Volume 11 • Issue R3

PLASTIC SURGERY OF THE

Richard Y. Ha, MD Matthew J. Trovato, MD

Reconstructive OUR EDUCATIONAL PARTNERS Selected Readings in appreciates the generous support provided by our educational partners.

facial aesthetics OUR EDUCATIONAL PARTNERS www.SRPS.org Selected Readings in Plastic Surgery appreciates the generous support provided by our educational partners. Editor-in-Chief Je•rey M. Kenkel, MD

Editor Emeritus F. E. Barton, Jr, MD

Contributing Editors R. S. Ambay, MD 30 Topics R. G. Anderson, MD S. J. Beran, MD Grafts and Flaps S. M. Bidic, MD Wound Healing, , and Burns G. Broughton II, MD, PhD J. L. Burns, MD Skin Tumors: Basal Cell Carcinoma, Squamous Cell J. J. Cheng, MD Carcinoma, and Melanoma C. P. Clark III, MD Implantation and Local Anesthetics D. L. Gonyon, Jr, MD Head and Neck Tumors and Reconstruction A. A. Gosman, MD Microsurgery and Lower Extremity Reconstruction K. A. Gutowski, MD Nasal and Eyelid Reconstruction J. R. Grin, MD Lip, Cheek, and Scalp Reconstruction R. Y. Ha, MD Ear Reconstruction and F. Hackney, MD, DDS Facial Fractures L. H. Hollier, MD Blepharoplasty and Brow Lift R. E. Hoxworth, MD J. E. Janis, MD Rhytidectomy R. K. Khosla, MD Injectables J. E. Leedy, MD Lasers J. A. Lemmon, MD Facial Disorders A. H. Lipschitz, MD Cleft Lip and Palate and Velopharyngeal Insuciency R. A. Meade, MD Craniofacial I: Cephalometrics and Orthognathic Surgery D. L. Mount, MD Craniofacial II: Syndromes and Surgery J. C. O’Brien, MD Vascular Anomalies J. K. Potter, MD, DDS Breast Augmentation R. J. Rohrich, MD M. Saint-Cyr, MD Breast Reduction and Mastopexy M. Schaverien, MRCS Breast Reconstruction facial aesthetics M. C. Snyder, MD Body Contouring and Liposuction M. Swelstad, MD Trunk Reconstruction A. P. Trussler, MD Hand: Soft Tissues R. I. S. Zbar, MD Hand: Peripheral Hand: Flexor Tendons Senior Manuscript Editor Dori Kelly Hand: Extensor Tendons Hand: Fractures and Dislocations, the Wrist, and Business Manager Becky Sheldon Congenital Anomalies

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Selected Readings in Plastic Surgery (ISSN 0739-5523) is a series of monographs published by Selected Readings in Plastic Surgery, Inc. For subscription information, please visit our web site: www.SRPS.org. SRPS • Volume 11 • Issue R3 • 2011

PLASTIC SURGERY OF THE EAR

Richard Y. Ha, MD1

Matthew J. Trovato, MD2

1,2Dallas Plastic Surgery Institute and 1Department of Plastic Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas

ANATOMY Circulatory System Skeleton The arterial supply of the comes from the The auricular framework consists of three posterior auricular and from the superficial tiers of delicately convoluted cartilage: the conchal temporal artery. Park et al.2 described two separate complex, the - complex, and the networks: one in the triangular fossa and scapha -lobule complex (Fig. 1). and one to the concha. The anterior auricular surface of the ear is dominantly supplied by Musculature perforators from the posterior auricular artery. The vestigial intrinsic muscles of the external The posterior auricular artery has perforators surface of the auricle are the helicis major and piercing the ear from its medial surface at the minor, tragicus, and antitragicus muscles. On the triangular fossa, cymba, concha, cavum conchae, cranial surface are the intrinsic transverse and helical root, and . Only one small branch intrinsic oblique muscles. The extrinsic muscles of of the superficial temporal artery crosses the the ear include the anterior, superior, and posterior helical rim superiorly and supplies the triangular auricularis muscles.1 fossa and scapha network (Fig. 2).2 Because of

Superior crus Helix Scapha Helix Triangular Superior fossa Helix crus Tuberculum Eminentia Inferior auriculae Superior crus scapha Eminentia fossa crus antihelicis triangularis Crus Fossa Transverse Antihelix triangularis Antihelix sulcus helicis Antihelix (inferior crus) Cymba Incisura conchae Spina Cymba anterior helicis Eminentia conchae cymba Tuberculum Cavum Crus Cauda helicis conchae supertragicum conchae helicis Fissura (root) antitragico- Eminentia Antitragus helicina cavum conchae Incisura Lamina intertragica tragi Cauda Ponticulus Cavum helicis Lobule conchae

Figure 1. of the external ear and landmarks for the auricular cartilage.

1 SRPS • Volume 11 • Issue R3 • 2011 interconnections between the two arterial networks, the ear would be well vascularized by either arterial 3 Auriculo- system alone. temporal n. A thorough knowledge of the arterial Lesser occipital n. perforators of the auricle is essential for designing Mastoid branch local chondrocutaneous flaps. Venous drainage is of lesser ocipital n. via the posterior auricular into the external Greater auricular n. jugular system and the superficial temporal and retromandibular veins. A Innervation The ear is innervated by the great auricular nerve (C2–C3), the (V3), the Lesser occipital n. , and the auricular branch of the vagus nerve (Arnold nerve) (Fig. 3).4 Mastoid branch of lesser ocipital n. Lymphatic Drainage Greater auricular n. The lymphatic drainage of the external ear B correlates with its embryological development. Figure 3. Sensory nerve supply of the external ear. n., The concha and meatus drain to the parotid and nerve. (Modified from Brent.4) infraclavicular nodes, and the external canal and cranial surface of the auricle drain to the mastoid and infra-auricular cervical nodes (Fig. 4).4 I 3 II EMBRYOLOGY 4 The auricle arises from the first (mandibular) and 2 second (hyoid) branchial arches. Hillocks appear 5 on these arches during the 6th week of gestation. 1 The anterior hillocks (on the first branchial 6 arch) give rise to the tragus, root of the helix, and superior helix. The posterior hillocks (on the second branchial arch) contribute to the antihelix, Parotid Cervical antitragus, and lobule (Fig. 5).5,6 nodes lymph nodes Figure 4. Lymphatic drainage of the external ear. I, first branchial arch; II, second branchial arch; numbers 1 through 6, gestational weeks 1 through 6.

I II 3 II 4 I 2 5 3 2 4 6 5 1 1 6

Figure 2. Perforating sites of the posterior auricular artery. Left, A B Anterior surface. Right, Posterior surface. Tr, triangular fossa; Figure 5. Embryological origin of the external ear. I, CyC, cymba conchae; HR, helical root; CaC, cavum conchae; Lb, first branchial arch; II, second branchial arch; numbers 1 earlobe. (Reprinted with permission from Park et al.2) through 6, gestational weeks 1 through 6.

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AESTHETIC RELATIONSHIPS of his contemporaries of the mid-19th century Leonardo da Vinci noted that the vertical height considered reconstruction of the auricle a surgical of the ear in adults was approximately equal to the impossibility, but by 1930, Pierce had reported distance between the lateral orbital rim and the root posttraumatic repairs that used autologous rib of the helix at the level of the brow. The ear width cartilage for reconstruction of the concha-antihelix is approximately 55% of its length. The helical rim and a thin roll of supraclavicular skin for helical 7 protrudes 1 to 2 cm from the skull, and the angle reconstruction. Later, Peer placed diced autologous 8 of protrusion averages 21 to 25 degrees. The long costal cartilage in a mold that was implanted in a axis of the ear is tilted posteriorly at an angle of 20 subcutaneous abdominal pocket. When fusion of degrees from vertical (range, 2−30 degrees). The the fragments by was complete, angle between the axis of the ear and the bridge the framework was used in auricular reconstruction. of the nose is approximately 15 degrees; in other During the 1940s, ear reconstruction with fresh and words, the ear axis does not parallel the bridge of preserved cartilage homografts and heterografts the nose in most normal adults.9 10 11 was reported. The results were uniformly dismal, Broadbent and Mathews and Tolleth characterized by late resorption and high reviewed the artistic relationships of the ear to the complication rates. The modern era of auricular surface anatomy of the face. Asymmetries of the ear 8 reconstruction began with classic descriptions of the usually are the rule and not the exception. Farkas principles and technique of total ear reconstruction reported that approximately 50% of people exhibit with autologous costal cartilage, as presented at least a 3-mm discrepancy in the horizontal and by Tanzer.15,16 vertical positions of the ear. Ear projection (defined by cephaloauricular angle) varies up to 5 degrees in ACQUIRED DEFORMITIES 25% of people.12 13 Principles of Acute Management Sullivan and colleagues (Brucker et al. ) The principles of management of acutely showed, in a morphometric study of the external traumatized can be summarized as follows: ear, differences between men and women and • Thorough cleansing, minimal débridement, changes in morphology over time. As expected, relative to head size, the vertical height of the and skin suturing only after cleansing pinna was 6.5% larger in men. However, the lobular • Begin at known structures and progress height and width was relatively similar in both to unknown sexes. With advanced age, only the lobule exhibited • Close the skin in delayed reconstruction significant changes with width decreasing and • Repair primarily after wedge excision length increasing, consistent with the accepted of the wound if the defect is small concept of lobular “ptosis.” and peripheral HISTORY OF EAR RECONSTRUCTION • Leave the wound open and reconstruct at Converse14 provided a detailed account of the a later date early history of ear reconstruction. According • When immediate closure is not feasible, to Converse, The Susruta, an Indian text of cleanse the wound and change dressings ancient medicine, noted a 900 bce case of partial frequently to avoid desiccation reconstruction of the earlobe with a cheek flap. • Graft skin defects only where underlying In 1597, Tagliacozzi of Italy transferred a flap perichondrium is present from the arm to reconstruct the auricle of a monk. Approximately 250 years later, Dieffenbach repaired • Reattach small avulsed ear pieces as a traumatic defect of the ear with a mastoid flap compromised grafts, especially in children folded on itself. Converse14 explained that Roux and many

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Avulsion with Exposed Cartilage the reconstruction and probably warps less and Avulsion injuries with partial-thickness loss of resists trauma better than does rib cartilage. A likely ear substance are managed acutely to ensure swift donor source is the concha of either ear combined coverage of any exposed cartilage. When the with a local skin flap or used as a chondrocutaneous avulsion is superficial and the perichondrium intact, composite graft. Gorney et al.22 described various a split-thickness skin graft from the postauricular methods of harvesting contralateral conchal skin is a good color match and an acceptable cartilage for ear reconstruction of posttraumatic treatment. When no perichondrium is present defects. Patients with large defects requiring near- and the avulsion has left a small peripheral area total ear reconstruction are candidates for costal of exposed cartilage, wedge excision might correct cartilage grafting, such as that used for microtia, the problem. Other methods to cover exposed ear covered with a temporoparietal flap. cartilage are preauricular flaps17 and postauricular One of the most difficult decisions is how flaps, which can be tunneled through the ear to to manage moderate-size defects involving one- cover exposed areas in the concha bow and the fourth to one-half of the ear. Reconstructive external auditory meatus.18 Even a thick flap can options include tubed flaps from the neck, parieto be used to provide substantial cover for exposed temporalis fascial pedicled flaps, and postauricular cartilage, as long as it is transferred according to mastoid skin flaps. The last is recommended because the cran principle presented by Millard,19 and skin the mastoid skin is thin and a good color match for grafting is then performed. the anterior auricular surface.23 Another option when posterior skin is intact is to excise the exposed cartilage and graft the Marginal Defects raw surface with the posterior skin. This method, Defects of the upper and middle third of the helix however, produces a less-than-desirable aesthetic are readily repaired with the chondrocutaneous result.17 If immediate surgical treatment is not advancement flap of Antia and Buch21 (Fig. 6). possible, frequent dressing changes are indicated to The single-stage procedure frees the helix keep the cartilage viable until the wound granulates from the scapha via an incision in the helical or appropriate delayed closure can be planned.17 sulcus extending through the anterior skin and cartilage. The posteromedial skin superficial to the Composite Defects perichondrium is undermined, and the helix is Repair of an acquired ear deformity requires both advanced as a chondrocutaneous component based accurate analysis of the defect and a systematic on a posterior skin flap. approach to the reconstruction.20 Traumatic For small to moderate-sized defects, only auricular injuries can present acutely or as secondary the caudal segment needs to be advanced. Larger deformities after initial treatment by débridement defects of the helix require mobilization of both and direct approximation. the inferior and the superior portions. The cephalic Small composite defects usually are repaired segment is elevated on a preauricular skin flap by means of a reduction procedure or skin-cartilage and rotated backward into the defect in a V-to-Y graft. Reduction methods include the Antia-Buch fashion. If this reconstruction of a large defect procedure21 and other techniques that resect a causes the ear to be smaller in size than the normal portion of the ear in such a way that the edges of ear, correction can be achieved by performing a the wound are brought together for closure. wedge excision of the normal ear and setback of the Brent20 discussed the various sources of prominent ear.21 cartilage for partial ear reconstruction. Unlike When the defect extends into the hollow congenital malformations, acquired deformities of the scapha, the Antia-Buch procedure can be usually do not require costal cartilage for structural combined with crescent-shaped chondrocutaneous support of a total-ear framework. Cartilage from excisions on either side of the defect, preserving the same or opposite ear generally is suitable for posterior perichondrium and skin (Fig. 7).24 The

