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Chinese Journal of Burns and Wounds logoLink to Chinese Journal of Burns and Wounds
. 2026 Jan 20;42(1):41–48. [Article in Chinese] doi: 10.3760/cma.j.cn501225-20250902-00384

应用自体肋软骨行二期法全耳再造术矫正先天性小耳畸形的临床疗效

Clinical efficacy of two-stage ear reconstruction using autologous rib cartilage in the correction of congenital microtia

Zhicheng Xu 1, Qun Zhang 1, Feng Xu 1, Datao Li 1, Yiyuan Li 1, Xia Chen 1, Ruhong Zhang 1,*
PMCID: PMC12835849  PMID: 41611287

Abstract

Objective

To explore the clinical efficacy of two-stage ear reconstruction using autologous rib cartilage in the correction of congenital microtia.

Methods

The study was a retrospective cohort study. From January 2000 to February 2025, 3 050 patients (1 992 males and 1 058 females, aged 6 to 52 years) with congenital microtia who met the inclusion criteria were admitted to the Department of Plastic and Reconstructive Surgery of Shanghai Ninth People's Hospital of Shanghai Jiao Tong University School of Medicine. All of them were corrected by the two-stage ear reconstruction. The first stage operation involved harvesting of the 6th to 8th autologous rib cartilages (the 9th autologous rib cartilage was harvested if necessary) for ear framework fabrication. Depending on the amount and location of residual ear tissue, the transverse, longitudinal, "V"-shaped, "U"-shaped, or "W"-shaped incisions were designed, and then fabricated frameworks were implanted, and the wounds were closed. The second stage operation was performed 3 to 6 months after operation. The reconstructed ear was first lifted, the reserved cartilage or titanium plate was used as supporting material to construct the cranio-auricular angle, and then the wound was closed with retroauricular fascial flap and split-thickness scalp skin graft. The wound at the donor site of the skin graft was packaged and fixed. After operation, the incidence of complications was recorded, and the occurrence rate was calculated. During the follow-up, the appearance of the reconstructed ear was observed, and the patients' satisfaction or reasons for dissatisfaction were counted.

Results

The complications, such as venous congestion, flap necrosis, and cartilage exposure, etc. occurred in the first stage operation, and the occurrence rate was 6.59% (201/3 050); partial skin graft necrosis, fascial flap necrosis, and cartilage exposure, etc. occurred in the second stage operation, and the occurrence rate was 9.18% (280/3 050). The complications were all controlled effectively after adopting treatment measures such as acupuncture and bloodletting combined with wet compress using gauze soaked in heparin solution, debridement and drainage, hyperbaric oxygen therapy, rational application of antibiotics, and repair with fascial flaps and skin grafts. During the follow-up of 6 months to 15 years after the second stage operation, the morphology of each sub-unit of the reconstructed ear appeared, the proportion was coordinated, and the structure was soft and natural. 89.02% (2 715/3 050) of the patients and their families were satisfied with the shape contour, position, and size of the reconstructed ear. The reasons for the dissatisfaction of the remaining patients were local structural defects of the reconstructed ear caused by postoperative complications, asymmetry in the position of the reconstructed ear due to factors such as hemifacial microsomia and ectopic auditory meatus.

Conclusions

Two-stage ear reconstruction using autologous rib cartilage in the correction of congenital microtia is a reliable surgical technique, characterized by a low incidence of postoperative complications, natural anatomical structure of the reconstructed ear, and high patient satisfaction.

Keywords: Congenital microtia, Costal cartilage, Postoperative complications, Ear reconstruction, Incision design, Cartilage framework

先天性小耳畸形是各类外耳畸形中最为严重的一种类型, 应用自体肋软骨进行全耳再造术已有百余年历史, 目前仍是国际主流修复方式。然而, 在耳区有限的空间内精确重建包含十余个亚单位的复杂耳郭三维结构, 始终是整形修复外科医师面临的一项重大挑战。随着Tanzer[1]、Brent[2]、Nagata[3]、Park[4]及Firmin[5]等耳再造先驱以及国内外学者对耳再造手术技术的持续改进[6-16], 应用自体肋软骨行二期法全耳再造术已成为国内外矫正先天性小耳畸形的首选术式。该术式具有周期短、并发症少、安全性高、可重复性好及易于掌握等优势。该术式的适应证如下：患者年龄≥6岁且剑突下胸围 > 60 cm[17-18], 针对先天性小耳畸形尚未接受过任何手术治疗, 患者乳突区局部皮肤无明显疾患且松弛度和弹性可[19-20]等。本研究对3 050例接受该术式的先天性小耳畸形患者临床资料进行了回顾性分析, 总结了该术式中切口设计方案、基于不同软骨特征的个性化支架雕刻技术和并发症产生原因和处理经验。

1. 对象与方法

本回顾性队列研究符合《赫尔辛基宣言》的基本原则, 按照上海交通大学医学院附属第九人民医院（以下简称本院）伦理委员会相关政策要求, 可在对患者信息保密的情况下分析使用其临床资料。

1.1. 入选标准

纳入标准：（1）性别不限, 年龄≥6岁；（2）临床确诊为先天性小耳畸形, 并采用自体肋软骨行二期法全耳再造术予以矫正；（3）随访时间超过6个月。排除标准：临床资料不完整。

1.2. 临床资料

2000年1月—2025年2月, 本院收治3 050例符合入选标准的先天性小耳畸形患者, 其中男1 992例、女1 058例；年龄6~52岁, 其中6~10岁患者占19.38%（591/3 050）, 11~15岁患者占43.11%（1 315/3 050）, 16~20岁患者占23.18%（707/3 050）, 21~52岁患者占14.33%（437/3 050）。小耳畸形位于左侧者885例、右侧者1 978例、双侧者187例, 属于耳甲腔型者1 173例、腊肠型者1 290例、耳垂型者587例。

1.3. 手术方法

1.3.1. 术前评估和准备

术前评估患者小耳畸形情况, 对半侧颜面短小畸形和存在异位耳道者, 应充分预判再造耳位置以及再造耳下极与健侧之间的差异。根据健侧耳郭大小准备模片[21]。

1.3.2. Ⅰ期手术中的耳支架雕刻

切取第6~8肋软骨, 必要时切取第9肋软骨作为补充。将第6、7肋软骨雕刻为底板[22]。当第8肋软骨长度和宽度适宜时, 将其外侧雕刻成外耳轮, 内侧雕刻成对耳轮和对耳屏复合体[23], 残耳软骨雕刻成为耳屏结构[24]。当第8肋软骨长度和宽度不足时, 将残余软骨或第9肋软骨作为补充延长外耳轮结构[25], 第9肋软骨也可被直接雕刻为对耳轮和对耳屏复合体。对于钙化软骨, 可切取底板外缘替代第8肋软骨作为外耳轮, 以防止第8肋软骨因钙化在术中或术后发生断裂。各亚单位结构由直径为0.25 mm钢丝或直径为0.2 mm钛丝固定成完整耳支架结构。见图 1。可将Ⅰ期手术后的多余软骨块埋于胸部皮下, 作为Ⅱ期颅耳角支撑材料[26]。

图 1.

图 1

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应用自体第6~9肋软骨进行的耳支架雕刻。1A.应用第8肋软骨（红色箭头示）、第9肋软骨（黄色箭头示）雕刻为外耳轮结构, 并将“Y”形对耳轮和对耳屏复合体固定于第6、7肋软骨雕刻的底板之上, 残耳软骨拟雕刻为耳屏结构；1B.支架雕刻完成后即刻

Framework fabrication of ear with the 6th to 9th autogenous rib cartilages

1.3.3. Ⅰ期手术中的切口设计和残耳处理

对于组织量丰富且位置理想的耳甲腔型和部分腊肠型小耳畸形, 可于残耳处设计横行或“V”形切口[27]；对于组织量较多且位置理想的大部分腊肠型和部分耳垂型小耳畸形, 可于残耳处设计“U”形或“W”形切口[28]；对于残耳位置异常或组织量较少而无法于Ⅰ期形成耳垂转位的部分腊肠型和耳垂型小耳畸形, 可于残耳处设计去除残耳组织的纵行切口[29-30], 沿切口线切开皮肤及皮下组织进行皮瓣分离, 去除残耳软骨, 同时保留皮下蒂。然后将雕刻完成的耳支架围绕皮下蒂旋转植入皮下, 注意避免卡压或扭曲皮下蒂, 以免影响皮瓣血运。分别于耳周和耳甲腔放置引流管后用可吸收缝线缝合切口, 完成Ⅰ期手术。见图 2。

图 2.

图 2

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二期法全耳再造术的Ⅰ期手术中的切口设计和残耳处理。2A.术中切口线设计；2B.术中切开皮下组织, 保留皮下蒂；2C.术中切取自体肋软骨；2D.将雕刻完成的耳软骨支架植入残耳皮下后即刻

Incision design and residual ear management in the first stage operation in a two-stage ear reconstruction

1.3.4. Ⅰ期手术的术后护理

术后在缝合口表面涂抹红霉素或者金霉素眼膏, 无须包扎以利于观察皮瓣血运。术后3 d拔除2根引流管[31]。术后注意睡姿避免压迫再造耳, 控制体重以免影响再造耳的形态。定期进行随访, 观察患者再造耳的恢复情况[32-33]。

1.3.5. Ⅱ期手术

Ⅰ期术后3~6个月可行Ⅱ期手术。沿再造耳外侧5 mm设计弧形切口, 掀起再造耳并保留支架表面纤维包膜。取出Ⅰ期埋于胸部皮下的软骨块作为颅耳角支撑材料, 用钛丝固定支架与支撑材料；若Ⅰ期无残余软骨块则采用定制钛板作为支撑材料[34]。分离大小为8 cm×4 cm耳后局部筋膜瓣覆盖支撑材料[35], 用电动取皮刀切取厚度为0.2 mm的头部断层皮片覆盖筋膜, 然后打包固定[36]。9~10 d后打开固定敷料并拆除缝线。创面完全愈合后可佩戴外用定制耳支架以利于颅耳角形态稳定[26]。对耳后供皮区创面进行打包固定。见图 3。

图 3.

图 3

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二期法全耳再造术的Ⅱ期手术过程。3A.术中切口设计；3B.术中应用的自体肋软骨块支撑材料的正面观（左侧）和侧面观（右侧）；3C.术中应用自体软骨块支撑再造耳, 用钛丝固定形成颅耳角；3D.术中应用耳后局部筋膜瓣翻转覆盖软骨块支撑材料；3E.应用头部断层皮片覆盖筋膜并封闭创面后即刻；3F.对耳后供皮区创面进行打包固定

The process of the second stage operation in a two-stage ear reconstruction

1.4. 观察指标

术后, 统计并发症发生情况并计算其发生率。随访时, 观察再造耳外观, 统计患者的满意度或不满意的原因。

2. 结果

2.1. 并发症发生情况

6.59%（201/3 050）的患者Ⅰ期术后发生静脉回流障碍、皮瓣坏死或软骨外露等并发症, 9.18%（280/3 050）的患者Ⅱ期术后发生部分皮片坏死、筋膜瓣坏死、软骨外露等并发症, 经采取相应处理措施后均得到有效控制, 见表 1。

表 1.

