A new operative method of correcting cryptotia using large Z-plasty

Transcription

1 British Journal of Plastic Surgery (2001), 54, The British Association of Plastic Surgeons doi: /bjps SURGERY A new operative method of correcting cryptotia using large Z-plasty T. Yotsuyanagi, K. Yamashita, Y. Shinmyo, K. Yokoi and Y. Sawada Department of Plastic and Reconstructive Surgery, Hirosaki University School of Medicine, Hirosaki, Japan SUMMARY. A large Z-plasty on the postauricular surface of the ear has been used for successful reconstruction of cryptotia. This technique provides extensive skin coverage of the posterior auricle without skin grafting. The technique is easy and simple. The natural hairline is not disturbed and the temporoauricular sulcus is emphasised. Almost all of the scar is hidden behind the auricle. It has been performed on 17 patients with no recurrence of the cryptotia. One patient had partial congestion in the cranial-flap tip, which improved within 1 week. There were no other complications The British Association of Plastic Surgeons Keywords: cryptotia, auricular deformity, Z-plasty. Cryptotia is a congenital auricular deformity common in Orientals but rare in Caucasians. The upper portion of the auricle is buried beneath the temporal skin and can be pulled out by hand but returns to its original state when released. This buried state makes the wearing of glasses or a mask difficult and is not cosmetically acceptable. It is known that conservative therapy using a splint is very effective in early neonates and we recently reported that it is also effective in older children when continuous and gradual correction is made. 1,2 However, an operative procedure is necessary if splint therapy is not effective because of severe deformity of the cartilage or if the patient discontinues applying the splint. We report a new method of cryptotia reconstruction in which a large Z-plasty is applied. Methods Traction is applied to the upper part of the auricle away from the scalp, and the shortest line is drawn to form the central ann of the Z-plasty. This central arm is usually orientated in the posterosuperior direction. In the posterior auricle, this arm begins at the hairline and runs across the temporoauricular sulcus to the posterior scaphoid fossa. The cranial lateral arm of the Z-plasty is drawn along the hairline and extended beyond the cephaloauricular sulcus. The caudal lateral arm of the Z-plasty is drawn such that it is extended to the temporoauricular sulcus. The angle between the middle arm and the cranial lateral arm is greater than 60 ~. The angle between the middle arm and the caudal lateral arm is less than 45 ~. The cranial flap is large and is later rotated to cover the posterior surface of the auricle. The caudal flap is small and is later advanced to the cranial side (Fig. 1). After skin incision, the posterior surface of the upper half of the cartilage is exposed. The deformity results from both the abnormal course of the superior auricular muscle and the shortening of the intrinsic transverse muscle. The superior auricular muscle is usually inserted into the prominence of the triangular fossa. However, in cryptotia, this muscle is abnormally inserted into the cartilage of the scapha and the upper portion of the ear is contracted. This muscle should be dissected and corrected to the normal position. 3-5 In addition, the fibrous tissue and the intrinsic transverse muscle causing the contracture of the antihelix should be dissected. When these procedures do not achieve complete release of the contracture, multiple vertical and horizontal incisions are made to remodel the cartilage using mattress sutures tied over bolsters. These cartilage incisions are made at 3-5 mm intervals over the entire antihelix and scaphoid fossa. With this procedure even severe deformities of the cartilage can be greatly improved. The gauzeroll bolsters are placed on the scaphoid fossa and the posterior auricular surface, and nylon sutures are passed through these bolsters including the full thickness of the auricle. If the cartilage deformity still remains and the cartilage provides no suspension force to the upper half of the auricle, a conchal-cartilage graft may be considered. In these cases postoperative splintage is recommended. 6'7 The cranial and caudal flaps are replaced and sutured. By advancing the caudal flap to the cranial side, the temporoauricular sulcus is emphasised and recurrence of the cryptotia is prevented. The cranial flap is big enough to cover the whole postauricular surface without tension. There is little dog-ear formation to be corrected (Fig. 2). Results This technique has been used on 17 ears in 17 patients (Figs 3 and 4). In 12 ears we observed an abnormal course of the superior auricular muscle. We could not find any muscle fibres in the other five ears. Although all the ears had an abnormal antihelical projection, shortening of the intrinsic transverse muscle was found in only 11 ears. The other six cases had tight fibrous tissues without any muscle fibres. In three patients the cartilage deformities could be treated by correction of the superior auricular muscle and 20