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helical rims are then advanced and closed. This outer border until the wound can be closed without modification allows closure of larger defects that tension. The technique represents a progression of extend into the scapha while benefiting from the the modification described by Bialostocki and Tan24 advantages of an Antia-Buch repair.24 for repair of defects involving the antihelix. Another option in the management of helix- Marginal defects larger than 2.5 to 3 cm and scapha defects is to combine an Antia-Buch isolated helical rim defects are best treated with procedure with a postauricular pull-through flap. auricular cartilage grafts covered with an adjacent The combination entails elevating a postauricular mastoid or postauricular skin flap.20 If local skin skin flap that is brought through the defect to cover is not available, tubed-pedicle flaps from the the anterior surface of the scapha. The helical rim postauricular or supraclavicular area can also be is then advanced for closure. The technique results used to restore the helical rim.20,27–29 Reduction in a sinus tract between the anterior and posterior techniques should be avoided. aspects of the ear, which is of little cosmetic or functional concern.25 Nonmarginal Defects A further modification of the Antia-Buch Defects of the ear that do not involve the helix operation was described for defects of the helix, usually are associated with resection for skin tumor. scapha, and antihelix. In that variant, wedge Songcharoen, Smith, and Jabaley (Songcharoen et excisions of anterior cartilage and skin are taken al.5) reviewed the management of such lesions and at the superior and inferior poles of the concha.26 suggested methods of reconstruction. For larger helical defects, it was recommended Ramirez and Heckler30 adapted the Antia- that the concha be further reduced by “paring” its Buch advancement technique for the repair of defects of 2 cm or less in diameter in the triangular fossa, scapha, and antihelix. Larger defects and defects low in the ear were treated by the authors with interlocking chondrocutaneous rotation- advancement flaps, albeit with some distortion of the reconstructed ear. Ladocsi31 used similar methods but described the preservation of postauricular artery perforators during flap design A B C to optimize vascularity. Ohsumi and Iida32 described reconstruction Figure 6. Antia-Buch procedure of helical rim advancement for the repair of upper-third auricular defects. of the conchal cavity and external auditory canal with an island chondrocutaneous postauricular flap transferred through the auricular cartilage onto the anterior aspect of the ear. A similar technique involving a retroauricular flap is currently used for reconstruction of the . Gingrass and Pickrell,18 Park et al.,33 and Dean Ferrer et al.34 had previously described similar procedures. Talmi et al.35 described a postauricular musculocutaneous island flap for conchal reconstruction after excision of defects that were 2 cm or larger. With this method, closure is achieved by a rotated postauricular island flap designed so Figure 7. Modified Antia-Buch repair. STA, superficial that its anterior part corresponds to the posterior temporal artery; UAB, upper auricular branch. (Reprinted margin of the surgical excision. The flap is pulled 24 with permission from Bialostocki and Tan. ) through an incision at the postauricular sulcus and

5 SRPS • Volume 11 • Issue R3 • 2011 rotated 180 degrees on its long axis to drape the rotation of the flap. Being an area rich in conchal bowl and antihelix. supply, no circulatory impairment of the mobilized flap is observed. The compound flap is rotated Upper-Third Defects from its place in the concha to the place to be Brent20 described several options for reconstruction reconstructed. The two cutaneous layers are sutured of upper-third defects. The specific technique with nylon, and the fibrocartilage does not need to chosen in each case depends on the size of the be sutured. At the donor site in the concha, a raw defect and how much local skin remains for area situated on the external aspect of the head the reconstruction. remains. The raw area is next covered with a free For small helical rim defects, the Antia-Buch skin graft. chondrocutaneous advancement flaps are adequate. Larger defects requiring cartilaginous support Second Stage are best repaired with preauricular banner flaps The helix is corrected first, by suitable adjustment combined with auricular cartilage grafts at the of the pedicle. The lobule is then pulled downward, helical rim, as described by Crikelair.36 In the event to make the auricle the same length as the opposite of major defects of the upper third of the ear, the normal side. An incision is made along the edge of reconstructive options depend on whether sufficient the lobule, cutting the cartilage and allowing the skin is available for a local flap (e.g., a contralateral lobule to descend the necessary degree.37 cartilage graft covered with a postauricular skin Alternatives to the compound flap presented flap). If not enough skin is available adjacent to the by Orticochea37 for one-stage reconstruction of defect to cover the graft, a compound pedicle flap is the upper third of the auricle include several local reliable for reconstruction (Fig. 8).37,38 flap combinations. Yotsuyanagi et al.39 described a complex method of reconstruction that consists of three different flaps. A chondrocutaneous flap is elevated from the conchal bowl and advanced into the defect to provide cartilage support and anterior skin coverage. A postauricular transposition flap is then used to provide posterior skin coverage of the wound, resulting in a secondary conchal bowl defect that is repaired with a postauricular subcutaneous pedicled flap similar to those described above for nonmarginal defects. The defect that results from A B C harvesting the postauricular subcutaneous pedicled flap is repaired with a full-thickness skin 39 Figure 8. Orticochea procedure of conchal rotation for the graft (Fig. 9). repair of upper- and middle-third auricular defects. Similar one-stage reconstruction of the upper ear has been described by Yoshimura et al.40 The authors combined a postauricular skin First Stage flap transferred anteriorly with a mastoid fascial A compound flap is outlined containing the whole flap for the posterior surface, and the two flaps concha and carrying the external-anterior skin, were then used to sandwich a fabricated costal cartilage, and retroauricular skin. The pedicle of the cartilage framework (Fig. 10). The donor area flap is situated on the outer border of the helix and for the mastoid fascial flap is skin grafted. This must be 1 cm wide. The pedicle is composed of the technique differs from the technique presented by skin of the external edge and of the anterior and Yotsuyanagi et al.,39 described above, in that the posterior aspects of the helix and the scapha. The cartilage is replaced with a free rib cartilage graft cartilage is cut inside the pedicle, to allow easier and not a chondrocutaneous flap from the conchal

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bowl. Although it seems to be technically simpler, the cartilage-graft framework implies increased SMFF morbidity from a remote donor site. Dagregorio and Darsonval41 proposed a peninsular conchal chondrocutaneous flap for upper- and middle-third reconstructions involving the helical rim. This novel flap is axial and based on the posterior auricular artery and the auricular A B branch of the superficial temporal artery. It is a reasonable alternative to multi-stage reconstructions involving costal cartilage grafts. SMFF

Middle-Third Defects In addition to the chondrocutaneous advancement flaps of Antia-Buch, minor defects of the middle framework third of the ear can be repaired by reducing the auricular circumference. Tanzer42 reviews various C patterns of excision of wedges and crescents for the correction of microtia (Fig. 11).

For major defects of the middle third of the ear, a costal cartilage graft can be inserted under the Figure 10. Reconstruction of the upper third of the ear mastoid skin and sutured to the edges of the defect, with a superficial mastoid fascial flap (SMFF). (Modified from 14 as in the tunnel procedure described by Converse, Yoshimura et al.40) or can be covered with a mastoid skin flap, as described by Lewin.43

A B C

D E F

Figure 11. Techniques for reducing the auricular circumference and decreasing tension at the suture line in Figure 9. Repair of defects of the upper third of the primary closure of helical defects of the upper or middle auricle with a combination of several flaps. (Reprinted with thirds. A through F, various patterns of excision. (Modified permission from Yotsuyanagi et at.39) from Tanzer.42)

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Songcharoen et al.5 presented a discussion island flap based retroauricularly. Typically, a skin of management alternatives for tumors of the graft is required for donor site coverage. Renard53 external ear, including reconstruction of middle- and Talmi et al.35 also described postauricularly third wounds. Hinderer et al.44 suggested placing based myocutaneous and dermal pedicled flaps the cartilage and skin suture lines at different for anterior conchal and ear defects. Azaria et levels to avoid notching of the helical rim. al.54 proposed a pull-through transpositional flap Mellette45 reviewed various techniques of partial based retroauricularly for reconstruction of smaller ear reconstruction with local flaps. Techniques for conchal defects. Turan et al.55 also discussed a repair of middle-third defects that do not rely postauricular pull-through type flap but with a on the reduction of auricular size include neurovascular island. multistage techniques.4 Adler et al.56,57 and Dagregorio and Darsonval41 discussed various local and regional Lower-Third Defects, Including the Earlobe flaps for non-helical ear reconstruction. A simple Auricular losses of the lower third, including the pre-auricular transposition flap folded on itself earlobe, can be repaired with a superiorly based flap was proposed for full-thickness tragal defects. doubled on itself, as described by Preaux,46 or with Other flaps for antihelical and triangular fossa a modified “valise handle” technique, as described reconstruction were also discussed. by Brent.20 Brent20 recommended using cartilage grafts to adequately reconstruct the lower third of Cleft Earlobe Deformity the ear. Contralateral conchal cartilage grafts can Cleft earlobe deformities can be congenital or be subcutaneously implanted and later raised as acquired. Deformities of the earlobe and their bipedicled chondrocutaneous flaps. A skin graft reconstructive alternatives were reviewed by Boo- is placed on the medial side of the flap to cover Chai,58 Brent,20 Effendi,59 Fearon and Cuadros,60 the cartilage, creating a valise-handle effect. This and Attalla.61 Clefts of previously pierced technique offers good definition to the posterior probably are the most common acquired defects aspect of the conchal wall and inferior crus on the seen. As a result of the gravity of large anterior surface of the ear. or from traction injuries from earrings, partial or 47 Brent also described a double-lobed complete tears of the earlobe can result. 48 postauricular flap for total earlobe defects. Davis Cleft earlobes can also be congenital in origin. described a technique that uses a posterior (medial) Kurihara62 classified congenital deformities into lining flap turned over from the anterior surface four categories: of the remaining helix and scapha and a mastoid Type I, vertical cleft with anterior and 49 flap for anterior (lateral) earlobe reconstruction. posterior divisions of the earlobe Cordova et al.50 reported total or subtotal earlobe reconstruction with an innervated retroauricular Type II, horizontal cleft with superior and skin flap. Sleilati51 proposed total earlobe posterior divisions of the earlobe reconstruction with double-crossed skin flaps, one Type III, combination horizontal and from the preauricular area and the other from the vertical (mixed cleft type) cleft earlobe retroauricular and/or neck skin. Type IV, hypoplasia, dysplasia, or agenesis of Non-helical Defects (Concha, Antihelix, Tragus) the earlobe Numerous techniques have been described for Types I, II, and III are considered to be “Simple conchal defect reconstruction. Most smaller defects Clefts” and can be reconstructed with Z-plasties are easily managed with split or full-thickness skin or wedge excisions of the cleft with eversion of grafts either onto conchal cartilage perichondrium the margins. Traumatic clefts usually are within or the retroauricular skin (if cartilage is absent). For this category. Clefts with tissue deficiencies might larger defects, Masson52 described a “revolving door” require local flaps, such as triangular flap, V-Y

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advancement flap, rectangular flap, and hinge flaps. anastomosis has been shown to be a suitable Typically, immediate re-piercing is avoided because alternative.71 The cosmetic results obtained with of potential early recurrence of the cleft. Delayed primary microvascular replantation of the ear have piercing after an appropriate period of healing been excellent.68,69 is recommended. Also, re-piercing at a different Successful ear replantation depends on location outside the line of the scars can reduce risk the presence of either the superficial temporal of recurrence. or posterior auricular for microvascular Pardue63 described a technique that permits anastomosis. For cases in which the injury includes these vessels and the likelihood of a successful the continued use of earrings after repair of the 72 cleft. A tiny flap of adjacent skin is rolled into the replantation is low, Jenkins and Finucan proposed superior aspect of the cleft and the torn edges are dissection of the cartilage and skin from the excised and reapproximated. Elsahy64 described amputated part, reattachment of the cartilage a technique that also preserved an at the to the side of the head, and coverage with a time of repair. Z-plasties and other geometric flap temporoparietal fascial (TPF) flap, which is in turn repairs counteract cicatricial forces that can lead to covered with the saved ear skin as a full-thickness notching at the lobular border. However, some of graft. It is presumed that the temporoparietal flap nourishes both the underlying cartilage and these techniques still have linear grooving of the the overlying skin. The ears of two patients were repair within the substance of the earlobe. Lee et 65 salvaged in this manner; in the second case, an al. proposed a two-flap and Z-plasty technique acrylic splint was applied for 3 months to that augments the lobular soft tissue at the repair increase the cartilaginous detail and the result site, preventing depression of the earlobe. The was satisfactory. inner margins of the cleft are raised as flaps, de- 73 A similar strategy was used by Sućur et al. epithelialized, and advanced into an ipsilateral when dealing with an almost completely avulsed subcutaneous pocket of the earlobe. A straight line ear. The authors buried the separated ear cartilage repair is performed except at the inferior margin, under the volar forearm skin as a composite radial where a z-plasty is performed. 66 forearm free flap. Approximately 10 weeks later, the Agarwal and Chandra described a technique composite forearm flap was transferred to the head of placing a conchal cartilage “disc” graft in a where it was revascularized by microanastomoses subcutaneous pocket within the lobule repair. to the superficial temporal blood vessels. The Simultaneous re-piercing is performed. The authors skin of the flap served as cover for the newly advocated this technique for improved support attached ear cartilage. Two revision procedures of the earring and reducing the risk of were subsequently performed to trim the excess recurrent clefting. subcutaneous tissue. Musgrave and Garrett74 reviewed several Total or Near-Total Defects reports of replantation of avulsed ears as composite 67 In 1976, Miller et al. reported the first successful grafts without microsurgical revascularization microvascular replantation of a scalp and part of and concluded that such replacement is almost an ear. The authors used grafts and a total of always doomed. In 1967, the authors were able to 68,69 13 anastomoses. Two years later, Nahai et al. document only three cases of successful composite described replantation of an entire scalp and ear auricular replantation. Other reports before and with microvascular anastomoses of only one artery since invariably lack sufficient follow-up to make an 70 and one vein. Not long after, Pennington et al. informed judgment about ear appearance.75–77 successfully replanted a totally avulsed ear with For cases of near-total loss in which the vein grafts to the superficial temporal artery and amputated part has been recovered, Mladick et vein. In situations in which no adequate artery is al.78 recommended the “pocket principle” of ear identifiable in the amputated part, an arteriovenous salvage. Based on this principle, the amputated

