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otoplasty revision before after case 1
otoplasty revision before after case 1
  •  This chapter reviews otoplasty for common auricular deformities such as prominent ears, macrotia, ears with inadequate helical rim, constricted ear, Stahl’s ear, question mark ear, and cryptotia.
Prominent Ears

The term prominent ears refers to ears that, regardless of size, “stick out” enough to appear abnormal. When referring to the front surface of the ear, the terms front, lateral surface, and anterior surface are used interchangeably. Similarly, when referring to the back of the auricle, the terms back, medial surface, and posterior surface are used synonymously. The normal external ear is separated by less than 2 cm from, and forms an angle of less than 25° with, the side of the head. Beyond these approximate normal limits, the ear appears prominent when viewed from either the front or the back. While these measurements provide a guideline, aesthetic judgment is more important. In 25 years of dealing with auricular deformities, the author has never measured either the angle with the skull or the distance from the side of the head. To correct prominent ears, the anatomic abnormality is determined (Figure 49.1). The three most common causes of prominent ears are the following and are usually present in combination:

  1. Underdeveloped antihelical fold. As a result of inadequate folding of the antihelix, the scapha and helical rim protrude. This anatomic abnormality causes prominence of the upper third and, in many cases, the middle third of the ear.
  2. Prominent concha. The concha may be excessively deep, the concha/mastoid angle may be excessive, or there may be a combination of these two factors. This anatomic abnormality causes prominence of the middle third of the auricle.
  3. Protruding earlobe. The protruding earlobe causes prominence of the lower third of the ear.

Although most prominent ears are otherwise normal in shape, some prominent ears have additional deformities. The conditions enumerated below are examples of abnormally shaped ears that may also be prominent. The term macrotia refers to excessively large ears that, in addition to being large, may be “prominent.” The average 10-year-old male has ears that are 6 cm in length. Most adults, men and women, have ears in the 6 to 6.5 cm range. In men, ears that are 7 cm or more will look large. In women, ears may look large even if significantly less than 7 cm. Ears with inadequate helical rims or shell ears are those with flat rather than curled helical rims. Constricted ears (Figure 49.2) are abnormally small but tend to appear “prominent” because the circumference of the helical rim is inadequate, causing the auricle to cup forward. The Stahl’s ear deformity (Figure 49.3) consists of a third crus, in addition to the normal crura of the triangular fossa, which traverses the scapha. This may give the ear a “Mr. Spock” pointed appearance in addition to being prominent. Question mark ears earn their name because deficiency of the supralobular region gives the ear the shape of a question mark. The upper portion of the auricle tends to be large and may be prominent as well. Cryptotia (Figure 49.4) describes the auricle in which the upper pole of the helix is buried beneath the temporal skin. Cryptotic ears are not prominent.

Goals of Otoplasty

The goal of otoplasty is to set back the ears in such a way that the contours appear soft and natural, there is no evidence of surgical intervention, and the setback is harmonious: that is, each portion of the ear appears in appropriate position relative to the rest of the auricle. When examined from the various angles, the corrected auricle should have the following characteristics:

  1. Front view. When viewed from the front the helical rim should be visible, not set back so far that it is hidden behind the antihelical fold.
normal ear
prominent ear

 

FIGURE 49.1.Comparison of normal and prominent ear anatomy. A. Normal ear. B. Components of the prominent ear. (Reproduced with permission of Charles H. Thorne, MD. Copyright Charles H. Thorne, MD.)

Constricted ear A
Constricted ear B

 

FIGURE 49.2.. Constricted ear. A. Mildly constricted ear. Otoplasty requires increasing the circumference of the helical rim by advancing the crus of the helix into the helical rim (see Figure 49.7). B. Severely constricted ear. This degree of constriction can only be repaired by discarding some of the cartilage and performing an ear reconstruction as in microtia. (Courtesy of David Furnas, MD.)

    1. Rear view. When viewed from behind, the helical rim should be straight, not bent like a “C” or a “hockey stick.” If the helical rim is straight, the setback will be harmonious; that is, the upper, middle, and lower thirds of the ear will be set back in correct proportion to each other. If, for example, the middle third is set back too

      stahls ear

 

FIGURE 49.3. Stahl’s ear. Note the third crus that traverses the scapha. (Courtesy of David Furnas, MD.)

much relative to the upper and lower thirds, the helical urgeryrim will form a “C” when viewed from behind, creating the so-called telephone deformity. Similarly, if the earlobe is insufficiently set back, the rear view will reveal a hockey stick appearance to the helical rim contour.

  1. Lateral view. The contours should be soft and natural, not sharp and “human-made.”
Timing of Otoplasty

There is no absolute rule about when otoplasty should be performed. In young children with extremely prominent ears, a reasonable age is approximately 4 years. In cases of macrotia associated with prominence, the author has performed the procedure as early as age 2 years, thinking that any restriction of growth is an advantage. Regardless of the exact age, the procedure requires general anesthesia. In other cases, usually more minor, the parents may choose to wait until the child can participate in the decision. This may allow the procedure to be performed under local anesthesia, although it is a rare child that can tolerate local anesthesia before age 10 years, and many not until they are adults.

Operative Procedure

Numerous methods have been described for correcting the anatomic abnormalities described above. The techniques that have stood the test of time are the simplest, most reliable, and least likely to cause complications or an “operated” look. The techniques described below are used alone or in combination depending on the anatomic deformity and the choice of the surgeon.

Antihelical Fold Manipulation

  • Suturing of cartilage. Mattress sutures are placed from the scapha to the triangular fossa or concha, as described by Mustarde,1 and are tied with sufficient tension to increase the definition of the antihelical fold, thereby setting back the helical rim and scapha (Figure 49.5).

Part V: Aesthetic Surgery


Cryptotia A
Cryptotia B

 

FIGURE 49.4. Cryptotia. A. Patient in whom a relatively normal helical rim is buried in the temporal soft tissues. The upper portion of the auricle can be exposed by outward traction on the ear. B. Outward traction (in a different patient) causes the upper portion of the ear to emerge from its hiding place. (Courtesy of David Furnas, MD.)

  • Stenstrom technique of anterior abrasion.2 The anterior surface of the antihelical fold cartilage is abraded, causing the cartilage to bend away from the abraded side (principle of Gibson) toward the side of intact perichondrium (Figure 49.6).
  • Full-thickness incisions. A single full-thickness incision along the desired curvature of the antihelix permits folding with slight force, creating an antihelical fold (Luckett procedure). Because the fold is sharp and unnatural appearing, this single-incision technique was modified. In the Converse/Wood-Smith technique,3 a pair of incisions is made, parallel to the desired antihelical fold, and tubing sutures are placed to create a more defined fold.

Conchal Alteration

  • Suturing. The angle between the concha and the mastoid skull can be decreased by placing sutures between the concha and the mastoid fascia as described by Furnas4 (Figure 49.5).
  • Conchal excision. From either an anterior or posterior approach, a full-thickness crescent of cartilage is removed from the posterior wall of the concha (taking care not to violate or deform the antihelical fold), thereby reducing the conchal height. The conchal defect is meticulously closed with sutures to avoid a visible ridge within the concha. The excision is designed so that the eventual closure will lie at the junction of the floor and posterior wall of the concha,
Conchal Alteration A
Conchal Alteration B
Conchal Alteration C

 

FIGURE 49.5.Otoplasty technique: The combination of a Mustarde scapha-conchal suture, conchal resection with primary closure, and a Furnas conchal-mastoid suture. Note that the conchal closure is at the junction of the floor and posterior wall of the concha. A. Sutures placed. B. Sutures tightened to create the desired contour. C. Same sutures as seen through the retroauricular incision. (Reproduced with permission of Charles H. Thorne, MD. Copyright Charles H. Thorne, MD.)

