{'fraction_non_alphanumeric': 0.02423469387755102, 'fraction_numerical': 0.01328656462585034, 'mean_word_length': 4.63750748951468, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Clinical Experience of Sturdy Elevation of the Reconstructed Auricle

Background The ear is composed of elastic cartilage as its framework, and is covered with a thin layer of skin. Auricular reconstruction using autogenous cartilage in microtia patients requires delicacy. This paper reports clinical experiences related to elevation of reconstructed ear in the last 11 years. Methods This study was based on 68 congenital microtia patients who underwent auricular elevation in our hospital. Among these 68 patients, 47 patients were recruited. We compared the differences in the ear size, auriculocephalic angle, and conchal depth with those in the opposite ear, and the patients' satisfaction levels were investigated using a survey. Results The difference in the sizes of the two ears was less than or equal to 5 mm in 32 patients, 5 to 10 mm in 10 patients, and greater than or equal to 10 mm in 5 patients. The difference in the auriculocephalic angles of the two ears was less than or equal to 10 degrees in 14 patients, 10 to 20 degrees in 26 patients, and greater than or equal to 20 degrees in 7 patients. The difference in the conchal depths of the two ears was less than or equal to 5 mm in 24 patients, 5 to 10 mm in 19 patients, and greater than or equal to 10 mm in 4 patients. The average grade of 3.9 points out of 5 points was obtained by the patients with satisfactory surveys. Conclusion We could make enough protrusion and maintain the three-dimensional shape for a long time to satisfy our patients.

in microtia patients requires delicacy and artistic skill. To meet these demands, different reconstruction methods have been suggested, with a single stage operation to 4-stage operation [2,4,5].
The two-stage reconstruction method was performed in this study. This method was shown better results than another technique in aspect of economic and cosmetic. In the first stage operation, the ear lobule was translocated to its normal location and a framework made of costal cartilages was inserted in the subcutaneous pocket of the area symmetrical to the opposite ear. Six months after the costal cartilage insertion, auricular elevation was performed in the second stage operation. When this two-stage method was used, auricular elevation in the second stage is important to the delicate shape of reconstructed auricle and maintaining adequate projection for a long time. We would introduce

Patients
This study was based on 68 congenital microtia patients who had undergone auricular elevation in this hospital from January 2000 to December 2011. Among these 68 patients, 47 who could be observed after over 1 year follow-up were recruited.

Elevation technique
In the first stage operation, costal cartilages for the auricular framework and block were harvested. The block of cartilage was to be used for the auricular elevation in the second stage operation. And the use of this cartilage for the auricular elevation was buried under the subcutaneous tissue in the donor site. The auricular elevation was performed in the second stage operation after 6 months. The cartilage that was buried in the donor site was taken out. An incision was made 5 mm behind the framework margin, and the framework was elevated above the level of the superficial temporal fascia with attention to avoid exposure of cartilage framework. The cartilage was carved to form a crescent shape with flat bottom and to get an enough height, and scarring or atrophy of reconstructed ear should be considered to making height of cartilage, so the projection of the reconstructed ear was symmetrical to the opposite normal or previously elevated ear (Fig. 1).
Then block of cartilage was located at the posterior auricular sulcus. This cartilage was fixed using 4-0 nylon sutures so that it would not fall off. The bottom parts were fixed up to the fascia and the periosteum, and the upper part was firmly fixed at the framework in two points. And then, the cartilage was covered by an ele- 3). The raw surface for the skin graft was minimized by advancing the retro-auricular skin, and then the area was covered with a full-thickness skin graft, which was harvested from the inguinal area.
And the tie-over dressing was performed. If the depth of the helical sulcus was insufficient depth at the first operation or shallow depth after the elevation, the helical cartilage of helix was trimmed and sutured to the scapha. Through and through sutures with tie-over bolster dressing were performed for maintenance of the helical sulcus.