9 SRPS • Volume 11 • Issue R3 • 2011 segment, if in good condition, is dermabraded to tissues are not available, such as after a burn. The remove the and is reattached to the procedure consists of subcutaneously implanting a ear stump. The repaired section is then buried carved cartilaginous framework in the forearm. At under the postauricular skin in a subcutaneous a second operation, the composite unit of cartilage pocket and is left in place for no longer than and forearm skin is transferred as a free flap to the 21 days, during which time it is nourished head to replace the missing ear. Despite the limited through the pocket. If the ear is removed from number of cases reported, the method promises to the pocket before 3 weeks of implantation, the offer a reconstructive solution for selected patients. previously dermabraded surface spontaneously re- epithelializes. This technique, in essence, increases ACUTE AURICULAR HEMATOMA the chances for survival of large composite flaps Acute hematoma of the pinna is a condition by providing an interim period of nourishment that occurs when a collection of blood forms of the amputated part in a subcutaneous pocket. beneath the perichondrial layer of the pinna. A However, a recent literature review of 74 cases systematic Cochrane database analysis conducted in 56 publications strongly discouraged both the by Jones and Mahendran85 failed to identify any pocket method and periauricular skin or fascia flaps method of treatment as providing a superior for immediate reconstruction, citing inconsistent cosmetic outcome, although the key to treatment aesthetic outcomes in comparison with delayed remains to extirpate the hematoma and prevent reconstruction with rib cartilage.79 its recurrence. A recent 22-patient study by Giles Delayed reconstruction in cases of near-total et al.86 found superior outcomes with incision, and total auricular defects differs significantly drainage, and absorbable whip-type mattress suture from reconstruction in cases of microtia. The repair without bolsters. Recurrent hematomas are microtic vestige is unfurled for an extra measure related to intracartilaginous as opposed to simple of skin. After trauma, the remaining skin can be subperichondrial collection, as demonstrated by poor in both quality (scarring and poor elasticity) Ghanem et al.,87 and should be recognized as such and quantity. The meatus precludes an anterior and treated with surgical incision and drainage. incision, further decreasing the effective amount of cover. Although some authors advocate banking of Cauliflower Ear traumatically avulsed cartilage remnants, this does The cauliflower ear deformity is common among not often yield useful reconstructive material. wrestlers, who constitute a much younger patient The practice of auricular reconstruction population than that usually presenting for excision currently favors the use of high-profile autogenous of auricular skin cancer. The cauliflower deformity cartilage or polyethylene frameworks overlaid is the result of repeated episodes of auricular with a TPF flap and split thickness skin graft hematoma after direct trauma, eventually leading in preference to techniques that use salvaged, to the typical appearance of a curled and thickened pocketed, or transferred cartilage. Reconstruction ear. The pathophysiology of the deformity is of the traumatic, complete deformity requires subperichondrial bleeding on the anterior surface fabrication of an auricular framework and, of the ear and new cartilage formation within the frequently, soft-tissue coverage with a TPF confines of the perichondrium.88 Griffin89 suggested flap,72,80–83 scalp roll, or skin grafts. If the mastoid treatment by open drainage of the hematoma and skin is relatively unaffected, it can be used primarily total excision of the fibroneocartilaginous layer and for soft-tissue coverage. Elevation of the framework perichondrium. The skin is closed under bolsters to and splicing to the remaining cartilage and external recontour cartilage detail. auditory canal can be performed at a later stage. Zhou et al.84 described a technique of MICROTIA secondary auricular reconstruction in patients Causes who have total or near-total defects in whom local Variable degrees of penetrance of the gene(s)

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responsible for hypoplasia account for the different evidence indicates that hemifacial microsomia, sizes of microtic remnants that occur. Even with Goldenhar syndrome, and oculoauriculovertebral extremely small microtic remnants, a lobular dysplasia are variants of the same condition, with a component is almost always present, although phenotypic spectrum of severity including various vertically oriented and superiorly displaced. degrees of microtia.97 , the severest of ear deformities, is extremely rare and probably represents complete Anomalies of the and failure of development of the auricular helix Associated Structures through a lack of mesenchymal proliferation.90 Embryologically, the external ear is formed Other severe forms of microtia probably represent earlier than the middle ear, so that even though arrests in embryonic development occurring at it is possible to encounter a normal auricle and a approximately 6 to 8 weeks of gestation. Less malformed middle ear, in the presence of microtia, extreme forms of microtia are likely the result of one should not expect to find a normal middle ear.98 embryonic accidents at a later stage, approximately Although Schuknecht99 finds no correspondence the 3rd month of fetal development.91 between severity of the microtia and degree of middle ear pathology, most otologists relate the Epidemiology severity of the auricular defect to the status of The incidence of microtia varies with the extent the middle ear.95 In a retrospective study of 224 of the deformity. Severe abnormalities occur in cases of aural atresia, Kountakis et al.100 noted a approximately 1:7000 to 1:8000 births.92,93 The right positive correlation between the grade of microtia side is affected approximately twice as often as the and middle ear development. They concluded that left, and bilateral deformities occur in 10% of cases. the better developed the external ear is, the better The male:female ratio is variously reported as 2:1 developed the middle ear is. Gill,101 however, to 3:1. believes the tragus is the only reliable indicator of middle ear pathology: when the tragus exists, there Classification is usually an adequate middle ear cleft. Numerous classification schemes have been In addition to the conductive-type deafness proposed for microtia. Rogers94 recognized four usually associated with microtia, (cochlear) degrees of external ear deformity: microtia, lop abnormalities and sensorineural deafness can also ear, cup ear, and protruding ear. In 1977, Tanzer95 occur. Fukuda102 stated that the presence of a small suggested a popular classification of auricular external auditory canal can indicate a severe mixed- defects according to decreasing severity of type (conductive and sensorineural) deafness, involvement, from anotia (group I) to prominent whereas atresia of the canal with common microtia ears (group V) (Table 1). usually is associated with deafness of a more simple conductive type. Associated Conditions Abnormalities of the middle ear range Atresia of the cartilaginous or bony external canal from minor dysplasia of the to complete is commonly associated with microtia. The atresia obliteration of the . Several degrees ranges from complete absence to several degrees of fibroplasia and fusion of ossicles are common, of narrowing, blind pouches, or tracts. In a case but the usually is normal. The series presented by Tanzer,95 all patients had some sometimes traverses an anomalous course, which deformity of the , middle ear, or both and must be considered during reconstructive surgery. 50% had overt evidence of the first and second branchial arch syndrome (hemifacial microsomia). A recent study suggested that isolated microtia Diagnostic evaluation of hearing usually involves might represent the mildest phenotypic expression audiogram or auditory brainstem response (ABR) of hemifacial microsomia.96 In addition, increasing testing. Audiograms are useful in children old

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Table 1 Clinical Classification of Auricular Defects42

Classification Defect

I Anotia

II Complete hypoplasia (microtia)

A With atresia of the external auditory canal

B Without atresia of the external auditory canal

III Hypoplasia of the middle third of the auricle

IV Hypoplasia of the superior third of the auricle

A Constricted (cup or lop) ear

B

C Hypoplasia of the entire superior third

V Prominent ears

enough to correctly respond to sound stimuli from ear typically have no need for a and are a cognitive standpoint. The ABR is recommended expected to develop speech normally. In contrast, to accurately determine the degree of sensorineural children who have bilateral microtia and aural and conductive loss in newborns and atresia must be fitted with bone conduction hearing infants. ABR can also help identify which is the aids shortly after birth if speech is to develop.103 better hearing ear.103 Bone conduction aids require intact and High-resolution computed tomography (CT) unscarred mastoid skin; therefore’ surgical incisions provides anatomic detail of the middle ear. This for or for the insertion of an information is useful to the otologist in assessing auricular framework are contraindicated because whether the child is a reasonable candidate for they compromise future use of hearing aids. For atresia repair. CT typically is performed when the patients who need bilateral bone conduction patient is between the ages of 4 and 6.103 hearing aids, an external, bone-anchored appliance combined with an osseointegrated Brånemark Hearing Aids titanium fixture is a good choice.104 For children to develop verbal communication Granström et al.104 showed excellent retention skills, they must be able to hear. Bone conduction of the implanted prostheses over the long term. hearing aids are generally used for this purpose, In addition, all patients who were supplied either permanently or pending surgery for aural with percutaneous bone-anchored hearing aids atresia. Children with unilateral microtia and aural considered them to be superior to conventional atresia who have normal hearing in the contralateral bone-conducting appliances. Even patients who had

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previously undergone surgical treatment for aural if present: atresia considered their hearing to be better with ‚‚an open the bone-anchored hearing aids than it was ‚‚adequate middle ear space after surgery. ‚‚normal course of the facial nerve In 1990, a team of researchers from Sweden105 ‚‚a - complex reported their results with a percutaneous ‚‚good mastoid pneumatization transducer, the Nobelpharma ‚‚incus-stapes connection HC 200 (Nobelpharma AB, Goteborg, Sweden), ‚‚good external ear appearance which they had been implanting since 1977. The ‚‚ear canal stenosis with malleus bar device consists of a bone-anchored hearing aid A perfect score is 10. A score ≥8 indicates that on the surface linked to an implanted Bränemark the patient is a good candidate for atresia surgery. titanium probe integrated in the mastoid A score of ≤5 is a contraindication for surgery. process. Audiological measurements indicate a Jahrsdoerfer et al.109 reported postoperative hearing considerable difference in performance between this improvement to normal or near-normal levels in 74 percutaneous system and transcutaneous devices, of 90 patients with scores of ≥8 (82%). Objective probably as a result of the gap between receiver measure of improvement was obtained with the and transducer. The large gap of the transcutaneous speech-reception-threshold test. Considering the system means increased power consumption, author’s considerable experience, the success rates lower maximum output capability, and high levels are likely the best that can be achieved. of second harmonic distortion. According to the Audiometric testing differentiates conductive authors, the only reason to choose a transcutaneous from sensorineural impairment. If the predominant device over a percutaneous system is to avoid deficit is sensorineural, middle-ear reconstruction permanent skin penetration, and they report is contraindicated. Lack of pneumatization of the that only one of 250 implanted devices had to be mastoid air cells by age 4 years denotes inadequate removed because of soft-tissue problems. development and is another contraindication to middle-ear reconstruction. Additional Indications for Atresia Repair considerations in the decision for or against surgery Conventional wisdom dictates that no attempt are the real possibilities of chronic postoperative should be made to restore hearing on the affected drainage, facial nerve injury, and subsequent side in patients who have a normal-hearing ear. stenosis of the reconstructed canal. The ultimate Only approximately 20 dB of improvement can be decision for atresia repair is a complex one and must expected from atresia repair.103 Many authors99,106,107 be mitigated by consideration of the risks, including therefore think that middle ear reconstructive facial nerve injury, stenosis of the external auditory procedures are contraindicated in patients with canal, and chronic infections or drainage from the unilateral microtia. Infants with bilateral microtia surgical site.110 in whom auditory acuity cannot be corrected with Siegert111 evaluated atresia repair and middle a hearing aid by 12 months of age should have ear surgery performed in specialized centers middle ear exploration on one side. and found disappointing outcomes: only 48% of A different philosophy is championed by patients had successful reconstructions (conductive Jahrsdoerfer and colleagues.108,109 Using high- deficit <30 dB). The authors advocated atresia resolution CT of the temporal bone in conjunction repair during the second stage of ear reconstruction with physical examination, the authors developed (framework elevation) for patients with a 50-dB a grading scheme of anatomic features to aid them conduction deficit. In their series, 76% of the in selecting candidates for atresia repair. The rating patients achieved a final scale is as follows: of ≤30 dB. During the first surgery, rib cartilage • 2 points if the stapes is present is placed around a Silastic tube (Dow Corning • 1 point for each of the following, Corporation, Midland, MI) to prefabricate an

13 SRPS • Volume 11 • Issue R3 • 2011 external auditory canal. At the same time, a has been available for centuries, but tympanic membrane is reconstructed by using ineffective, messy, and inconvenient the of the lobular remnant. This is adhesives have detracted from its assembled during the second surgery and implanted practicality. In addition, there is after mastoid drilling. During the third and final tremendous variability in the aesthetic operation, the concha is deepened with Z-plasties quality of prostheses and, given the and a full-thickness skin graft is used to line the problems with retention, any prosthesis new external auditory canal. must be aesthetically excellent for the More recent studies confirm that patient to tolerate its use.” approximately 50% of patients undergoing aural Classic techniques of ear reconstruction atresia repair achieve the 30-dB hearing reception depend on construction of an auricular framework threshold with an average improvement of 22 112 with either autologous costal cartilage or alloplast. dB. Digoy and Cueva did not find significant Considering that good aesthetic results are possible differences in short- and long-term outcomes. 113 with both materials, the choice of one method Chang et al. followed 93 patients for an average over another is based primarily on the number and of 57 months. They found long-term hearing severity of associated complications. Other factors success in 73% of patients for primary cases and influencing the selection of an auricular framework only 50% for revision cases. The authors cautioned include the following: 1) number of operations against aural atresia repair in revisionary or severely involved; 2) donor-site morbidity; 3) postoperative microtic patients; they advocated a low threshold distortion of cartilage; 4) tendency toward for bone anchored hearing aids in such patients. migration or malposition; 5) infection or extrusion of the framework; and 6) durability. Beahm and EXTERNAL EAR Walton115 reviewed the embryology, anatomy, Reconstructive Options clinical evaluation, and reconstructive options for Although staged reconstruction with autologous microtia repair. rib cartilage is considered the technique of choice, other options make this a somewhat controversial 114 Prosthetic issue. Thorne et al. discussed the advantages and Since the advent of osseointegrated implants, disadvantages of each: ear reconstruction with auricular prostheses has “The standard results obtained by these become a valid option in cases of missing ears. experts [experts in microtia] are difficult Osseointegrated auricular prostheses are dental- to match because the deformity is rare. type implants constructed out of pure titanium that As in other areas in plastic surgery, but are placed into the mastoid bone. The implants are perhaps even more so, the first attempt at left buried under the skin to allow for a period of reconstruction is of paramount importance osseointegration. After firm union with the bone is because a suboptimal result may be established, the implant is uncovered and abutments uncorrectable. that protrude through the skin are affixed to it. “Because consistently good results with These abutments are then used to attach an ear autogenous reconstruction have proved prosthesis by a variety of mechanisms, such as elusive in the hands of many surgeons bull-and-studs, magnetic retention, or bar-and-clip around the world, other techniques systems. In contrast to other prosthetic methods, for auricular reconstruction have been osseointegrated auricular prostheses do not need a evaluated. To date, replacing the cartilage skin adhesive for attaching the ear. However, the framework with an alloplastic framework patients must commit to lifelong follow-up and has not proved to be effective… meticulous hygiene around the metal abutments “Prosthetic reconstruction of the auricle protruding through the skin.116,117

