Abstract
Objectives:
Microtia is a severe congenital malformation of the external ear, and auricular reconstruction is still a challenge for plastic surgeons because of the complicated procedures and rare conditions. This study aimed to describe the location of subcutaneous effusion after auricular reconstruction and explore the clinical efficacy of the indwelling needle puncture drainage method in the treatment of local subcutaneous effusion.
Methods:
From January 2017 to December 2019, 1240 patients (1296 affected sides) who underwent auricular reconstruction using autogenous cartilage framework in the Plastic Surgery Hospital of Chinese Academy of Medical Science and Peking Union Medical College were selected. The local subcutaneous effusion occurred within 5 days after the drainage tube was removed, and the indwelling needle was used for puncture and drainage in the postoperative treatment.
Results:
A total of 55 patients had subcutaneous effusion after the operation, including 24 cases with Nagata’s method and 31 cases with the expanded single-flap method. One patient showed no obvious reduction after puncture and drainage by indwelling needle and improved after the secondary operation. Two patients had slight cartilage absorption. The remaining patients had good results.
Conclusions:
The method of the indwelling needle for puncture and drainage is easy to operate. The problem of local subcutaneous effusion after auricular reconstruction can be solved and good efficacy can be obtained.
Introduction
Congenital microtia is regarded as the second craniofacial malformation after cleft lip and palate, involving rudimentary auricle, external auditory meatus atresia, and middle ear malformation. 1,2 The incidence is reported to range from 0.83 to 17.4 per 10 000 births, with an average of 2.06 per 10 000 births. 3,4 Auricular reconstruction with autogenous cartilage framework is the mainstream method for microtia, including the Nagata’s method and expanded flap method. 5 -7 Covering the well-sculptured framework with thin skin tissues is the prerequisite for good results. 8 However, local subcutaneous effusion often occurs after the reconstruction because of surgical and postoperative drainage problems. The overlying skin flap may not fit closely with the scaffold, causing framework absorption, flap necrosis, and infection. 9 Therefore, this study reviewed patients with microtia who underwent auricular reconstruction in our hospital and introduced the management strategy for local subcutaneous effusion.
Materials and Methods
From January 2017 to December 2019, patients who underwent auricular reconstruction in the Department of Auricular Reconstruction at the Plastic Surgery Hospital, Chinese Academy of Medical Science and Peking Union Medical College (Beijing, China) were enrolled in this study. According to Nagata’s definition, we excluded patients with concha-type microtia, because this type of microtia can be corrected by local flap transfer or free transplantation of auricle composite tissue flap. 10 In addition, patients with the expansion double-flap method for auricular reconstruction were excluded because the local subcutaneous effusion was rarely observed. As a result, 1240 patients with microtia (1296 affected ears) were included in this study. A total of 912 patients were male, and 328 patients were female. Seven hundred twenty-one patients had their right ear affected, 463 patients their left ear affected, and 56 patients were bilateral. The ages ranged from 6 to 25 years, and the mean age was 11.4 years. According to Nagata’s definition, 905 ears (69.8%) were typical lobule-type microtia, 312 ears (24.1%) were small concha-type, and 79 ears (6.1%) were anotia. 10 Among the 1296 affected ears, 751 underwent the modified Nagata’s method, and 545 underwent the expanded single-flap method. This study was conducted according to the ethical standards of the World Medical Association Declaration of Helsinki. 11
Auricular reconstruction requires multiple stages, and costal cartilage transplantation is necessary for the scaffold shaping stage, which is prone to subcutaneous effusion. In this study, the reconstructed ear was clinically observed after the first stage of modified Nagata’s and the second stage of the expanded singe-flap method. The drainage tube was removed routinely in the first 5 days after the surgery. The reconstructed ear was observed daily since the local subcutaneous effusion was prone to occur within 1 to 3 days after removing the drainage tube. We considered there was no postoperative local subcutaneous effusion if no effusion was found 10 days after the surgery. If effusion occurred, the location was observed firstly and gently pressed with a sterile cotton swab to determine the amount and affected parts. After disinfection with 2% iodine tincture and 75% alcohol, the indwelling needle (Figure 1) was placed in the deepest part of the effusion location or avoid the framework to puncture at the most suitable position. After piercing the skin, the needle core was pulled out and a syringe was connected to maintain the negative pressure. Then, the needle was slowly advanced until contacting the framework and aspirated the effusion simultaneously. The extension tube could be connected if necessary, then a 20 mL syringe was connected at the end of the device to maintain negative pressure. The 0 suture or 5-0 Prolene was used to fix. The effusion was sent to the cultrate bacterium. Changing the syringe and recording the effusion volume daily were necessary. The device was removed after the effusion disappeared. Besides, the patient was known to take antibiotics orally until 2 days after pulling out the needle. The whole treatment time was 2 to 6 days, with an average of 3 days.