2 Large Z-plasty for correction of cryptotia 21 /? A Figure 1--Schematic diagram of our technique. Design from (A) the anterior side of the auricle and (B) the posterior side when the upper portion of the auricle is retracted to the desirable form. ] i,i A B Figure ~-Postoperative view of the auricle. (A) The anterior side and (B) the posterior side. After replacing the flaps, the middle ann of the Z-plasty is coincident with the temporoauricular sulcus. dissection of the intrinsic transverse muscle. In 12 patients simultaneous multiple cartilage incisions were necessary and in two patients conchal-cartilage grafting was necessary. Recurrence of the cryptotia was prevented and there was no recurrence of the cartilage deformity in any of the cases. One patient had partial congestion in the cranialflap tip, which resolved within a week. There were no complications in the other patients. Discussion There have been many operative techniques reported for the correction of cryptotia. They can be classified broadly into local flaps, local flaps with skin grafting, buried sutures, and tissue expansion. In the group of techniques using local faps, representative methods are a V-Y procedure, 3'8-15 a rotation flap, 4't6-18 a transposition flap, a subcutaneous pedicle flap 23 or a Z-plasty Local flaps are cosmetically satisfactory and the complications are minimal. However, early recurrence of the cryptotia, due to deficient posterior coverage of the skin, is often a major problem. The operative scar is conspicuous when the flap is designed on the scalp or in the preauricular area. Also, a combination of small flaps that are difficult to design and suture is another problem, and almost all of the techniques using local flaps create a dog ear that must be corrected.

3 22 British Journal of Plastic Surgery Figure A 12-year-old girl with right-sided cryptotia corrected by using our technique. (A) Preoperative view. (B) Flap design. (C) After cutting and undermining of the skin, the cartilage was corrected to a normal position. The tip of the forceps indicates the abnormal insertion of the superior auricular muscle to the eminence of the scapha. (D) Immediate postoperative view. Some surgeons have pointed out that it is difficult to cover the posterior surface of the auricle using local flaps only because of the deficiency of skin, and have recommended that a skin graft be applied at the same time as a local flap. 2s-34 However, a skin graft takes longer to heal and the texture and colour match are sometimes poor. The use of buried sutures is easy and safe However, recurrence of cryptotia frequently occurs and the cartilage deformity may not be corrected efficiently. The use of a tissue expander takes a long time and involves a minimum of two stages. 3s We found that using skin grafting and local flaps requires only a very small grafted area. Some surgeons

4 Large Z-plasty for correction of cryptotia 23 Figure 4--Postoperative appearance at 1 year: (A) anterior view and (B) posterior view. have recommended that the skin to be grafted should be taken from the dog ear after transposition of a local flap. 2s-3~ This suggests that a technique using local flaps that do not make a dog ear should achieve success without skin grafting. Techniques using the principle of multiple small Z-plasties have been reported but these cannot cover the posterior auricular surface sufficiently. Our technique has the following significant advantages: dog-ear formation is rare; posterior coverage using a large amount of skin is possible; the design is simple and the procedure is easy; the temporoauricular sulcus is deepened; the scar is almost hidden behind the auricle; there is wide operative exposure to correct the cartilage deformity and the natural hairline is not disturbed. We recommend that operations for cryptotia are performed before the age of 5 years if possible. We believe that earlier release from the deformity will accelerate the normal growth and development of the auricles. This technique works even if the deformity of the auricle is severe. References 1. Yotsuyanagi T, Yokoi K, Sakuraba M, Sugawara M. The use of a thermoplastic splint for treating cryptotia. Jpn J Plast Reconstr Surg 1993; 36: Yotsuyanagi T, Yokoi K, Urushidate S, Sawada Y. Nonsurgical correction of congenital auricular deformities in children older than early neonates. Plast Reconstr Surg 1998; 101: Torikai K, Ando S, Yoshida T, Asano T, Matsumoto Y, Anse M. Anatomy of the auricular muscles and its surgical application. Jpn J Plast Reconstr Surg 1982; 25: Matsuo K. Study of cryptotia: part 1. Otology for cryptotia. Jpn J Plast Reconstr Surg 1988; 8: Yotsuyanagi T, Nihei Y, Shinmyo Y, Sawada Y. Stahl's ear caused by an abnormal intrinsic auricular muscle. Plast Reconstr Surg 1999; 103: Yotsuyanagi T, Yokoi K, Urushidate S, Sawada Y. A supportive technique using a splint to obtain definite contour and desirable protrusion after reconstruction of microtia. Plast Reconstr Surg 1998; 101: Yotsuyanagi T. Compressive plastic splint for postoperative management of the ear. Br J Plast Surg 1993; 46: Kubo I. Taschenohr und Otoplastik. Oto-Rhino-Laryngologie 1933; 6: Tachibana M. Uber Taschenobr. Plast Otol (Kyoto) 1941; 36: Holmes EM. The microtic ear. Arch Otolaryngol 1949; 49: Fukuda O. Otoplasty of cryptotia. Jpn J Plast Reconstr Surg 1968; 11: Ohmori S, Matsumoto K. Treatment of cryptotia, using Teflon string. Plast Reconstr Surg 1972; 49: Matsumoto K. The characteristics of cryptotia and its therapy. Jpn J Plast Reconstr Surg 1977; 20: Ono I, Gunji H, Suda K, Tateshita T, Kaneko F. A new operative method for treating severe cryptotia. Plast Reconstr Surg 1995; 96: Arai K, Fukuda O. On the morphological classification of cryptotia and its operational method. Jpn J Plast Reconstr Surg 1974; 17: Onizuka T, Tokunaga S, Yamada K. A method for repair of cryptofla. Ptast Reconstr Surg 1978; 62: Hirose T, Tomono T, Matsuo K, et al. Cryptotia: our classification and treatment. Br J Plast Surg 1985; 38: Pollock WJ. Technique for correction of cryptotia: case report. Plast Reconstr Surg 1969; 44: Argamaso RV. Cryptotia: its surgical correction. Ann Plast Surg 1979; 2: Matsumoto K, Moriguchi T, Inoue K, Fukamizu H. New surgical reconstruction of cryptotia with local flaps. Jpn J Plast Reconstr Surg 1982; 25: Elsahy NI. An alternative technique for correction of cryptotia. Ann Plast Surg 1989; 23: Chana JS, Fourie LR. A technique for the correction of cryptotia. Ann Plast Surg 1997; 39: Nakajima T, Yoneda K, Yoshimura Y. Correction of cryptotia using a subcutaneous pedicled flap. Br J Plast Surg 1991; 44: Takahashi Y. A new operative method of cryptotia: a modification of Z-plasty. Jpn J Plast Reconstr Surg 1963; 6:

5 24 British Journal of Plastic Surgery 25. Kantu K, Aretsky PJ, Polisar IA. Cryptotia. Laryngoscope 1972; 82: Hyakusoku H, Fumiiri M. The square flap method. Br J Plast Surg 1987; 40: Yanai A, Tange I, Bandoh Y, Tsuzuki K, Sugino H, Nagata S. Our method of correcting cryptotia. Plast Reconstr Surg 1988; 82: Ogino Y, Shiraishi T. Operative procedure for pocket ear. Jpn J Plast Reconstr Surg 1963; 6: Tani T, Hosokawa C, Akazawa A. Operative procedure for cryptotia. Jpn J Plast Reconstr Surg 1963; 6: Ohara Y. A method for surgical correction of the congenital invagination of the external ear. Jpn J Plast Reconstr Surg 1969; 12: Wesser DR. Repair of a cryptotic ear with a trefoil flap: case report. Plast Reconstr Surg 1972; 50: Matsunaga T, Nakajima R, Yamada S, Okumura S, Ogino S, Nishio T. Treatment of cryptotia. Otolaryngology (Tokyo) 1974; 45: Nishimura Y. Correction of cryptotia. Jpn J Plast Reconstr Surg 1975; 18: Park S, Takushima M, Minegishi M. Reconstruction of cryptotia using a skin graft. Ann Plast Surg 1994; 32: Ichihara M. Cryptotia plasty. Otolaryngology (Tokyo) 1954; 26: Nagai S. A new surgical technique for cryptotia. Syujutsu (Tokyo) 1960; 2: Inoue Y, Nishitani S, Yoshitatsu S, Ohara Y. PDS suture therapy for cryptotia. Jpn J Plast Reconstr Surg 1993; 36: Mutimer KL, Mulliken JB. Correction of cryptotia using tissue expansion. Hast Reconstr Surg 1988; 81: The Authors Takatoshi Yotsuyanagi MD, PhD, Associate Professor Ken Yamashita MD, Resident Yasuhiro Shinmyo MD, Instructor Katsunori Yokoi MD, Instructor Yukimasa Sawada MD, PhD, Professor Department of Plastic and Reconstructive Surgery, Hirosaki University School of Medicine, 5 Zaifu-cho, Hirosaki , Japan. Correspondence to Takatoshi Yotsuyanagi. Paper received 2 July Accepted 11 September 2000, after revision. Published online 9 November 2000.