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Wilkes and Wolfaardt116 described their Fairburn, GA). Cronin,122 Cronin et al.,123 and experience with osseointegrated alloplastic Cronin and Ascough124 introduced the Silastic ear reconstruction and suggested criteria for framework (Dow Corning) for ear reconstruction treatment selection. The authors concluded that and described their experiences with it. The osseointegrated alloplastic ear reconstruction is prosthesis is inserted in a generous pocket dissected indicated in the following types of cases: from the mastoid area, leaving a thin layer of 1) reconstruction after major cancer resection; subcutaneous fat on the skin flap, and the auricle is 2) poor local tissue; 3) absence of the lower half of elevated at a second (or third) stage approximately 3 the ear; 4) salvage after unsuccessful autogenous months later. Descriptions of the technique can be - reconstruction; and 5) in patients who are poor found in the articles by Cronin and colleagues122 124 - anesthetic risks. Autogenous ear reconstruction and in articles by Ohmori and colleagues125 127 is indicated in cases of classic microtia when the (Ohmori125,126 and Ohmori et al.127). lower third of the ear is relatively normal, for Brauer (personal communication) later patients whose compliance is in question, and for abandoned the use of silicone frames for patients with a strong preference for reconstruction reconstruction of the ear because of gradual erosion with autogenous tissue. The authors reported of the implant from either internal or external achieving excellent results in appropriately selected pressures, with eventual exposure. The exact patients but indicated that osseointegrated incidence of this complication is not clear. The procedures should be performed only in a properly author did note that in patients in whom organized, multidisciplinary setting that includes a the silicone frames survived (some for more than maxillofacial prosthetist. 15 years), the ears had what he called a normal Han and Son118 described use of an implant- look and feel to them, more so than with carrying plate system to overcome the problem cartilage reconstruction. of retention of implants in young temporal bone. Clinical experience with auricular framework Excellent stability of the implants was achieved, and implants of porous polyethylene (Medpor) was no submergence (beneath the skin) occurred with reported by Wellisz.128 Porous polyethylene has their technique. an important advantage over Silastic implants Thorne et al.114 reviewed different (Dow Corning): it allows tissue ingrowth into reconstructive options and outlined the relative its pores. Of 41 Medpor frameworks used for advantages and disadvantages of each. Relative auricular reconstruction, five extruded: two in indications for prosthetic reconstruction included patients with microtia and three in burned ears. the following: 1) failed autogenous reconstruction, None of the implants had to be removed, and 2) excessively low hairline, and 3) severe hypoplasia the exposures healed with local wound care. of soft tissue or bone in the auricular region. The author concluded that soft-tissue coverage Miles, Sinn, and Gion (Miles et al.119) is of paramount importance to the success of reviewed their technique for one-stage cranial auricular reconstruction with porous polyethylene implantation for prosthetic auricular reconstruction. frameworks and recommended using a TPF flap to They reported good stability and a 6.1% incidence ensure an adequate blood supply to the cutaneous of infection. Gentile et al.120,121 also reported cover and to anchor the ends of the implant that low complication rates for cranial implant might otherwise spring through the skin. reconstruction for both microtia and burn injury. Reinisch129 described his technique of Medpor auricular reconstruction, which he performed in Alloplastic more than 100 patients, achieving early promising Alloplastic frameworks are an alternative to results. Initially, the complication rate was 44%, frameworks made of costal cartilage. The most which went down to almost nil after a TPF flap was commonly used materials are silicone and porous added to the procedure. Despite substantial recent polyethylene (Medpor; Porex Technologies Corp., data on temporoparietal flap and full-thickness skin

15 SRPS • Volume 11 • Issue R3 • 2011 techniques from Romo and Reitzen130 and Yang are fused and calcified and the framework must be et al.,131 which delineate the benefits of Medpor as carved from a single block of cartilage. a reliable, aesthetic option for ear reconstruction, Tanzer95 preferred contralateral cartilage but long-term risks of exposure and infection cannot noted that ipsilateral cartilage is also acceptable. be ignored. The author formerly removed the rib cartilage extra-perichondrially (taking perichondrium with Autogenous Harvest the graft), but because of several instances of Autologous costal cartilage for ear framework postoperative chest wall depression, Tanzer now construction is traditionally harvested from the advocates a subperichondrial technique of leaving sixth, seventh, and eighth ribs. Brent132 harvested a the perichondrium behind when harvesting the rib portion of the ninth rib to function as a strut for the graft. Thomson et al.,133 on the other hand, reported tragus, which was incorporated into the auricular deformity of the chest wall when extraperichondrial framework. Other modifications include taking a dissections were performed. Clearly, chest wall wedge of cartilage to be banked in the postauricular deformities can occur whether perichondrium is left skin at the time of framework placement, for use in in the donor site or is removed with the graft. ear elevation at a later stage, and preserving a rim Fukuda and Yamada134 use ipsilateral cartilage of cartilage at the superior aspect of the sixth rib that has been dissected extraperichondrially on the to minimize postoperative pain, clicking, and chest graft (outer) surface but subperichondrially on the wall contour deformities (Fig. 12).4 visceral (inner) surface. This is a logical approach because it keeps perichondrium at the donor site (for possible cartilage regeneration) and on the newly built framework in contact with mastoid tissues (for potential cartilage revascularization). Donor site reconstruction with spare rib cartilage is recommended.135 In fact, Kawanabe and Nagata136 described a new method of complete perichondrial A B preservation and creation of donor-site pocket for return of residual cartilage framework and found no donor site contour deformity at a mean of 2 years in 273 patients. Moreover, a histological study was conducted that revealed regenerated cartilage to be Graft cylindrical and histologically normal at 12 months, allowing it to be used during the second-stage operation.137 Although perichondrium on the outer C D surface of the framework helps with skin adherence, even with total extraperichondrial harvest, most of Figure 12. Dieffenbach’s technique for reconstruction of the surfaces are denuded of perichondrium in the the middle third of the auricle. A, Defect and outline of the process of carving and fabricating the framework. flap. B, Flap advanced over the defect. C, Flap is divided at a second stage. D, Flap is folded around the posteromedial aspect of the ear and a skin graft covers the donor site. Timing of Surgery (Modified from Brent.4) Middle ear and auricular reconstructive procedures are planned jointly by the otologist and the plastic surgeon, and the timing of the surgery In addition to the cartilage-sparing techniques takes into account the hearing status of the described above, Brent132 also reported differences patient and cosmetic considerations with its in framework construction according to patient psychological sequelae. As plastic surgeons, we age. For example, in older patients, the ribs often focus on factors that determine the appropriate

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time for reconstructing the external ear: 1) rate for approximately 8 years and noted incremental at which costal cartilage develops, 2) risk of growth of the reconstructed ear at a rate almost the child’s becoming a target of ridicule,138 and equal that of the normal ear. Thomson and 3) corresponding size between the fabricated Winslow142 later confirmed that finding. Brent141 framework and the normal ear. reported that in a series of patients operated on It generally is agreed that by approximately at ages 5 through 10 years, 37 of 76 ears grew at age 6 years, affected children become targets an even pace with the opposite normal ear, 32 of of ridicule by their peers. At that age, the child 76 grew larger by several millimeters, and 8 of 76 is aware of being different and is motivated grew smaller by several millimeters. The follow-up to conform, which will make him or her more duration in that study was ≥5 years. cooperative with the surgery and the restrictions DellaCroce et al.146 confirmed vertical and it entails.139 Before age 6 years, sufficient rib horizontal growth of the ear (5 and 2.75 mm, cartilage might not be available to build an ear respectively) after cartilage framework implantation. framework of the proper vertical dimension and That observation led to the following question: horizontal projection. Tanzer,95 Edgerton,140 and Should the reconstructive framework be smaller, Brent141 recommended auricular reconstruction larger, or the same size as the normal ear? Tanzer145 at about ages 5 to 6 years, and that view is shared recommended constructing a costal cartilage by most otologists and plastic surgeons. Thomson framework that is 2 to 3 mm larger than the normal and Winslow,142 however, reported performing ear. Brent,139 on the other hand, thought that one auricular framework construction when the should try to match the opposite ear regardless of child is 2 to 3 years old, confident that sufficient patient age. He saw no reason to construct an ear cartilage is available by then to match the normal larger than the normal one and suggested that in ear. The reconstructive framework with intact younger patients, one could consider making the perichondrium will proceed to grow concomitantly framework several millimeters smaller, because the with the normal ear if left undisturbed. growth rate of costal cartilage might be expected to Adamson, Horton, and Crawford (Adamson be faster than that of auricular cartilage. et al.143) reviewed the growth patterns of the auricle. After examining 2300 ears, the authors Middle-Ear Surgery concluded that the average child attains 85% of ear Surgery of the middle ear associated with development by age 3 years; ear height continues to reconstruction for microtia must be planned jointly increase until adulthood, but its width and distance by the plastic surgeon and the otologist. This is from the scalp change little after age 10 years. Based most important for patients with bilateral microtia. on anthropometric studies, Farkas144 noted that the If hearing aids can provide adequate hearing for ear reaches approximately 85% of its full size by speech development, atresia repair can be postponed age 6 years, 90% by age 9 years, and 95% by age 14 until after the costal cartilage framework has been years. Approximately 88% to 94% of the adult ear placed. The reason for the delay is that attempted width is reached during the first year of life, and atresia repair before auricular reconstruction will girls’ ears grow faster than boys’. With respect to lead to scarred, poorly vascularized tissue in the ear length, however, the figure is 75% by the end mastoid area and will compromise the quality of the of year 1 and 93% by age 10. The ear continues to soft-tissue coverage for the framework.103,139 Even grow longer during the next decade,12,144 although in cases of unilateral microtia, atresia repair can for practical purposes, the ear is considered to be be incorporated into the reconstructive sequence almost fully developed at age 6 years.8 for the microtia. In cases with both bilateral and A fundamental question in deciding the unilateral microtia, surgery of the middle ear should appropriate timing of surgery is whether the not be attempted until after the costal cartilage costal cartilage framework continues to grow framework has been placed. once implanted. Tanzer145 followed 37 patients

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Operative Sequence fabrication and placement in some patients. He The stages of auricular reconstruction depend on avoids repositioning vestigial remnants (earlobe) the severity of the deformity, the position and because the resultant scars can impair circulation quality of the microtic elements, and the surgeon’s and skin elasticity and render insertion of the three- preference. The exact sequence of operations is less dimensional framework difficult.139 important than following the operative plan and Brent139 emphasized that the reconstructed carefully tailoring the procedures to the specific ear will not project adequately unless a high-profile anatomic deformity. framework has been used. In cases of inadequate Tanzer95 initially described a four-stage projection, or when the patient wears glasses or reconstruction in 1971: desires a well-defined auriculocephalic sulcus, a • Rotation of the lobule into a fourth stage is necessary to elevate the ear and transverse position release it with skin grafts. Occasionally, the middle • two stages are reversed to accommodate the Fabrication and placement of a costal 139 patient’s preferences. cartilage framework For patients deemed to be candidates for • Elevation of the ear from the side of atresia repair, Aguilar103 proposed an integrated the head protocol of auricular reconstruction in five operative • Construction of a tragus and stages, as follows: conchal cavity. • Framework construction and placement 145 Tanzer subsequently combined the first • Lobule creation two to complete the reconstruction in three stages • Atresia repair but noted that when extensive mobilization of the • lobule was necessary, such as in cases of marked Tragal creation malposition or an extremely small remnant, • Auricular elevation the four-stage reconstruction was still in order. The approach presented by Aguilar103 Additional operative stages to create a tunnel and combines the technique presented by Brent147 for final closure are also needed when middle ear with correction of aural atresia as stage 3. Once reconstruction is contemplated. the atresia repair is completed, the new ear canal The most significant addition to the is lined with a skin graft. The ear is then placed in literature of ear reconstruction in the last few its original position and adjusted so that the new years comes from Brent’s 2 decades of experience ear canal is under the concha of the reconstructed 139 with 600 cases followed for a median 5 years. ear. An oval segment of skin is excised from the 139 In a long-term retrospective analysis, Brent reconstructed ear to create an opening into the recounts his treatment plan, surgical technique, new external auditory canal. If the position of and perioperative management of the microtic the external auditory canal and the concha of the deformity. Brent141 prefers a four-stage technique framework do not align, the framework can be consisting of the following: relocated by undermining a flap anteriorly as in a • Framework placement rhytidectomy procedure. • The surgical technique of atresia repair was Lobule transposition 109 • described by Jahrsdoerfer et al. Salient points Tragus construction and conchal are exposure through a postauricular incision and excavation dissection at the level of the mastoid periosteum • Elevation of the ear framework with deep to the auricular framework. To form the creation of the auriculocephalic sulcus external auditory canal, the auricular framework is Brent147 subsequently added tragal elevated and retracted anteriorly to permit drilling. reconstruction as part of the initial framework In a series of articles, Nagata148–152 traced the