Stenstrom technique

 

FIGURE 49.6. . Stenstrom technique. The antihelical fold is scored. The cartilage bends away from the scoring, moving the helical rim closer to the head and increasing the prominence of the antihelix.


  • where it is least conspicuous and causes the least distortion of the normal auricular contours (Figure 49.5).
  • A combination of Furnas suture and conchal excision techniques (Figure 49.5).

Correction of Earlobe Prominence. Earlobe prominence is not corrected by the above maneuvers. In fact, these maneuvers may increase the prominence of the earlobe, making earlobe repositioning the most difficult and neglected part of the procedure. An auricle that has been repositioned in its upper two thirds but still has a prominent lobule will appear just as abnormal and disharmonious as the original deformity (Figure 49.7). It has been said that suturing the tail of the helical cartilage to the concha will correct earlobe prominence. Unfortunately, the tail of the helix does not extend into the lobule and setting it back does not reliably set back the earlobe. Other authors have described techniques involving skin excision and sutures between the fibrofatty tissue of the lobule and the tissues of the neck. The best technique in the author’s experience is the technique described by Gosain,5 or a variation thereof, in which a small amount of skin is excised on the medial surface of the earlobe. When this defect is closed with sutures, a bite of the undersurface of the concha is taken, which pulls the earlobe toward the head.

Alteration of the Position of the Upper Auricular Pole. Depending on the degree of prominence of the upper third of the ear preoperatively, the antihelical fold creation may be inadequate to correct the position of the helical rim near the root of the helix. In other words, the angle that the helix makes with the temporal scalp is sufficiently large that, even after the Mustarde sutures are placed, an excessive angle exists. An additional mattress suture between the helical rim and the temporal fascia may be required.

Choice of Otoplasty Technique

The final operative plan for an otoplasty is a combination of surgical maneuvers based in part on the anatomic diagnosis

Choice of Otoplasty Technique A & C


 

Choice of Otoplasty Technique B & D

 

FIGURE 49.7. Pre- and post-op otoplasty. (AB): Pre-op appearance. (CD): Post-op appearance demonstrating straight helical contour.

of the deformity and in part on the surgeon’s personal preferences.6 This author’s preferred technique involves Mustarde sutures to recreate the antihelix and set back the upper and middle thirds of the ear. The abrasion techniques are unreliable, uncontrollable, and unnecessary and may result in sharp edges or an overdone appearance. It should be noted that the antihelix is not straight; rather it curves forward superiorly, to almost parallel the inferior crus. To create an antihelix of the correct contour, the sutures are not placed parallel to each other but rather placed like spokes of a wheel, with the center of the wheel being the top of the tragus. If the sutures are placed parallel to each other, the antihelix will be excessively straight. In the conchal region, the author most commonly uses both a conchal resection and Furnas conchal-mastoid sutures as shown in Figure 49.5. The combination allows the resection to be small (1 to 2 mm), minimizing iatrogenic deformity. When conchal excision is used alone, a deformity of the posterior wall of the concha may result. When Furnas sutures are used alone, the correction may be inadequate, the patient may have pain, the external auditory canal can be narrowed, and the depth of the retroauricular sulcus is decreased. As mentioned above, earlobe repositioning is the most difficult part of the procedure. The Webster technique of repositioning the helical tail has not been effective in the author’s hands for correction of earlobe prominence. Rather, the Webster technique appears to reposition the ear just above the earlobe, exaggerating the earlobe prominence

Other Deformities

Macrotia. To reduce the size of the ears, an incision is made on the lateral surface of the ear, just inside the helical rim, through the skin and the cartilage, stopping short of the


medial skin (Figure 49.8). A crescent of scapha is removed. A segment of helical rim along with a triangle of medial skin is then excised and closed primarily, so that the helical rim is not redundant relative to the smaller scapha.7,8

Shell Ear. The incision is made as described above for macrotia. The wedge excision of helical rim creates just enough tension not only to allow approximation of the helix but also to create some overhang of the rim.

Constricted Ear. A number of complex classifications and surgical procedures have been described for constricted ears, but, from a practical point of view, constricted ears can be divided into three types depending on what procedure is required to repair them. In the mildest cases, the superior helix is folded over, creating the lop ear. Attempts to correct the overhang using mattress sutures will not be successful. Better options include directly trimming the overhanging skin and cartilage (this will leave a slightly short but more normal appearing ear) or resecting the overhanging cartilage only and replacing it with a conchal cartilage graft to increase the height and to improve the shape of the ear. In intermediate cases, the circumference of the helix is inadequate for the rest of the ear, causing it to be cupped forward. These deformities are true to the name constricted ear because that is exactly how the ears look. To improve the appearance, the crus of the helix is advanced out of the concha and into the helical rim, as in the Antia-Buch procedure, and standard otoplasty techniques are used in addition. In severe cases of constricted ear,

the cartilage is discarded and a complete auricular reconstruction performed as in microtia (Chapter 27).

Stahl Ear. Various techniques have been described to excise the extra crus. This author prefers the technique described by Kaplan and Hudson.9 An incision is made inside the helical rim, the lateral skin is carefully dissected off the cartilage, the extra crus is excised, and the cartilage defect is closed primarily. The excised cartilage can be used as an onlay graft to reconstruct the superior crus of the triangular fossa (Figure 49.9).


Cryptotia. The superior aspect of the auricular cartilage is pulled out from under the scalp, an incision is made around the now-visible helical rim, and the medial surface of the freed cartilage is resurfaced with a graft or flap. In some cases, the buried cartilage is quite normal, and in other cases, it is markedly abnormal and requires modification.


Question Mark Ear. The supralobular deficiency is variable. Repair requires a cartilage graft. In milder cases, this can be taken from the concha and resurfaced with a V-Y advancement of the medial skin. In more severe cases, a rib cartilage graft is required and a standard two-stage reconstruction is performed, as one would perform for a significant posttraumatic defect (Chapter 27).10,11 The deformity is often associated with excess tissue in the upper third of the ear requiring reduction. In the severe cases, the entire ear is reconstructed as in microtia.

Technique for reduction otoplasty 1
Technique for reduction otoplasty 2

Technique for reduction otoplasty 3
Technique for reduction otoplasty 4

 

FIGURE 49.8. Technique for reduction otoplasty. (With permission from Thorne CH, Wilkes G. Otoplasty, ear deformities and ear reconstruction. Plast Reconstr Surg. 2012;129(4):701e, Figure 2.)

Technique for repair of Stahl’s ear 1
Technique for repair of Stahl’s ear 2

Technique for repair of Stahl’s ear 3
Technique for repair of Stahl’s ear 4

 

FIGURE 49.9. Technique for repair of Stahl’s ear. (With permission from Thorne CH, Wilkes G. Otoplasty, ear deformities and ear reconstruction. Plast Reconstr Surg. 2012;129(4):701e, Figure 3.)

Postoperative Care

A bulky, noncompressive dressing is placed for a day or two. Excessive pressure from the dressing will cause pain, increase swelling, and may lead to abrasion or even necrosis of auricular skin. When the dressing is removed, the patient wears a loose headband at night only for 6 weeks. Again, the headband should only be tight enough that it does not fall off. The purpose is to prevent the corrected ear from being pulled forward when the patient rolls over in bed. A tight headband can erode the lateral surface of the ear, creating an open wound.