A, The indwelling needle for infusion. B, An extension tube can be connected to the indwelling needle to increase the length of the catheter and then connected with a 20 mL syringe to maintain the negative pressure.
All statistical analyses were performed using SPSS software, version 22.0. The enumeration data were compared with the χ2 test, in which a P value less than.05 was considered statistically significant.
Results
A total of 55 patients had local subcutaneous effusion after surgery, of which 38 patients were male and 17 patients were female. Thirty-four patients were affected on the right, and 21 patients on the left. Twenty-four patients underwent the modified Nagata’s method and 31 patients underwent the expanded single-flap method. Of the 55 patients, 8 patients were positive for Staphylococcus aureus infection. The results indicated that the prevalence of gender (P = .443) and laterality (P = .254) showed no statistical differences in the occurrence of local subcutaneous effusion. The factor of the surgical procedure showed a significant difference with the P value of .009 (Table 1).
Characteristics and Statistical Analysis of the 1240 Patients (1296 Ears) With Microtia.
a Bilateral patients were classified according to the more severe ears.
b Modified Nagata’s method.
c Expanded single-flap method.
The locations of subcutaneous effusion were shown in Table 2 and Figure 2. It mostly occurred in the scapha (58.3%) for patients with modified Nagata’s method, while in the postauricular region (35.5%) and the concha cavity (32.3%) for patients with the expansion method. The indwelling needle puncture drainage method was used for salvage treatment. One patient with the expansion method showed no obvious effusion reduction in the postauricular region but improved by surgery. Two patients with the modified Nagata’s method and the expansion method showed slight framework absorption (Figures 3 and 4). Fifty-two reconstructed ears were satisfactory with delicate appearance, suitable flap color, and bilateral symmetry of position. No complications occurred in the procedure, such as delayed wound healing or infection (Figures 5 and 6).
Location of the Effusion.
a Modified Nagata’s method.
b Expanded single-flap method.
Red area represents the most common site of local subcutaneous effusion, followed by orange area, yellow area, and green area. A, For patients with the modified Nagata’s method, subcutaneous local effusion mostly occurred in the scapha, followed by concha cavity, triangular fossa, and postauricular region. B and C, For patients with the expansion method, subcutaneous local effusion mostly occurred in the postauricular region, followed by concha cavity, scapha, and triangular fossa.
Local subcutaneous effusion occurred after the modified Nagata’s method, and partial cartilage absorption was observed at the junction of scaffold and lobule after 5 months.
A 9-year-old boy who underwent auricular reconstruction with the expanded single-flap method. A, Local subcutaneous effusion occurred in the concha cavity and triangular fossa on the third day after removing the drainage tube. B, Immediate result after the treatment using this method. C, Immediate result of removing the device after 3 days of the treatment. D, Partial cartilage absorption was observed at the helix after 10 months.
A 9-year-old boy who underwent auricular reconstruction with the modified Nagata’s method. A, Local subcutaneous effusion occurred in the scapha on the second day after the drainage tube was removed. B, Immediate result after the treatment using this method. C, Immediate result of removing the device after 3 days of the treatment. D, Seven-month postoperative view.
A 12-year-old boy who underwent auricular reconstruction with the expanded single-flap method. A, Local subcutaneous effusion occurred in the scapha and triangular fossa on the first day after removing the drainage tube. B, Immediate result of removing the device after 3 days of the treatment. C and D, 12-Month postoperative view.
Discussion
Congenital microtia is a severe malformation of the external ear, and the incidence is reported to vary from 0.83 to 1.53 per 10 000 births in China. 12 The auricle is a 3-dimensional organ on the body surface that composes over 10 detailed anatomic structures. Auricular reconstruction is still regarded as a challenge for plastic surgeons because of the complicated procedures and rare conditions. 13,14 The appropriate thickness of the skin flap fitting well on the delicate framework is the key to obtain satisfactory outcomes. 15 At present, the continuous negative pressure aspiration technology on auricular reconstruction is applied to maintain the early form of the reconstructed ear. The drainage set is usually removed 5 to 7 days after reconstruction, considering the catheter-related infection problem (Supplemental Material). 5 However, local subcutaneous effusion often occurs after removing the drainage tube, and the incidence was 55 of 1296 (4.2%) in this study. The reasons are as follows: (1) The creation of the pocket or the local skin flap could damage the soft tissues and produce more tissue fluid after the operation, such as the separation of the skin in the mastoid area and the dissection of the capsule of the expanded flap. (2) The auricular framework is wholly embedded in the encapsulated cavity and easy to cause fluid collection, because the framework should be tightly wrapped by soft tissues to prevent cartilage exposure. (3) Insufficient drainage occurs in local depressions because of the irregular surface of the 3-dimensional ear framework. In addition to surgery-related factors, the drainage tube shifts may lead to insufficient drainage because of the displacement of the tube itself, improper sleeping posture, and accidental external force. The movement of the drainage tube before extubation, such as pulled out of a small piece by an external force, could lead to insufficient drainage in triangle fossa and concha cavity. Therefore, partial skin flap might have poor contact with the framework and form a dead space after extubation, resulting in effusion. And the excessive abrasion of the tube and the local soft tissues may cause extra effusion accumulation.
