PEDIATRIC/CRANIOFACIAL

Microtia Reconstruction in Hemifacial

Microsomia Patients: Three Framework
Coverage Techniques
Jung Youl Park, M.D.
Background: Microtia with hemifacial microsomia is difficult to treat because
Chul Park, M.D., Ph.D.
of skin volume deficiency. To provide further information for coverage tech-
Seoul, Republic of Korea niques in microtia reconstruction, the authors have reviewed and analyzed
patients who underwent surgery at their center.
Methods: A total 52 patients with microtia with hemifacial microsomia who
underwent reconstruction between 2006 and 2016 were involved. Patients were
reviewed retrospectively by examining medical records and photographic data.
Downloaded from http://journals.lww.com/plasreconsurg by BhDMf5ePHKbH4TTImqenVAJP5BDjqW51YmEQdvy3goBnyq88m0sR1zCHA0IZptXH on 12/14/2018

Results: All reconstructed cases were followed for 6 months to 10 years (me-
dian, 33 months). The average (median) surgeon’s satisfaction score was 8.2
(median, 9) for the embedded and elevation technique (n = 23); 7.89 (median,
8) for the temporoparietal fascia flap technique (n = 10); and 6.30 (median, 7)
for the subfascial expansion technique (n = 19). The median score difference
between the embedding and subfascial expansion techniques was statistically
significant (p = 0.03). Major factors that deteriorated aesthetic outcomes were
large reconstructed ears (11 cases), cartilage framework resorption (11 cases),
mismatched skin color (eight cases), different axis (seven cases), and different
shapes (five cases). Mismatched skin color was significant in cases treated with
the fascia flap technique (p < 0.0001), whereas cartilage framework resorption
was significant in cases treated with the tissue expansion technique (p = 0.004).
Conclusions: To obtain better aesthetic outcomes, the embedding technique
should be used when the patient shows a mild to moderate degree of low hair-
line and usable remnant vestiges. In cases showing severe degrees of associated
anomalies, the temporoparietal fascia flap technique should be used.  (Plast.
Reconstr. Surg. 142: 1558, 2018.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

M
icrotia with hemifacial microsomia is one of
the most difficult disorders to treat among Disclosure: The authors have no financial interests
all types of microtia because the disorder is to disclose in relation to the contents of this article.
accompanied by a number of abnormalities, such
as asymmetric balance of the face, low hairline,
depression of the temporoparietal joint, and low-
set ear vestige.1 These deformed external features Supplemental digital content is available for
in microtia can cause deficient skin volume and this article. Direct URL citations appear in the
make the covering of the new auricular framework text; simply type the URL address into any Web
in microtia reconstruction a difficult task. browser to access this content. Clickable links
to the material are provided in the HTML text
From the Seoul Center for Developmental Ear Anomalies and of this article on the Journal’s website (www.
the Department of Plastic and Reconstructive Surgery, Korea PRSJournal.com).
University Anam Hospital.
Received for publication January 17, 2018; accepted May
18, 2018.
Presented in part at the 2nd Congress of the International A Video Discussion by John Reinisch, M.D., ac-
Society for Auricular Reconstruction, in Beijing, People’s Re- companies this article. Go to PRSJournal.com
public of China, September 22 through 24, 2017. and click on “Video Discussions” in the “Digi-
Copyright © 2018 by the American Society of Plastic Surgeons tal Media” tab to watch.
DOI: 10.1097/PRS.0000000000005063