Nonoperative Technique in Infants

During the early weeks of infancy, the auricular cartilage has unusual plasticity, attributed to circulating maternal estrogens. During this privileged period, prominent ears and related deformities can be corrected permanently by molding the ears into the correct shape with tape and soft dental compound.12,13 The splints and tape are replaced regularly, and the skin is checked compulsively for erosion. The process is continued for several months or until there is no further improvement in auricular contour. This ability to mold cartilage is currently being exploited in presurgical molding of the cleft nasal deformity (Chapter 23). It is not clear how long cartilage retains this “moldability” and therefore it is not clear when infants are too old to have this technique attempted.

Complications14
Hematoma

Hematomas are one of the few early complications of otoplasty. Excessive pain or bleeding necessitates immediate removal of the dressing to rule out and, if necessary, evacuate a hematoma

Infection

Cellulitis is rare after otoplasty but is treated aggressively with intravenous antibiotics in an attempt to avoid chondritis. The latter may require debridement and leave the ear permanently disfigured.

Suture Complications

By far the most common complication of otoplasty in the author’s experience is related to suture extrusion in the retroauricular sulcus. Such sutures are easily removed but may be associated with unattractive and/or painful granulomas. The use of absorbable sutures might eliminate this complication but the author has not had the courage to abandon permanent sutures. The author prefers monofilament sutures that are less likely to form pustules or granulomas when protruding through the skin. On the other hand, the monofilament sutures require more knots and may be more likely to protrude through the skin in the first place.

Overcorrection/ Unnatural Contours

The most common significant complication of otoplasty is overcorrection. Attention to the principles outlined above will minimize overcorrection and the creation of unnatural contours

The author’s personal thoughts about otoplasty are as follows6:

  1. Incisions. The incision is best placed in the retroauricular sulcus, not up on the back of the ear. The latter is more convenient for the surgeon and more expeditious, but may leave a scar that is visible when the patient is viewed from behind. Specific indications (macrotia, constricted ear, or ears with inadequate helical rim) call for an incision on the front (lateral surface) of the ear, where it is ideally made just inside the helical rim.
  2. Skin excision. Skin excision is unnecessary, does not contribute to the correction, and may lead to hypertrophic or undesirable scars. The only exception is the earlobe, where it may be necessary. When performing the latter, care is taken to remove only enough skin, adjacent to the retrolobular sulcus, to allow repositioning and to leave a full, free earlobe for ear piercing and an aesthetically normal earlobe
  3. Techniques. The simplest techniques are best. Techniques that involve abrasion or full-thickness incisions and/or tubing to create the antihelical fold are unnecessary and should be avoided.
  4. Choice of sutures. The author has returned to monofilament permanent sutures because of occasional granulomas associated with braided sutures such as Mersilene. A long-lasting monofilament suture such as polydioxanone suture may be the best choice, but the author has no experience with this suture and therefore cannot credibly recommend it
  5. Degree of correction. Overcorrection of the ears is the most common problem. Contours should be soft, round, and natural rather than sharp and surgical in appearance.

References

  1. Mustardé JC. Correction of prominent ears using buried mattress sutures. Clin Plast Surg. 1978;5:459.
  2. Stenstrom SJ, Heftner J. The Stenstrom otoplasty. Clin Plast Surg. 1978;5:465
  3. Converse JM, Wood-Smith D. Technical details in the surgical correction of the lop ear deformity. Plast Reconstr Surg. 1963;31(2):118.
  4. Furnas D. Suture otoplasty update. Perspect Plast Surg. 1990;4:136
  5. Gosain AK, Recinos RF. A novel approach to correction of the prominent lobule during otoplasty. Plast Reconstr Surg. 2003;112(2): 575-583.
  6. Thorne CH. Otoplasty. Plast Reconstr Surg. 2008;122(1):291-292
  7. Gault D, Grippaudo F, Tyler M. Ear reduction. Br J Plast Surg. 1995;48:30
  8. Argamaso R. Ear reduction with or without setback otoplasty. Plast Reconstr Surg. 1990;85(2):316.
  9. Kaplan H, Hudson D. A novel surgical method of repair for Stahl’s ear: a case report and review of current treatment modalities. Plast Reconstr Surg. 1999;103(2):566.
  10. Greig AVH, Podda S, Thorne CH, McCarthy JG. The question mark ear in patients with mandibular hypoplasia. Plast Reconstr Surg. 2012;129(2):368e-369e.
  11. Al-Qattan MM. Cosman (question mark) ear: congenital auricular cleft between the fifth and sixth hillocks. Plast Reconstr Surg. 1998;102(2):439.
  12. Matsuo K, et al. Non-surgical correction of congenital auricular deformities in the early neonate: a preliminary report. Plast Reconstr Surg. 1984;73:38
  13. Matsuo K, Hayashi R, Kiyono M, et al. Nonsurgical correction of congenital auricular deformities. Clin Plast Surg. 1990;17(2):383
  14. Thorne CH, Wilkes G. Ear deformities, otoplasty, and ear reconstruction. Plast Reconstr Surg. 2012;129(4):701e-716e.
partial acquired defects

Most acquired, partial auricular defects have a good surgical solution. The more superior on the ear the defect is located, the more choices there are for reconstruction. Reconstruction of the lobule is the most difficult and is aesthetically the most important.

Although some defects can be closed by soft tissue alone, cartilage is usually required for support. For smaller defects, a conchal cartilage graft may suffice. However, for larger defects the rules of firmin (Firmin, Personal communication, 2013) are extremely helpful: defects that consist of 25% or more of the helical rim orinvolve more than two planes (i.e., involve antihelix as well as helix and scapha) will require rib cartilage for support. Conchal cartilage will not provide sufficient support in these cases.

Specific Regional Defects

External Auditory Canal. Stenosis is best treated by a full-thickness graft applied over an acrylic mold, provided a reasonable recipient vascular bed can be prepared. Occasionally, multiple Z-plasties are used to relieve webbing of the orifice, or a local flap is employed to line the canal and break up the contracture. an acrylic stent is recommended for several months to counteract the inexorable tendency toward contracture.

Helical Rim Acquired losses of the helical rim vary from small defects to major portions of the helix. The former defects, which usually result from tumor excisions or minor traumatic injuries, are best closed by advancing the helix in both directions, as described by Antia and Buch 1 (Figure 27.1). The success of this excellent technique depends first on freeing the helix from the scapha via an incision in the helical sulcus that extends through the cartilage but not through the posterior skin. The posterior auricular skin is undermined, until the entire helix

is hanging as a chondrocutaneous flap on the posterior skin. Extra length can be gained by a V-Y advancement of the helical crus, as described in the correction of the constricted ear. defects up to 1.5 cm can be closed without tension. Defects larger than 2 cm are too large for this technique. In order to facilitate closure, it is necessary to “cheat” by removing some of the scaphal cartilage, taking tension off the reapproximated helical rim. Reducing the scapha reduces the size of the ear and the patient should be alerted to this fact in advance. Although originally described for upper-third auricular defects, this technique is also effective for middle-third defects, as well as for defects at the junction of the middle and lower thirds.

If the helical rim alone is missing, as may occur in burn injuries, a thin tube of retroauricular skin can be applied to the residual scapha with acceptable results (Figure 27.2). This is one example where cartilage may not be necessary. The disadvantage of this technique is that it requires three stages to “waltz” the tube into place: (a) formation of the tube in the sulcus, (b) transfer and insetting of one end of the tube, and (c) transfer and insetting of the other end of the tube.

Upper-Third Defects. Techniques available for upper-third defects in increasing order of size and complexity are as follows (Figure 27.3):

  1. Local skin flaps (Figure 27.3 A and B)
  2. Helical advancement (Figure 27.3 C and D).
  3. Contralateral conchal cartilage graft covered with a retro-auricular flap (Figure 27.3 E and F).
  4. Chondrocutaneous composite flap (Figure 27.3 G and H).
  5. Rib cartilage graft covered with retroauricular skin or tem-poroparietal flap/skin graft (see Figure 27.5).
  • helical1
  • helical2
  • helical3

Figure 27.1. Antia-Buch helical advancement. a. An incision is designed inside the helical rim and around the crus of the helix. B. The incision is made through the skin and the cartilage, but not through the posterior skin. The helical rim is advanced to allow closure and a dog-ear of skin (dotted line) is removed on the back of the ear. c. Closure showing the crus of the helix advanced into the helical rim. (Copyright Charles H. Thorne, MD.)