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evolution of a new method for reconstruction of Surgical Techniques the ear in microtia. Technical details are provided A detailed description of the various techniques regarding construction of the costal cartilage of ear reconstruction is beyond the scope of this framework, development of skin flaps for insertion overview. The articles by Tanzer,95 Brent and Byrd,80 and closure, and elevation of the constructed Burnstein,155 Bauer,156 Yanai et al.,157 Isshiki et al.,158 auricle. Indications for this approach in three Aguilar,49 and Nagata148 should be carefully studied different types of microtia—the lobule type, the by anyone not familiar with the procedures. Zim159 concha type, and the small concha type—are also and Walton and Beahm160 provided an excellent presented. Nagata’s two-stage technique consists of overview and comparison of several of the most the following: commonly used techniques. Brent132,147 presented • Fabrication of a three-dimensional costal his extensive series of more than 1000 cases of cartilage framework and simultaneous microtia reconstruction, describing modifications rotation of the lobule. Framework and refinements to his technique. construction includes fashioning of a tragus and accentuation of the concha. Soft-Tissue Coverage Framework insertion is combined with Sufficient soft tissue to adequately cover rotation of the lobule and development an auricular framework is a prerequisite to of skin flaps, which maximize the skin reconstruction. The skin must be thin, pliable, covering the vestigial cartilage. Lobule a good match in color and texture, and of good transposition, tragus construction, and vascularity and elasticity to fit snugly over the conchal excavation are all achieved during underlying skeleton. In primary ear reconstruction, the first operative stage. the source of skin might be compromised by a • Ear elevation with placement of a cartilage relative skin deficit (in severe microtia), a low graft in the auriculocephalic sulcus covered hairline, or trauma. with a pedicled TPF flap and skin graft. Unlike Brent,147 Nagata148 encountered no Temporoparietal Fascial (TPF) Flap deformations or irregularities of the grafted The most versatile method for obtaining additional framework and no infection or cartilage exposure in soft-tissue coverage is use of the TPF flap based on the superficial temporal artery or its 36 patients followed for up to 7 years. 80–82,127,161–163 153 branches. The flap can be elevated Park et al. described a one-stage procedure ipsilaterally and turned down or transferred as for total ear reconstruction that is derived from a single-stage method presented by Song and a free flap from the opposite side. A thick split- Song.154 The technique uses two flaps—a thin skin thickness or full-thickness skin graft completes flap and an arterialized mastoid fascial flap—to the reconstruction. Flap edema-obscuring detail cover a cartilage framework that is carved and resolves over a period of weeks to months. inserted on the spot. The auriculocephalic sulcus is “After first mapping the vessels with a created at the same time. The skin flap is expanded doppler, exposure to the fascia is gained intraoperatively, and external molds are used by a Y-shaped incision that extends after surgery to maintain proper dimensions and superiorly above the proposed auricular contour of the reconstructed ear. The photographs region. The dissection begins just deep to in the article by Park et al.153 show a contour the follicles and continues down to a definition that is not as fine as that achieved with plane where subcutaneous fat adheres to the technique presented by Brent.147 Moreover, the temporoparietal fascia. Since initial attempts at middle ear reconstruction seem to cross identification of this plane can be difficult, the vascular axis of the flaps used in reconstructing care must be taken to damage neither the auricle. the follicles nor the underlying axial

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vessels. Although tedious, once the scalp with an external mold to keep it thin and prevent dissection is accomplished, the inferiorly secondary of the grafted skin over the based temporoparietalis fascial flap is cartilaginous framework. The mold should be worn raised easily from the underlying for 3 months after surgery. deep fascia that envelops the Tegtmeier and Gooding163 and Nakai82 temporalis musculature. reported their results achieved with the TPF “Subsequently, the fascial flap is first flap beneath intact skin or to supplement a small draped over the framework and then remnant in primary microtia using Silastic and costal cartilage frameworks. coapted to it by means of suction with 139 a small infusion catheter. Then the flap Brent outlined his technique for managing is affixed to the peripheral skin “vest the low hairline in 600 cases of auricular under pants” fashion so as to secure a reconstruction. The framework is located in the tight closure. Finally, a patterned, thick position that will produce the best result in terms of split thickness skin graft is sutured on symmetry and aesthetics, even if this means placing top of the fascia-covered framework it where it is partially covered by hair. When hair and, likewise, is coapted to the fascia by covers only the upper helix and scapha, it can be means of a suction catheter. Then the removed by electrolysis. When hair covers the new ear’s convolutions are packed with upper third of the new ear, the hair-bearing skin is petrolatum gauze. Finally, a head dressing excised, taking care not to expose the underlying is applied.”80 cartilage. A graft of postauricular skin taken from 164 the contralateral ear is used to cover the raw area Park et al. analyzed their experience with on the reconstructive framework. When a skin 122 TPF flaps for auricular reconstruction. The shortage and low hairline that can threaten the vascular anatomy was found to be variable among reconstruction are identified preoperatively, use 93 flaps examined. The dominant blood supply of a TPF flap covered by skin graft should be was the superficial temporal artery in 82 (88%) of considered.139 Brent recommends presurgical hair the 93 flaps, the posterior auricular artery in eight removal with a laser to create the ideal hairline (9%), and the occipital artery in three (3%). Venous before embarking on the ear repair. Brent and drainage was similarly variable: the superficial Byrd80 discussed several ways of elevating and temporal vein in 62 (67%) flaps, the posterior transferring the TPF flap for secondary ear auricular vein in 23 (25%), the occipital vein in six construction and reviewed its advantages, potential (6%), and the diploic vein in two (2%). role in reconstructive surgery, and complications. Technical refinements in the series presented Nagata166 recounted his experience with the 164 by Park et al. aimed primarily at making the flap TPF flap and innominate fascial flap for secondary thinner and more reliable, so the innominate fascia reconstruction of unfavorable results of microtia and subcutaneous fat were excluded from the flap. surgery. Secondary reconstruction in such cases This increases the risk of injury to the flap vessels, is more difficult than the primary microtia repair and the authors recommend immediate repair because during the revision procedure, all of the of even small branches to prevent focal vascular superficial must be removed, further reducing insufficiency to the flap. Advances in endoscope- the skin surface available for the reconstruction. assisted temporoparietal fascia harvest technique The soft-tissue problems are compounded for auricular reconstruction have been shown to by subcutaneous scar tissue, which decreases reduce scarring, alopecia, and surgical time with extensibility of the tissue and hampers insertion of comparable blood loss.165 Other modifications are the three-dimensional framework, and by previous the use of split thickness scalp skin whenever a skin grafts, which are likely to be contracted, skin graft is required, which results in better color depressed, and shiny. match, and compression of the flap postoperatively Nagata166 proposed transferring a TPF flap

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to cover the costal cartilage framework during results with tissue expansion mainly because of the first stage of the secondary ear reconstruction. contraction of the expanded skin.170 The capacity The second stage consists of elevating the ear and of skin expanders to produce thin, pliable, resilient, placing a cartilage graft in the auriculocephalic and long-lasting cover for skeletal frameworks is sulcus. The posterior auricle and sulcus are then a subject of debate. Pan et al.171 and Jiang et al.172 covered with an innominate fascial flap and a reported excellent results achieved in a large series skin graft. Nagata was able to complete secondary with tissue-expanded non-hair-bearing mastoid auricular reconstruction in two operative stages by skin flaps. However, any complication resulting capitalizing on the virtues of the TPF flap and the from use of the expander, such as infection or innominate fascial flap interposed between cartilage extrusion, can permanently jeopardize the available and skin. skin in a “virgin” microtia.

Deep Temporal Fascia 167 Thermosensitivity Hirase, Kojima, and Hirakawa (Hirase et al. ) Using three-stage reconstruction based on the recently described a salvage procedure that makes techniques presented by Brent139 and Nagata,166 use of the deep temporal fascia when the TPF flap a Scandinavian group found significantly higher has become partially necrotic and the cartilage thermal thresholds in reconstructed helical and framework is exposed. Although a single case was antihelical regions. The lower thermosensitivity reported, the outcome was good, and the technique of the reconstructed ear did not translate to any offers hope for successful completion of a one- 173 clinical disadvantages. stage reconstruction of the auricle using a TPF flap regardless of complications. Projection Tai et al.137 achieved improved projection by using Posterior Temporoparietal and Galeal hydroxyapatite-tricalcium phosphate ceramic to Fascial Flap 168 augment conchal support and limit total amount of Alexander et al. described a combined flap cartilage required in a 42-patient series. based on the posterior branches of the superficial temporal artery to assist with elevation of the cartilage framework. The flap consists of COMPLICATIONS temporoparietal fascia posteriorly and its fusion The reported complication rates in several series with the galea. It can be used as a buttress for of auricular reconstruction are summarized in framework elevation or as soft-tissue coverage for Table 2. The following points emerge from a salvage of exposed frameworks. review of the data. Extrusion rates are higher for Silastic frameworks than for autogenous cartilage 123,125,133,141,145,162,174–176 Tissue Expansion frameworks. Extrusion rates Tissue expansion offers another possible solution for Silastic frameworks seem to be decreasing as 123,126 for the patient with a small microtic remnant, severe techniques for soft-tissue coverage improve. shortage of skin, and low hairline. Brent169 reported The temporoparietal flap in particular has been inserting an inflatable implant beneath relatively shown to be useful in this regard, even in some 127 inelastic skin and gradually expanding it with saline primary procedures. Extrusion of Silastic infusions during the next 3 weeks. On removal of frameworks is thought to be the caused by the the expander and subsequent framework placement, following: the thick capsule that had formed around the • Too thin a skin cover implant obscured detail. The patient subsequently • Scar tissue in the flap had to undergo a secondary procedure for revision • and to improve helical definition. Tension of the skin over the implant Other authors have reported poor long-term • Trauma126

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• Dead space around the framework126 discontinuing the bolster sutures and inserting • Infection126 suction drains, the complication rate dropped The largest survey of complications of significantly. Brent reported only three infections auricular reconstruction with autogenous cartilage (0.5%), two hematomas (0.3%), and five skin is the large series of 606 cases reported by losses (0.8%) with cartilage exposure. He stated Brent.139 Problems with the soft-tissue coverage that most complications can be prevented with of the costal cartilage framework were common appropriate postoperative care. Considering the when compression mattress sutures were used author’s extensive experience with autogenous to coapt the skin to the helical cartilage. After cartilage ear reconstruction, the excellent results and

Table 2 Complications of Ear Reconstruction with Frameworks of Autogenous Cartilage and Silastic

Exposure to Extrusion and Follow-up Study No. of Frameworks Infection, n (%) Removal, n (%) (yr)

Autogenous cartilage

Wray and Hoopes, 1973174 13 0 0 ?

134 Fukuda and Yamada, 1978 329 44 (13) ? ≤16

Tanzer, 1978145 43 5 (12) 0 6−19

141 Brent, 1980 63 5 (8) 0 ≤4 Brent, 1992139 606 8 (1) 0 1−17

Alloplasts

Silastic

140 Edgerton, 1969 18 9 (50) 2 (11) ≤16

175 Curtin and Bader, 1969 42 ? 5 (12) ≤3

176 Monroe, 1972 17 ? 4 (24) ≤5 Wray and Hoopes, 1973174 16 13 (81) 13 (81) ?

Cronin, 1978124 71 24 (34) 19 (27) 1−15

Ohmori, 1978126 78 2 (3) 1 (1) 0−3

Medpor

Wellisz, 1993128 41 5 (12) 0 1−4

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low complication rate obtained would have to be and whether unfolded or fully developed, it tends considered optimal. to exaggerate the cupping deformity. In some cases, Thomson et al.133 documented residual the helical margin or helical fold drapes forward problems with the chest donor sites after ear and over the scapha like a hood. reconstruction for microtia. In a long-term study of In an excellent review of the constricted 80 patients (88 donor sites), the authors evaluated ear anomaly, Cosman179 analyzed the anatomic the appearance of the chest scars, chest topography, deformity and the requirements for its correction; and contour changes of the costal margin. The illustrated the various surgical techniques that results of their analysis are summarized as follows: have been proposed; and discussed the indications, • Chest scars: 14% were considered “less advantages, and disadvantages of each. According than acceptable”; the younger the patient to the author, the choice of procedure should be was at the time of surgery, the better the based on accurate definition of the anatomic defect chest scars were. and the size difference between the normal and • abnormal ears. Chest topography: normal in 75% of 179 patients, mild retrusion in 19%, and severe Cosman dismissed Tanzer’s Group III retrusion in 6%; deformities were less deformities as forms of microtia that demand severe in patients who underwent surgery total or near-total reconstruction. For less severe at an older age. deformities (Tanzer’s Group I, IIA, and IIB) within specific anatomic limits, Cosman recommended the • Rib cage contour: all patients exhibited procedures listed in Table 4.180 Correction of the some degree of change in the costal deformity is by the simplest operation that can be margin, typically manifesting as a flat, expected to approximate the contralateral normal triangular defect; the authors speculated ear (Fig. 13).4 that their closure method, which involved 179 suturing the tip of the ninth rib to the Cosman concluded the following: sixth rib cartilage to cover the defect at the 1) It seldom is necessary to detach the harvesting site, might have contributed to helical crus from the face. the altered contour. 2) It often is the case that more tissue is available for reconstruction of the CONSTRICTED EAR DEFORMITY constricted ear than is initially apparent. The constricted ear anomaly can be either the “lop” 177 178 3) Whenever possible, one should avoid or “cup” type. Tanzer categorized constricted procedures that add tissue, because they ears as shown in Table 3. are more complex and therefore prone to A lop ear is a malformed auricle in which complications and skin color mismatch. the characteristic major deformity is an acute 181 179 downward folding or deficiency of the helix and Horlock et al. concurred with Cosman scapha, usually at the level of the tuberculum that the deformity designated as type III by 178 auriculae (Darwin’s tubercle). The deformity is Tanzer requires autogenous costal cartilage 139 associated with a malformed antihelix, usually at reconstruction as described by Brent. The authors the superior crus. suggested a graded sequence of procedures to treat A cup ear is essentially a malformed, Tanzer type I, IIA, and IIB deformities. A mastoid protruding ear combining characteristics of both a hitch, in which a postauricular pocket is created lop ear and a prominent ear. Typical features are an and the newly built helix is sutured to the mastoid overdeveloped, deep, cup-shaped concha; a deficient fascia, is a recommended adjunct to maintain superior part of the helical margin and antihelical helical elevation and prevent recurrence. With type crura; and apparently small vertical height. The I deformities, the helical lidding is dissected free body of the antihelix often is wider than normal, on both sides with a postauricular incision and

