Reconstructing congenital auricular defects due to hemifacial microsomia (HFM) is often required to deal with low hairline and defects of the temporal fascia/muscular systems. In this report, we present two cases of HFM patients (16-year-old and 20-year-old) with positional anomaly of the remnant lobule and 95% low hairline, who were treated with serratus anterior fascial flap (SFF) at the second stage of auricular construction. At the first stage, 3D costal cartilage framework was placed following the removal of hair-bearing skin, and was resurfaced with the pericranial flap. At the second stage, ear elevation was performed with cartilage block grafting, then the free SFF was used to construct cephaloauricular sulcus because of local fascial defect. The pedicles of SFF, subscapular vessels were anastomosed to the cervical vessels. No complications developed during the follow-up period of 4 years in both cases and projections of the constructed ears were satisfactorily maintained. The free SFF is naturally thin and flexible with sufficient circulation and it may be an alternative to temporo-parietal fascia flap in complicated microtia construction in HFM.
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