 
Part iii: Congenital Anomalies and Pediatric Plastic surgery
  • Congenital Anomalies1
  • Congenital Anomalies 2
  • Congenital Anomalies 3
  • Congenital Anomalies 4

Figure 27.2. Helical reconstruction with a thin caliber tube flap. a. Burn deformity of the helix. B. Construction of the tube flap in the retroauricular sulcus. c. Transfer of one end of the tube. d. Final result. (Courtesy of Burt Brent, MD.)

  1. Helical advancement.
  2. Conchal cartilage graft and retroauricular flap.
  3. Rib cartilage graft and retroauricular flap and/or temporo-parietal flap (Figure 27.5).

Cartilage grafts can be inserted via the Converse tunnel procedure in which the skin is not detached at the junction of the residual ear and the retroauricular skin. The problem is that precise placement of the graft with exact coaptation

  • Cartilage grafts 1
  • Cartilage grafts 2
  • Cartilage grafts 3
  • Cartilage grafts 4
  • Cartilage grafts 5
  • Cartilage grafts 6
  • Cartilage grafts 7
  • Cartilage grafts 8

Figure 27.3. Four techniques for repairing upper-third auricular defects. a and B. Preauricular flap. The flap is transposed to repair a minor rim defect. c and d. Antia-Buch helical advancement. e and f. The combination of a retroauricular flap and conchal cartilage graft. G and H. Chondrocutaneous conchal flap to reconstruct the helical rim. Of the upper-third techniques, the only one not shown is a rib cartilage graft, which is shown in Figure 30.11. (Courtesy of Burt Brent, MD.)

  • Wedge resection1
  • Wedge resection2

Figure 27.4. Wedge resection and primary closure with excision of accessory triangles. A Wedge excision performed and accessory triangles designed. B. Closure of the defect. The accessory triangles help prevent the auricle from cupping forward. (Copyright Charles H. Thorne, MD.)

to remaining cartilage is difficult using this approach, and a detached retroauricular flap (Figure 27.5) is preferable. Middle -third auricular tumors are excised and closed by either a wedge resection with accessory triangles (Figure 27.4) or a helical advancement, as previously described.

lower-third auricular defects. SVarious techniques have been described to reconstruct earlobe defects using soft-tissue flaps. These techniques are not as effective as those that employ cartilaginous support. Like the alar rim, the normal earlobe does not contain cartilage. A reconstructed earlobe, however, will only maintain its contour if cartilage is included,analogous to nonanatomic alar rim grafts. The author prefers to use thin, flat cartilage obtained from the nasal septum.2 The cartilage is placed beneath the cheek/retroauricular skin in the first stage. A hole can be made in the cartilage at this initial stage for later ear piercing. In the second stage, an incision is made around the cartilage graft and the flap is advanced beneath the earlobe as in a facelift (Figure 27.6).

Microtia

Microtia literally means small ear. The simplicity of the term belies the vast complexity of this entity, in terms of both the variable clinical presentation and the difficulty of surgical reconstruction.

  • Wedge excision 1
  • Wedge excision 2

Figure 27.5. Wedge resection and primary closure with excision of accessory triangles. A Wedge excision performed and accessory triangles designed. B. Closure of the defect. The accessory triangles help prevent the auricle from cupping forward. (Copyright Charles H. Thorne, MD.)

Part iii: Congenital Anomalies and Pediatric Plastic surgery
History

Gillies is credited with the first use of rib cartilage for con-struction of an auricular framework in 1920. The importance of his contribution was temporarily obfuscated by several reports using allogeneic cartilage. The allogeneic cartilage, whether from a living donor such as the patient’s parent or preserved cadaver cartilage, always underwent gradual resorption.

The modern era of auricular reconstruction began with Tanzer 3 who reintroduced the technique of autogenous costal cartilage grafts as a method of auricular reconstruction. Tanzer’s results inspired Brent who modified, improved, and standardized a four-stage technique of auricular reconstruction. 4 Nagata developed a more complex technique that condensed microtia repair into two stages.5 The Nagata technique requires more cartilage and the construction of a higher profile, more detailed framework than the Brent technique. Firmin analyzed those characteristics of a “Brent ear” that fall short of a normal ear and reported a large series using her modification of the Nagata technique.

While the technique of autogenous auricular reconstruction was evolving, silastic was also used, instead of rib cartilage, as the auricular framework. This material, as well as other artificial materials, led to a high incidence of extrusion. More recently, the use of porous polyethylene frame-works has been explored and has become the standard treatment offered by some surgeons. The largest series was reported by Reinisch.7 Early attempts were associated with a 42% incidence of framework extrusion leading to modifications of the original technique and coverage of the framework using a temporoparietal fascial flap. This drastically reduced the complication rate and is the technique of choice in his opinion.

Finally, an auricular prosthesis is another option. The introduction of titanium osseointegrated fixtures by Branemark has made prosthetic reconstruction of the auricle a more stable and user-friendly alternative. 8 The role of prosthetic reconstruction in microtia will also be discussed later.

anatomy and surgical challenge

The ear is composed of a delicate and complex-shaped cartilage framework covered on its visible surface with thin, tightly adherent, hairless skin. A reconstructed auricular framework must be more rigid than the cartilage framework of a normal ear. When the auricular framework is placed beneath the skin in the temporal region, a combination of the tight skin envelope and the progressive scar contracture will gradually obliterate the fine details if the framework is built to mimic the delicate framework of the normal ear. as such, any reconstructed ear that maintains its projection and definition in the long term will be more bulky and will lack the flexibility of the normal ear.

Consequently, even the best result using current techniques for auricular reconstruction is imperfect. The deficiencies of current techniques make it even more important that the reconstructed auricle be the correct size, be located in the proper position such that one earlobe is not higher than the other, and be properly angulated relative to the other facial structures.

embryology

The middle and external ears are derived from the first (mandibular) and second (hyoid) branchial arches. Most patients with microtia have atresia (absence) of the external auditory canal and tympanic membrane with variable deformities of the middle ear ossicles. Rarely, a patient will present with microtia and a patent, stenotic canal. Least common but most difficult to repair are patients with an auricular vestige and canal that are markedly abnormal in position. Because

Part iii: congenital anomalies and Pediatric Plastic surgery
  • Earlobe reconstruction 1
  • Earlobe reconstruction 2

Figure 27.6. Earlobe reconstruction using nasal septal cartilage. a. Original defect secondary to discoid lupus erythematosus. B. Final result after two-stage reconstruction using thin cartilage from the nasal septum. (Copyright of Charles H. Thorne, MD).

the meatus can only be moved a limited distance, the surgeon must consider complete excision of the canal. The inner ear is derived from totally separate embryologic tissues from the middle/external ear and is, therefore, almost always normal in patients with microtia. In other words, the hearing loss in microtia/atresia patients is conductive in nature

incidence/Genetics

The incidence of microtia varies widely among ethnic groups. Textbooks cling to the figure of 1 in every 6,000 births. The incidence is higher in patients of Asian ethnicity. In addition, microtia is almost twice as common among males as females and almost twice as common on the right side compared with the left. Bilateral microtia occurs somewhere between 10% and 20% of patients with microtia.