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Table 3 Tanzer Classification of Constricted Ears and Suggested Correction178

Type Anatomy Correction I Helical involvement only Detach the folded helix and reattach it in an upright position

IIA Involvement of the helix and scapha with Adjust the anterior helix, filet the deformed helix and no supplemental skin necessary scapha, and reconstruct the upper pole of the ear with “banner” flaps of cartilage

IIB Involvement of the helix and scapha Use skin flap from the medial surface of the ear with various with supplemental skin needed at methods for expanding the ear cartilage auricular margin

III Extreme cupping deformity with Unfurl and use the remnants for the superior and middle involvement of the helix, scapha, anti-helix, thirds, and reconstruct the remainder with contralateral and conchal wall conchal cartilage

Table 4 Suggestions Presented by Cosman for Correction of Constricted Ear Deformities179 Anatomy Correction Lidding is major problem, no protrusion, height Direct excision of overhanging helical curl difference< 1 cm

Lidding, no protrusion, height difference 1−1.5 cm Banner flap or radial incision

Vertical expansion and correction of prominence Lidding, protrusion, height difference 1−1.5 cm (Cosman technique)

Lidding, protrusion, height difference 1.5−2 cm (compression of scapha) Kislov technique to add tissue180

Graft

A C B D E

Figure 13. Brent technique for reconstruction of the earlobe with a reverse contoured flap. A, Earlobe defect. B, Auriculomastoid flap outlined. C, Elevated flap hanging as a curtain from the inferior auricular border. D, Flap folded under and sutured. E, Completed earlobe, exaggerated by one-third to allow for shrinkage. (Modified from Brent.4)

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the cartilage is scored with a scalpel to reproduce Al-Qattan183 described an approach for ears the antihelical fold. Type II deformities are also with mild to moderate constriction that combines treated by cartilage scoring and mastoid hitch, plus Mustardé suturing and excision of the lidded V-Y advancement of the helical root. This releases cartilage. The lopped cartilage margin is excised skin tightness at the anterior helix and allows through a retroauricular transverse incision in superior expansion of the cartilaginous framework, the superior portion of the ear; this is in contrast with the effect of increasing ear size. For type IIB to cartilage expansion procedures. A traditional deformities, the authors recommend additional mastoid hitch suture is used to prevent framework expansion with a double banner flap. recurrent lopping. The existing skin often is sufficient provided the A number of techniques have been proposed V-Y advancement and undermining over the to correct type II constriction, including radial mastoid fascia have released the skin tightness. cartilage scoring in a fan-like manner for expansion 182 Park proposed correction of type I as described by Stephenson.184 Musgrave185 deformities with a simpler technique that elevates a modified the technique presented by Stephenson. superiorly hinged rectangular or T-shaped cartilage A double banner flap was described by Tanzer178 to flap from the concha. The flap is bent back on expand the constricted helix. More recently, Ohjimi itself and sutured to the lidded helix or scapha. The et al.186 proposed a double pennant technique for recoiling force of the flap on the conchal side holds 4 helical elongation and recreation of the anti-helix. the lidded portion of the helix erect (Fig. 14). The authors’ technique uses composite flaps that minimize skin dissection from the underlying Covering cartilage. The authors reported between 7 and 22 mm of helical rim elongation. Nagata187 described an approach to management of constricted ear x deformity. For type I constrictions, Xiaogeng et y 188 x al. dissected the skin envelope off the underlying cartilage to perform V-Y cartilage advancement along the anti-helix, with Mustardé suturing A B for shaping. The authors advocated two-stage reconstruction for type II deformities, with a 1- to 1.5-cm composite cartilage graft from the contralateral ear (wedge from the upper third of the ear) to the affected ear. Shaping is performed similar to the shaping in their type I corrections in y the second stage. For type III deformities, many authors x advocate techniques involving new costal cartilage frameworks, as in microtia reconstruction. Xiaogeng 189 C D et al. presented their experience with staged reconstruction of type III constricted ears with mastoid skin tissue expansion and then autogenous rib cartilage graft reconstruction. Figure 14. Davis technique for reconstruction of the lower third of the auricle and earlobe. A, Defect and outline of the lining flap. B, Outline of the cover flap of the fat flap used STAHL EAR for fill. C, Lining flap is covered by the cover flap with the fat Stahl ear is a helical rim deformity first reported flap between them. D, Secondary defect is closed by direct in the 19th century that currently could be aptly approximation. (Modified from Brent.4) renamed Spock’s ear. The main features are a third

25 SRPS • Volume 11 • Issue R3 • 2011 crus, flat helix, and malformed scaphoid fossa (Fig. to the temporal skin associated with cartilage 15).147 The condition is much more common among malformation in the scapha-antihelix complex and Asians than among other populations.190 possibly occurring secondary to abnormalities of the intrinsic and extrinsic ear muscles.199,200 The condition is rare among Caucasians but common among Asians (ratio, 1:400). As with microtia, the right ear is affected more often than the left and the deformity is bilateral in approximately 40% of cases.201 Hirose et al.202 developed a classification system in which two categories of cryptotia are described based on the type of cartilage constriction by abnormally developed intrinsic ear muscles: Type I for transverse muscle or superior crus deformity Figure 15. Rib used in total ear construction. 1, and type II for oblique muscle or inferior synchondritic block used for body of framework; 2, floating crus deformity. rib used for helix; 3, strut used for tragus; 4, extra cartilage Early splinting is successful,203 and when wedge to be banked fur use during the elevation procedure. (Reprinted with permission from Brent.147) therapy is initiated in a neonate, molding is the preferred method of correction. Later correction requires surgical division of the abnormal muscle(s) with the addition of skin to the deficient Chongchet191 described the classic approach retroauricular sulcus. Cartilaginous reconstruction of excision of the aberrant third crus and redraping might also be required. Numerous techniques have of the skin. Ferraro et al.192 modified the technique been proposed, including Z-plasty,204 local and by avoiding an anterior skin incision and using regional skin or subcutaneous flaps,205−216 tissue the resected cartilage as a graft to support the expansion,193 V-Y advancement flaps,217 and skin reconstruction. Ono et al.193 described a technique grafting.218,219 Cho and Han220 described their of wedge excision of the third crus with helical technique of a V-Y temporal advancement flap advancement. Kaplan and Hudson194 proposed for deepening of the auriculotemporal sulcus and a modification that uses a wedge excision of the either ear cartilage graft or Medpor for helical cartilage and posterior skin only. Both of these rim splinting and stabilization. The authors favor techniques resulted in smaller ears. Other surgical Medpor for greater stability and experienced no techniques for correction include Z-plasty,190 exposures in four cases. They noted that more periosteal tether,195 cartilage turnover and aggressive manipulation of the cartilage is required rotation,196 and cartilage scoring with cartilage with greater vertical deficiency. flap transposition.197 Al-Qattan and Hashem198 offered a complete EAR MOLDING AND SPLINTING review of their experience with the various In neonates, many ear deformities can be corrected techniques, highlighting efficacy and limitations. by splinting because the ear cartilage is soft and The authors proposed an alternative approach to malleable,203,221 but in older children and adults, Stahl ear reconstruction that involved resection of operative correction usually is required. Byrd et the abnormal third crus, helical rim reconstruction al.222 described a series of 488 patients with 831 ears with the resected third crus cartilage, and anti- that were treated with external molding. The series helical reconstruction with an ipsilateral conchal included patients with prominent cup ear (373 ears, cartilage graft. 45%); lidding or lop ear (224 ears, 27%); mixed ear deformities, all including associated conchal crus CRYPTOTIA (83 ears, 10%); Stahl ear (66 ears, 8%); helical rim Cryptotia is abnormal adherence of the ear abnormalities (58 ears, 7%); and conchal crus (25

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ears, 3%). Ninety percent of patients achieved good operation to correct prominent ears. Rogers228 also to excellent results and avoided surgery. Success noted that the next milestone in the evolution of increased when therapy was initiated within the otoplasty occurred in 1910, when Luckett described first week of life. The authors described use of the a procedure for the correction of prominent ears EarWell Infant Ear Correction System (Becon that correctly assumed that the protruding ear Medical Ltd., Tucson AZ) with a two-piece cradle, resulted from an undeveloped or unfolded antihelix. retractors, and adhesives. They encountered Many of the surgical methods proposed since few complications. Luckett’s time are in some way modifications of the operation he described, and most represent attempts OTOPLASTY at improving the overly sharp antihelical crest and Prominent Ears excessively steep recess of the scapha produced by The prominent ear has been classically characterized the classic technique. by excessive height of the conchal wall or absence of an antihelical fold (a concha-scapha angle >90°) Surgical Goals 223 or both. Madzharov defined the protruding ear In an excellent review of techniques for the deformity as a cephalic-auricular angle >34° caused correction of prominent ears, McDowell7 listed the by a flattened antihelix or protrusion of the concha following basic goals of otoplasty: or both. The deformity usually occurs bilaterally. The • condition results from embryonic arrest during the Complete correction of upper final convolutions of the ear, with failure of folding third protrusion of the antihelix. • Visibility of the helix beyond the antihelix The “telephone deformity” refers to relative when viewed from the front prominence of the upper and lower poles, whereas • Smooth and regular helix the “reverse telephone deformity” means excessive • prominence of the concha relative to the upper and Prevention of distortion or decrease in the lower poles.224 These deformities usually occur as depth of the postauricular sulcus postsurgical complications. • Placement of the ear at the correct Frustration with otoplasty techniques has distance from the head and not overly led to an awareness of additional features of close; the helix-to-mastoid distance should prominence: the antihelix, conchal bowl, helical tail, be 10 to 12 mm at the top, 16 to 18 mm in ear lobule, and helical root.225 Otoplasty techniques the middle, and 20 to 22 mm in the for the correction of prominent ears can be grouped lower third into operations that involve the following: • Bilateral symmetry; the difference in • Excision of cartilage helix-to-mastoid distance between sides • Molding the ear with sutures should be <3 mm • Molding the ear with scoring or sculpting To this list, one should add the following: of cartilage • Smooth, rounded, correctly placed and • Combination of any of the above adequately prominent antihelical fold Various techniques are used at the key anatomic • Helical rim that projects laterally farther locations to correct ear prominence. than the lobule229

History Timing of Surgery 226 Rogers noted that the origins of otoplasty were Otoplasty can be performed in patients of all wrongly attributed to Dieffenbach and that it was ages. Many factors should be considered when probably Ely227 in 1881 who first described an determining optimal timing for surgery. With

27 SRPS • Volume 11 • Issue R3 • 2011 advanced age, increasing mineralization and buttonhole the skin on the external surface calcification of auricular cartilage can make of the auricle. The skin and the cartilage suture suspension or cartilage-scoring techniques are now sutured separately, and it is the unreliable, unpredictable, and/or prone to relapse. method of suturing the cartilage that is Growth concerns arise when performing early emphasized. The cartilage suture is passed childhood otoplasty. Historically, most corrections from the cranial side from within out- have been performed when the patient is older and-back again, care being taken not to than 5 years. Adverse psychosocial interactions for perforate the skin on the external surface, children and adolescents with prominent ears are then crossed over the excised portion also important factors to consider. Gosain et al.230 and passed on the other side from within conducted a survey and found that most surgeons out-and-back again as a Lembert suture, perform otoplasty when the patient is older than in such a manner that when the suture is 5 years. However, their small prospective series of drawn tight and tied, not the edges but 12 patients underwent otoplasty when they were the sides or flat surfaces of the cartilage younger than 4 years. With a mean follow-up will be in apposition. The edges have been duration of 41 months, prominence recurred in turned forwards or outwards to form the one patient (8%). Three patients who underwent antihelix and at the same time the helix is unilateral otoplasty did not exhibit any growth set closer to the cranium, thus diminishing discrepancy relative to the contralateral ear up to 63 the cephalo-auricular angle. Four or five months postoperatively. interrupted sutures are usually enough for Gasques et al.231 examined the psychosocial the cartilage. A so-called fistula, one-half effects of prominent ears and demonstrated a circle, needle is best for the cartilage. The clear benefit for otoplasty. Several questionnaires, skin is sutured with horsehair and leaves a including the Child Behavior Check List, State- very small cicatrix.”228 Trait Anxiety Inventory for Children, and Children’s Depression Inventory, were administered, Conchal Cartilage and improvement was noted postoperatively for Davis232,233 described the technique of conchal nearly all measures by both teachers and parents. bowl excision at the base of the vertical wall. The authors recommended that the optimal age for Using methylene blue dye to create percutaneous correction is 6 years. transfixion tattoos on the conchal cartilage, the posterior vertical conchal wall is marked at a height Excisional Techniques of 8 mm. The marks delineate a conchal half-circle, Antihelix and the conchal bowl (or floor) anteriorly is marked Rogers228 explained that Luckett excised a crescent- for resection. Through a retroauricular skin incision, shaped segment of skin and cartilage from the the conchal cartilage is exposed and the methylene entire vertical length of the ear on its cranial side blue tattoo marks are visualized. An incision is and sutured the edges of the cartilage to create an created, connecting these points and the anterior antihelical fold (Fig. 16).179 conchal cartilage dissected in a subperichondrial “A crescentic incision is made through plane. Care is taken to avoid injury to the anterior the integument opposite to the line of the skin. The entire conchal bowl is excised. The intended new or reconstructed antihelix. posterior conchal wall remains and is placed The inscribed integument is removed; passively on the mastoid surface, establishing the the edges of the skin are now dissected new conchal projection. free from the cartilage and retracted. A Hinderer et al.44 resected skin and cartilage at similar crescentic segment is removed different levels of the scapha, concha, and helical from the cartilage, care being exercised in arch to avoid notching of the helical rim during incising and excising the cartilage not to reapproximation. The author warned against