1558 www.PRSJournal.com
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 Volume 142, Number 6 • Microtia in Hemifacial Microsomia
There are few reports in the literature about
microtia coverage techniques for patients with
hemifacial macrosomia.2–4 To provide further infor-
mation for the coverage techniques, we reviewed
a number of microtia patients with hemifacial
microsomia on whom we had previously operated
at our center. We attempted to elicit the following
information on the basis of the collected data: (1)
the coverage technique that showed better post-
operative outcomes than others; (2) the relation
between the severity of the deformed external
features on the microtia side and the postopera-
tive aesthetic outcomes, and between the severity
of the deformed external features and the cover-
age technique; and (3) the factors that diminished
postoperative outcomes in cases that underwent
reconstruction with each coverage technique.
PATIENTS AND METHODS
A total of 52 hemifacial microsomia patients
who underwent microtia reconstruction between
2006 and 2016 were involved in the study. Patients
were reviewed retrospectively by examining medi-
cal records and photographic data. (See Table,
Supplemental Digital Content 1, which shows case
data for 2006 to 2016 for microtia reconstructions
of 52 hemifacial microsomia patients, http://links.
lww.com/PRS/D111.)
Deformed External Features on
the Microtia Side
To perform successful ear reconstructions,
deformed external features of the microtia side
were considered. These included the degrees of
hemifacial microsomia (midline shift and under-
developed hemiface), the presence or absence of
mastoid atrophy, the degrees of low hairline, and
the size and location of the ear vestiges (Table 1).
Patients showing minimal asymmetric faces that fell
in the normal range were excluded from our study.
Operative Techniques
All procedures were performed by a senior
surgeon (C.P.). Autogenous costal cartilages were
used for framework construction. Three types of
coverage techniques were used for the patients:
the subfascial expansion technique, the embed-
ded and elevation technique, and the temporopa-
rietal fascia flap technique.
Preoperative Preparation
Whenever we performed the expansion tech-
nique or the embedding technique on patients
with moderate to severe degrees of low hairline,
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
we planned preoperative laser epilation. The epi-
lation was performed using Apogee laser (Cyno-
sure, Inc., Westford, Mass.) (wavelength, 755 nm;
duration, 20 msec; energy density, 20 to 22 J/cm2).
For most cases, we performed three or four cycles
of laser treatment, with each cycle given within a
3-month period.
In patients with moderate to severe degrees
of hemifacial microsomia, it is difficult to deter-
mine a balanced ear position on the defect site
that would be symmetric with the ear position on
the normal side; the vertical location, horizontal
location, and axis of the reconstructed ear have
to be well planned. Balanced vertical locations of
the reconstructed ears were determined while the
ears were in front-facing positions. In hemifacial
microsomia patients, the affected faces are short-
ened because of underdeveloped mandibles and
contiguous bones of the facial skeleton.5–7 This
gives the reconstructed ear a larger appearance
in vertical length even if the reconstructed ear’s
vertical length is similar to the vertical length of
the opposite ear. When a reconstructed ear’s lob-
ule is adjusted to match the level of the opposite
(normal) ear’s lobule, the reconstructed ear’s
uppermost portion will appear higher than the
level of the opposite (normal) ear’s uppermost
portion. To camouflage this optical illusion, the
vertical lengths of the reconstructed ears were
made slightly smaller than the vertical lengths of
the opposite ears in patients with severe degrees
of hemifacial microsomia.
Determining the horizontal locations of the
reconstructed ears was more difficult in patients
showing severe midline shifts and dystrophic ves-
tiges. In these patients, vestiges cannot be used
as landmarks for determining the location of the
reconstructed ear. When deciding the position of
the inferior otobasion of the reconstructed ear,
the posterior margin of the mandibular ascend-
ing ramus was used as a reference. The final deci-
sion when determining a horizontal location was
made by checking the attached two-dimensional
traced ear film model on the defect site, which
was compared with ear position of the opposite
side. The axis of the reconstructed ear was deter-
mined by referencing the line along the dorsum
of the nose.8
Coverage Methods
Subfascial Expansion Technique: A Four-
Stage Technique, with 10 Cases
This technique is basically similar to the
expanded two-flap method that was previously
reported by the senior author.8 With this technique,
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 Plastic and Reconstructive Surgery • December 2018

Table 1.  Classification and Selected Operation Methods According to the Severity of Deformed External
Features on the Microtia Side
Methods (no. of cases)
Degree of Deformed Features No. (%) Fascia Flap Embedding Expansion
Hemifacial microsomia
 Mild 7 (13) 1 5 1
 Moderate 16 (31) 4 8 4
 Severe 29 (56) 14 10 5
Mastoid atrophy
 None or mild 29 (56) 6 18 5
 Moderate 3 (6) 1 2
 Severe 20 (38) 13 4 3
Low hairline*
 None or mild 18 (35) 2 12 4
 Moderate 10 (19) 3 5 2
 Severe 24 (46) 14 6 4
Size of vestige†
 Anotia 7 (13) 6 1
 Small lobule but usable 11 (21) 5 3 3
 Normal lobule 24 (46) 3 15 6
 Concha type 6 (12) 4 2
 Scapha type 1 (2) 1
 Enlarged mass 3 (6) 1 2
Location of vestige‡
 Normal position 16 (31) 2 9 5
 Slightly low 5 (10) 2 3
 Remarkably low, usable during embedding 19 (37) 5 11 3
 Remarkably low, not usable during embedding 6 (11) 4 2
 Anotia 6 (11) 6
*When the hairline was included in the helix of the newly created ear, the case was classified in the mild group. When the hairline reached
down to the scapha, the case was considered part of the moderate group. When the hairline reached down lower than the scapha, the case was
included in the severe group.
†According to the variable size of the ear vestige, patients were classified into six groups: (1) a group with no vestige (anotia) or vestiges too
small to use for newly created ears; (2) a group with small vestiges that can be used for newly created ears; (3) a group with a vestige as the
lobule-type microtia; (4) a group with a vestige as concha-type microtia with external meatus; (5) a group with a vestige as scapha-type microtia;
and (6) a group with an enlarged mass.
‡According to the variable location of the vestige, patients were classified into four groups: (1) the same position of the vestige as the opposite
earlobe; (2) the vestige located lower by <1 cm compared with the opposite earlobe; (3) the vestige located 1 cm or more below the opposite
earlobe (in these cases, the vestiges could be used for ear reconstruction during the embedding procedure); And (4) the vestige located 1 cm
or more below and anteriorly compared to the opposite earlobe (in these cases, the vestiges could not be used for ear reconstruction during
the embedding procedure).

however, we cannot use a subcutaneous pedicled
vascularized skin flap because of the variable size
and location of the lobule vestige characteristic of
hemifacial microsomia. We therefore performed
the skin flap coverage and elevation of the frame-
work in separate steps, to avoid the risk of vascular
compromise. The operative procedures are shown
in Figure 1. The patient in case 1, who underwent
reconstruction with the subfascial expansion tech-
nique, is shown in Figure 2.
Embedded and Elevation Technique:
A Three-Stage Technique, with 23 Cases
In the first stage, the constructed ear frame-
work was embedded underneath the mastoid
skin. A lobule vestige was used for coverage of
the embedded framework whenever possible. In
almost all the cases, a subcutaneous pedicle for
the mastoid flap could not be attached because
of the variable size and location of the ear vestige.
Six months after this procedure, we performed
the second stage of the technique. The embedded
framework was elevated for projection; the pre-
served cartilage block was inserted underneath
the elevated framework, and the posterior por-
tion of the elevated framework was covered with a
fan-shaped mastoid fascia flap. In the third stage,
a minor touch-up procedure was performed to
remove the remaining ear vestige and to reshape
the reconstructed ear, if necessary. The patients in
cases 2 and 3, reconstructed with the embedded
and elevation technique, are shown in Figures 3
and 4, respectively. (See Figure, Supplemental
Digital Content 2, which shows case 4, a 17-year-
old woman with microtia and a moderate degree
of hemifacial microsomia of the left face, who
underwent reconstruction with the embedded
and elevation technique. On the microtia site, a
normal sized bifid lobule vestige was located at a
slightly lower level than the opposite lobule. The
case was followed for 2 years after the operation.

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 Volume 142, Number 6 • Microtia in Hemifacial Microsomia

Fig. 1. Illustration showing operative procedures using the subfascial expansion technique. In the first stage, a tis-
sue expander was inserted under the mastoid fascia through a scalp incision on the mastoid region (above). A 25-cc
elliptical tissue expander with medium-sized remote valve (catalogue no. 350-5301 M; Mentor, Santa Barbara, Calif.)
was used. A serial saline expansion was performed (3 to 5 cc per week). The final saline volume was between 80 and
90 cc. It generally takes approximately 5 months from placement to removal of the expander. In the second stage, a
subfascial expander was removed through the previous scalp incision site (center, left) and a constructed ear frame-
work using an autogenous costal cartilage was inserted between the skin and fascia layer through the skin incision
around the ear vestige (center, center). A lobule vestige was used for covering of the lobule framework whenever
possible (center, right). Six months later, in the third stage, the embedded framework was elevated for projection:
a preserved cartilage block was inserted underneath the elevated framework (below, left) and the posterior por-
tion of the elevated framework was covered with the previously expanded mastoid fascia flap (below, right). In the
fourth stage, a minor touch-up procedure was performed to remove the remaining ear vestige and to reshape the
reconstructed ear, if necessary. L, lobule vestige; M, mastoid fascia; C, a piece of cartilage.

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 Plastic and Reconstructive Surgery • December 2018

Fig. 2. Case 1. A 12-year-old girl showing microtia with a severe degree of hemifacial microsomia of the right face. On the microtia
site, a severe degree of lower hairline was shown, and the lobule vestige was located remarkably low, but was usable during the
framework embedding. The ear was reconstructed with the subfascial expansion technique. (Above, left) Preoperative anterior and
(above, right) lateral views after treatment of the low hairline using a laser. The black drawn line is a representation of the location
of the future reconstructed ear. A framework fabricated with autogenous costal cartilage was inserted underneath the expanded
skin. At the second stage, the embedded framework was elevated for projection. (Below) Views of both ears 7 years after the final
operation. The score of the surgeons’ aesthetic outcome was 9.

The score of the surgeons’ aesthetic outcome was
10 points, http://links.lww.com/PRS/D112.)
Temporoparietal Fascia Flap Technique:
A Two-Stage Technique, with 19 Cases
A single-stage coverage using the temporopa-
rietal fascia flap technique was performed in most
cases for projected ear frameworks. In anotia or
cases with a very small vestige, a temporoparietal
fascia flap measuring 13 cm in length and 10 cm in
width was harvested for whole coverage, down to the
lobular framework (Fig. 5). In some cases, a deep
temporal fascia flap or a mastoid fascia flap was also
used. (See Figure, Supplemental Digital Content 3,

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 Volume 142, Number 6 • Microtia in Hemifacial Microsomia

Fig. 3. Case 2. A 14-year-old girl with microtia and a severe degree of hemifacial microsomia of the left face. On the microtia site,
a moderate degree of lower hairline was shown, and the lobule vestige was located lower by less than 1 cm compared with the
opposite earlobe. The lobule vestige was used during the framework embedding. The ear was reconstructed with the embedded
and elevation technique. (Above, left) Preoperative lateral view after treatment of the low hairline using a laser. The black drawn line
is a representation of the location of the future reconstructed ear. (Above, right) Fabricated framework. (Below) Views of both ears
3 years after the final operation. The score of the surgeons’ aesthetic outcome was 10 points.

which shows case 5, a 30-year-old man with micro-
tia and a severe degree of hemifacial microsomia
of the left face, who underwent reconstruction
with a temporoparietal fascia flap and deep tem-
poral fascia flap techniques. The fascia was closed
with skin obtained from the scalp. On the microtia
site, a severe degree of lower hairline was shown,
and the lobule vestige was very small and located
remarkably low. The repaired lateral cleft lip defor-
mity and the branchial cleft deformity immediately
behind the lobule vestige were associated. (Below,
right) Views of both ears 2 years after the operation.
The score of the surgeons’ aesthetic outcome was 8
points, http://links.lww.com/PRS/D113.)
Evaluation of Postoperative Aesthetic Outcomes
and Others
In assessment of the aesthetic outcome,
scores were assigned on a 10-point scale (where
1 = worst and 10 = best) considering the following

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 Plastic and Reconstructive Surgery • December 2018

Fig. 4. Case 3. A 12-year-old boy with microtia and a severe degree of hemifacial microsomia of the right face. On the microtia
site, a mild degree of lower hairline was shown, and the lobule vestige was located remarkably low, but was usable during the
framework embedding. The ear was reconstructed with the embedded and elevation technique. (Above) Preoperative anterior
and lateral views after treatment of the low hairline using a laser. (Below) Views of both ears 3 years after the operation. The score
of the surgeons’ aesthetic outcome was 10 points.

assessment factors: symmetry, size, convolution,
skin color, and shape (the entire and each unit
of the ear). The senior author reviewed the pre-
operative and final photographs of each patient,
and assigned scores for the aesthetic outcome. To
test the authenticity of the senior author’s analy-
sis, the senior author’s scores were compared with
the scores of two different groups (two plastic sur-
geons and two laypersons).
Two plastic surgeons who did not participate
in our ear operations and two laypersons reviewed
the photographs of each patient through an inde-
pendent and blind process. If the two surgeons or
the two laypersons scored differently from each
other, the final score of each patient was deter-
mined by forming a consensus in each group.
Subsequently, the senior author’s scores were
compared with the final scores of the two different

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 Volume 142, Number 6 • Microtia in Hemifacial Microsomia

Fig. 5. Diagrammatic representation showing three types of fascia flap techniques, and their size. (Left) temporoparietal fascia flap
(TPF) only type. (Center) Temporoparietal fascia flap plus the mastoid fascia flap technique (MF). (Right) Temporoparietal fascia flap
plus the deep temporal fascia flap (DTF) technique. In anotia or cases with a very small vestige, for whole coverage, down to the
lobular framework, a temporoparietal fascia flap measuring 13 cm in length and 10 cm in width were harvested. When the width of
the temporoparietal fascia flap was narrower than 8 cm, an additional mastoid fascia measuring 3 cm in width or a deep temporal
fascia was needed.