应用自体肋软骨行二期法全耳再造术矫正3 050例患者先天性小耳畸形术后并发症相关情况

Postoperative complications of the two-stage ear reconstruction using autologous rib cartilage in the correction of congenital microtia in 3 050 patients

发生时间 例数 类型 原因 处理措施
注：手术修复指根据并发症情况进行的切除部分软骨+封闭创面、应用筋膜瓣+皮片移植等手术
Ⅰ期术后 61 静脉回流障碍 皮瓣分离不均匀、皮下蒂位置不佳 针刺放血+用肝素溶液浸润的纱布湿敷、高压氧治疗
42 皮瓣坏死或软骨外露 支架边缘锐利、亚单位结构过于凸显、皮瓣分离不均匀、皮下蒂位置不佳 清创、应用筋膜瓣+皮片移植修复、高压氧治疗
31 血肿 止血不彻底、麻醉苏醒延迟 清创引流、加压包扎、高压氧治疗
31 钢丝外露 钢丝直径较粗 随访时或Ⅱ期术中去除外露钢丝
20 支架变形 钙化软骨处理不当、感染、睡姿不当、两期手术间隔时间过长 手术修复
16 感染（易发生于有外耳道的患者） 无菌操作和抗生素应用不规范 清创引流、合理应用抗生素、高压氧治疗
Ⅱ期术后 106 瘢痕增生 个人或家族史、皮肤张力过大、创面并发症处理不及时、预防和治疗措施不规范 定期随访并进行及时处理、瘢痕综合治疗、手术修复
97 部分皮片坏死 止血不彻底、打包压力不均匀、引流不充分、筋膜瓣血运不佳 对症换药、高压氧治疗
38 筋膜瓣坏死或软骨外露 支架背侧过于锐利、打包压力过大、筋膜瓣血运不佳 清创、应用颞浅筋膜瓣+皮片移植修复、高压氧治疗
26 支撑材料外露 筋膜瓣坏死、感染、打包固定不佳、睡姿不当、外力创伤 去除支撑材料、手术修复
13 感染（易发生于应用人工支撑材料的患者） 无菌操作和抗生素应用不规范 清创引流、合理应用抗生素、高压氧治疗
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2.2. 再造耳外观和患者满意度

Ⅱ期术后随访时间为6个月~15年, 平均2年。随访时, 再造耳各亚单位形态显现, 比例协调, 结构柔和自然, 89.02%（2 715/3 050）的患者及其家属对再造耳轮廓形态和位置大小表示满意, 其余患者不满意原因为术后并发症引起再造耳局部结构缺陷或因半侧颜面短小畸形及异位耳道等因素引起再造耳位置不对称。

2.3. 典型病例

例1  男, 12岁, 右侧耳为耳甲腔型先天性小耳畸形。残耳组织量丰富, 位置理想, 采用横行切口设计行二期法全耳再造术。术后恢复良好, 未见明显并发症。Ⅱ期术后9个月随访时, 可见再造耳各亚单位结构显现, 形态自然、柔和；患者对术后效果表示满意。见图 4。

图 4.

图 4

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应用自体肋软骨行二期法全耳再造术矫正例1患儿右侧耳甲腔型先天性小耳畸形的效果。4A.术前残耳侧面观；4B.Ⅰ期术后即刻；4C.Ⅱ期术后9个月随访时残耳侧面观

Effects of the two-stage ear reconstruction using autologous rib cartilage in the correction of right congenital microtia of the conchal cavity-type in case 1

例2  男, 15岁, 右侧耳为耳垂型先天性小耳畸形。残耳组织量少且位置异常, 因此废弃残耳组织, 采用纵行切口切开残耳组织行二期法全耳再造术, 术后未发生并发症。Ⅱ期术后2年随访时, 再造耳外观效果自然, 整体结构协调柔和；患者对术后效果表示满意。见图 5。

图 5.

图 5

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应用自体肋软骨行二期法全耳再造术矫正例2患儿右侧耳垂型先天性小耳畸形的效果。5A.术前残耳侧面观；5B.Ⅰ期术后即刻；5C.Ⅱ期术后2年随访时残耳侧面观

Effects of the two-stage ear reconstruction using autologous rib cartilage in the correction of right congenital microtia of the lobule-type in case 2

例3  男, 21岁, 右侧耳为腊肠型先天性小耳畸形。残耳组织量和位置均比较理想, 采用“U”形切口行二期法全耳再造术, 术后未发生并发症。Ⅱ期术后11年随访时, 再造耳形态结构清晰自然, 耳后皮片移植区域较为平整, 仰视图显示颅耳角形态佳, 双侧接近对称；患者对术后效果表示满意。见图 6。

图 6.

