RU2813811C1 - Method of surgical removal of closed ear deformation - Google Patents

Abstract

FIELD: medicine; maxillofacial surgery.

SUBSTANCE: method consists of two surgical stages. At the first stage, plastic surgery of local tissues is carried out, preserving the resulting excess skin and using it in the second stage. During the first stage, a fragment of costal cartilage is implanted, covered with a rotated sheet of superficial temporal fascia and moved into the previously left skin pocket. An incision is made in the skin and cartilage from the dorsal surface of the auricle parallel to the course of the intended antihelix along the entire length of the cartilaginous part of the auricle without damaging the integrity of the perichondrium from the anterior surface. Then the incisions are made parallel to the previous incision, retreating 1.5–2 mm from each other. Further, these incisions continue towards the upper cartilaginous edge in the form of diverging rays. The formed cartilaginous strips, gradually expanding from the base to the edge, are mobilized. The anterior edge of the auricle is cut off from the temporal region. The shape of the auricle is compared in the new position, the cartilaginous strips are fixed in the new position to each other with long-absorbable monofilament. The skin flaps along the edges of the wound are placed back on top of the formed auricle, preserving the resulting excess skin. Next, forming rollers soaked in Levomekol, Heparin and Vasilin ointments are placed above and below the antihelix. They are fixed with U-shaped sutures. The second stage is carried out after 1 year. A skin incision is made in the temporal region, 1 cm away from the edge of the auricle. The skin flap is mobilized and the cartilaginous part of the helix is exposed. A fragment of a costal cartilaginous autograft is implanted, restoring the relief and size of the opposite relatively healthy ear. It is fixed to the cartilaginous rudiment. The parietal branch of the superficial temporal artery is ligated below the site of the intended incision. A fascial flap is cut out and mobilized on the feeding pedicle with the base facing the auricle. Next, the fascial flap is tilted along with the feeding vessel by 180°, covering the cartilage autograft and a part of the auricle's own cartilage. Vacuum aspiration is created by introducing active drainage under the fascia. Skin flaps are placed over the auricle. The wound is sutured. The forming rollers soaked in Levomekol, Heparin and Vasilin ointments are fixed with U-shaped sutures above and below the antihelix. The drainage is removed.

EFFECT: method makes it possible to increase the efficiency of eliminating deformation of the folded auricle due to a deficiency of cartilage tissue, reduce the trauma of surgical treatment, preserve local tissue, reduce the number of cicatricial deformities, and reduce the risk of postoperative complications.

1 cl, 8 dwg, 2 ex

Description

The invention relates to medicine, namely to maxillofacial surgery, and can be used for surgical elimination of deformation of the auricle such as a “folded” (rolled) ear with a significant deficiency of cartilage tissue.

When the auricle is folded, its upper part bends forward and downward. Depending on the severity of the lesion, there are 3 degrees of deformation. In grade I, the expanded part of the helix bends downward, and its upper edge is located at the level of the lateral leg of the antihelix. The vertical size of the auricle is reduced, but when extended (moved to the correct position) it is close to normal. In degree II, the edge of the helix is at the level of the upper part of the cup, the antihelix is underdeveloped. The vertical size of the shell has been reduced. It will not be possible to move the curl upward with your fingers due to a lack of tissue. In grade III, the edge of the helix is located at the level of the tragus, the entire upper part of the auricle is underdeveloped and displaced anteriorly. The deformity is often accompanied by stenosis of the external auditory canal and deafness. [Pshenisnov K.P., Bessonov S.N. Congenital deformities and reconstruction of the auricle. / Plastic surgery course. Ed. K.P. Pshenisnova. - Yaroslavl; Rybinsk: Publishing House OJSC Rybinsk House of Printing. 2010;(T.1). - P. 553], [Sergienko V.I., Kulakov A.A., Petrosyan N.E., Petrosyan E.A. Otoplasty (ear plastic surgery) / Plastic surgery of the face and neck. - M..: GEOTAR-Media, 2010. - P. 273].

There are known methods for eliminating congenital deformation of folded ears, indicated depending on the degree of damage. The most commonly used method is Musgrave (1966), identical to the Stephenson method modified by Kruchinsky. In this case, the deformed area of the cartilage is cut in several places, strips are formed that diverge to the sides, thereby expanding the restored part of the auricle. Next, a strip of cartilage is excised at the base of the cochlear fossa, which is then fixed along the upper and anterior edge of the dissected areas, forming a curl of the auricle. [Chkadua T.Z. Rehabilitation of patients with defects and deformations of the auricles: dis... Dr. med. Sciences: 01/14/14, 01/14/17 / Chkadua Tamara Zurabovna. - M., 2011. - P. 27-28.] [Pshenisnov K.P., Bessonov S.N. Congenital deformities and reconstruction of the auricle. / Plastic surgery course. Ed. K.P. Pshenisnova. - Yaroslavl; Rybinsk: Publishing House OJSC Rybinsk House of Printing. 2010;(T.1). - P. 554-555]. This technique is suitable for cases where the patient has enough cartilage tissue in the deformed area to be formed into the correct anatomical structures after cutting into strips. In most cases, with congenital pathology of the “folded ear,” the cartilage is deformed not only in shape, but also in size, and this type of operation can lead to unsatisfactory results, as well as to necrosis of cartilage strips that are too widely spaced from each other. The remaining known methods are not widely used.

There is a known method for eliminating protruding ears according to Pshenisnov, which consists in the formation of longitudinal notches in the area of the antihelix, in order to weaken the cartilage, form the antihelix and reduce the ear-head angle. [Pshenisnov K.P. Facial plastic surgery: a guide for doctors / ed. K.P. Pshenisnova. - Moscow: GEOTAR-Media, 2022. - P. 778-780]. This method allows obtaining stable results for the correction of deflated ears, but is not used to eliminate deformation of the folded ear.

The technical result of the invention is to increase the efficiency of eliminating deformation of the folded auricle by reducing the trauma of the first stage of surgical treatment, preserving local tissues, reducing the number of cicatricial deformities and reducing the risk of postoperative complications.

The technique involves 2 stages. During the first stage, the redistribution of local tissues is carried out and their maximum preservation, as well as the preservation of blood supply to the temporal region. During the second stage, a cartilaginous element taken from the rib is implanted (in addition to the rudiment), which brings the aesthetic appearance of the affected auricle closer to a healthy one.

This is achieved by combining the Musgrave method for eliminating the deformation of the folded auricle with the Pshenisnov method for eliminating the spaced auricles during the first stage of the proposed technique. In this case, incisions that do not reach the perichondrium on the anterior surface are carried out not in both directions, which will lead to irreversible deformation and lysis of the cartilage, but in single lines parallel to each other in the area of the cup and diverging at the upper edge, corresponding to the landmarks described in both of these techniques.

The incisions, located at a distance of 1.5-2 mm from each other, are not through and parallel to the antihelix, continue into diverging through cuts of the cartilage, perpendicular to the helix.

The incision is made along the dorsal surface of the auricle, without excision of excess skin and without moving to the temporal region. This allows the remaining skin to be used in the second stage and preserve the integrity of the vessels of the superficial temporal artery.

During the second surgical stage, an incision is made along the old scar, and the excess skin left after the first stage allows the additional fixed cartilaginous element to be covered along with the rotated fascial sheet. Since the postoperative scar remains only on the dorsal surface of the auricle, good conditions are created near the skin of the anterior surface for the formation of relief, and the trophism of the reconstructed auricle remains undisturbed.

List of figures

Fig. 1 - diagram of the location of cartilage incisions during the first surgical stage of eliminating the deformity of the folded auricle.

Fig. 2 - diagram of skin incisions and movement of flaps during the first surgical stage of eliminating the deformity of the folded auricle.

Fig. 3 - appearance of the auricle at the end of the first surgical stage of eliminating the deformity of the folded auricle.

Fig. 4 - appearance of the auricle 14 days after the first surgical stage of eliminating the deformity of the folded auricle.

Fig. 5 - appearance of the auricle 2 weeks after the second surgical stage of eliminating the deformity of the folded auricle.

Fig. 6 - appearance of the auricle of patient K. before treatment.

Fig. 7 - appearance of the auricle of patient K. 14 days after the first surgical stage.

Fig. 8 - appearance of the auricle of patient F. 1 year after the second surgical stage.

The method is carried out as follows (Fig. 1-7).

At the first stage during the operation, anatomical landmarks of the cartilage incision lines are marked using a permanent marker and injection needles soaked in brilliant green (Fig. 1). A skin incision is made along the dorsal surface of the deformed auricle, parallel to the course of the intended antihelix, along the entire length of the cartilaginous part of the auricle. The perichondrium is exposed bluntly and cut sharply without damaging the underlying cartilage. The cartilaginous part of the auricle is exposed along the entire dorsal surface, moving to the edge and anterior surface, so as to mobilize its deformed area. Anatomical landmarks and cartilage cut lines are re-marked. From the dorsal surface, a cartilage incision is made parallel to the lower part of the antihelix of the auricle, without damaging the integrity of the perichondrium from the anterior surface. At a distance of 1.5-2 mm from each other, several more incisions are made, parallel to the previous one, also without violating the integrity of the anterior perichondrium. Further, these incisions continue at an angle towards the upper cartilaginous edge, in the form of diverging rays that do not intersect each other. From the level of cartilaginous deformation to the upper edge of the auricle, the incisions are through. The formed cartilaginous strips, gradually expanding from the base to the edge, are mobilized. The anterior edge of the auricle is cut off from the temporal region. The shape of the auricle is compared in a new position, the cartilaginous strips are fixed in a new position among themselves with a long-absorbable monofilament. To enhance the stability of the structure in the area of previously located deformation, cartilage strips are fixed to the subcutaneous fat. The skin flaps along the edges of the wound are placed back on top of the formed auricle and redistributed (Fig. 2). Since corrective surgeries are planned in the future, during which it will be necessary to use additional soft tissue, excess skin is not removed. The wounds are sutured with non-resorbable monofilament thread. Next, forming rollers soaked in Levomekol, Heparinova and Vasilin ointments are placed above and below the antihelix, fixed with U-shaped sutures and braided resorbable thread (Fig. 3). A pressure aseptic bandage is fixed. 2 weeks after the operation, the forming ridges and sutures are removed (Fig. 4).

1 year after the first stage, the second surgical stage is performed. During the operation, an incision is made in the temporal region, 1 cm away from the edge of the auricle. The skin flap is mobilized bluntly and the cartilaginous part of the helix is exposed. A fragment of a rib cartilaginous autograft is implanted, restoring the relief and dimensions corresponding to the opposite conditionally healthy ear. The autograft is fixed with a non-resorbable monofilament to the cartilaginous rudiment. The tissues are bluntly separated subcutaneously in the temporal region distally, exposing the superficial temporal fascia. A template is created from a gauze napkin, which is used to determine the size of the fascia necessary to cover the upper part of the auricle. The parietal branch of the superficial temporal artery is ligated below the site of the intended incision. Using an oblique incision, an incision is made in the superficial temporal fascia according to the template. The fascial flap is mobilized bluntly on the feeding pedicle, with the base facing the auricle. The fascial flap is tilted along with the feeding vessel 180 degrees, covering the cartilage autograft and part of the auricle's own cartilage, and is fixed with a braided resorbable thread in the new position. Vacuum aspiration is created by introducing active drainage under the fascia. Skin flaps are placed over the auricle. The wound is sutured with interrupted sutures and non-resorbable monofilament thread. Forming rollers soaked in Levomekol, Heparinova and Vasilin ointments are placed above and below the antihelix, fixed with U-shaped sutures and braided resorbable thread. The drainage is removed. An aseptic non-pressure, forming bandage is fixed. 2 weeks after the operation, the forming ridges and sutures are removed (Fig. 5).

The proposed technique can be used for patients with degrees II and III of severity of deformation of the folded auricle.

Using the proposed method, 5 patients (children aged 6 to 8 years) were operated on. Four patients underwent one (first) stage and continued treatment is planned. One patient underwent both stages, and long-term results were obtained - 5 years after the deformity was eliminated. In all cases, the patients obtained a similar technical result, namely: in patients who underwent the first stage, in the early stages and a year after the operation, the shape of the simulated local tissues was preserved, without the occurrence of secondary deformations and without the occurrence of scar deformities; in the patient who underwent both stages, after 5 years, stable preservation of the aesthetic result was determined, without the occurrence of postoperative complications.

The proposed method has a number of advantages, such as:

• achieving a final aesthetic result close to a healthy ear;

• preservation of all cartilage tissue of the auricle, without excision of its deformed areas and without the risk of necrotization;

• maintaining the integrity of the skin in the area of future implantation of an additional cartilage fragment;

• absence of noticeable postoperative skin scars in patients with folded auricle deformity.

Clinical example 1 (Fig. 6, 7). Patient K., 6 years old, presented with an aesthetic defect - deformation of the folded auricle (Fig. 6). An examination was carried out and a treatment plan was drawn up.

At the first stage of the operation, anatomical landmarks of the cartilage incision line were marked using a permanent marker and injection needles soaked in brilliant green. A skin incision was made along the dorsal surface of the deformed auricle, parallel to the course of the intended antihelix, along the entire length of the cartilaginous part of the auricle. The perichondrium was exposed bluntly and cut sharply without damaging the underlying cartilage. The cartilaginous part of the auricle is exposed along the entire dorsal surface, with a transition to the edge and anterior surface, so as to mobilize its deformed area. Anatomical landmarks and cartilage cut lines were re-marked. A cartilage incision was made from the dorsal surface parallel to the lower part of the antihelix of the auricle, without damaging the integrity of the perichondrium from the anterior surface. At a distance of 1.5-2 mm from each other, several more incisions are made, parallel to the previous one, also without violating the integrity of the anterior perichondrium. Next, these incisions were continued at an angle towards the upper cartilaginous edge, in the form of diverging rays that did not intersect each other. From the level of cartilaginous deformation to the upper edge of the auricle, the incisions were through.

The formed cartilaginous strips, gradually expanding from the base to the edge, are mobilized. The anterior edge of the auricle was cut off from the temporal region. The shape of the auricle is compared in a new position, the cartilaginous strips are fixed in a new position among themselves. To enhance the stability of the structure in the area of previously located deformity, cartilage strips are fixed to the subcutaneous fat. The skin flaps along the edges of the wound were laid back over the formed auricle and redistributed. Since corrective surgeries are planned in the future, during which it will be necessary to use additional soft tissue, excess skin was not removed. The wounds were sutured.

Forming rollers soaked in Levomekol, Heparin and Vasilin ointments are placed above and below the antihelix and fixed. A pressure aseptic bandage is fixed. 2 weeks after the operation, the forming rollers and sutures were removed (Fig. 7).

The patient is currently under dynamic observation. The observation period is 1 year. At the age of 8 years, the second stage of ear reconstruction is planned.

Clinical example 2 (Fig. 8).

Patient E., 9 years old, presented with an aesthetic defect - deformation of the folded auricle. An examination was carried out and a treatment plan was drawn up. The first stage of surgical treatment was carried out according to the method we proposed, described above.

1 year after the first stage, the second surgical stage was performed. During the operation, an incision was made in the temporal region, 1 cm from the edge of the auricle. The skin flap was mobilized bluntly and the cartilaginous part of the helix was exposed. A fragment of costal cartilaginous autograft was implanted, restoring the relief and dimensions corresponding to the opposite conditionally healthy ear. The autograft is fixed. The tissues are bluntly separated subcutaneously in the temporal region distally, exposing the superficial temporal fascia. The parietal branch of the superficial temporal artery was ligated below the site of the intended incision. Using an oblique incision, an incision was made into the superficial temporal fascia according to the template. The fascial flap was mobilized bluntly on the feeding pedicle, with the base facing the auricle. The fascial flap will tilt together with the feeding vessel 180 degrees, covering the cartilage autograft and part of the auricle's own cartilage, fixed. Vacuum aspiration was created by introducing active drainage under the fascia. Skin flaps are placed over the auricle. The wound is sutured. Forming rollers soaked in Levomekol, Heparin and Vazilin ointments are laid and fixed. Drainage removed. An aseptic non-pressure bandage is fixed. 2 weeks after the operation, the forming rollers and sutures were removed (Fig. 8).

The patient is currently under dynamic observation. The observation period is 5 years.

Claims (1)

A method for eliminating deformation of the folded auricle, consisting of two surgical stages, in which the first stage involves plastic surgery of local tissues, preserving the resulting excess skin and its use in the second stage, during which a fragment of costal cartilage is implanted and covered with a rotated sheet of superficial temporal fascia and moving to the previously left skin pocket, characterized in that an incision is made in the skin and cartilage from the dorsal surface of the auricle parallel to the course of the intended antihelix along the entire length of the cartilaginous part of the auricle without damaging the integrity of the perichondrium from the anterior surface, then incisions are made parallel to the previous incision, retreating 1 .5-2 mm from each other, then these incisions continue towards the upper cartilaginous edge, in the form of diverging rays, the formed cartilaginous strips, gradually expanding from the base to the edge, are mobilized, the anterior edge of the auricle is cut off from the temporal region, the shape of the auricle is compared in the new position, the cartilaginous strips are fixed in the new position between each other with a monofilament of long-term resorption, the skin flaps along the edges of the wound are placed back on top of the formed auricle, preserving the resulting excess skin, then forming rollers are placed, soaked in Levomekol, Heparin and Vasilin ointments above and below the antihelix, fixed with U-shaped sutures; the second stage is carried out after 1 year, during which a skin incision is made in the temporal region, 1 cm away from the edge of the auricle, a skin flap is mobilized, the cartilaginous part of the helix is exposed, a fragment of a rib cartilaginous autograft is implanted, restoring the relief and size of the opposite conditionally healthy ear, and fixed it to the cartilaginous rudiment, the parietal branch of the superficial temporal artery is ligated below the site of the intended incision, a fascial flap is cut out and mobilized on the feeding pedicle with the base facing the auricle, then the fascial flap is tilted along with the feeding vessel 180°, covering the cartilage autograft and part of its own cartilage of the auricle, create vacuum aspiration by introducing active drainage under the fascia, skin flaps are placed over the auricle, the wound is sutured, forming rollers are fixed with U-shaped sutures, soaked in Levomekol, Heparin and Vasilin ointments, above and below the antihelix, the drainage is removed.