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s dimensions. The authors concluded that auricular t growth does not stop after the cartilage excision d method of surgery for prominent ears, that surgery b b a e had restored harmony between the width and c length of the ear (ear index), and that patient f satisfaction was high (74 of 77 patients were A B C satisfied with their outcomes).

b´ Earlobe b´ b´ Posterior skin excision of varying shapes has been d 235 e a c´ described for correction of prominent earlobes. b f c b Dumbbell, fishtail, tennis racket, and wedge f excision patterns have commonly been used. D E F G Suturing Techniques Antihelix Mustardé236 described the creation of an antihelical fold with concha-scapha mattress sutures I placed on the cranial cartilaginous surface and incorporating the full thickness of the cartilage and H J perichondrium on the lateral (anterior) surface (Fig. 17).182 With the method presented by Mustardé, Figure 16. Kislov technique for correction of the the ear is folded back to produce an antihelix, the constricted ear. (Modified from Cosman.179) summit of the fold is marked with ink, and the positions for the mattress sutures are marked on the skin. The mattress suture positions should be transections of the antihelix or transverse excisions at least 7 mm from the summit line, considering through the superior crus for the same reason. that less than that amount will produce too narrow 234 Balogh and Millesi studied 77 patients who a fold. Because of the curve of the antihelix, the had undergone surgery for prominent ears with the markings on the concave aspect are closer together cartilage excision method to determine whether than those on the convex side. It might therefore be any growth alterations had occurred and to find out necessary to introduce an additional mattress suture the right timing of the operation. The mean age to produce a superior crus, although this seldom is of patients at the time of surgery was 7.2 years. In required because both crura usually appear when every case, surgery had been performed 15 to 25 the ear is folded back. After insertion of a traction years previously. The standard ear morphometric suture through the margin of the helix to hold the variables of the operated patients were compared ear forward, an ellipse of skin approximately 3 to 4 with those of 200 unoperated control participants. cm × 1 cm is removed from behind the ear on the The authors found no difference in retroauricular medial or conchal side of the proposed antihelix. angle between the surgical group and the control The skin and soft tissues on both sides of the group, suggesting that the surgical objective had excised area are elevated off the perichondrium with been accomplished. The surgical group showed blunt dissection to expose the dye marks. Mustardé significantly smaller morphological ear length used a half-curved needle to insert white silk (affected by surgery) and significantly larger mattress sutures. The sutures should include the full morphological ear width (not affected by surgery). thickness of the cartilage and the perichondrium on The formerly prominent ears were larger than both sides but not any skin on the anterior surface. the ears of the control participants in all other At that point, the sutures can be temporarily

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Figure 17. Operative technique using a tumbling concha-cartilage flap (TF). (Reprinted with permission from Park.182) tightened and the ear inspected to confirm that Earlobe and Helical Tail the new antihelical fold is satisfactory. Finally, Prominent earlobes and helical tails (cauda the sutures are tied at a tension that produces an helices) have been a commonly overlooked aspect aesthetically pleasing folding of the antihelix. of ear prominence. Webster240 and Beernink Johnson237 proposed a refinement of the et al.241 emphasized the importance of proper Mustardé suturing technique that places the repositioning of the helical tail to correct excessive sutures obliquely to control and shape the curve prominence of the lower third of the ear. Goulian of the antihelix. Johnson thought that oblique and Conway242 also advocated control of the helical placement of the sutures would better check upper tail as a way of properly positioning the lobule. pole prominence, such as telephone deformity, and The cadaveric studies conducted by the authors prevent overfolding of the antihelix. showed a distinction between the conchal and helical cartilage. They recommended dissection Conchal Bowl between them and suturing the helical tail to its Concha-mastoid sutures were described by new position on the concha to help achieve a Furnas238 to reduce the conchal prominence (Fig. proper relationship. Spira243 described his technique 18). Spira and Stal239 described modifications of for dermal-to-mastoid suturing for earlobe this technique that involve the addition of a flap of repositioning. Gosain and Recinos244 described a conchal cartilage sutured to the periosteum. modified technique of lobule-to-mastoid sutures, identifying a key point of control for correction of prominent earlobes.

Helical Root A laterally projecting helical root can be repositioned by suturing the medial cartilage to the temporalis fascia, with or without a combined skin excision. Kelley, Hollier, and Stal (Kelley et al.225) described this technique as a Hatch suture.

Cartilage Scoring or Sculpting Techniques These operations are based on the observation by Gibson and Davis245 that cartilage tends to curl Figure 18. Left, normal ear. Right, Stahl ear deformity. away from a cut surface. This phenomenon was

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later confirmed by Fry,246 who attributed it to Weinzweig et al.250 studied the histological “interlocked stresses” that were released by incision effects of antihelical cartilage scoring and of the perichondrium. found that a fibrocartilaginous layer develops that promotes and stabilizes cartilage bending Antihelix away from the scored surface. Di Mascio and Stenstrom247 applied this principle to an otoplasty Castagnetti29 described use of a dermabrader for procedure for the correction of prominent ears. “burring” the anterior surface of the antihelix. The Stenstrom initially scored the anterior surface of authors advocated this technique as more precise the scapha through a small medial incision near and safer for cartilage weakening, compared with the cauda helicis to produce a helical roll and a parallel scoring. 251 satisfactory antihelical fold. He later modified the Karacalar et al. described a “subcision” technique248 to include a postauricular incision technique for cartilage scoring. An 18-gauge and wide undermining to expose the surface of hypodermic needle is inserted percutaneously the scapha, where scoring was completed with a over the antihelix, and perichondrial scoring is 252 “scratching instrument,” which is a procedure that accomplished subdermally. Fritsch described we now call otobrasion (Fig. 19). his technique for “incisionless” otoplasty, which The degree of scratching or scoring of the uses similar antihelical scoring with a hypodermic anterior surface of the scapha is adjusted to produce needle and percutaneous mattress suturing. the desired amount of curl in the cartilage for an Recent interest has been shown in other antihelical fold. The postauricular skin is carefully experimental technologies for cartilage shaping. trimmed to effect the final delicate relationship of Use of lasers of varying wavelengths for cartilage 248 reshaping have been proposed since 1993. Mordon helix to antihelix. Stenstrom did not perform any 253 m suturing to create the antihelical fold. et al. described the use of a 1.54- m erbium:glass Stenstrom248 suggested marginal excision of laser for ear cartilage reshaping in 12 ears. a portion of the horizontal helix as a solution to No thermal skin injury was observed. After an the problem of continued protrusion of the upper initial tendency for shape recovery (at 1 week), pole of the ear. For persistent prominence of the stable alteration was observed for up to 6 weeks. lobule, he recommended crosswise scratching of the Histological examination showed chondrocytic anterior surface of the helical tail. proliferation on the treated surface of the cartilage Chongchet191 described a technique of anterior and thickening of the cartilage layer. scoring for antihelical reconstruction in 1963, the Combined Techniques same year the technique presented by Stenstrom 249 Otoplasty procedures that combine excision, was published. Crikelair and Cosman also suturing, and cartilage-scoring techniques avoid reported a similar approach that involves an incision some of the disadvantages of each method and through the posterior helix and anterior scoring of often produce the best aesthetic result. For example, the scapha. because cartilage scoring of the anterior surface of the ear tends to produce sharp edges, a judicious blend of conservative anterior scoring and posterior excision and suturing might provide the best final ear shape and position. Tanzer254 described his classic otoplasty technique in 1962. Several authors have described notable variations of the basic procedures.222,255–257 A B C Baker and Converse258 reported their 20-year experience with otoplasty. Madzharov222 described Figure 19. Stenstrom otoplasty technique. a method for the correction of prominent ears that is based on measurements of ear-to-skull distances

31 SRPS • Volume 11 • Issue R3 • 2011 and the size of the ears. The amount of setback in each case is established preoperatively from normal anthropometric data derived from an Eastern European population. The antihelix is shaped by two derma-subcutaneous perichondrial flaps; the conchal spring is eased by means of a wedge-shaped cartilage excision in the area of the isthmus of the cartilage or the auricle, and the residual protrusion of the lobule is corrected by Z-plasty. Technical details of the operation are presented in the article, which merits further study by surgeons planning setback otoplasty. Hinderer et al.255 combined anterior cartilage scratching, posterior mattress sutures along the antihelical fold, trimming of the tail of the helix, thinning of the antitragus, and a double-spindle A B skin excision along the posterior medial surface. 256 Pitanguy et al. created an “island” of cartilage Figure 20. Mustardé otoplasty technique. on the anterior surface of the ear that is pushed forward to resemble a smooth antihelical fold by suturing the edges of the wound after resection of a timing, indications, and operative technique are generous ellipse of skin from the posterior surface. described in detail. Postoperative care and early and Kaye257 combined Mustardé-type sutures and late complications are also discussed. This article Stenstrom-type scoring through limited incisions to should be read by any surgeon who is planning to create an antihelical fold. perform setback otoplasty. 263 Chait and Nicholson259 reported their Graham and Gault described endoscopic- extensive experience (973 ears) with a “universal” assisted otoplasty involving posterior scoring and technique for the correction of all types of scapha and mastoid suture. Use of the endoscope prominent ears. Their procedure combines posterior eliminates the need for a postauricular incision and skin excision, cartilage transection, anterior hence the possibility of hypertrophic scar or . skin elevation off the concha, auricular cartilage The authors’ classification of prominent ears guides scoring, a single mattress suture to anchor the patient selection for this technique. 155 new concha-scapha angle in place, and variable Burstein presented a report of his 10-year amounts of cartilage rotation and excision as experience with a cartilage-sparing technique that needed. Commenting on the article by Chait and involves modified Mustardé suturing, anterior Nicholson, Stal260 expressed his preference for scoring, conchal bowl scoring, and concha-mastoid an algorithmic approach to otoplasty that uses suturing. An 8% relapse rate was noted. 264 combinations of different established techniques Bauer et al. discussed use of anterior that specifically address different patients’ needs chondrocutaneous resection of the conchal bowl (Fig. 20).261 The algorithm addresses three basic as the preferred method of treating conchal anatomic abnormalities of the prominent ear hypertrophy. The authors described a combined deformity: 1) a deep concha with a prominent otoplasty technique for their series of 47 patients posterior wall; 2) an unfolded antihelix with a (87 ears). Three patients experienced early scaphoconchal angle >90°; and 3) a prominent relapse of the upper pole caused by failure of the lobule after setback. antihelical suturing; they reported no late recurrent Spira262 presented a 30-year retrospective prominence. Anterior chondrocutaneous resection review of his experience with >200 otoplasties. The did not result in any unsatisfactory scarring and

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eliminated any potential for skin fold redundancy in The authors discussed the three main causes the conchal bowl. for prominence as being conchal valgus with a Peker and Celiköz265 described an otoplasty cranium-auricle angle >40°, lack of antihelical technique that involves incising the scapha to access fold, and, more rarely, conchal hypertrophy. For the anterior cartilage surface, anterior scoring to conchal valgus, myoplasty of the posterior auricular weaken the cartilage, and posterior rolling of the muscle was proposed as an adjunctive maneuver in free edge of cartilage to recreate an antihelical fold. otoplasty or even an isolated procedure with simple Kelley, Hollier, and Stal (Kelley et al.225) conchal . described their algorithmic approach to otoplasty, Scuderi et al.271 described a technique for which focuses primarily on cartilage preservation repositioning the posterior auricular muscle as rather than on cartilage excision. Janis, Rohrich, and an adjunct to otoplasty. The muscle is raised as Gutowski ( Janis et al.266) provided an alternative a chondromuscular flap (distal cartilage paddle summary and algorithm for correction of the around the insertion at the ponticulus), advanced prominent ear. A summary of various otoplasty peripherally, and secured to the antihelical cartilage techniques is presented in Table 5. to reduce prominence. The authors reported no relapse among 55 patients. Other Concepts Shinohara et al.272 performed CT of Nicoletis and Guerin-Surville267 were the first to randomly selected heads to examine correlation of describe the posterior auricular muscle as it relates prominence to selected relevant auricular angles: to the pathogenesis of ear protrusion. Smith268 scapha-triangular fossa angle, concha cymba- and Smith and Takashima269 also emphasized triangular fossa angle, and scapha-concha angle. the importance of the muscle in ear protrusion, Based on these data, the authors concluded that proposing that neuromuscular dysfunction and/or the deformity of the inferior crus has a more direct deficiency was the cause for prominence. Guyron correlation to prominence than does the superior and DeLuca270 found a linear correlation of the crus. The authors proposed reconstruction of the muscle length and the degree of ear protrusion. inferior crus for correction of prominent ears.