groups, and the intraclass correlation coefficient
between the senior author’s scores and the final
scores of the two different groups was measured.
The relations between the severity of the
deformed external features on the microtia side
and the postoperative aesthetic outcomes, and
between the severity of the deformed external
features and the operation technique, were evalu-
ated. Apart from the surgeon’s satisfaction rating,
we assessed factors that diminished the postopera-
tive outcome in each patient.
Statistical Analysis
On univariate analysis, either the Pearson chi-
square test or Fisher’s exact test was used for cate-
gorical variables, and either the Kruskal-Wallis test
or Mann-Whitney U test was used for continuous
variables indicating the nonnormal distribution.
Bonferroni-adjusted p values were presented in mul-
tiple comparisons between operation techniques.
On multivariable analysis, a binary logistic regres-
sion analysis was used for testing the effects of the
risk factors after adjusting the effects of the other
covariates. A value of p < 0.05 was considered sig-
nificant. The statistical analysis was performed using
IBM SPSS Version 22.0 (IBM Corp., Armonk, N.Y.).
RESULTS
Fifty-two cases were followed between 6 months
and 10 years (average, 40.3 months; median, 33
months) after the respective final operations.
Surgeon’s Satisfaction Scores for Postoperative
Outcomes
The intraclass correlation between the senior
author’s scores and the other two surgeons’ final
scores was 0.80 (95% CI, 0.67 to 0.88; p < 0.0001),
which was meaningful (Portney and Watkins
defined an intraclass correlation coefficient of
0.75 or more as one indicating good reliability9).
Meanwhile, the intraclass correlation between the
senior author’s scores and the two laypersons’ final
scores was 0.74 (95% CI, 0.59 to 0.84; p < 0.0001),
which indicated moderate reliability (Table 2).
The average (median) scores of aesthetic
outcomes for cases corrected through three dif-
ferent coverage techniques were measured and
compared with each another. The mean aes-
thetic score for the embedding technique was
rated as 8.26 (n = 23; median, 9), whereas the fas-
cia flap technique and the expansion technique
were rated as 7.89 (n = 19; median, 8) and 6.30
(n = 10; median, 7), respectively (Fig. 6). The
difference in scores among the three techniques
was statistically significant (p = 0.017, deter-
mined by the Kruskal-Wallis test). The difference
between the median scores for the embedding
technique and the expansion technique was sta-
tistically significant (determined by the Mann-
Whitney test; p = 0.03; the p value was obtained
with Bonferroni correction). However, the differ-
ence in the median scores between the embed-
ding technique and the fascia flap technique, or
between the expansion technique and the fascia

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 Plastic and Reconstructive Surgery • December 2018

Table 2.   Mean Aesthetic Scores for Three Different Surgical Techniques as Measured by Three Groups of Raters
Rater Fascia (SD)* Embedding (SD)* Expansion (SD)* Total (SD†
Senior author 7.89 (1.15) 8.26 (1.89) 6.30 (2.21) 7.75 (1.85)
Two surgeons 7.53 (1.51) 8.07 (1.91) 6.10 (1.85) 7.49 (1.87)
Laypersons 7.40 (1.33) 8.44 (1.35) 6.85 (1.93) 7.75 (1.58)
*There were no significant differences among mean aesthetic scores of three different surgical techniques given by three groups of raters using
repeated measures analysis of variance (p = 0.160).
†There were no significant differences among mean aesthetic scores by three groups of raters (p = 0.153).

