructed ears as a protective guard. The widely used traditional earmuff was designed by Tanzer and Chaisson. We renovated a more comfortable and much safer individual earmuffs using a low-temperature thermoplastic splint. METHODS: The low-temperature thermoplastic splint was softened by hot water at 60°C to 70°C. Afterward, the low-temperature thermoplastic splint was stretched over an oval plaster mold. Then, it was fabricated, followed by trimming of the excess material, leaving a quarter-inch flange attached to the cup. Individualized adjustment of the earmuff was performed by immersing in hot water at 60°C to 70°C. When intenerated, it was placed around the reconstructed ear for 10 to 15 minutes until completion of shaping could be achieved. Finally, the earmuff was fixed with elastic band, which was based on the size of child's head circumference and could be adjusted for the patient's comfort. RESULTS: The individualized earmuff was applied in more than 400 patients after surgery of microtia reconstruction. Such individualized earmuffs are proved to provide sufficient protection, while leaving no major problems. CONCLUSIONS: The individual earmuff provides effective protection, secure fit, and comfort for the reconstructed ear.

[A surgical strategy and treatment outcome of acquired auricular defect].

OBJECTIVE: To investigate the clinical outcome of a surgical strategy by soft tissue expansion in treating acquired auricular defect. METHODS: Between January 2007 and December 2009, 136 patients with acquired auricular defect were treated with a surgical strategy by putting autoallergic costal framework after soft tissue expansion. There were 93 males and 43 females, aged 8-60 years (median, 20 years). Defects were caused by burn in 82 cases, by trauma in 47 cases, and by bite in 7 cases. Defect involved in almost the whole auricle and earlobe in 50 patients, 2/3 superior part of auricle in 35 patients, 1/3 superior part of auricle in 31 patients, 1/3 middle part of auricle in 9 patients, and 1/3 inferior part of auricle and earlobe in 11 patients. RESULTS: All the flaps had good blood supply, skin grafts all survived, and all the wounds healed by first intention after operation. All patients were followed up 6-24 months with an average of 14 months. All reconstructive auricle survived with good color, soft texture, and normal sensory function; the appearance had no enlargement and attrition, and the grafted costal cartilage framework had no melanosis, absorption, and deformation. The reconstructed ear had the same position, size, shape, and oto-cranium angle as normal ear. The curative effect was good according to ZHUANG Hongxing's evaluation standard of auricular reconstruction. CONCLUSION: To reconstruct auricle by soft tissue expansion is an effective method. The position of putting expander and the number of expanders are different in different patients.

Tumbling cartilage flap and free auricular composite tissue transplantation for correcting mild and moderate forms of constricted ear.

OBJECTIVE: To report a new surgical approach that results in a natural size and contour of the external malformed constricted ear. METHODS: A total of 62 consecutive patients with constricted ear underwent surgery between July 1, 2005, and December 31, 2007. Depending on the features and severity of the deformity, the methods of tumbling cartilage flap (CF), free auricular composite graft, or a combination of these 2 techniques were applied. RESULTS: A total of 45 patients were treated with the method of tumbling CF. Twelve were treated with an auricular composite graft from the contralateral ear, and in 5 patients a combination of the 2 methods was used. In all cases, there was an improvement in the size, shape, and symmetry of the ears, and most patients were satisfied with the outcome. Complications were rare, and there was no donor site deformity. CONCLUSIONS: The technique of tumbling CF and free auricular composite graft provides a simple and promising treatment for constricted ears. Furthermore, this technique is easy to apply with a predictable good outcome.

Surgical management of polyotia.

BACKGROUND: Polyotia is an extremely rare type of congenital external ear malformation, which is defined as an accessory ear that is large enough to resemble an additional pinna. The terms 'mirror ear' or 'accessory ear' are sometime used. We present our methods in correcting this malformation and summarise the aetiology. METHODS: The posterior part of the polyotia may presents with a normal ear, a constricted ear or a microtic ear. Free auricular composite tissue transplantation was used to correct the constricted ear. Ear reconstruction was applied in cases of microtia. The anterior auricle was mainly used to form the tragus. RESULTS: 7 cases polyotia were treated between 2004 and 2008. After free auricular composite tissue transplantation the size of the constricted ear and the contralateral ear was similar. In microtia cases the reconstructed ears were natural looking and had a satisfactory three-dimensional contour. The extra tissue of the anterior ear was excised and the tragus was reconstructed. CONCLUSIONS: Through operative intervention tailored to the individual case natural-looking and symmetric ears were acquired. The aetiology of polyotia probably relates to abnormal migration of neural crest cell.

Clinical analysis, repair and aetiology of question mark ear.

