Congenital microtia, with an estimated incidence of 1 in 5,000-10,000 live births, presents a significant challenge in craniofacial surgery¹.The goal of reconstruction is to create a symmetrical, aesthetically pleasing auricle that withstands the test of time. For decades, the autologous costochondral graft, popularized by Brent² and Nagata,³ has been considered the gold standard. This technique utilizes the patient's own tissue, offering excellent biocompatibility and durability. However, it is a complex, multi-stage procedure requiring significant surgical expertise, associated with donor-site morbidity (chest wall deformity, pain), and a prolonged overall treatment time⁴

These challenges are amplified in the adult population. Adults often have less pliable skin, calcified costal cartilage that is difficult to carve, and a strong desire to minimize time away from professional and personal commitments. The prospect of multiple surgeries can be a significant deterrent⁵ .Consequently, alloplastic frameworks have been explored as an alternative. Materials such as Medpor® (porous polyethylene) have shown success but still carry a persistent risk of exposure and infection, especially in the long term⁶  Silicone, while historically plagued by high extrusion rates when placed subcutaneously, has seen a resurgence when combined with robust vascularized soft tissue coverage⁷.

The temporoparietal fascia flap (TFF) provides an ideal, well-vascularized covering for alloplastic implants. Its proximity to the auricle, reliable anatomy, and pliability make it an excellent option for enveloping a framework⁸. This case series describes and evaluates the outcomes of a single-stage reconstruction technique using a custom-carved silicone implant covered by a TFF in 12 adult patients with congenital microtia.

MATERIALS AND METHODS

A single-surgeon, retrospective case series was performed. Ethical approval was obtained from the institutional review board.

Patient Selection

Twelve consecutive adult patients (8 males, 4 females) with unilateral congenital microtia (Grades III and IV according to the Marx classification) who underwent primary reconstruction between January 2020 and December 2022 were included. The mean age was 28.5 years (range: 19-42). All patients were thoroughly counselled on the risks and benefits of both autologous and alloplastic techniques, and they specifically opted for the single-stage alloplastic approach. Exclusion criteria included a history of previous ear reconstruction, radiation therapy to the head and neck region, and uncontrolled systemic diseases.

Surgical Technique

Preoperative Planning: A template of the contralateral, normal ear was created using a radiographic film. A solid, medical-grade silicone block was custom-carved intraoperatively to match the template's size and projection.

Implant Fabrication: The silicone framework was carved to replicate the helix, antihelix, and scapha. It was then thoroughly cleansed and soaked in an antibiotic solution.

Pocket Creation and Flap Elevation: A pre-auricular incision was made. A subcutaneous pocket was dissected precisely to accommodate the implant. A pedicled TFF, based on the superficial temporal artery, was elevated through a separate temporal incision.

Flap Transposition and Inset: The TFF was tunneled inferiorly to completely envelope the silicone framework. The flap was sutured to the surrounding soft tissues to ensure stable, tension-free coverage.

Skin Grafting: A thin split-thickness skin graft, harvested from the ipsilateral scalp, was used to resurface the neoauricle.

Closure and Dressing: A suction drain was placed under the flap. A compressive, non-adherent dressing was applied to define the auricular contours.

Outcome Measures

Patients were followed up at 1 week, 1 month, 3 months, 6 months, and annually thereafter. Primary outcomes were:

Aesthetic Outcome: Evaluated at 6 months postoperatively by a panel of three independent plastic surgeons blinded to the study using a 10-point Likert scale (1=very poor, 10=excellent). Criteria included symmetry, definition of contours, and color match.

Complication Rate: Recorded as early (≤30 days) or late (>30 days). Major complications were defined as implant extrusion, infection requiring removal, or flap failure. Minor complications included hematoma, seroma, partial skin graft loss, and temporary alopecia.

Secondary outcome was patient satisfaction, assessed via a simple questionnaire at the final follow-up, rating satisfaction as "Very Satisfied," "Satisfied," or "Not Satisfied."

RESULTS
All 12 procedures were completed successfully in a single stage. The mean operative time was 3.5 hours (range: 3-4.5 hours). The mean follow-up period was 18 months (range: 12-30 months).

Aesthetic Outcomes

The mean aesthetic score given by the independent panel was 8.2 out of 10 (range: 7-9). The panel consistently noted good symmetry and well-defined helical contours. The color match of the skin graft was deemed satisfactory in all cases.

Complications
There were no major complications. No implants were lost to extrusion or infection. One patient (8.3%) experienced a partial loss of the skin graft over the superior pole, which healed completely with conservative wound care, resulting in a minor contour irregularity. Two patients (16.7%) had noticeable temporal hollowing at the donor site at the 3-month follow-up; both cases improved significantly without intervention by the 12-month mark.

Patient Satisfaction

At the final follow-up, 10 patients (83.3%) reported being "Very Satisfied," and 2 patients (16.7%) reported being "Satisfied." The most frequently cited reason for satisfaction was the avoidance of a chest scar and the completion of reconstruction in a single operation.

DISCUSSION
This case series demonstrates that a single-stage approach using a silicone implant and TFF is a reliable method for microtia reconstruction in carefully selected adults. The results indicate a favourable aesthetic outcome and a low rate of significant complications.

The primary advantage of this technique is its single-stage nature, which aligns with the preferences of many adult patients⁵. By avoiding the harvest of rib cartilage, it eliminates donor-site morbidity, a significant concern for patients engaged in physical labor or athletics. The use of the TFF is the critical factor in mitigating the historical weakness of silicone implants: extrusion. The flap provides a richly vascularized cushion that protects the implant and promotes graft take, a principle well-supported in the literature^8,9.

Our complication profile compares favorably with other alloplastic techniques. The reported extrusion rates for Medpor frameworks can be as high as 5-10%, even with flap coverage⁶. Our series had no extrusions, though the sample size is modest. The minor complications we encountered, such as partial graft loss and temporary temporal hollowing, were manageable and did not affect the final outcome. Temporal hollowing can be minimized by meticulous dissection in the subfollicular plane to preserve temporal fat pad volume.

The aesthetic results, while not aiming to surpass the nuanced, living quality of a well-carved cartilage framework, were deemed highly satisfactory by both surgeons and patients. The silicone framework allows for precise and sharp definition of the auricular landmarks, which can sometimes be challenging to achieve with cartilage in older patients⁷.

This study has limitations, including its retrospective design, small sample size, and lack of a direct comparative group (e.g., a cohort of adults who underwent autologous reconstruction). Furthermore, the long-term durability of the reconstruction beyond 3-5 years remains to be fully evaluated, as silicone implants may be prone to late-term complications like capsular contracture or migration¹⁰. Long-term follow-up is essential.

CONCLUSION
For adult patients with microtia, single-stage reconstruction with a silicone implant covered by a temporoparietal fascia flap presents a compelling alternative to multi-stage autologous rib cartilage reconstruction. It offers the significant benefit of a definitive correction in one operation, with acceptable aesthetic outcomes and a low risk of major complications. This technique is a valuable addition to the armamentarium of the craniofacial surgeon, particularly for adults who are well-informed about the risks and benefits of alloplastic materials.

REFERENCES

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