flap technique, was not statistically significant
(p = 0.405 and p = 0.168, respectively).
To assess the predictability of the three tech-
niques, the score measured by a 10-point scale in
each patient was graded again as poor (score of
1 to 4), fair (score of 5 to 6), good (score of 7 to
8), and excellent (score of 9 to 10). (See Table,
Supplemental Digital Content 4, which shows
the distribution of the satisfaction scores using a
four-point scale in patients treated through three
different coverage methods, http://links.lww.com/
PRS/D114.) Based on the sample size of this study,
we regrouped the cases in two groups: “excel-
lent” and “others.” The probability of obtaining
an excellent result was compared among the
three techniques used. Using a binary logistic
regression analysis, the probability of getting an
excellent result (score of 9 to 10) in patients who
underwent reconstruction with the embedding
technique is higher than in patients who under-
went reconstruction with the expansion tech-
nique (OR, 11.7; 95% CI, 1.72 to 108.20; p = 0.03)
(Fig. 7). [See Table, Supplemental Digital Content
5, which shows a binary logistic regression analysis
for the postoperative aesthetic results according
to various factors. The results were divided into
two groups: one with scores of 9 to 10 (excellent),
and one with scores of 8 or less (not excellent),
http://links.lww.com/PRS/D115.]
Assessment of Differences in Postoperative
Outcomes According to the Severity of Deformed
External Features on the Microtia Side
The severity of deformed external features
did not affect postoperative aesthetic outcomes.
Their differences were not statistically significant
(Table 3).
Assessment of Selected Operation Techniques
According to the Severity of Deformed External
Features on the Microtia Side
In cases with severely deformed external fea-
tures, the fascia flap technique was predominantly
chosen over other coverage techniques (Table 3).

Fig. 6. Comparison of aesthetic outcomes for cases corrected through use of three
different techniques. F, fascia flap technique; M, embedding technique; X, expansion
technique. Aesthetic outcomes were assessed on the basis of a surgeon’s satisfaction
rating system. Scores were assigned on a 10-point scale.

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 Volume 142, Number 6 • Microtia in Hemifacial Microsomia

Fig. 7. Comparison of the probability of obtaining an excellent result through the use
of three different techniques as determined by a binary logistic regression analysis.
F, fascia flap technique; M, embedding technique; X, expansion technique. The per-
centage on the y axis represents the probability of obtaining 9 or 10 points (orange
bar), and 8 or less points (blue bar) in cases operated on with the three coverage
techniques. Nineteen cases were covered with the fascia flap technique, 23 cases
were covered with the embedding technique, and 10 cases were covered with the
expansion technique. The probability of obtaining 9 or 10 points is higher in patients
operated on with the embedding technique than in patients operated on with the
other two techniques.

Assessment of Factors That Diminished the DISCUSSION

Aesthetic Outcomes
Multiple factors can be responsible for dimin-
ishing the postoperative outcome in the same
patient: the large size of the reconstructed ear (11
cases), a delayed partial resorption of the cartilage
framework (11 cases), mismatched skin color (eight
cases), different ear axis (seven cases), different
ear shape (five cases), obtuse ear convolution (two
cases), and unsightly operative scars (two cases)
were considered as factors that diminished the aes-
thetic outcomes. With this in mind, we analyzed the
factors that significantly diminished the postopera-
tive aesthetic outcomes for each of the three cover-
age techniques (Table 4). Mismatched skin color
diminished aesthetic outcomes in cases treated with
the fascia flap technique significantly more than
with the other coverage techniques (p < 0.0001).
Delayed resorption of the cartilage framework
diminished aesthetic outcomes in cases treated
with the tissue expansion technique significantly
more than with the other coverage techniques
(p = 0.004). Larger reconstructed ears diminished
aesthetic outcomes more in cases treated with the
tissue expansion technique, but their difference
was not statistically significant (p = 0.059).
The OMENS5,6 and Pruzansky-Kaban7 classifi-
cations of hemifacial microsomia malformations
are based on the severity of the facial skeletal
deformity. In microtia reconstructions of hemi-
facial microsomia patients, the skeletal deformity
affects the location and size of the reconstructed
ear, but not the coverage techniques. In this arti-
cle, we assessed postoperative outcomes of patients
who underwent reconstruction with three cover-
age techniques by considering the severity of five
deformed external features of hemifacial microso-
mia: mastoid atrophy, low hairline, size, and loca-
tion of the ear vestige.
Resorption of the grafted cartilage frame-
work is one of the difficult problems in auricular
reconstruction using an autogenous costal car-
tilage. Acute resorption might occur because of
infection or delayed healing of the coverage tis-
sue during the early postoperative period. Early
postoperative infections or delayed healing of
the coverage tissue did not occur in any of our
reconstructed cases. However, 11 cases (21.2 per-
cent) showed delayed resorption of the grafted
cartilage. Of these, six cases were treated with
the expansion technique, four cases were treated

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 Plastic and Reconstructive Surgery • December 2018

