摘要
正常耳廓系由细薄的皮肤软组织包裹弹力软骨支架所组成的形态复杂的薄壳结构,耳廓再造术一直被认为是整形外科中最为困难、复杂的手术之一。每个人的耳廓大小与形状不尽相同,因各种原因需行耳廓再造时,在临床工作中均需分别对待。成功的耳廓再造术取决于两个因素:塑形良好的软骨支架和充裕覆盖支架的皮肤组织。在目前,耳廓再造的软骨支架仍以自体肋软骨为好;皮肤则以尽量利用残耳后乳突区皮肤为主,扩张后皮肤量的增加与变薄,更有利于显示雕塑软骨支架的四层面概念,使再造的耳廓形态达到满意的结果。
目前,对于自体肋软骨游离移植生物学转归系统的研究报道不多。对于自体肋软骨移植后能否成活,肋软骨膜在移植软骨中的作用,供区的修复以及软骨间的愈合方式等均存在不同的看法;特别是对先天性小耳畸形患儿的手术时机的选择,肋软骨膜在移植软骨生长中的作用以及学龄前儿童再造耳能否随年龄增长而与正常耳同步按比例生长等均存在不同的观点。随着皮肤扩张术在外耳再造中的应用,更需了解扩张皮瓣对自体肋软骨支架的影响。因此,进一步研究和明确自体肋软骨游离移植的生物学转归,将会更好地指导我们的临床工作。本课题主要通过动物实验、临床病理标本检查和病例随访三方面的研究工作来探讨相关问题,以期能指导临床。
在动物实验研究中,3个月幼龄猪自体肋软骨游离移植术后3、6个月经大体观察、测量、光镜、电镜检查及细胞外基质GAG和胶原含量检测表明:移植软骨块能成活、生长,若同时携带软骨膜移植,则成活、生长更为显著,二者对移植软骨的成活和生长起互补及加强作用,主要表现在移植软骨块的长度、重量、体积显著增大(P<0.001),移植后6个月软骨块的GAG及胶原分泌明显提高(P<0.001),在光镜和电镜中存在具有活力的软骨细胞。但移植软骨的成活不完全,主要表现在移植3个月后软骨组织中有局灶性坏死,GAG及胶原含量明显下降(P<0.001)。术后6个月上述情况均有明显改善,说明移植软骨的生物学特性逐渐向正常状态恢复。另外,肋软骨间不能融合,其愈合主要为纤维结缔组织连接。
在临床上,先天性小耳畸形由于乳突区皮肤面积不足,给耳廓再造带来一定的困难,利用皮肤扩张术可以使耳后无毛皮肤得以充分扩张提供足够的无毛皮肤覆盖耳支架前面,基本解决了皮肤不足的问题;同时使扩张后皮肤变薄,达到理想厚度,为耳廓的塑形提供了有利条件:去除纤维包膜的扩张皮瓣与耳支架贴附紧密并增强支架血供,为耳支架的成活和生长提供了良好的外部条件。在肋软骨支架方面,我们强调了带软骨膜的软骨移植和支架四层面的合理塑型,提出肋软骨采取和雕塑时的注意事项。临床观察8例肋软骨移植后的组织学检
Normal external ear is a shell structure of complicated shape which is made by flimsy skin tissue that warps elastic cartilage. Ear reconstruction is one of the most difficult and complicated plastic surgery. When ear reconstruction is needed by various reasons,we should treat it respectively as the size and shape of each is different. The success of ear reconstruction is made by two factors:good framework of sculpted cartilage and enough integument of skin tissue to cover the framework.Now, the framework is often made by costal cartilage autograft and the skin tissue is provided by the skin in mastoid region . When the skin has been expanded with expander, Its quantity increases and the quality becomes thinner, which is better for the display of the four layer concept of the sculpted cartilage framework.Thus,the shape of the reconstructed ear can get more satisfied outcome.
Now, the systemic report is not enough about the biological result of costal cartilage free autograft. There are different viewpoints about the live of costal cartilage autograt, the repair of offer region and the recovery style of the cartilage ,especially about the selection of surgical time in congenital microtia, the use of chondrium in the growth of cartilage autograft and the growth ability of the reconstructed ear in preschool children .With the use of skin expansion in the ear reconstruction, it is better to know the effect of the expanded skin flap on the cartilage framework.So we studied biological change of costal cartilage free autograft in reconstructed ear to offer advice in our clinical practice. This study includes three respects of animal experiment, clinical examination of autograft cartilage and followed cases.