In this study, the subcutaneous effusion often occurred in the scapha (58.3%) in the modified Nagata’s method, considering the skin cannot better fit the framework early. After removing the drainage tube, the space caused by the drainage tube could not fast attach the scaffold, resulting in effusion. In the expanded single-flap method, the incidence was higher (35.5%) in the postauricular region. The base increased the height of the framework was easy to form a postauricular cavity. 5,16,17 Therefore, placing another drainage tube at the postauricular area to facilitate the attachment was recommended. The incidence of local subcutaneous effusion was found to be higher (56.4%) in the expanded single-flap method. The reasons are as follows: (1) Additional dissection of the fibrous capsule might be necessary for the expansion method, producing tissue fluid. (2) The dead space was easy to form because of a comparatively big soft tissue pocket and a high framework, causing effusion collection. (3) The localization and contour of the reconstructed ear entirely relied on the negative pressure drainage. The expanded flap with strong retraction force brought more difficulties for attachment. Once the skin floated, it was hard to fit again and even caused an infection. Therefore, especially alert to the occurrence of effusion in the expansion method is necessary.
The reconstructed ear once produced local subcutaneous effusion, and the processing was not prompt, the attachment was more difficult, resulting in unsatisfied outline even severe complications, like an infection. 5,10,16 The traditional method was percutaneous needle puncture aspiration and local pressurization to prevent the effusion regeneration. There are some limitations. The local pressure is inappropriate and ineffective to make the skin and scaffold fully attached, which means the effusion regeneration and repeated punctures. The exogenous infection would occur and cause the operation failure. In our practice, the indwelling needle puncture drainage with continuous negative pressure was suitable and offered several advantages. This method was performed as a simple, single-stage, and outpatient procedure and would not separate the already-fitted skin flap. It could form a local continuous negative pressure to ensure the attachment and the soft needle would not cause additional compression on the cartilage framework. An extension tube could be connected to the needle to facilitate the patient’s activities, and a syringe or a drainage ball was used to adjust negative pressure and record drainage volume. However, the relatively small negative pressure could not afford massive fluid, and the obstruction might occur with turbid fluid. Thus, the effusion traits were considered when performing this method. The possibility of infection for turbid and large effusion was considered, and sufficient drainage was recommended. In our study, 8 patients were positive for S aureus infection. They all were performed by continuous negative pressure drainage with an indwelling needle, and only 2 patients showed local cartilage absorption. At the early stages of infection, sufficient drainage and antibiotic treatment were necessary to control the infection and obtain better outcomes.
Conclusions
Auricular reconstruction is easy to produce postoperative local subcutaneous effusion because of the rare conditions and complicated procedures. The expanded single-flap method is more likely to occur effusion, because of the higher height of the framework, compared to the modified Nagata’s method. Aiming at the local subcutaneous effusion, the indwelling needle puncture drainage method with continuous negative pressure is versatile and offers several advantages. This method is simple to operate, has a good clinical effect, and can improve the early infection to obtain satisfactory results.
Supplemental Material
Supplemental Material, sj-docx-1-ear-10.1177_01455613211022104 - Management Strategy of Local Subcutaneous Effusion After Auricle Reconstruction
Supplemental Material, sj-docx-1-ear-10.1177_01455613211022104 for Management Strategy of Local Subcutaneous Effusion After Auricle Reconstruction by Rui Guo, Tun Liu, Bingqing Wang and Qingguo Zhang in Ear, Nose & Throat Journal
Supplemental Material
Supplemental Material, sj-tif-1-ear-10.1177_01455613211022104 - Management Strategy of Local Subcutaneous Effusion After Auricle Reconstruction
Supplemental Material, sj-tif-1-ear-10.1177_01455613211022104 for Management Strategy of Local Subcutaneous Effusion After Auricle Reconstruction by Rui Guo, Tun Liu, Bingqing Wang and Qingguo Zhang in Ear, Nose & Throat Journal
Footnotes
Authors’ Note
Written consent forms were received from all individuals or their guardians.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Natural Science Foundation of China (grant numbers 81571924 and 81701930).
Supplemental Material
Supplemental material for this article is available online.
References
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