图 6

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应用自体肋软骨行二期法全耳再造术矫正例3患者右侧腊肠型先天性小耳畸形的效果。6A.术前残耳侧面观；6B.Ⅰ期术后即刻；6C.Ⅱ期术后11年随访时残耳侧面观；6D.Ⅱ期术后11年随访时患者仰头, 可见两耳对称；6E.Ⅱ期术后11年随访时残耳背侧面观

The effect of two-stage ear reconstruction using autologous rib cartilage in the correction of right congenital microtia of the sausage-type in case 3

3. 讨论

应用自体肋软骨行二期法全耳再造术是目前国内外术者矫正先天性小耳畸形广泛采用的术式。该术式在Nagata二期法和Brent四期法的基础上予以改良, 具有以下特点：软骨切取量少；手术次数少, Ⅰ期完成耳垂转位, Ⅱ期构建颅耳角时采用耳后局部筋膜瓣替代颞浅筋膜瓣, 创伤较小并可减少头部大面积切口痕迹和秃发可能性；术中采用厚度为0.2 mm头部断层皮片修复创面, 取材方便；术后并发症少, 有利于患者早期康复。

全耳再造手术实质上是对外耳重要亚单位结构（包括外耳轮、对耳轮、耳屏和对耳屏等）的形态进行重建的过程。为满足软骨支架雕刻需求, 一般要求患者剑突下胸围 > 60 cm。考虑到东方人种的发育特点, 患者理想手术年龄为11~15岁[37]。对于部分健侧耳郭较大的6~10岁患儿, 除切取第6~8肋软骨外还常需同时切取第9肋软骨, 而软骨拼接可能影响再造耳轮廓的流畅度。对于存在软骨钙化的成年患者, 应用第8肋软骨形成外耳轮在术中或术后均可能会发生断裂。因此, 术前可行CT检查与三维重建, 根据影像学指标预判软骨钙化程度。若第8肋软骨钙化严重无法弯曲, 可改用第6、7肋软骨雕刻底板, 并切取其外缘肋软骨条作为外耳轮, 通过在底板上局部挖槽形成对耳轮等结构, 此过程常需借助电钻完成[25]。

在Ⅰ期手术进行耳垂转位是二期法全耳再造术的重要技术亮点, 适用于耳甲腔型、大部分腊肠型及部分耳垂型小耳畸形的矫正。但对于残耳组织量少或位置不理想的少数腊肠型、耳垂型小耳畸形患者, 则需废弃残耳组织, 利用底板下半部构建耳垂形态[22]。该术式的另一个关键点是在分离皮瓣时应保持层次均匀, 充分保留皮下血管网, 确保软骨支架获得安全覆盖。同时, 须保留合适大小的皮下蒂, 避免其扭曲或受支架卡压, 以维持良好血运, 从而减少静脉回流障碍、皮瓣坏死及软骨外露等并发症的发生。

个性化的软骨支架雕刻是耳再造手术的核心环节。底板是形成耳轮、对耳轮、耳屏、对耳屏等亚单位结构的基础, 其稳定性与完整性至关重要。若第6、7肋软骨联合部连接不稳则需以钛丝加强固定；底板上下端如有缺损则应用软骨块修补[22]。外耳轮作为最突出的亚单位结构[38], 常由第8肋软骨雕刻而成, 长度和宽度不足时可用残余软骨或第9肋软骨延长, 部分钙化者可用底板外缘替代[25]。对耳轮结构多由第8肋软骨内侧缘或第9肋软骨雕刻而成, 有时需联合残耳软骨拼接形成对耳轮下脚[23]。耳屏与对耳屏结构虽易被忽视, 却直接影响耳郭宽度与耳甲腔深度, 其突出形态可掩饰外耳道缺失, 并对佩戴耳机或助听器具有重要功能意义。耳屏多由残耳软骨雕刻而成, 对耳屏常与对耳轮一体成形[24]。所有雕刻过程须保证软骨表面光滑, 否则锐利边缘可能影响皮瓣血运, 导致皮瓣坏死或软骨外露。