Table 5 Summary of Otoplasty Techniques

Anatomical Site Technique Study

Antihelical fold Concha-scaphal suture technique Mustardé277

Antihelical scoring or otobrasion Stenstrom248

Antihelical excision Luckett (Rogers228)

Conchal bowl Concha-mastoid suture technique Furnas238

Conchal bowl excision Davis232,233

Helical tail Suture repositioning to concha Goulian and Conway242

Concha and/or skin excision and suture repositioning Webster240 Lobule Posterior skin excision: dumbbell, fishtail, tennis racket Lavy and Sterns235 Spira243; Lobule to mastoid suture technique Gosain and Recinos244

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Late Results and Complications unsightly scars, suture problems, and dysesthesias The most common unsatisfactory results of occurring later. otoplasty are deformities occurring secondary to Tan275 compared the incidence and severity surgery, such as the following: of complications resulting from posterior suturing • Sharp ridges along the antihelical fold techniques with those of anterior scoring • Vertical post (lack of normal curvature of procedures. Patient satisfaction with the aesthetic the superior crus) results was no different between the Mustardé and Stenstrom otoplasties. The author found that • Irregular contours • a substantially large number of patients treated by Antihelical roll too small or malpositioned the posterior suture method of Mustardé required • Excessively large scapha reoperation: 24% versus 10% with the anterior • Narrow ear scoring technique. Numerous complications were • Telephone deformity specific to the Mustardé technique, particularly • Hidden helix relating to the presence of white silk stitches that tended to cause sinus tract and wound • Buckled helix • infections (15%). External auditory canal stenosis In a 10-year survey of his results with 264 ears, or distortion 276 • Mustardé listed several potential problems with Conchal skin redundancy the otoplasty procedure that bears his name, such • Hypertrophic scarring or as kinks in the antihelix, sutures cutting out, sinus • Prominent tragus tract formation, recurrence of prominence, and • Overcorrection horizontal projection of the lobule and antitragus. • Obliterated or shallow postauricular sulcus He also provided tips for avoiding them. A subsequent review of the results in 600 ears treated • Asymmetry during a 20-year period revealed only six cases of

Recurrent prominence is also a common sinus tract formation and no suture rejection.277 problem after otoplasty. Many authors have Most remarkably, only 10 ears required reoperation advocated combining techniques to minimize 273 for recurrent prominence. relapse. Corchado and Infante thought that The Mustardé otoplasty has not been as anterior scoring alone was not sufficient for durable successful in other hands. The initial enthusiasm antihelix reconstruction, especially in adults and 278 262 that Spira and Hardy expressed for the those with thick cartilages. Similarly, Spira Mustardé method was tempered by two factors: reported that Mustardé’s suture technique alone the large number of relatively minor complications was insufficient for durable correction in adults. He encountered and the high rate of partial recurrence subsequently proposed performing Stenstrom-type of the deformity. anterior scoring adjunctively. Heftner279 surveyed 167 patients who had 224 Webster and Smith provided a detailed undergone Stenstrom otoplasties and found that account of the long-term results of otoplasty and 40% declared themselves very satisfied, 49% its many potential associated complications. Their satisfied, and 4% fairly satisfied. Symmetry and review is strongly recommended for additional setting were considered to be good in 71% of cases, reading on this subject. whereas 4% had negligible incomplete correction, 274 Elliott examined the unsatisfactory results 19% had slight overcorrection, and 6% had marked of otoplasty, which he separated into an early group overcorrection. A round natural antihelix was noted (complications) and a late group (undesirable in 81% of patients and a sharp antihelix in 14%. sequelae). Complications include pain, bleeding, Isolated small nodules occurred in 5% of cases, and pruritus, infection, chondritis, and necrosis. 15% were considered to be overcorrected. Undesirable sequelae include patient dissatisfaction, Calder and Naasan280 reviewed their

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experience with 562 otoplasties performed with inferius” (OI), which is the anterior implantation the anterior scoring technique. The most common of the earlobe to the cheek skin. The distance from complication was residual deformity (8%). In the inter-tragal notch to the OI (cephalic segment) order of decreasing frequency, the authors also typically is 1 to 2.5 cm. The caudal segment is reported infection, keloid and/or hypertrophic defined as the distance from the OI to the subaurale scarring, hemorrhage, and anterior skin necrosis. (inferiormost point of the earlobe). Loeb advocated Further analysis revealed that the cause of residual earlobe reduction if the cephalic segment exceeds deformity was primarily a fault in the design of the 2.0 cm in length. procedure or in the execution of the technique. The McKinney et al.286 determined that the authors stated that most of these complications average lobule height is 18 mm (caudal segment) are avoidable. and advocated earlobe reduction as an adjunct to Messner and Crysdale281 reviewed their rhytidectomy when the lobule:total ear height ratio experience with a combination technique of exceeds 33%. Mustardé and Furnas sutures in 31 patients Mowlavi et al.287 discussed the incidence of who were followed for a minimum of 1 year earlobe ptosis and pseudoptosis and proposed a (average follow-up duration, 3.7 years). Regarding classification system based on the measurements recurrence of the deformity, the authors reported defined by Loeb285 and the relationship between that at the time of evaluation, one-third of the the “attached” cephalic and “free” caudal segments ears had returned to their original position, one- (Table 6). The authors found that the average third remained in their immediately postoperative height of the cephalic segment was 11.1 mm and position, and one-third were between the pre- and of the caudal segment was 7.15 mm. The caudal postoperative positions. segment was found to exhibit increasing ptosis Walter and Nolst Trenité282 presented a with advanced age; the average height increased discussion of the management of post-otoplasty to 10 mm in the 8th decade of life. In their study, deformities. Common sequelae include obliterated all patients had caudal segment heights of 15 postauricular sulci, irregularities of the antihelical mm or less (Grade III ptosis or less). The authors fold or a sharp antihelical fold, telephone determined that pseudoptosis was defined as a deformities, protruding lobules, obliterated external cephalic segment height >15 mm. Mowlavi et al.288 auditory canals, and post-perichondritis deformities. also proposed an algorithm for correction of ptotic The appropriate course of action for addressing each and pseudoptotic earlobes and described their of these deformities is detailed in the article. surgical technique of an anterior wedge excision Firmin et al.283 presented a series of 49 and reduction. patients with severe deformities resulting from El Kollali289 proposed an alternative otoplasty. Conchal cartilage grafts are useful for classification of normal earlobe morphology minor contour irregularities, but costal cartilage depending on the angle of the earlobe-cheek is recommended for deformities involving more junction: acute, earlobe is not attached to the than 25% of the ear or more than two planes of the cheek; right angle, neutral relative to the cheek; or normal folds. obtuse angle, adherent to the cheek. The author Limandjaja et al.284 provided a comprehensive disputed the “ideal” aesthetic of a free, unattached review of published series of otoplasties. earlobe relative to the cheek and determined that Complications were specifically examined, and approximately one-third of the population has the the authors lamented the lack of uniformity “adherent” earlobe morphology and that this should in reporting. be considered a normal variant.

EARLOBE REDUCTION TISSUE ENGINEERING According to Loeb,285 the earlobe is divided into Most techniques for total ear reconstruction have two components separated by the “otobasion relied on usage of autogenous costal cartilage grafts

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Table 6 Classification of Earlobe Ptosis and Designation of Pseudoptosis Based on Analysis of Preferred Otobasion Inferius to Subaurale and Intertragal Notch to Otobasion Inferius Distances287

Classification Segment (mm)

Ptosis grade Free caudal segment (otobasion inferius to subaurale distance)

0 0

I 1−5

II 6−10

III 11−15

IV 16−20

V >20

Pseudoptosis Attached cephalic segment (intertragal notch to otobasion inferius distance)

Abnormal >15

Normal ≤15 or alloplastic materials to construct a framework to sheep. Histological examination 6 months later be inserted under a skin envelope. Recent advances showed excellent cartilage formation and three- in tissue engineering have propelled the concept dimensional shape retention. The authors showed of using cellular constructs as an alternative source the effectiveness and simplicity of an injection for an ear-shaped framework. The basic elements of molding technique for large implants without construction include cells, cell-carrier, scaffolding exhibiting central graft necrosis. type, and technique (e.g., pre-fabrication, injection Ting et al.294 fabricated various cartilage molding, external molding, in vitro, in vivo). Kim shapes in vitro by using human costal chondrocytes et al.290 and Vacanti and colleagues (Shieh et al.291) and fibrin glue. These early attempts at auricular engineered predetermined shapes of cartilage by cartilage construction yielded small and inflexible using techniques for cell transplantation onto frameworks that lacked perichondrium and often biodegradable polymers. Cao and Vacanti and could not be constructed to the dimension of a colleagues (Cao et al.292) later created an ear human ear. Xu and Yaremchuk and colleagues framework that was a polymer-cell construct that (Xu et al.295) were successful in constructing used articular cartilage. Chang and Vacanti and flexible constructs by using swine chondrocytes colleagues (Chang et al.293) examined the feasibility engineered with lyophilized perichondrium. The of an injection molding technique for cartilage graft authors reviewed previous attempts at constructing tissue engineering. Alginate implants were seeded a stable framework that can withstand the with autologous chondrocytes and injected into external soft-tissue tension or avoid resorption. Silastic molds (Dow Corning). They were removed Previously published methods have included use after they had conferred reasonable stability and of degradable or nondegradable endoskeletal shape and were then implanted subcutaneously in scaffolds, prefabrication molding, or injection

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molding techniques. In the study by Xu et al., large of engineered tissues. Sterodimas and Pitanguy ear-shaped constructs were implanted in athymic and colleagues (Sterodimas et al.298) provided an mice that withstood the soft-tissue tension and updated review in 2009. maintained projection and shape. 296 In a rat model, Neumeister et al. EAR TRANSPLANTATION showed that transposing a vascular pedicle to a Because of the complex morphology and tissue subcutaneously placed silicone block creates a characteristics of the ear, composite allograft vascularized capsule over the mold. The capsules transplantation might be an emerging alternative were filled with chondrocytes and a fibrin glue to autogenous or alloplastic reconstructions. carrier in the experimental group. Good viability of Recent advances in transplant immunology have the new construct via an extrinsic capsular blood spurred interest in composite tissue transplantation supply was shown, but shape was not reliably of the face and hand. Ulusal and Wei and maintained with the capsule alone. When an 299 colleagues (Ulusal et al. ) described auricle external mold was retained for at least 4 weeks, allotransplantation in rats. Using a cyclosporine- the construct began maintaining its shape. Longer based immunosuppressive regimen, graft survival term evaluation of the construct shape was not was 100% at 30 days. The authors proposed their undertaken in that study. The authors concluded that transposing a vascular pedicle will not only model as a basis for further immunological studies. Based on human cadaveric dye-injection studies, incorporate itself to a capsule but will become 300 the dominant blood supply to it. This method of Ulusal et al. further showed that adequate prefabrication showed development of an intrinsic auricular transplant perfusion would require both vascularity to an engineered construct that could be superficial temporal and posterior auricular arterial transferred as a pedicled or free flap. systems, suggesting that an external carotid artery Ciorba and Martini,297 in 2006, reviewed pedicle could therefore be used. A successful the status of tissue engineering and stem cells cephalo-cervical composite tissue allograft as it relates to auricular reconstruction. The transplant including two ears was performed authors identified several key components under secondary to radical resection of malignant investigation, including type of scaffolding, melanoma using a tacrolimus and mycophenolate source cells, suitable animal models, and stability mofetil regimen with steroid adjuvant.301

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72. Jenkins AM, Finucan T. Primary nonmicrosurgical ear: An experimental study in . Scand J Plast Reconstr reconstruction following ear avulsion using the Surg 1975;9:34–39. temporoparietal fascial island flap. Plast Reconstr Surg 89. Giffin CS. Wrestler’s ear: Pathophysiology and treatment. 1989;83:148–152. Ann Plast Surg 1992;28:131–139. 73. Sućur D, Ninković M, Marković S, Babović S. 90. Melnick M, Myrianthopoulos NC, Paul NW. External ear Reconstruction of an avulsed ear by constructing a malformations: Epidemiology, genetics and natural history. composite free flap. Br J Plast Surg 1991;44:153–154. Birth Defects Orig Artic Ser 1979;15:1–140. 74. Musgrave RH, Garrett WS Jr. Management of avulsion 91. Converse JM. Construction of the auricle in unilateral injuries of the external ear. Plast Reconstr Surg 1967;40: congenital microtia. Trans Am Acad Ophthalmol Otolaryngol 534–539. 1968;72:995–1013. 75. McDowell F. Successful replantation of a severed half 92. Grabb WC. The first and second branchial arch ear. Plast Reconstr Surg 1971;48:281–283. syndrome. Plast Reconstr Surg 1965;36:485–508. 76. Salyapongse A, Maun LP, Suthunyarat P. Successful 93. Kaseff LG. Investigation of congenital malformations of replantation of a totally severed ear. Plast Reconstr Surg the ears with tomography. Plast Reconstr Surg 1967;39: 1979;64:706–707. 282–286. 77. Lewis EC II, Fowler JR. Two replantations of severed ear 94. Rogers BO. Microtia, lop, cup and protruding ears: parts. Plast Reconstr Surg 1979;64:703–705. Four directly inheritable deformities? Plast Reconstr Surg 78. Mladick RA, Horton CE, Adamson JE, Cohen BI. The 1968;41:208–231. pocket principle: A new technique for the reattachment of a 95. Tanzer RC. Total reconstruction of the auricle: The severed ear part. Plast Reconstr Surg 1971;48:219–223. evolution of a plan of treatment. Plast Reconstr Surg 79. Steffen A, Katzbach R, Klaiber S. A comparison of 1971;47:523–533. ear reattachment methods: A review of 25 years since 96. Bennun RD, Mulliken JB, Kaban LB, Murray JE. Microtia: Pennington. Plast Reconstr Surg 2006;118:1358–1364. A microform of hemifacial microsomia. Plast Reconstr Surg 80. Brent B, Byrd HS. Secondary ear reconstruction with 1985;76:859–865. cartilage grafts covered by axial, random, and free flaps of 97. Figueroa AA, Friede H. Craniovertebral malformations temporoparietal fascia. Plast Reconstr Surg 1983;72:141–152. in hemifacial microsomia. J Craniofac Genet Dev Biol Suppl 81. Brent B, Upton J, Acland RD, Shaw WW, Finseth 1985;1:167–178. FJ, Rogers C, Pearl RM, Hentz VR. Experience with the 98. Jahrsdoerfer RA. Congenital ear atresia. In, Tanzer RC, temporoparietal fascial free flap. Plast Reconstr Surg Edgerton MT (ed): Symposium on Reconstruction of the 1985;76:177–188. Auricle. vol 10. St. Louis, CV Mosby, 1974:150–159. 82. