Source 丨21 Healthnews21 original work
Author 丨Wu Ying Gang
Editor 丨Xu Xu
Image courtesy of | respondents
The ear is a non-renewable organ that needs to be artificially reconstructed if a defect occurs. One way to do this is to remove part of the patient's rib cartilage, make it into the shape of an external ear, and implant it under the skin of the affected area.
Recently, Professor Guo Shuzhong, president and chief physician of Xi'an International Medical Center Plastic Surgery Hospital, a well-known expert in domestic ear reconstruction, said in an exclusive interview with 21st Century Business Herald that every year, about 2500 children with microtia in China need ear reconstruction surgery, and most of them choose to use rib cartilage to compare with ear carving and implantation.
It is understood that congenital microtia belongs to the morphological dysplasia of the ear, the incidence is 0.83 ~ 17.4 / 10000, in the head and face congenital malformations are only lower than the congenital cleft lip and palate, and the incidence of men is 20%-40% higher than that of women.
The main treatment method for microtia is ear reconstruction surgery, and auricular is a three-dimensional three-dimensional structure of a body surface organ composed of multiple subunits, involving more than ten fine anatomical structures, so ear reconstruction surgery is one of the most difficult surgeries in the field of plastic surgery.
Guo Shuzhong told the 21st Century Business Herald that ear reconstruction surgery is constantly improving, the treatment effect is much better than in the past, and the surgical effect of several well-known doctors in China has been internationally recognized and reached the international advanced level, but the distance is 100% similar to the real ear, and there is at least 20% room for improvement in details.
Guo Shuzhong further said that to do a good job in ear reconstruction surgery, doctors must not only have exquisite plastic surgery skills, but also have excellent aesthetic literacy.
How to plant ears?
Guo Shuzhong told the 21st Century Business Herald that the main treatment method of microtia is ear reconstruction surgery, surgical technology is constantly improving, the treatment effect is much better than in the past, and the surgical effect of several well-known doctors in China has been internationally recognized and reached the international advanced level.
According to reports, ear reconstruction surgery has undergone many changes and improvements in history, and is currently divided into two categories, one is the direct burial method, ancient and classic, about 70% of the domestic surgery is still in use, and the other is the expansion method, which is divided into semi-expansion method (half package) and full expansion method (all inclusive).
According to the "Chinese Journal of Aesthetic Plastic Surgery" and other information, the direct burial method is generally divided into two stages, one stage of surgery first removes the residual ear, while cutting the patient's 6th to 8th rib cartilage, imitating the ear cartilage for carving, making an ear cartilage bracket (ear stent), that is, "false ear", buried in the positoid area behind the ear, at this time the ear has not yet stood up.
After about 6 months, the second stage of surgery is performed, a circular incision is made along the "false ear" to separate it from the skin behind the ear, and then the "false ear" is supported so that it is angled by about 30 degrees from the skull, and then the skin is taken from the head, chest or abdomen, and the skin is grafted.
The partial dilation method is completed in three stages, the first phase is to embed the dilator in the mastoid area behind the ear to expand the skin to cover the "false ear" in the follow-up, the second phase is to remove the dilator, and the autologous rib cartilage is engraved and transplanted, and the third phase is partially trimmed. The main difference between semi-expansion and full expansion is the size of the dilator and the size of the expanded skin, Guo Shuzhong mainly performs full expansion surgery, and has improved the operation from stage 3 to stage 2.
Guo Shuzhong told 21st Century Business Herald that in the late 1980s and early 90s, ear reconstruction surgery introduced the use of expanders, and before the advent of expansion technology, basically 100% were direct burial methods, and now the expansion method is used more and more.
Professor Guo Shuzhong
Guo Shuzhong said that the main difference between direct burial, half package and all package is whether to graft the skin, direct burial and half pack need to be grafted, the area of the half pack of skin graft is small, and the whole package does not need to be grafted.
"We are using expanders for ear reconstruction, but there are two ways to expand, one is to use small expanders, the skin that is expanded out is less, not enough to create an ear, it can only cover the front of the ear, there is still a certain skin graft behind the ear, the expander we are currently using is relatively large, the skin that is expanded out is more, and it can completely cover the front and back of the ear."