Table 3.  Assessment of Difference in Postoperative Outcomes and Assessment of Selected Operation Methods
According to the Severity of Deformed External Features on the Microtia Side
Postoperative Outcomes Methods
(no. of cases) (no. of cases)‡
Fascia Embedding or
Degree of Deformed Features* ≤8 >9 Total p† Flap Expansion Total p†
Hemifacial microsomia
  Mild to moderate 14 9 23 5 18 23
 Severe 16 13 29 0.680 14 15 29 0.048
Mastoid atrophy
  Absent to moderate 19 13 32 6 26 32
 Severe 11 9 20 0.756 13 7 20 0.001
Low hairline
  Extend to scapha or less 17 11 28 5 23 28
  Below scapha 13 11 24 0.634 14 10 24 0.003
Size of vestige
  Anotia or too small 11 7 18 11 7 18
  Average size or large 19 15 34 0.717 8 26 34 0.007
Location of vestige
  Usable, when framework
 embedding 23 17 40 9 31 40
  Not usable, when framework
  embedding or anotia 7 5 12 0.959 10 2 12 0.000
*Deformed features were categorized into two subgroups for statistical analysis.
†The p value was obtained by Pearson χ2 test or Fisher’s exact test.
‡We combined the embedding and expansion cases, because of small sample size of each embedding or expansion case for statistical analysis.

Table 4.  Factors That Diminished the Aesthetic Outcomes and Their Analysis*
Total (%) Fascia Flap (%) Embedding (%) Expansion (%) p‡
No. 52 19 23 10
Factors†
 Shape 5 (9.6) 2 (10.5) 2(8.7) 1 (10.0) 1
 Size 11 (21.2) 3 (15.8) 3 (13.0) 5 (50.0) 0.059
 Scar 2 (3.8) 1 (5.0) 0 (0.0) 1 (10.0) 0.306
 Color 8 (15.4) 8 (42.0) 0 (0.0) 0 (0.0) <0.0001
 Convolution 2 (3.8) 2 (10.0) 0 (0.0) 0 (0.0) 0.163
 Resorption 11 (21.2) 1 (5.0) 4 (17.4) 6 (60.0) 0.004
 Axis 7 (13.5) 2 (10.5) 2 (8.7) 3 (30.0) 0.238
*(%) represents the percentage within operation methods.
†Multiple deteriorating factors were counted in some patients.
‡The p value was obtained by Pearson χ2 test or Fisher’s exact test.

with the embedding technique, and one case was
treated with the fascia flap technique. (See Docu-
ment, Supplemental Digital Content 6, which
shows a delayed resorption of the grafted frame-
work in cases 6, 7, and 8, http://links.lww.com/
PRS/D116.) The degree of resorption was vari-
able. The causes for the delayed resorption phe-
nomena observed in many cases remain difficult
to explain. We presume five conditions have been
causing a delayed resorption to date:
1. Neglected treatment of the exposed wire
can cause chronic inflammation of the car-
tilage and finally result in the resorption of
the framework (case 6).
2. An uncontrolled sculpturing technique of
the costal cartilage during framework fab-
rication can cause a delayed resorption.10
Growing costal cartilage consists of outer
high-density and central low-density zones.
After the shaving or carving-out procedure,
the exposed central layer might be eas-
ily resorbed postoperatively. The resultant
resorptive defect is more conspicuous on
the helix and antihelix components.
3. Poorly vascularized coverage can cause a
delayed resorption. We presume that the
skin expansion technique makes a skin layer
that is too thin, which offers poor vascular
supply to the grafted cartilage framework in
the long term (case 7).
4. Unknown conditions can also cause a
delayed resorption, as shown in case 8.
5. Continuous compressive pressure under-
neath the tight skin areas can cause resorp-
tion of the embedded cartilage during