The experiment of costal cartilage autograft in three-month old pig has proved that autograft cartilage can live and grow after three or six months by gross observation, examinations of histology and TEM(transmission electron microscopy) and measurement of the content of GAG (glycosaminoglycan) and collagen in extracelluar matrix. If cartilage autograft with chondrium, the live and growth of autograft becomes more evident. It is mainly expressed in that the length, weight and volume of the graft cartilage increased strikingly (P<0. 001). The secretion of GAG and collagen increased after six months (P<0. 001) and there is young and viable cartilage cell in the examination of histology and TEM. At the same
引文
1 Berghaus,A ., Toplak,F.:Surgical concepts for reconstruction of the auricle. Arch Otolaryngol Head Neck Surg .121:388,1986.
2 Davis ,j: Aesthetic and Reconstruction Otoplasty..Springer Verlage ,New York Inc., 1987.
3 Tagliacozzi,G.:De Curtorum Chirurgia per Insitionem. Venice,Gaspare Binkoni ,1597.
4 Gillies, H.: Plastic surgery of the face .London, H. Frowde,Hodder and Stoughton, :381,1920.
5 Pierce,G.w.: Reconstruction If the external ear.Surg.Gynecol.Obstet,50:601,1930.
6 Gillies,H: Reconstruction of the external ear with special reference to the use of maternal ear cartilages as the supporting structure .Rev.Chir.Structive,7:169,1937.
7 Peer,L.A.:Rconstruction of the auricle with diced cartilage grafts in a Vitallium ear mould.Plast.Reconstr.Surg.,3:653,1948.
8 Kirkham,H.J.D.:The use of preserved cartilage in ear reconstruction.Ann.Surg.,11:896,1940.
9 Brown,J.B.,Cannon,B.,Lischer,C.E.,et al.:Surgical substitution for losses of the external ear.simplified local flap method of reconstruc-tion.,Surg.Gynecol.Obstet.,84:192,1947.
10 Tanzer.R.C. :Total reconstruction of the external ear. Plast.Reconstr.Surg.,23:1,1959 .
11 Cronin, T.D.: Use of a Silastic frame for total and subtotal reconstruction of the external ear: Preliminary report.Plast.Reconstr.Surg.,37:399,1966.
12 Cronin,T.D.:Use of a silastic frame for reconstruction of the auricle.InTanzer,R.C, and Edgerton,M.T.(Eds.):Symposium on Reconstruction of the Auricle.St.louis,MO,C.V.Mosby Company, :33,1974.
13 Gorney,M.,Murphy,S., and Falces,E.:Spliced autogenous conchal cartilage in secondary ear reconstruction.Plast.Rceonstr.Surg.,47:432,1971.
14 Davis,J.E.On auricular reconstruction.Internatl.MicroformJ.AestheticPlast.Surg., Otoplasty, 1972.
15 Tanzer,RC.:An analysis of ear reconstruction.Plast. Reconstr.Surg.,31:16,1963.
16 Tanzer RC. Total reconstruction of the auricle. The evolution of a plan of treatment. Plast Reconstr Surg. 47(6):523, 1971.
17 Fukuda,O.:The microtic earsurvey of 180 cases in 10 years Plast.Reconstr.Surg.,53:458,1974.
18 Fukuda 0. :Long-term evaluation of modified Tanzer ear reconstruction. Clin Plast Surg. 17(2):241, 1990.
19 Brent.B.:The correction of microtia with autogenous cartilage grafts.I. The classic deformity.Plast.Reconstr.Surg.,66:1,1980a.
20 Brent.B.:Total auricular construction with sculpted csotal cartilage.InBrent,B.(Ed.):The Artistry of Reconstructive Surgery.St.Louis, C.V. Mosby Company, 113,1987.
21 Brent B. :Technical advances in ear reconstruction with autogenous rib cartilage grafts:personal experience with 1200 cases. Plast Reconstr Surg. Aug;104(2):319, 1999.
22 Neuman. C.G. The expansion of an area of skin by progressive distention of a subcutaneous baloon. Plast. Reconstr. surg.19:124, 1957.
23 Brent. B.:The correction of microtia with autogenous cartilage grafts. II. Atypical and complex deformities. Plast. Reconstr. Surg. 66:13, 1980b.