Most cases of microtia occur in an isolated fashion. Only rarely does microtia appear to run in families. One exception is Treacher Collins syndrome, which frequently presents with bilateral microtia and is inherited in an autosomal dominant fashion.

Microtia in Hemifacial Microsomia

Older publications suggest that isolated microtia and hemifacial microsomia are distinct entities. In fact, microtia is part of the spectrum of hemifacial microsomia deformities, all of which owe their origin to maldevelopment in the first and second branchial arches. At one end of the spectrum is the patient with microtia who appears to have an otherwise symmetrical face. At the other end of the spectrum is a patient who manifests underdevelopment of all tissues on one side of the face, including microtia, aural atresia, underdevelopment of the mandible, underdevelopment of the soft tissues of the cheek, and underdevelopment of the facial nerve. Microtia and hemi - facial microsomia should not be considered as separate enti - ties (Chapter 24).

canaloplasty and Middle ear reconstruction

Patients with unilateral microtia/atresia usually have normal hearing in the contralateral ear. This should be verified by an otologist as early as possible after birth. The main goal then becomes protection of the better hearing ear throughout development. It is important that otitis media in the ear with normal hearing be treated completely and that a hearing test be repeated after completion of treatment. Residual middle ear fluid in the normal ear may result in hearing impairment and consequently interference with speech development.

Patients with unilateral microtia reasonably do well from a hearing/speech point of view. They have difficulty localizing sounds and discriminating sounds in noisy environments. Patients with unilateral atresia can frequently function in a classroom and traditionally have survived without amplification. School performance, however, is improved if the child/ teacher employ an FM unit or, even better, if the child has a bone-conduction or bone-anchored hearing aid to provide binaural hearing.

Patients with bilateral microtia/atresia are in an entirely different situation. These patients are functionally deaf with complete conductive hearing loss bilaterally. These patients are fitted with a bone-conduction hearing aid as early as pos - sible in life and benefit from a bone-anchored hearing aid retained with a titanium abutment when they get older.

Approximately one-half of the patients with microtia/aural atresia have middle ear anatomy that can be reconstructed surgically. In bilateral cases, this is extremely important and may eliminate the need for a hearing aid or at least decrease total dependence on such a device.

The issue in the unilateral case is not as clear because, as stated above, these patients function reasonably well. Most otologists around the world do not recommend canaloplasty

in patients with unilateral microtia . The surgical results are prone to stenosis of the external auditory canal meatus as well as scar contracture of the reconstructed tympanic membrane. While the immediate postoperative audiograms show excellent results, the hearing in the reconstructed ear tends to deteriorate with time. There are otologists, however, who believe that the results of canaloplasty are more than sufficient to warrant the procedure in unilateral cases. The timing of the auricular reconstruction relative to the canaloplasty is important. the auricular reconstruction is best performed before the canaloplasty . Auricular reconstruction is possible after canal surgery but the result is compromised by the scarring in the region.

classification

The microtia deformity itself is enormously variable. At one end of the spectrum is an auricle that is slightly small but otherwise normal in appearance. At the other end of the spectrum is the patient with complete anotia. Various classifications have been proposed to deal with the vast variability in clinical presentation. The Nagata classification is useful because it correlates with the surgical approach

  • bullet
    Lobule type. These patients have an ear remnant and mal-positioned lobule but have no concha, acoustic meatus, ortragus.
  • bullet
    Concha type. T These patients present with an ear remnant,malpositioned earlobe, concha (with or without acoustic meatus), tragus, and antitragus with an incisura intertragica
  • bullet
    Small concha type. These patients present with an ear rem- nant, malpositioned lobule, and a small indentation insteadof a concha
  • bullet
    Anotia. These patients present with no, or only a minute,ear remnant.
chapter 27: ear reconstruction
  • bullet
    Atypical microtia. These patients present with deformities that do not fit into any of the above categories.
surgical reconstruction

The following are the three options for reconstruction of microtia:

  1. Autogenous reconstruction.
  2. Composite autogenous/alloplastic reconstruction using an alloplastic ear framework.
  3. Prosthetic reconstruction.

Autogenous Reconstruction. The two main techniques described for autogenous reconstruction of the auricle using a rib cartilage framework are the Brent technique and the Nagata technique.

The Brent technique involves four stages:

  1. Creation and placement of a rib cartilage auricular frame-work (Figures 27.7 and 27.8).
  2. Rotation of the malpositioned ear lobule into the correct position (Figure 27.9).
  3. Elevation of the reconstructed auricle and creation of a retroauricular sulcus (Figure 27.10)
  4. Deepening of the concha and creation of the tragus(Figure 27.11)

The Nagata technique is performed in two stages:

  1. Creation of an auricular framework including the tragus and rotation of the lobule into the correct position (in other words, combining stages 1, 2, and 4 from the Brent technique) (Figures 27.12 and 27.13).
  2. Elevation of the reconstructed ear and creation of the ret- roauricular sulcus (Figure 27.14).
  • Fabrication of ear framework

Figure 27.7. Fabrication of ear framework from rib cartilage. Brent technique, stage 1. a. The base block is obtained from the synchondrosis of two rib cartilages. The helical rim is obtained from a “floating” rib cartilage. B. Carving the details into the base using a gouge. c. Thinning of the rib cartilage to produce the helical rim. d. Attaching the rim to the base block using nylon sutures. e. Completed framework

Part iii: congenital Anomalies and Pediatric Plastic surgery
  • Insertion of the ear framework 1
  • Insertion of the ear framework 2
  • Insertion of the ear framework 3

Figure 27.8. Insertion of the ear framework. Brent technique, stage 1. a. Preoperative markings indicating the desired location of the framework (solid line) and the extent of the dissection necessary (dotted line). B. Insertion of cartilage framework. c. Appearance after the first stage. A suction catheter is used to suck the skin into the interstices of the framework. (Courtesy of Burt Brent, MD.)

Technical Details of the Two Techniques. SThe patient is examined standing and the location of the earlobe on the normal side is transferred to the affected side. This is the single most important marking because symmetrical earlobes is one of the primary goals of the procedure. If the reconstructed ear is too low, it will not be aesthetically pleasing, no matter how beautiful it is in isolation. The normal ear is traced on clear x-ray film and sterilized. Using this tracing, additional templates are made. A template of the desired framework is made, approximately 3 to 4 mm shorter and narrower than the eventual ear. If the Nagata technique is performed, additional templates are constructed of the antihelix/triangular fossa piece and the tragus/antitragus piece.

The exact location and orientation of the desired auricle are drawn on the patient. Decisions are made about the location of the incisions. In the Brent technique, an incision is designed that can be used again at the time of lobule rotation and at the time of tragus construction. If the Nagata technique is used, the incision is designed as shown in Figure 27.13, to allow rotation of the lobule. The incision is made and the cartilage remnant is removed, carefully preserving the skin and avoiding buttonholes if possible. The pocket is dissected

  • Rotation of lobule 1
  • Rotation of lobule 2

Figure 27.9. Rotation of lobule. Brent technique, stage 2. The ear-lobe is rotated from its vertical malposition into the correct position at the caudal aspect of the framework. a. Design of lobe rotation is made such that the same incision can be used in stage 4, tragus construction. B. After rotation of the lobule. (Copyright Charles H. Thorne, MD.)

beyond the outline of the eventual auricle. In the Nagata technique, a pedicle is maintained to the dissected flap to improve blood supply.

Attention is turned to the chest. Although a transverse incision will heal more favorably than an oblique incision, the latter provides better exposure. The rectus abdominis muscle is divided. In the Brent technique, two pieces of cartilages are harvested. In the Nagata technique, five pieces are required. In addition to the synchondrosis of two cartilages and a free rib for the helical rim, the Nagata technique requires removal of a piece for the antihelix/triangular fossa, a piece for the tragus/ antitragus, and a piece to be banked in the chest for the second stage. This piece is wedged into the sulcus at the second stage to provide projection of the auricle. Nagata harvests the cartilages in a subperichondrial plane, leaving the perichondrium in the chest when the cartilages are removed. The author tends to take the cartilages with the perichondrium and has not noticed a significant difference in the chest wall deformity. If a pneumothorax is created, a catheter is placed into the pleural cavity. After the incision is closed the catheter is withdrawn while the anesthesiologist applies positive pressure ventilation. An additional catheter is left in the wound for the administration of Marcaine postoperatively.

Details are applied to the base using gouges. In the Nagata technique, the antihelix/triangular fossa piece is attached. The helical rim is attached in a similar fashion in both techniques. The difference is that Nagata recommends waiting until the child is 10 years old, which yields cartilages that are long enough to reconstruct the crus of the helix. Finally, the tragus/ antitragus piece is attached in the Nagata technique. Nagata uses wire sutures. The author has used nylon sutures, rather than wire, for both the Brent and Nagata techniques, with adequate fixation and a low incidence of suture extrusion.

The framework is inserted into the pocket along with two suction drains. Once the closure has been accomplished and the dressing has been applied, the drains are attached to Vacutainer tubes. The tubes are changed every half hour for 2 hours, then every hour for 2 hours, and then every 4 hours overnight. The dressing is removed on the second postoperative day and the patient is discharged.

Firmin has made significant modifications in the Nagata technique and has now accumulated the largest experience with experience with ear reconstruction in the worldover 3,500 cases. The modifications will not be discussed in detail because she has not yet published them but they must be recognized as her contributions.9 In most cases, she employs a simpler incision than Nagata that preserves

chapter 27: ear reconstruction
  • Elevation of framework 1
  • Elevation of framework 2
  • Elevation of framework 3

Figure 27.10. Elevation of framework and skin graft to sulcus. Brent technique, stage 3. a. Incision is designed behind the ear. B. The retroauricular scalp is advanced into the sulcus so that the eventual graft will not be visible. c. Full-thickness graft to the exposed medial surface of the auricle. (Copyright Charles H. Thorne, MD.)

the retrolobular skin and increases the likelihood that the patient can have the ear pierced in the future. In addition, she has added additional pieces of cartilage on the deep surface of the framework to increase the projection of and stabilize the tragus and to increase the height of the posterior conchal wall. She has also developed classifications and algorithms for the management of the skin, the type of framework necessary, and the technique used for the elevation at the second stage.

An example of framework construction is shown in Figure 27.15. The appearance after insertion in the skin pocket is shown in Figure 27.16. An example of a postoperative result is shown in Figure 27.17.

complications. Complications of the Brent technique are rare in experienced hands. Complications of the Nagata technique, at least in the author’s hands, are relatively common. The most common complication is exposure of the cartilage framework. Management requires experience, but these wounds may heal by secondary intention if they are less than 1cm in maximum dimension and not over a prominent part

of the framework. Exposed areas of more than 1 cm in greatest dimension require urgent coverage, usually with a temporoparietal flap and skin graft. In some cases, a flap of skin from the retroauricular region may be used to cover a small area of exposed helix. For areas of exposure over the antihelix, a flap of conchal skin can be rotated, leaving the concha to be skin grafted. In fact, if there is the slightest question about whether an exposed area will heal, then flap coverage is indicated. one never regrets performing flap coverage of an exposed area of cartilage framework, but one may certainly regretnot performing such a procedure.

elevation of framework. In the third stage of the Brent technique and the second stage of the Nagata technique, the previously placed framework is elevated and the retroauricular sulcus is resurfaced. Nagata adds a piece of rib cartilage covered with a temporoparietal flap. The cartilage is banked under the skin at the time of the first stage and is wedged into the sulcus to provide projection to the reconstructed auricle in the second stage. The fascial flap covers the graft and provides a bed for skin grafting (Figure 27.14). In both the techniques

  • Construction of tragus 1
  • Construction of tragus 2

Figure 27.11. Construction of tragus. Brent technique, stage 4. a. The conchal graft is taken from the posterior conchal wall of the contralateral ear. B. An L-shaped incision is made and the graft is inserted with the skin surface down. c. The graft healed nicely. (Copyright Charles H. Thorne, MD.)

Part iii: congenital Anomalies and Pediatric Plastic surgery
  • Fabrication of ear framework from rib cartilage

Figure 27.12. Fabrication of ear framework from rib cartilage. Nagata technique, stage 1. a. In a manner similar to Brent, the base and its details are carved from the synchondrosis of two adjacent ribs. B. The four pieces of cartilage that make up the cartilage framework are seen and numbered. The base and helical rim are present as they are for the Brent technique. There is an additional antihelix-triangular fossa piece and an additional tragus-antitragus piece that are unique to the Nagata procedure. (Copyright Charles H. Thorne, MD.)

  • Insertion of the cartilage framework

Figure 27.13. Insertion of the cartilage framework. Nagata technique, stage 1. a. The incision is designed, robbing most of the skin on the medial surface of the lobule that will be necessary to line the concha. B. The pocket is dissected,leaving an intact “pedicle” at the caudal end of the flap. c.The framework is inserted. d. Appearance of the framework after stage 1. Suction drains are in place to coapt the skin to the underlying cartilage. (Copyright Charles H. Thorne, MD.)

chapter 27: ear reconstruction
  • Elevation of framework A
  • Elevation of framework B
  • Elevation of framework C

Figure 27.14.Elevation of framework. Nagata technique, stage 2. a. The auricle is elevated, the scalp is advanced into the sulcus (arrows), the cartilage graft is wedged into the sulcus, and the graft is covered with a temporoparietal flap and skin graft. B. The skin graft is in place. Nagata described the use of split-thickness skin but this author has noted tremendous shrinkage of the thin grafts and recommends full-thickness graft. c.Cross section showing the cartilage graft in place providing projection as well as the temporoparietal flap covering the cartilage graft. (Copyright Charles H. Thorne, MD.)

the scalp is advanced into the depth of the sulcus, and the medial surface of the elevated framework is resurfaced with a skin graft

Both Nagata and Brent recommend a split-thickness graft for this stage. The grafts contract significantly, however, in

some cases obliterating the reconstructed sulcus. For this reason, the author prefers a full-thickness graft from the groin. The disadvantage is a visible scar but the full-thickness graft resists contracture and is more likely to result in maintenance of the reconstructed sulcus.

  • Construction of the cartilage A
  • Construction of the cartilage C
  • Construction of the cartilage

Figure 27.15.Construction of the cartilage framework. a. This author uses Nylon sutures to attach the cartilage pieces to construct the framework. Firmin and Nagata employ stainless steel wire. B. The completed framework. c. The deep surface of the completed framework showing the extra pieces described by Firmin to stabilize the tragus and to increase the projection of the posterior wall of the concha. (Copyright Charles H. Thorne, MD).

Part iii: congenital anomalies and Pediatric Plastic surgery
  • Appearance of the framework A
  • Appearance of the framework B

Figure 27.16.The framework immediately after insertion. a.Appearance of the framework after insertion and application of suction to the drains. B. Close-up view. The abnormal contour near the lobule is one of the drains. (Copyright Charles H. Thorne, MD.).

composite Autogenous/Alloplastic Reconstruction.In these patients, an auricular framework composed of porous polyethylene (Medpor) is used instead of costal cartilage. Reinisch originally reported a 42% incidence of implant exposure. He modified the technique, adding temporoparietal flap coverage of the framework, and reported a vastly decreased complication rate.

Prosthetic Reconstruction.Prior to the introduction of implant retention of prostheses, prosthetic reconstruction depended on adhesive retention and was impractical. Branemark osseointegrated titanium implants have made prosthetic reconstruction somewhat more practical but this technique remains, in the author’s opinion, a second choice to autogenous reconstruction.

children are poor candidates for prostheses, often refusing to wear them regardless of the retention mechanism. Children

also tire of the maintenance required of the abutments and the surrounding soft tissue. If adequate hygiene is not maintained, the skin/abutment interface becomes inflamed and use of the prosthesis must be discontinued awaiting resolution of the inflammation. Additionally, the daily removal and replacement of the prosthesis serves as a constant reminder of the deformity. In contrast, children with an autogenous reconstruction incorporate the new ear into their sense of self. Finally, prostheses lack the warmth and texture of autogenous reconstructions and, despite the superior details, are not more “lifelike.”

It is important to note that prostheses require replacement every five years for the life of the patient and, therefore, prosthetic reconstruction is more expensive in the long term than autogenous reconstruction.

To this author’s thinking, the only absolute indication for prosthetic reconstruction in a child with microtia is failed

  • patient with microtia 1
  • patient with microtia 2

Figure 27.17.Example of a patient with microtia and the postoperative result. (Copyright Charles H. Thorne, MD.).

autogenous reconstruction with inadequate soft tissue for either a second autogenous reconstruction or a Medpor reconstruction. In such a patient, a prosthesis may represent the only salvage procedure available.

Relative indications for the use of prosthetic reconstruction include a very low hairline where a temporoparietal flap would be required to allow autogenous reconstruction or extreme hypoplasia of the tissues with a concavity where the auricle will eventually be located.

Personal Thought on Surgical Reconstruction.The author has extensive experience with both the Brent and the Nagata techniques of auricular reconstruction and it is on the basis of that experience that the following comparative statements are made.

The Nagata procedure was designed to address the perceived weaknesses of the Tanzer/Brent technique, particularly the region of the concha, crus of the helix, tragus, and incisura intertragica. As such, the best possible Nagata-type result may have superior details to the best possible Brent-type result. The problem is that the “best possible results” do not occur most of the time.

The Nagata procedure, at least in the hands of this author, is definitely associated with a higher complication rate. The framework is of much higher profile, is much more complex in its details, and contains many more sutures. As such, the chance of cutaneous necrosis with framework exposure is significantly greater using the Nagata technique. On the other hand, these areas of exposure are generally small and heal without further surgical intervention and do not necessarily compromise the result.

The individual surgeon must decide, factoring in his/her experience, whether the possibility of a superior result is worth the increased risk of the Nagata procedure. In his own practice, this author currently uses the Nagata/Firmin technique in most patients. In patients with extremely tight skin, or the presence of other scars, the Brent technique is used because of its safety and reliability.

The other issue involves the chest donor site. The Nagata technique requires harvesting twice as much cartilage as the Brent technique. While Nagata harvests all cartilage subperichondrially, no detailed study has been performed comparing the chest wall deformity created by the Nagata technique at age 10 years with the deformity created by the Brent technique at age 6 years. Although the donor site is an issue not to be ignored, it tends not to be an issue regardless of which technique is used. Patients simply do not complain about the chest unless they are extremely thin.

Proponents of the composite alloplastic/autogenous reconstruction using Medpor cite the lack of chest donor-site scars/ deformity as an advantage. Although that is true, these same reports fail to mention the scars/deformity that replaces the chest deformity. For example, the composite technique robs the contralateral normal ear of all the skin behind it, resulting in obliteration of the sulcus or a skin graft donor-site scar if the retroauricular defect is replaced with partial-thickness skin. Additionally, this technique requires a scalp scar to harvest the temporoparietal flap. These scars are frequently hypertrophic and/or associated with thin strips of alopecia, which may be more troublesome to the patient than a chest wall scar.

Severe Facial Asymmetry

Placing the reconstructed ear in the best location is straight forward if the face is symmetrical or near symmetrical. In cases of significant asymmetry, however, compromises must be made. The surgeon cannot rely on measurements from landmarks such as the lateral canthus and oral commissure, because the entire side of the face is so much smaller than the other side. If such measurements were

chapter 27: ear reconstruction

used, the ear would be placed far too posteriorly and would appear strikingly abnormal. Of equal importance, however, the ear must not be placed too low or too anterior. The author attempts to place the ear in the correct craniocaudal position so that the earlobes are at the same level and then determines the anteroposterior positioning based on the relationship to the sideburn. No ear will look normal unless there is a sideburn in front of it.

Acquired Deformity versus Microtia

Total auricular reconstruction of the acquired deformity differs from congenital microtia. There is always less skin available. In microtia, removal of the cartilaginous remnant provides some supple, unscarred skin to supplement the retroauricular skin. In the acquired situation, there may be no residual ear skin, and the presence of scarring from the traumatic or surgical removal of the ear restricts the skin pocket. In many cases, a temporoparietal flap with skin graft is required in addition to the native skin. The flap provides an unlimited amount of vascularized tissue, but the combination of the flap and the skin graft never has the definition or color match of the native skin. In addition, the presence of an external auditory meatus limits the access incisions, the extent of the skin pocket, and the risk of infection. The canal is colonized with bacteria, frequently Pseudomonasspecies, which adds additional problems not encountered in microtia cases.

Special Situations
Acute Auricular Trauma and Cauliflower Ear

A hematoma may result from trauma and frequently occurs in wrestlers. Unless evacuated, the blood tends to become cartilaginous, resulting in the so-called cauliflower ear. Once fully developed, the cauliflower ear is extremely difficult to correct. Hematomas may require repeated aspirations or an incision to fully evacuate. Suturing gauze bolsters to the auricle to compress the skin against the cartilage usually prevents reoccurrence (Figure 27.18).

Amputated Ear

Most attempts to replace an amputated ear will fail, resulting in additional incisions/scars and “burning bridges” that may be useful for secondary reconstruction. The patient, however, will not easily accept the decision to discard the amputated part without an attempt at replacement. There is no easy answer.

Replantation of amputated ears has been reported and some excellent results have been obtained. The vessels are small, however, and failure is common. Any attempt at replantation must consider that success is unlikely and may result in scars that limit later reconstructive attempts. Incisions for the exposure of recipient vessels are kept to a minimum.

Reattaching large pieces of auricular tissue as composite grafts is doomed to failure. The good news is that such an attempt does not disrupt the surrounding tissues, does no harm, and makes the patient feel that “something” is being done.

Removing the skin from the cartilage and burying it beneath the retroauricular skin is a poor choice. The thin, delicate cartilage will not maintain its shape sufficiently against the forces of scar contracture. An alternative is to cover the de-skinned cartilage with a temporoparietal flap. The esthetic result will be poor for the reasons mentioned above and this useful tissue will not be available for secondary reconstruction.

Several successful cases have been reported in which the posteromedial skin was removed from the amputated part, the cartilage was “fenestrated,” retroauricular skin was excised, and the part was placed on the healthy bed. The anterolateral auricular skin is vascularized through the

Part iii: congenital anomalies and Pediatric Plastic surgery
  • acute othematoma A
  • acute othematoma B
  • acute othematoma C

Figure 27.18. Management of an acute othematoma. A. Recurrent conchal hematoma. B. Through-and-through bolster sutures, after evacuation of the hematoma. C. Appearance of ear after the compression dressing has been removed at 10 days. (Courtesy of Burt Brent, MD.)

cartilage fenestrations by direct contact with this healthy, vascularized bed.

In the opinion of the author, the ideal scenario for an amputated ear is an attempt at microvascular replantation through the available wound, without additional incisions. If unsuccessful, secondary reconstruction with rib cartilage grafts is performed, with or without a temporoparietal flap. If replantation is not an available option, the part should be replaced as a composite graft (knowing it will fail), or the part should be discarded.

