PRS Journal Club: Novel Techniques in Autologous Ear Reconstruction and a New Grading System for Unilateral Cleft Severity and Presurgical Orthopedic Outcomes

Pediatric plastic surgery continues to evolve through a steady stream of refinements, innovations, and critical reassessments of established practices. Although reconstruction of congenital anomalies, such as microtia and cleft lip and palate, have evolved over centuries, no universally accepted algorithms exist. Instead, surgeons rely on a blend of mentorship, experience, and incremental evidence to guide decision-making. This month’s PRS Journal Club highlights 3 contemporary studies that focus on second-stage autologous auricular reconstruction and a standardized anthropometric grading system for unilateral cleft lip severity and presurgical infant orthopedic outcomes. Autologous rib cartilage frameworks remain the global standard for microtia, despite the rise of porous polyethylene implants. Numerous techniques have been described for total auricular reconstruction.1 Historically, greater emphasis has been placed on framework carving than on projection, yet projection and postauricular contour after the second stage ultimately define aesthetic success2 and can be strongly influenced by the choice of soft-tissue coverage. Achieving an aesthetically pleasing reconstruction while minimizing donor-site morbidity is particularly challenging in patients with deficient mastoid skin, such as those with hemifacial microsomia.3 Furthermore, achieving an aesthetic ear reconstruction while limiting donor-site morbidity is challenging, particularly when there is deficient mastoid skin (for example, in cases of hemifacial microsomia). The temporoparietal fascial flap, previously described by Brent et al.,4 has been widely used for soft-tissue coverage in both autologous and porous polyethylene implant reconstructions. However, this flap is associated with considerable donor-site morbidity, including an additional incision with temporal scarring and alopecia, color mismatch, variable flap thickness, and the requirement for a full-thickness skin graft from a second donor site. In the February of 2026 issue, 2 novel techniques for limiting donor-site morbidity and improving patient satisfaction are presented. In the first article, “Total Ear Reconstruction with Costal Cartilage in Challenging Cases: Silicone-Induced Vascularized Capsule Technique,” Dr. Chul Park5 proposes a novel silicone-induced vascularized capsule technique to optimize outcomes and limit complications, especially in complex cases. This 3-stage technique includes (1) creation of a vascularized bed for coverage of the construct using silicone blocks; (2) construct elevation using cartilage blocks and use of a mastoid fascial flap; and (3) full-thickness skin grafting of the vascularized bed. Park presents his findings in a 12-patient cohort, 9 of whom developed well-vascularized capsules. Although limited by small sample size, this technique offers an alternative for soft-tissue coverage with reliable projection and tension-free mastoid skin closure, potentially reducing delayed cartilage resorption and donor-site morbidity. In the second article, “A Modified Method for Ear Projection in Auricular Reconstruction: Split-Thickness Skin Graft Combined with Retroauricular Fascia Flap for Postauricular Coverage,”6 by Li et al., the authors’ refinements to the 2-stage Nagata technique combine a split-thickness skin graft with a retroauricular fascia flap to achieve vascularized postauricular coverage and improved contour. Ultrathin skin grafts have previously been described with good aesthetic outcomes and high patient satisfaction7; however, Li et al. describe skin graft harvest from the region of the retroauricular fascia flap, thereby limiting donor-site morbidity. In their series of 324 patients with 5 years of follow-up, they reported a 94% satisfaction rate, low donor-site morbidity, and no major complications, such as hypertrophic scarring, flap necrosis, framework deformation, cartilage exposure, infection, or color mismatch. This large cohort demonstrates that careful integration of vascularized coverage and skin grafting can reliably achieve projection and contour with minimal morbidity. Finally, in the third article, “Anthropometrics versus Experts’ Subjective Analysis of Cleft Severity and PSIO Outcomes in Unilateral Clefts: A Proposal for a New Grading,”8 Tanikawa et al. address a longstanding gap in the cleft care algorithm. Nasolabial distortion, particularly in wide clefts, exacerbates asymmetry and complicates reconstruction. Presurgical orthopedics (PSIOs), such as nasoalveolar molding, have commonly been utilized to decrease cleft width before surgical repair and to improve surgical outcomes.9 Nasoalveolar molding has demonstrated long-term improvements in symmetry and columellar lengthening9,10; however, the impact of PSIOs on postoperative outcomes in unilateral cleft lip repair is poorly understood. While individual and separate severity grading systems and objective measurements for grading nasal deformity have been proposed,11–13 a universally accepted system to quantify cleft lip severity and the impact of PSIOs is lacking. Without such standards, comparisons across centers and evaluation of the effect of PSIOs on surgical outcomes remain limited. Tanikawa and colleagues propose a new grading system for unilateral clefts that combines objective anthropometric measurements (nostril-width ratio, columellar angle, and subnasale displacement ratio) and subjective expert evaluation, linking severity measures with PSIO outcomes. Their proposed classification was developed and tested utilizing an expert panel of 3 orthodontists and 3 surgeons who each reviewed 50 cases of unilateral cleft lip for severity before and after PSIO use. The grading system demonstrated significant interrater reliability in both pre-PSIO and post-PSIO assessment. Although the authors acknowledge several limitations, this is the first standardized classification system for cleft severity and PSIO outcomes and a next step toward global consensus. Future refinements should include intraoral measurements, 3-dimensional imaging, and evaluator calibration sessions. Ear projection and cleft lip repair in complex presentations remain areas of active iteration. The February 2026 Journal Club articles illustrate how incremental refinements drive progress in pediatric reconstructive surgery. Park’s capsule technique, the retroauricular fascia flap introduced by Li et al., and the classification system proposed by Tanikawa et al. exemplify how innovation builds on decades of surgical creativity and critical evaluation. As surgeons strive to improve both function and aesthetics for children worldwide, the integration of technical refinements with standardized outcome measures will be essential for moving from anecdote to evidence. DISCLOSURE The authors have no relevant financial disclosures to report.