24 Oneal RM, Rohrich RJ, Izenberg PH. Skin expansion as an adjunct toreconstruction of the external ear.Br J Plast Surg. 37(4):517, 1984.
25 Quaba, A:Reconstruction of a posttraumatic ear defect using tissue expansion:30 years after Neumann. Plast. Reconstr. Surg. 82:521, 1988.
26 Cao YL Vacanti JP, Paige KT,et al. Transplantation of chondrocytes utilizing a polymer-cell construct to produce tissue-engineered cartilage in the shape of a huaman ear. Palast Reconstr Surg. 100:297,1997.
27 Cutright DE, Pere AB, Beasley JD,et al. Degradation rates of polymers and copolymers of polylactic and glycolic acid. Oral Surg,. 37:142,1974.
28 Tanzer RC. Microtia—a long-term follow-up of 44 reconstructed auricles. Plast Reconstr Surg. Feb.61(2):161, 1978.
29 郝铸仁: 全耳廓再造术13例报告中华外科杂志18:352, 1985.
30 Spina V, Kamakura L, Psillakis JM. Total reconstruction of the ear in congenital microtia. Plast Reconstr Surg. 48(4):349,1971.
31 Brent B. Ear reconstruction with an expansile framework of autogenous rib cartilage.Plast Reconstr Surg. 53(6):619,1974.
32 Fukuda 0, Yamada A. Reconstruction of the microtic ear with autogenous cartilage. Clin Plast Surg. 5(3):351,1978.
33 Tolleth H. Artistic anatomy, dimensions, and proportions of the external ear. Clin Plast Surg. 5(3):337, 1978.
34 Matsumoto M. : A new method of reconstruction in microtia, with emphasisoconchalcreation. Ann Plast Surg. 1980 Jul;5(1):51—7.
35 Song R, Chen Z, Yang P, et al: Reconstruction of the external ear. Clin Plast Surg. 9(1) :49, 1982.
36 Nakai H. Reconstruction of microtia with a contour-accentuated framework and supple mental coverage. Plast Reconstr Surg. 78(5):604, 1986.
37 Isshiki N, Koyama H, Suzuki S, Taira T. Surgical techniques for a deep concha, a pseudomeatus, and high projection incongenital microtia. Plast Reconstr Surg. 77(4): 546, 1986.
38 Rueckert F, Brown FE, Tanzer RC. Overview of experience of Tanzer's group with microtia.Clin Plast Surg. 17(2):223,1990.
39 Nagata S. A new method of total reconstruction of the auricle for microtia. Plast Reconstr Surg. 92(2):187, 1993.
40 Brent B. The acquired auricular deformity. A systematic approach to its analysis and reconstruction. Plast Reconstr Surg. 59(4):475,1977.
41 Brent B. Reconstruction of traumatic ear deformities. Clin Plast Surg. 5(3) :437, 1978.
42 Suraci AJ. plastic reconstruction of acquired defects of the ear . Am J Surg. 66:196, 1944.
43 Tanzer RC.Microtia—a long-term follow-up of 44 reconstructed auricles. Plast Reconstr Surg. 61(2):161, 1978.
44 Park C, Lee TJ, Shin KS, et al.A single-stage two-flap method of total ear reconstruction. Plast Reconstr Surg. 88(3):404, 1991.
45 Kruchinski GV.External ear reconstruction. Acta Chir Plast. 33(2):87,1991.
46 Nakai H.Reconstruction of microtia. Pursuing a natural appearance. Clin PlastSurg. 17(2):287,1990.
47 Matsumoto K, Maeda M, Fujikawa M. Staged, laminated, costal cartilage framework for ear reconstruction. Clin Plast Surg. 17(2):273,1990.
48 Isshiki N.:Technique of total ear reconstruction with open framework, composite pseudomeatus graft, and postauricular transposition flap. Clin Plast Surg. 17(2):263,1990.
49 Song YG, Zhuang HX. One-stage total reconstruction of the ear with simultaneous tympanoplasty. Clin Plast Surg. 17(2):251,1990.
50 Fukuda O. Long-term evaluation of modified ranzer ear reconstruction. Clin Plast Surg. 17(2):241,1990.
51 Peer, 1.A. The neglected septal cartilage graft. Arch. Otolaryngol. 42:384,1948.
52 Gibson, r.,and Davids, W.B.'rhe distortion of autogenous cartilage grafts:Its cause and prevention. Br.J. Plast. Surg. 10:287,1958.
53 Kruger, E.: Absorption of human rib cartilage grafts transplanted to rabbits after preservation by different methods. Br.J. Plast. Surg. 17:254,1964.
54 Pirsig W Morphologic aspects of the injured nasal septum in children. Rhinology 17(2):65,1979.
55 Gubisch W, Greulich M, Donath K.:Experimental and clinical study on the vitality of orthotopic cartilage transplants. Plast Reconstr Surg. 95(4):663, 1995.
56 王炜主编,整形外科学,1999.
57 周伟东,张和,石学明:软骨移植的实验研究。白求恩医科大学学报18(2):156,1992.
58 Rudderman RH, Guyuron B, Mendelsohn G.:The fate of fresh and preserved, noncrushed and crushed autogenous cartilage inthe rabbit model.,Ann Plast Surg. 32(3):250,1994.
59 Ducan, M.J.,Ihompson, H.G.,and Mancer, J.F.:Free cartilage grafts:the role of peri chondrium. Plast. Reconstr. Surg. 73:916,1984.
60 李太颖:软骨移植的实验研究。协和医科大学硕士毕业论文 1998.
61 Shenn,J.H:festhetic Rhinoplasty.Znd ED.St.louis,C.V.Mosby company,1987a.
62 汪良能,高学书主编,整形外科学1989.
63 侯成群,常晓峰:同种软骨移植后胶原含量变化的实验研究。中华整形烧伤外科杂志.11(4).274 1995.
64 郑信民,杨壮群:同种透明软骨移植后蛋白多糖动态变化的实验观察,中华整形烧伤外科杂志.,11(2).129,1995.
65 Hjertquist SO, Lemperg R :Microchemical studies on glycosaminoglycans and calcium in autologous costal cartilage transplanted to an osteochondral defect on the femoral head of adult rabbits. Calcif Tissue .5(2):153,1970.
66 Dupertuis, S.M.:Actual growth of young cartilage trowsplants in rabbits, Arch. Surg.,43:32,1941.
67 Stoll DA, Furnas DW.:The growth of cartilage transplants in baby rabbits. Plast Reconstr Surg., 45(4):356 1970.
68 Eisemann ML.:The growth potential of autograft cartilage. An experimental study. Arch Otolaryngol., 109(7):469, 1983.69 鲍卫汉 孙晓光:幼兔耳软骨移植后增长的研究.中华整形烧伤外科杂志,7(2).119,1991.
70 Dupertius, S.M.: Growth of youn human autogenous cartilage grafts. Plast. Reconstr. Surg.,5:486,1950.
71 Peer, L.A.:Experimental observations on the growth of yong human cartilage grafts. Plast. Reconstr. Surg.,1:108,1946.
72 Peer, L.A. : Behaviour of grafts and implants:Observations on materials used for structural suppoort of the external ear. Arch. Otolaryngol.,77:34,1963.
73 Peer, L.A, Walia, I.S.,and Bernhard, W.G.:Further studies on the growth of rabbit ear cartilage graft. Br.J. Plast. Surg.,19:105,1966.
74 Muraf M, Celebioglu S, Sensoz O. Growth potential of autogenous cartilage grafts in expanded skin: anexperimental study in rabbits. Ann Plast Surg;32(2):126,1994.75 Yang F:Autogenous cartilage grofts:An esperimental study, lO:7,1941.
76 Eisemann ML The growth potential of autograft cartilage. An experimental study. Arch Otolaryngol. 109(7):469, 1983.
77 Depalma. A.F.: Viability of osteochondral grafts as determined by uptake of S,J Bone Joint Surg .45:1565,1963.
78 李子荣,王桂生,苟启旺,:关节软骨移植的实验研究中华骨科杂志4(1):54,1984.
79 Ohlsen L.:Cartilage formation from free perichondrial grafts: an experimental study inrabbits. Br J Plast Surg., 29(3):262 1976.
80 Skoog T, Ohlsen L, Sohn SA.:Perichondrial potential for cartilagenous regeneration. Scand J Plast Reconstr Surg. , 6(2):123,1972.
81 Upton J, Sohn SA, Glowacki J.:Neocartilage derived from transplanted perichondrium: what is it?Plast Reconstr Surg., 68(2):166,1981.
82 Ohlsen L.:Cartilage regeneration from perichondrium: experimental studies and chinical applications. Plast. Reconstr. Surg.,62:507,1978.
83 许彪,王翰章:自体肋骨肋软骨移植后的骨愈合及再生修复实验研究。实用口腔医学杂志9(1):32,1993.
84 Thomson HG, Winslow J. Microtia reconstruction: does the cartilage framework grow? Plast Reconstr.Surg. 84(6):908, 1989.
85 Brent B. Auricualr repairwith antogenous rib cartilage grafts:two decades of experience with 600 cases. Plast Reconstr Surg. 90:355, 1992.
86 Rupertuis, S.M.,and Musgrave, R.H.:Experiences with reconstruction of the congenitally deformed ear. Plast, Reconstr. Surg.,23:261,1959.
87 Hagerty, R.F.,Braid, H.L.,Bonner, W.M.,et al. Viable and Ronveable human cartilage homografts. Surg. Gynecol. Obstet.,125:485,1967.
88 krutchinsdij, G.V.,and Schved, I. A. :Attempt to reconstrust the auricle using the ear cartilage from a living donor. Acta Chir. Plast.,26:100,1984.
89 Vacanti CA. Paige KT, Ki W, et al. Tracheal replacement using tissue engineered cartilage. J Pediatr Surg.,29(2):201,1994.
90 Puelacher WC, Kim SW, Vacanti JP. Tissue engineered growth of cartilage:The effect of varying the concentration of chondrocytes seeded onto synthetic polymer matrices. Oral Maxillofac Surg., 23:49,1994.91 Puelacher WC,Mooney D,1anger R, et al. Design of nasoseptal cartilage replacements.Synthesized fron biodegradable polymers and chondrocytes. Biomaterials ,15:774, 1994.
92 Puelacher WC,Wisser J.Vacante CA,et al.Temporomandibular joint disc replacement made by tissue-engineered growth of cartilage.J Oral Maxillofac Surg. ,52:1172, 1994.
93 Chen ZJ. One stage total auricle reconstruction and reestablishment of hearing in severe congenital microtia. Ann Chir Plast Esthet. 33:335 1988
94 Paige KT, Cima LG, Yaremchuk MJ, et al, Injectable cartilage. Plast Reconstr Surg, 96:1390, 1995.
95 Vacanti CA, Kim WS, Mooney D. Tissue engineered composites of bone and cartilage using synthetic polymers seeded with two cell types. Orthopaed Trans, 18:276, 1993.
96 Grande DA, Sorthland SS,Manji R, et al. Repair of articular cartilage defects using mesenchymal sten cells.Tissue Engin, 1:345,1995.
97 Zimber MP, Tong B,Dunkelman N,et al. TGF-beta promotes the growth of bovine chondrocytes in monolayer culture and the formation of cartilage tissue in three dimensional scaffolds. Tissue in three dimensional scaffolds, Tissue Engin, 1:289,1995.
98 Duke PJ, Daane EL, Montufar-Solis D. Studies of chondrogenesis in rotating systems. J Cell Biochem. 51 (3):274, 1993.
99 Livne E. In vitro response of articular cartilage from mature mice to human transforming growth factor beta. Acta Anat (Basel). 149(3):185 ,1994.
100 Vacanti CA, Cao YL, Upton J, et al:Neo-cartilage generated from chondrocytes isolated from 100-year-old human cartilage. Transplant Proc. 26(6) :3434, 1994.
101 Pujol JP, Galera P, Redini F, et al: Role of cytokines in osteoarthritis: comparative effects of interleukin 1 and transforming growth factor-beta on cultured rabbit articular chondrocytes. J Rheumatol Suppl. 27:76, 1991.
102 Zellin G, Beck S, Hardwick R, et al: Opposite effects of recombinant human transforming growth factor-beta 1 on bone regeneration in vivo: effects of exclusion of periosteal cells by microporous membrane. Bone. 22(6):613,1998.
103 Shibanuma M, Mashimo J, Mita A, et al:Cloning from a mouse osteoblastic cell line of a set of transforming-growth-factor-beta 1-regulated genes, one of which seems to encode a follistatin-related polypeptide. Eur J Biochem. 217(1) :13, 1993.
104 Blumenfeld I, Laufer D, Livne E. :Effects of transforming growth factor-beta 1 and interleukin-1 alpha on matrix synthesis in osteoarthritic cartilage of the temporo-mandibular joint in aged mice. Mech Ageing Dev. 95(1-2): 101, 1997.
105 Dounchis JS, Goomer RS, Harwood FL,et al. Chondrogenic phenotype of perichondrium-derived chondroprogenitor cells is influenced by transforming growth factor-beta 1.J Orthop Res. 15(6):803 ,1997 .
106 Arai Y, Kubo T, Kobayashi K, et al. Adenovirus vector-mediated gene transduction to chondrocytes: in vitro evaluation of therapeutic efficacy of transforming growth factor-beta 1 and heat shock protein 70 gene transduction.J Rheumatol.24(9):1787, 1997.
107 Tanzer RC. Total reconstruction of the auricle. The evolution of a plan of treatment. Plast Reconstr Surg. 47(6):523, 1971.
108 Tegtmeier RE, Gooding RA. The use of a fascial flap in ear reconstruction. Plast Reconstr Surg. 60(3):406, 1977.
109 Avelar JM:Total reconstruction for the auricular pavilion in one stage. Rev Bras Cir 67:139,1977.
110 Avelar JM, Psillakis JM. Microtia: total reconstruction of the auricle in one single operation. Br J Plast Surg. 34(2):224,1981.
111 Song YG, SONG YL:An improved one-stage total ear reconstruction procedure.Plast,Reconstr. Surg, 71:615, 1983.
112 Letterman, G. S. ,and Harding, R. 1. The management of the hairline in ear reconstruction. Plast. Reconstr. Surg. 18:199, 1956.
113 Brent B, Byrd HS. Secondary ear reconstruction with cartilage grafts covered by axial, random, and free flaps of temporoparietal fascia, plast Reconstr Surg. 72(2): 141, 1983.
114 Lask , G. , Elman, M., and Slatkine, M. Laser-assisted hair removal by selective photothermolysis:Preliminary results. Dermatol Surg. 23:737, 1997.
115 Nanni, C. A., and Alster, T. S. Optimizing treatment parameters for hair removal using a topical carbonbased solution and 1064-nm Q-switched neodymium:YAG laser energy. Arch:Dermatol. 133:1546, 1997.
116 Littler, CM. Laser hair removal in apatient with hypertrichosis lanuginosa congenita. Dermatol. Surg. 23:705, 1997.
117 Dierickx, C. C. , Grossman, M. C. , Farinelli, W. A., and Anderson, R. R. Permanent hair removal by normalmode ruby laser. Arch. Dermatol. 134:837, 1998.
118 Takatoshi, Y, Katsunori, Y, Yoshihiro, N, et al. Management of the hairline using a local flap in total reconstruction for microtia. Plast Reconstr Surg. 104(1) :41, 1999.
119 Mutimer, K, L and Mulliken, J. B. Correction of cryptotia using tissue expansion.Plast.Reconstr. Surg. 81:601, 1988.
120 Hata Y, Hosokawa K, Yano K, et al. Correction of congenital microtia using the tissue expander. Plast Reconstr Surg. 84(5):741,1989.
121 Sasaki GH. Tissue expansion in reconstruction of acquired auricular defects. Clin Plast Surg. 17(2):327,1990
122 Sasaki,GH. Intraoperative sustained limited expansion(ESLE) as an immediate reconstructive technigue. Clin Plast Surg. 14:563, 1987.
123 Chana JS, Grobbelaar A0, Gault DT. Tissue expansion as an adjunct to reconstruction of congenital and acquired auricular deformities. Br J Plast Surg. 50(6):456,1997.
124 Firmin F. Ear reconstruction in cases of typical microtia. Personal experience based on352 microtic ear corrections. Scand J Plast Reconstr Surg Hand Surg. 32(1) :35, 1998.
125 Pisarski GP, Mertens D, Warden GD, Neale HW. Tissue expander complications in the pediatric burn patient. Plast Reconstr Surg. 102 (4):1008, 1998.
126 Nagata, S. Secondary reconstruction for unfavorable microtia results utilizing temporoparietal and innominate fascia flaps. Plast. Reconstr. Surg. 94:254, 1994.
127 Yoshimura K, Nakatsuka T, Ichioka S, One-stage reconstruction of an upper part defect of the auricle. Aesthetic Plast Surg. 22(5):352,1998.
128Bhandari PS Total ear reconstruction in post burn deformity. Burns 24(7) :661, 1998.
129 Somers T, De Cubber J, Govaerts P, et al. : Total auricular repair: bone anchored prosthesis or plastic reconstruction?Acta Otorhinolaryngol Belg. 52(4) :317, 1998.
130 Tateshita T, Ono I One-stage reconstruction of microtia in microform. Plast Reconstr Surg. 103(1):179, 1999.
131 Nagata, S. Mdification of the stages in total reconstruction of the auricle:PartII. Grafting the three-dimensional costal catilage framework for concha-type microtia. Plast. Reconstr. Surg.93:231,1994.
132 Nagata, S. Mdification of the stages in total reconstruction of the auricle:Part III. Grafting the three-dimensional costal catilage framework for small concha-type microtia. Plast. Reconstr. Surg. 93:243, 1994.
133 Nagata, S. Mdification of the stages in total reconstruction of the auricle:Part IV. Ear elevation for the constructed auricle. Plast Reconstr Surg. 93:254, 1994.
134 Eavey RD :Microtia repair: creation of a functional postauricular sulcus. , Otolaryngol Head Neck Surg , 120(6):789, 1999.
135 Leach JL, Jordan JA, Brown KR,et al: Techniques for improving ear definition in microtia reconstruction. Int J Pediatr 0torhinolaryngol25;48(1):39, 1999.
136Wang RR, Andres CJ : Hemifacial microsomia and treatment options for auricular replacement: A reviewof the literature. J Prosthet Dent 82(2):197,1999.
137 Park C, Lew DH, Yoo WM :An analysis of 123 temporoparietal fascial flaps: anatomic and clinical considerations in total auricular reconstruction. Plast Reconstr Surg. 104(5): 1295, 1999.
138Harris PA, Ladhani K, Das-Gupta R et al: Reconstruction of acquired sub-total ear defects with autologous costalcartilage. Br J Plast Surg. , 52(4):268, 1999.
139Tellioglu AT, Tekdemir I, Erdemli Eaet al: Temporoparietal fascia: an anatomic and histologic reinvestigation with newpotential clinical applications. Plast Reconstr Surg. 105(1):40,2000.
140 Yoshimura K, Asato H, Nakatsuka T, et al: Elevation of a constructed auricle using the anteriorly based mastoid fascialflap. Br J Plast Surg ., 52(7):530,1999.
141 Osorno G : Autogenous rib cartilage reconstruction of congenital ear defects: report of 110 cases with Brent's technique. , Plast Reconstr Surg, 104(7) : 1951, 1999.
142 Park C: Subfascial expansion and expanded two-flap method for microtia reconstruction. Plast Reconstr Surg . 106(7):1473,2000.
143Bhandari PS: Use of triamcinolone acetonide injection in ear reconstruction.Ann Plast Surg. 45(4):458, 2000.
144 Can Z, Apaydin I, Ercocen AR, Prefabrication of a high-density porous polyethylene implant using a vascularinduction technique. Ann Plast Surg 41 (3): 264, 1998.
145 Yotsuyanagi T, Urushidate S, Watanabe M, et al : Reconstruction of a three-dimensional structure using cartilage regenerated from the perichondrium of rabbits. Plast Reconstr Surg. 103(4):1120, 1999.
146 Chalain T, Phillips JH, Hinek A : Bioengineering of elastic cartilage with aggregated porcine and human auricularchondrocytes and hydrogels containing alginate, collagen, and kappa-elastin. J Biomed Mater Res . 44(3):280,1999.
147 Megerian CA, Weitzner BD, Dore B, et al: Minimally invasive technique of auricular cartilage harvest for tissue engineering.Tissue Eng 6(1):69, 2000.
148 Brown AN, Kim BS, Alsberg E, et al: Combining chondrocytes and smooth muscle cells to engineer hybrid soft tissue constructs. Tissue Eng 6(4):297, 2000.
149 Van Osch GJ, Van Der Veen SW, Burger EH, et al: Chondrogenic potential of in vitro multiplied rabbit perichondrium cells cultured in alginate beads in defined medium. Tissue Eng. 6(4) :321, 2000.
150Tanino R, Miyasaka M. Reconstruction of microtia using tissue expander. Clin Plast Surg.17(2):339, 1990.
151 Bengtson BP, Ringler SL, George ER, et al. Capsular tissue: a new local flap. Plast Reconstr Surg.91 (6):1073, 1993 .
152 M. Heymans, B Lengele, N. Lahlali, et al.A peri-implant capsule flap. Br. J. Plast. Surg. 46 (6): 456, 1993.