Evaluation
The ear size (length between the lowest part of the lobule and the most distant part of the helix), auriculocephalic angle (difference   A difference in the sizes of the both ears that was less than or equal to 5 mm was categorized as excellent; 5 to 10 mm, acceptable; and greater than or equal to 10 mm, poor. A difference in the auriculocephalic angles of both ears that was less than or equal to 10 degrees was categorized as excellent; 10 to 20 degrees, acceptable; and greater than or equal to 20 degrees, poor. A difference in the conchal depths of both ears that was less than or equal to 5 mm was categorized as excellent; 5 to 10 mm, acceptable; and greater than or equal to 10 mm, poor. The survey on the subjective satisfaction of patients with the degree of the ear projection and ear shape after elevation had a 5-point scale, with 5 meaning the respondent was very satisfied; 4, satisfied; 3, neither satisfied nor unsatisfied; 2, unsatisfied; and 1, very unsatisfied (Figs. 4-7). We gave questionnaires to patient that follow up our hospital. When some patients had replied several times, the score of the latest last questionnaires was selected.

RESULTS
The

DISCUSSION
It is very difficult to define a normal ear. Since the ear has constant anatomical landmarks such as the helix, scapha, antehelix, triangular fossa, concha, and tragus, it seems as if a normal ear can be defined when the ear is seen from the lateral side. However, many factors affect the normality of ears, such as their projecton, degree of folding, relative size, depth, and angles [6]. Nevertheless, since the ear is not located in the middle of the face, it does not draw attention unless it is too unnatural. Thus, the purpose of microtia reconstruction is to make an ear that does not look too awkward, so that others will not notice it [7]. Thus, when reconstructing the auricle, more focus should be given to the big contour, location, and degree of the ear projection rather than to detailed factors.
The following are important factors of elevation of auricle. should be minimized [8].
Many methods of auricle elevation have been introduced to meet these purposes. Steffensen [9] used a retro-auricular skin transposition flap to cover the sulcus, and Rueckert et al. [10] sug-gested a technique that uses tunnel formation. Alexander [11] also reported a method of elevation that uses a fascial flap. Maintaining a stable auriculocephalic angle using only soft tissue to support the auricle is difficult, however, which emphasizes the need for hard tissue to support the concha.
Brent [12] performed limited elevation of the auricle by heightening and exaggerating the helical rim. Nagata [8] used the temporoparietal fascial flap to wrap a semilunar piece of cartilage, which can create a fine firm projection. Ou et al. [13] reported the use of a retro-auricular fascial flap instead of a temporoparietal fascial flap to wrap a cartilage wedge. Prantl et al. [14] reconstructed the post-auricular sulcus using a rotation flap elevated from the neck.
The cartilage that would be used for the auricular elevation in our operation was the semilunar wedge shaped to be made big and tall enough to support the framework. As in the reports of Ou et al. [13] and Yoshimura et al. [15], the cartilage was covered using a superficial fascial flap in the retro-auricular area. In this process, the cartilage was fixed in more than 4 points with 4-0 nylon sutures. It is very important that the cartilage was fixed firmly and stably so that it would not fall off or move.
Lim et al. [16] reported that a retro-auricular fascial flap is less Deep mastoid fascial flap must be enough large to wrap the supporting cartilage block and was elevated above periosteum in rectangular shape, and then fixed with 4-0 vicryl sutures. Unlike in the study of Lim, however, we could elevate the flap with definitive anatomy and inevitable depression did not occur in our study.
Using only a skin flap among various surgical methods of auri- And we could decrease the secondary contracture of the skin graft by using FTSG instead of split-thickness skin graft. Although implanted cartilage may be absorbed some degree spontaneously but, the impact of the absorption could not be evaluated in this study. Complication rate was low and these complications were easily corrected in most of cases. We were able to reconstruct the competent ear, to maintain the three-dimensional shape and enough projection for a long time, and to give the patients satisfaction. Furthermore, our operation method was designed for the best time and economic efficiency with only twice of operations, and the results are mostly satisfying. Also, its gradual approach allows easy response to broad situations, which leads to less deformities and complications. It's a good strategy for gradual ear reconstruction.