Acute Auricular Burns

Acute burns may result in chondritis. Characterized by tenderness, erythema, warmth, and induration, chondritis usually occurs several weeks after the initial injury. Once chondritis is diagnosed, aggressive steps are taken to eradicate the infection and prevent subsequent deformity. Drainage and placement of an irrigation system is an appropriate first step. If this therapy fails, the involved cartilage must be debrided. When the latter becomes necessary, incisions are planned judiciously to minimize the effect on secondary reconstruction.

Skin Cancer/Malignant Melanoma

Cutaneous malignancies of the helical rim can be excised and closed with helical advancement as described above. Lesions in the concha or over the antihelix can usually be excised and skin grafted. If the cartilage is involved, it can be excised and the graft placed directly on the posterior skin. Malignant melanomas should be excised with the same margins as melanomas of the equivalent depth in other parts of the body. Melanoma in situ does not require a full-thickness excision. These lesions are excised with a 5-mm margin, preserving the perichondrium, and the skin grafted. Invasive melanomas of the helical rim require wedge resection to achieve adequate margins, eliminating helical advancement as an alternative for closure. These defects may be large and require secondary reconstruction.

Earring Complications

While ingenious techniques have been described to reconstruct traumatic clefts in the lobe caused by earrings, the most reliable method is to excise and close the defect in one stage and re-pierce the ears 6 weeks later, or whenever the induration subsides.

Another complication of earrings is keloid formation. Small keloids can be excised and closed primarily and may not recur. If the patient is truly prone to keloids, then excision, triamcinolone injection, and pressure earrings are warranted. If the keloid recurs, excision with immediate irradiation offers the best chance of avoiding recurrence.

Finally, piercing through the cartilage in the upper portion of the ear can result in severe infections. While not common, chondritis can lead to severe, permanent disfigurement of the auricle. Infections, therefore, are treated aggressively. If cartilage requires debridement, it is performed early to limit the deformity and incisions are planned carefully to minimize these deformities.

  1. Antia NH, Buch MS. Chondrocutaneous advancement flap for the marginal defect of the ear. Plast Reconstr Surg. 1967;39:472
  2. Bastidas N, Jacobs JM, Thorne CH. Ear lobule reconstruction using nasal septal cartilage. Plast Recon Surg. 2013;131(4):760.
  3. Tanzer R C. Total reconstruction of the auricle: a 10-year report. PlastReconstr Surg. 1967;40:547.
  4. Brent BD. Technical advances in ear reconstruction with autogenous ribcartilage grafts—personal experience with 1,200 cases. Plast Reconstr Surg. 1999;104:319.
  5. Nagata S. A new method of total reconstruction of the auricle for microtia.Plast Reconstr Surg. 1993;92:187.
  6. Firmin R. Ear reconstruction in cases of typical microtia. Personal experience based on 352 microtic ear corrections. Scand J Plast Surg. 1998;32:35.
  7. Reinisch JF, Lewin S. Ear reconstruction using a porous polyethylene framework and temporoparietal fascia flap. Facial Plastic Surg. 2009;25(3):181
  8. Thorne CH, Brecht LE, Bradley JP, et al. Auricular reconstruction: indications for autogenous and prosthetic techniques. Plast Reconstr Surg. 2001;107(5):1241.
  9. Firmin, Personal communication and unpublished data, 2013.

Dr. Charles Thorne is an experienced surgeon who has been performing otoplasty surgery in the New York, NY, area for over 30 years for both children and adults dissatisfied with the appearance of their ears. This cosmetic ear surgery is often recommended to reshape and reposition ears that protrude away from the head. It can also be used to address overly large ears and certain ear deformities. If you style your hair to conceal your ears, avoid wearing hats and hairstyles that draw attention to your ears, or are simply unhappy with their appearance, you may benefit greatly from otoplasty surgery.

otoplasty before
otoplasty after

Otoplasty with reduction of upper ear

Who is a Good Candidate for Otoplasty Surgery?

Ears come in all shapes and sizes and are unique to the individual patient. No matter the cause of your concern, your procedure will be precisely customized to your needs. Otoplasty surgery can address a number of cosmetic imperfections, including:

Candidates for otoplasty surgery include patients at any age from four to 90. However, many parents choose to wait until the child is old enough to voice their opinion on whether or not to undergo treatment, typically around age seven. Before undergoing surgery, patients and parents should have realistic expectations and a positive perspective for what otoplasty can provide.

Planning Your Otoplasty Procedure

The first step to improving your appearance is meeting with Dr. Thorne during a private consultation to discuss your concerns and goals. He will also perform a complete medical examination to make sure you are a good candidate for otoplasty surgery. This will include reviewing your medical history, current medications, and evaluating you for any signs of ear infections or medical conditions that could cause complications and compromise your results.

Ears come in all shapes and sizes and are unique to the individual patient. No matter the cause of your concern, your procedure will be precisely customized to your needs.

After deeming you a good candidate, a treatment plan tailored to your unique goals will be created and carefully explained in detail. You will also be given a list of pre-surgical and post-surgical instructions that should be followed to assist in your recovery.

What to Expect During Treatment

On the day of your procedure, you will be taken to a private surgical room. Dr. Thorne offers both local and general anesthesia. The type used will depend on your age and the intricacy of the procedure. Local anesthesia is typically administered for teens and adults, while general anesthesia is used for young children.

Incisions

Once you are comfortable, Dr. Thorne will begin the procedure. The location of the incisions will be contingent on the imperfections being addressed. For overly large, uneven, or misshapen ears, incisions will be discreetly made in the natural folds of the ear. This allows Dr. Thorne to decrease and reshape the cartilage and skin. When ears protrude, an incision will be made in the back of the ear in the natural crease so Dr. Thorne can move the ears closer to the head.

Sutures and Bandages

Once the ears are properly positioned, Dr. Thorne will close the incisions. Permanent sutures are frequently left in the ear under the skin to hold the cartilage in the correct position. The sutures on the outside are absorbable and do not require removal. Dr. Thorne will carefully apply fluff bandages to protect the ears. You will also be given a compression headband to wear after the bandages are removed to keep the ears properly contoured. The overall procedure typically takes an hour and a half, and you can expect to fully return to normal activities within two weeks.

Financing is Available

The overall cost of otoplasty surgery is dependent on a number of factors, including the type of anesthesia used, the complexity of the procedure, surgical fees, and exams and lab tests. Because it is typically considered an elective procedure, most insurance companies do not cover treatment. To help offset costs, Dr. Thorne accepts CareCredit® financing to assist with out-of-pocket expenses.

Schedule Your Consultation

If you are interested in learning more about otoplasty and how it can benefit you or your child, we invite you to meet with Dr. Thorne. He will take all the time necessary to explain the procedure, benefits, and risks and answer any questions or concerns you may have. To schedule your consultation, please contact us online or give us a call at (212) 794-0044. We also have provided answers to many common questions on our site for you to read in the meantime.

In The Media


Dr. Thorne is consistently highlighted in every publication profiling the Best Doctors in Manhattan or the Best Doctors in the entire United States. He has been featured in the New York Times multiple years running, as well as America's Top Doctors, and has hosted a radio show on plastic surgery alongside dermatologist Dr. Linda Franks.


  • New York Best Doctors 2019
  • New York Best Doctors 2017
  • New York Best Doctors 2014
  • New York Best Doctors 2008


  • New York Best Doctors 2005
  • Americas Top Doctors 2002
  • Castle Connolly 10th
  • Castle Connolly 6th

PROFESSIONAL AFFILIATIONS