Guo Shuzhong further said that skin grafting is to dismantle the east wall to make up for the west wall, to cut a piece of skin from the body, transplanted to the back of the ear, then the skin and skin grafting place will leave scars, and after skin grafting, the color behind the ear is different from the front, so the choice of half-pack and all-inclusive people are increasing.
Researchers at the Plastic Surgery Hospital of Peking Union Medical College have also analyzed that the single treatment of direct burial method has a relatively short duration and no complications related to skin dilation, but the skin graft area is large, the scar is obvious, and for patients with thick and tight skin, the detail structure of the ear is difficult to present.
After the use of dilation, the thickness, texture, area and blood circulation of the skin have been improved, which is conducive to the display of fine structure, reducing the area of skin grafting, so that the splicing scar can be better hidden, but to master the skin dilation as the premise, for beginners without technical reserves, a long learning process is required.
What else can be improved with ear reconstruction surgery?
Guo Shuzhong told 21st Century Business Herald that in general, the improvement direction of ear reconstruction surgery is to make the reconstructed ear and the real ear more and more similar, but the current reconstructed ear, the first is that the rib cartilage is hard and cannot be curled well, the second is that most of the skin is thicker than the ordinary ear, and the third is that the details are not 100% consistent, and it is already a world-class level to achieve 80% similarity, that is, there is at least 20% room for improvement.
"There are two ways to improve the surgery – the skin covering the outside is getting thinner and thinner, the color is getting better and better, and the ear braces are becoming more and more sculpted. For the covered skin, dilation technology has been able to make the skin more and thinner, and there is no alternative to skin dilation at present, but there is still a lot to be improved in the ear bracket. Guo Shuzhong said.
In terms of ear stent materials, studies have shown that although most experts believe that rib cartilage is a reliable material for permanent ear stents, the damage to the supply area caused by rib cartilage collection has always been a common pain point for both doctors and patients, so people have never stopped trying alternative materials.
It is understood that there are currently two types of materials that may replace rib cartilage, one of which is pseudo-compound, "fake" is a fake, "complex" is a copy, and fake complex refers to medical products that make up for human birth defects, such as prosthetic eyes, prosthetic ears, prosthetic nose, prosthetic limbs, etc.
Guo Shuzhong said that the fake compound can be seen as sticking a plastic ear to the child, the color, texture, and size can be done very similarly, but if you use special glue to stick, it is not good for the skin, if it is fixed with metal nails, the place in contact with the skin is easy to infect, so most patients still choose rib cartilage.
The other type is tissue engineering technology, Guo Shuzhong introduced, that is, take the residual cartilage on the patient's ear, cultivate in a Petri dish, and then make an ear stent through 3D printing, China is leading in the world, but the cultivated ear stent can not completely replace the rib cartilage, there is a risk of absorption and deformation, so continue to return to the laboratory for research.
In addition, China Medical Beauty magazine also shows that porous polyethylene materials are also used to make ear braces, that is, Medpor ear stents , a material with high durability and high biocompatibility , commonly used in craniofacial reconstruction surgery. However, over time, Medpor ear stents may be displaced or fractured due to trauma, especially in highly active children.
"In the long run, organizational engineering is the future direction of development, but in the short term there may be no way to break through, I also participated in the research of organizational engineering, but found that it is much more difficult than imagined." Innate ear cartilage is a work of nature's ingenuity, and in the laboratory it is simulated by Petri dishes, which is very difficult because the regulation and development process of our normal ear cartilage has not yet been figured out. Guo Shuzhong said.
Researchers from the Affiliated Eye, Ear, Nose and Throat Hospital of Fudan University have also analyzed that the technology of cultivating auricular cartilage through tissue engineering technology is becoming more and more mature, but there are still many challenges to be applied to the clinic, such as: the choice of seed cell source and differentiation; how to improve the mechanical and anti-wear properties of cartilage to maintain shape for a long time; how to coordinate the regeneration and degradation rate of chondrocytes in vivo, so as not to degrade too quickly and lead to structural loss.
What are the difficulties of ear reconstruction surgery?
