How To: 3D Customization for Microtia Repair in Hemifacial Microsomia

by Kyle Kimura, MD, Seth Davis, MD, Evan Thomas, DO, Raj Dedhia, MD, Karthik Shastri, MD, Priyesh Patel, MD, Scott Stephan, MD, Sumit Pruthi, MBBS, and Brenton Griffith, BS •

Introduction

Microtia, the absence or underdevelopment of the auricle, is thought to affect 1 in 5 to 10,000 live births worldwide and has been associated with significant psychosocial morbidity that may dramatically improve following surgical repair (Facial Plast Surg Clin N Am. 2016;24:577-591). Currently, these techniques largely fall into two major categories: autologous reconstruction using costal cartilage, and synthetic reconstruction using a porous polyethylene (PPE) construct. There is considerable debate regarding the superior technique for various clinical settings in which to apply these differing methods. Nonetheless, both techniques aim to create a reliable construct for the novel auricular framework, which is then covered with native tissue (skin, fascia, or both). For the purpose of discussion in this paper, the senior author primarily performs the porous polyethylene-based reconstruction.

Microtia can present in isolation or as part of a syndrome such as oculo-auriculo-vertebral syndrome (OAVS), which encompasses Treacher Collins and Goldenhar syndromes. Patients with OAVS may be distinguished by the presence of hemifacial microsomia, the underdevelopment of the bony and soft tissue structures of one or both sides of the face with resulting facial asymmetry. These patients have a host of unique anatomical abnormalities that present surgical challenges and often preclude favorable aesthetic outcomes following reconstructive surgery (Plast Reconstr Surg. 2018;142:1558-1570). Associated abnormalities can include asymmetric malar height and projection, mandibular hypoplasia, and a deficient mastoid, among others. Failure to recognize and address these deficiencies can lead to obvious asymmetries and poor aesthetic outcomes.

A common problem seen postoperatively in this subset of patients includes underprojection of the lower third of the ear, most notable when seen in frontal view. This asymmetry likely results from undercorrection of mastoid hypoplasia, resulting in decreased projection of the lower third of the ear. Despite multiple studies intending to determine ideal angles and size of the reconstructed ear, this particular measure has not been described in the literature to our knowledge. Referred to as the axis of projection (AOP), this measurement represents an angle seen on frontal view formed from the superior helix of the ear (vertex) bisecting the lobule in a vertical axis. Given the importance of this angle in relation to the aesthetic outcome of surgery, different methods to achieve symmetry were explored and described herein.

An increasingly popular tool used across multiple surgical specialties is three-dimensional (3D) printing, which offers the opportunity for case-by-case customization. This is particularly useful during surgical planning and can help the surgeon better understand each patient’s unique anatomy. Within the field of microtia reconstruction, these types of 3D models have been utilized to help train future microtia surgeons, while other groups have attempted to integrate 3D printing into the creation of a modifiable implant for the day of surgery (Otolaryngol Head Neck Surg. 2017;156:999-1010).

Matching the axis of projection when reconstructing the microtic ear allows for the optimization of aesthetic outcomes, in particular along the frontal view.

This manuscript aims to address the difficulties presented with microtia repair in patients with hemifacial microsomia. We discuss our approach to preoperative planning as well as our intraoperative technique, focusing on descriptive measures that are important to identify at the time of surgery to maximize cosmetic outcomes.

Method

The following method was applied to six consecutive cases for:

Preoperative Planning: Patients scheduled for microtia repair underwent thincut computed tomography scans that specifically included the entirety of both ears and surrounding soft tissue. These scans were uploaded into Mimics and Autodesk Meshmixer to create digitally manipulatable models, allowing for measurements of mastoid and midface deficiency. Virtual images were used to create 3D-printed models for physical manipulation (Figure 1).