UNLABELLED: The question mark ear is a malformation involving a cleft between the helix and the earlobe. The upper portion of the ear appears protruding and the scapha is absent from the affected region. The severity of this ear malformation varies from a small notch in the helix to complete separation of the helix and the lobe. In this article, we classify the question mark ear according to the severity of the malformation and propose two different methods of correction. In addition, we review the aetiology of the question mark ear and hope this can enhance the understanding of the pathology. METHODS: In the repair of moderate question mark ears, the local chondrocutaneous flap is used. In severe cases, tissue expander and autogenous rib cartilage are applied to reconstruct the deficiency of the lower part of the ear. RESULTS: There were 32 cases of question mark ears from July 2003 to December 2007. Thirty cases were sporadic and two cases had familial history. Twenty-two moderate question mark ears were repaired using chondrocutaneous flap transposition and ten severe question mark ears were repaired using tissue expander and autogenous cartilage. CONCLUSIONS: In moderate question mark ears, the corrected auricle showed a shape similar to that of the unaffected auricle, but the size was a little smaller. Most of the reconstructed severe question mark ears showed excellent contour.

Use of the remnant ear for reconstruction in lobule-type microtia.

OBJECTIVE: To present in detail a reconstruction technique using the remnant ear in lobule-type microtia. METHODS: By comparing the location of residual ear and the contralateral normal ear, we classified 3 different types of the remnant ear. Three techniques of transposition were applied to adjust the location of the reconstructed ear. RESULTS: The reconstructed earlobes not only looked real but also were symmetrical with the contralateral normal ears. CONCLUSION: The remnant ear is a key factor-in addition to the framework and covering skin-in ear reconstruction in microtia.

[Application of quantitative tissue expansion in ear reconstruction].

OBJECTIVE: To explore the application of tissue expander in ear reconstruction and to deal with the complications. METHODS: 50 ml kidney-shape tissue expanders were implanted subcutaneously in the mastoid area. The drainage tube was removed 3 days after operation. The suture was removed 10 days later. Since 7 days after operation, 5 ml NS was injected into the expander every time, three times a week. The total injection volume was about 60 ml. After that, the expander was maintained for one month. RESULTS: From January 1992 to December 2006, 5,248 patients of microtia were treated with 6,252 expander. After the maintaining period, the expanded skin was thin and well-vascularized. The complication rate was 7.79%, including hematoma, malunion and infection. CONCLUSIONS: The quantitative tissue expansion is easily manipulated with few complications. It can provide hairless, thin skin with reliable blood supply for ear reconstruction.

[Fabrication and application of three-dimensional autogenous cartilage framework in auricular reconstruction].

OBJECTIVE: To explore the fabrication and application of three-dimensional autogenous cartilage framework in auricular reconstruction. METHODS: The process of fabrication of three-dimensional cartilage framework consisted of cartilage harvesting, carving and assembling the cartilage. The rib cartilage was harvested separately. The three-dimensional framework was composed of three main parts:the helix, the base and the pad, at different layer. The framework was fabricated according to the development of rib cartilage and contour and height of the reconstructed ear. RESULTS: From January 1992 to December 2006, 5,248 patients of microtia were treated with 6,252 autogenous cartilage frameworks. CONCLUSIONS: The three-dimensional framework is easily manipulated. The reconstructed ears look natural and had an erect contour. This method can effectively use the cartilage.

[Application of the remnant in repairing the reconstructed ear in microtia].

OBJECTIVE: To explore the application of the remnant in repairing the reconstructed ear in microtia. METHODS: From October 2000 to July 2006, 1,823 patients with reconstructed ear underwent the second operation for repairing. The remnants were used to reconstruct tragus, antitragus, crus of helix, concha cavum, or relax the adhesion between the reconstructed auricle and cranio wall, or insert into the reconstructed lobule or under the basement of the costal cartilage frame to restore the cranio-auricular angle or to the preauricular subcutaneous to correct the facial local depression. RESULTS: In 1,823 cases, the tragus, antitragus and concha cavum was reconstructeded by remnant auricle in 1,180 cases; helix crus was repaired by remnant auricle in 743 cases; the wound was repaired by remnant auricle flap resulted from relaxing the adhesion between the reconstructed auricle and cranial wall in 68 cases; Subcutaneous and cartilage flap was formed and transferred in 95 cases, and among them the flap was transferred under the basement of the frame to restore the cranio-auricular angle in 77 cases and was transferred to the preauricular subcutaneous to correct the facial local depression in 18 cases; the skin flap was formed by remnant auricle to repair the lobule in 37 cases. All flaps survived completely. The appearance of reconstructed ear was satisfied. CONCLUSION: The remnant is very useful in repairing the reconstructed ear in microtia. It should be preserved propriately in auricular reconstruction.