Ear reconstruction surgery is one of the most difficult surgeries in the field of plastic surgery, but there are very few good doctors. Guo Shuzhong told 21st Century Business Herald that any doctor who wants to do a good job in surgery must have sufficient surgical accumulation, but the incidence of microtia is not high, and domestic ear reconstruction surgery is generally concentrated in the hands of a small number of doctors.
"There are about 2,500 children in China who need surgery every year, I alone did 600 to 800 cases, accounting for 1/4, every province in The country has doctors who do ear reconstruction surgery, but many of them can only do a few, dozens of them a year, which is certainly not OK, at least hundreds of surgeries a year, it is possible to slowly accumulate enough technology."
Guo Shuzhong further said that in fact, the overall number of domestic ear reconstruction doctors is sufficient, but there are many doctors who are not high-level. It is difficult for this part of the doctor to improve the technology, because ear reconstruction surgery is not learned by listening to lectures and lectures, but needs to follow an excellent teacher and teach by hand for a long time to improve.
In addition, carving out an ear brace with a three-dimensional structure with rib cartilage can be said to be the core step of ear reconstruction surgery, and the difficulty is the greatest, but the doctor wants to carve well, and it is not experienced to do it.
Sculpt rib cartilage
Guo Shuzhong told 21st Century Business Herald that ear reconstruction surgery requires two aspects of ability: first, very exquisite plastic surgery technology, including dilator technology, flap technology, skin grafting technology, etc.; second, carved ear brackets should be like making works of art, in addition to surgical operations, but also aesthetic literacy, the combination of science and art can have excellent results.
"But many doctors have not done aesthetic training, can not carve out the ear bracket that is very similar to the real ear, lack of three-dimensional three-dimensional imagination ability, but the difficulty lies in this, there are differences between people, some doctors even if they practice for eight years, ten years, still lack three-dimensional three-dimensional imagination ability."
"Ear bracket carving has a lot of similarities with making art, I often recommend that young doctors usually do more painting and carving, cultivate aesthetic literacy, but ear reconstruction is very demanding on talent, just like many people can paint, but not all of them can become Leonardo da Vinci and Picasso." Guo Shuzhong said.
So are there any other potential treatments besides ear reconstruction surgery?
Relevant researchers of the Affiliated Eye, Ear, Nose and Throat Hospital of Fudan University have said that due to the complexity of this type of congenital malformations and the relatively low incidence, microtia has not received enough attention and systematic research in the world, making the understanding of the laws of this type of disease insufficient and the treatment effect limited.
Guo Shuzhong also said that the pathogenesis of microtia is still unclear, although more than 100 kinds of microtia-related genes have been found, but only 1 in 20 children who have the disease is genetic, accounting for only 5%, more likely to be related to the external environmental impact. In addition, even if the pathogenesis is clarified, more significance lies in prevention, treatment also depends on surgery, and there is no alternative to surgery in the short term.
Interview Afterword:
The ear needs surgery, but the heart needs to be guarded
In the interview, the reporter can deeply feel that in addition to the physiological need for surgery, the psychological impact of microtia on children cannot be ignored.
Guo Shuzhong also told reporters that because most of the children are unilateral ear deformities, the contralateral ear is no problem, the hearing is not completely lost, the impact on daily life is not large, but it is easy to be ridiculed, nicknamed, and has a great impact on the psychological development of the children, "In fact, these children are no different from ordinary people, calling on society to be more tolerant of these children with congenital development abnormalities." ”
Studies at Peking Union Medical College have found that patients with microtia may be aware of their facial differences as early as three or four years old, and parents hope that their children will be able to operate sooner. However, Guo Shuzhong said that the rib cartilage can not be better carved until the child is 7 years old, otherwise it is too fine and soft, and the effect of the ear bracket is not good, so in the years before the operation, parents' psychological guidance of the child is very important.
"In fact, many times because parents are very concerned, then children will also care, some parents will also give the little boy long hair, cover the deformed ears, if the parents do not care, leave short hair for the child, others see it, then the child's psychology may be healthier, there will be no inferiority psychology."
Studies have also shown that children with pre-mathematical microtia rarely go out to play, and parents will minimize their contact with outsiders in order to avoid external harm to their children, but excessive protection and preference of parents will affect the independence of children, which in turn will aggravate their social anxiety, so parents should not be overly protective and favoritistic in the process of educating their children.