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Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 142, Number 6 • Microtia in Hemifacial Microsomia
the period of framework embedding. The
prominent helix is the usual resorption site.
Our analysis showed that the severity of the
deformed external features of hemifacial microso-
mia patients did not affect postoperative aesthetic
outcomes of the reconstructed ears (Fig. 2). Our
selection of coverage technique might affect the
postoperative outcome. In the past two decades,
we have made various attempts to acquire reli-
able results for microtia reconstructions of the
patients with hemifacial deformity. In the earlier
periods of our experience, we used the expansion
method in some of the severe cases. However, we
did not use the expansion technique after finding
a higher percentage of occurrence of factors that
diminished the aesthetic outcomes (i.e., resorp-
tion, larger size, different axis). Lately, the fascia
flap technique was predominantly used in patients
with severe degrees of deformed external features
(Table 1). We also used the embedding technique
in some cases with severe degrees of deformed
external features.
We listed five deformed external features
of hemifacial microsomia and measured the
severity in each feature. The number of severe
deformed features was different in each patient:
some showed a single severe external feature
and others showed multiple severe external fea-
tures. Patients who underwent reconstruction
with the fascia flap technique showed an average
of 3.37 (median, 3.00) multiple severe external
features; meanwhile, patients who underwent
reconstruction with the embedding technique
showed an average of 1.48 (median, 1.00) mul-
tiple severe external features. The difference
was statistically significant (p < 0.0001, Mann-
Whitney test). However, the number of severe
features did not affect postoperative outcomes
by statistical analysis.
When the fascia flap technique is used, a large
skin graft is needed for closure of the fascia. In
this case, selection of skin donor site is important,
as the quality (color and texture) of the grafted
skin does affect postoperative aesthetic outcomes
(see Document, Supplemental Digital Content 6,
which shows color mismatch in cases 9, 10 and 11,
http://links.lww.com/PRS/D116). Furthermore, in
some patients who underwent reconstruction with
the fascia flap technique, the anteroauricular sub-
units were poorly defined postoperatively because
of thick or contracted fascia and grafted skin.
We described the selection of skin donor site
in detail in our previous article.11 Lately, we have
been using scalp skin for closing the entire surface
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
of the fascia in all cases. Three to six months later,
in some cases needing better definition and color
match on the anteroauricular surface, debulking
and skin grafts obtained from the contralateral
postauricular and mastoid region were applied
after removal of the previously grafted scalp skin.
The donor site of the postauricular and mastoid
region was regrafted with a split-thickness skin
graft obtained from the buttocks.
In some of the patients with severely dystopic
vestiges, the vestige skin could be used for coverage
of the lower portion (lobule portion) of the new
framework: the lower portion of the vestige skin was
transposed upward and the upper portion of the ves-
tige was positioned on the lower margin of new ear-
lobe, as shown in case 1 and case 3. However, when
the vestiges were positioned too inferiorly and ante-
riorly and could not be used for coverage of the new
framework, they were completely removed and used
as skin graft for coverage of the fascia flap.
Qian et al.2 used the subcutaneous expansion
technique for microtia reconstruction in the hemi-
facial microsomia patients with successful results.
We also used the expansion technique. However,
we used the subfascial expansion technique, but
not the subcutaneous expansion technique. We
believe that the subfascial expansion technique
offers a more pure subcutaneous vascular layer of
mastoid skin.8
Larger ears and axis difference were major
factors in diminution of the aesthetic outcomes
(see Document, Supplemental Digital Content 6,
which shows a larger ear and a different axis for
the reconstructed ear, respectively, in cases 12 and
13, http://links.lww.com/PRS/D116).
Table 3 shows factors that diminished the aes-
thetic outcomes in reconstructed ears. The factors
were graded mild to severe. In assessing postopera-
tive aesthetic outcomes of the reconstructed ears,
some mild-degree deterioration factors resulted in
a reduction of 1 point, whereas other, severe-degree
deterioration factors resulted in a remarkable
reduction of points, as in case 7 (see Document,
Supplemental Digital Content 6, http://links.lww.
com/PRS/D116). Even though they are somewhat
subjective, we show our scores in representative
cases 6 through 13 (see Document, Supplemental
Digital Content 6, http://links.lww.com/PRS/D116).
CONCLUSIONS
The following suggestions are proposed for
the selection of coverage techniques in micro-
tia reconstruction of cases with hemifacial
microsomia:
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 Plastic and Reconstructive Surgery • December 2018
1. When the patient has a mild (no hair) to
moderate degree of low hairline and usable
remnant vestiges, and enough mastoid skin
volume is available, the embedding tech-
nique should be used with the addition of
laser hair removal.
2. In cases with severe degrees of hemifacial
microsomia, mastoid depression, low hair-
line, small ear vestiges (anotia or small lob-
ule type), and/or remarkably low-set ear
vestiges, the fascia flap technique should be
used.
3. The expansion technique, which is slow and
cumbersome, yielded the poorest results
and in most patients should be avoided.
Chul Park, M.D., Ph.D.
Department of Plastic and Reconstructive Surgery
Korea University Anam Hospital
Inchon-Ro73, Seongbuk-Gu
Seoul 136-705, Republic of Korea
chulpark.md@gmail.com
PATIENT CONSENT
Parents or guardians provided written consent for
the use of patients’ images.
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Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
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