The Firmin Technique in Microtia Reconstruction
The Firmin technique is a two-stage surgical approach for auricular reconstruction in microtia patients, involving fabrication and grafting of a three-dimensional costal cartilage framework in the first stage, followed by ear elevation with additional cartilage grafting to increase projection in the second stage. 1
First Stage: Framework Creation and Placement
- The initial stage involves harvesting costal cartilage from the patient's ribs to create a detailed three-dimensional framework that replicates the complex anatomy of the external ear 1
- The cartilage framework is meticulously carved to include the antihelical complex, which is crucial for creating a natural-looking ear with appropriate contours 2
- This framework is then implanted subcutaneously in the planned auricular position, with concurrent transposition of any existing ear lobe if present 3
Second Stage: Ear Elevation
- The second stage is performed approximately 5-6 months after the first stage to allow for adequate healing and integration of the cartilage framework 1
- During this stage, the reconstructed ear is elevated from the side of the head to create projection similar to a normal auricle 1
- An additional cartilage graft is placed behind the framework to serve as a supporting strut, increasing the projection of the ear 1
- A mastoid fascial flap is used to cover the posterior aspect of the elevated ear framework, and a skin graft is applied to protect the cartilage graft 1
Modifications and Refinements
- Various surgeons have modified the original Firmin technique while maintaining its core principles 4, 3
- Some modifications include:
- Using retroauricular fascial flaps with porous polyethylene (Medpor) wedges as struts instead of cartilage wedges 4
- Employing rotation flaps from the mastoid and neck region to close the defect behind the auricle, avoiding additional scars on the scalp 3
- Utilizing tissue expansion techniques before framework placement to improve skin quality and reduce the need for skin grafting 5
Outcomes and Considerations
- The Firmin technique has demonstrated high success rates with low morbidity and high patient satisfaction 1
- Potential complications include flap congestion, skin necrosis, and cartilage exposure, though these are relatively uncommon 2
- The technique requires significant surgical expertise, particularly in carving the cartilage framework to achieve natural-looking results 1
- Postoperative care is essential for optimal outcomes, including protection of the reconstructed ear and monitoring for complications 1
Advantages of the Firmin Technique
- Provides excellent aesthetic results with natural-appearing ear contours 1
- Creates good projection of the reconstructed ear, typically ranging from 0.8 to 1.6 cm depending on the measurement point 4
- Allows for reconstruction that closely matches the contralateral ear in terms of size, shape, and position 1
- Has demonstrated durability with long-term follow-up 1
The Firmin technique represents one of the most refined approaches to microtia reconstruction, balancing the complex requirements of creating an aesthetically pleasing ear with appropriate projection while minimizing complications and donor site morbidity 1, 2.