Ⅰ期术后最常见并发症为皮瓣静脉回流障碍, 多发生于术后1~2 d的皮瓣远端（如耳屏间切口处）, 主要因皮瓣分离不均匀或皮下蒂受压扭曲所致。该并发症多可采用针刺放血+用肝素溶液浸润的纱布湿敷缓解, 少数情况下可发展为皮瓣坏死与软骨外露, 需手术修复。对于面积≤10 mm²的软骨外露, 可通过换药进行治疗。对于面积较大的软骨外露, 若外露区位于没有明显张力的耳屏区域, 可清创后切除部分软骨+直接封闭创面修复；若外露区位于外耳轮边缘, 则可采用局部筋膜瓣+皮片移植修复；若外露区位于对耳轮、耳甲腔等中心区, 则需采用带蒂颞浅筋膜瓣+皮片移植修复。

感染多见于合并外耳道的耳甲腔型患者及Ⅱ期使用人工支撑材料者, 虽发生率低, 但如果没有及时控制可能会导致软骨吸收, 最终影响再造耳形态。因此应严格无菌操作流程, 合理预防性使用抗生素。一旦发生感染, 应及时引流、换药, 并结合药物敏感试验结果选用敏感抗生素, 必要时配合高压氧治疗[39]。

Ⅱ期术后最常见且难以避免的问题是瘢痕增生所致颅耳角缩小。虽然采用厚度为0.2 mm头部断层皮片具有取材便利、无须注水行扩张术等优点, 但该皮片较薄, 加之个体体质差异与并发症等因素, 可能引起瘢痕增生。为尽量避免瘢痕增生, 应保持皮片张力适宜, 并避免各类术后并发症的发生。耳后局部筋膜瓣因血供可靠、切取方便, 常作为支撑材料的覆盖组织, 切取时须保持适度松弛, 避免张力过高影响血运[40]。术后定期随访、规范实施瘢痕综合防治措施及佩戴定制耳支架, 有助于抑制瘢痕增生, 维持颅耳角稳定。

手术技术、术后护理与定期随访是决定再造耳最终形态的关键因素。个性化的切口设计、精细的肋软骨雕刻与均匀的皮瓣分离是二期法全耳再造术的核心环节。手术与术后恢复过程复杂多变, 密切观察与及时处理有助于预防与控制各类并发症。术后应注意术区的清洁保湿, 避免外力压迫, 促进皮瓣与软骨支架紧密贴合。为避免睡眠中不自觉压迫影响耳郭形态, 建议两期手术间隔不超过12个月。正如耳再造先驱Brent[2]所言：“在整复外科没有哪一个领域比耳再造更需关注每一个细节。”本团队致力于优化每一个手术步骤, 将术后并发症发生率降至最低, 力求构建出形态自然、协调统一的再造耳。

Funding Statement

上海市科技计划项目（22MC1940300）

Shanghai Science and Technology Plan Project (22MC1940300)

要点

(1) 回顾性分析了3 050例先天性小耳畸形患者应用自体肋软骨行二期法全耳再造术的疗效。

(2) 总结了该术式中切口设计方案、基于不同软骨特征的个性化支架雕刻技术和术后并发症产生原因及其处理经验。

Highlights

(1) This article retrospectively analyzed the efficacy of two-stage ear reconstruction using autologous rib cartilage in 3 050 patients with congenital microtia.

(2) This article further summarized incision design scheme, individualized framework fabrication technique based on different cartilage characteristics, causes of postoperative complications, and their treatment experience in this procedure.

利益冲突  所有作者声明不存在利益冲突

作者贡献声明  许志成：数据分析、文章撰写；张群、张如鸿：研究指导、论文修改；许枫、李大涛：数据整理；李意源、陈霞：数据采集

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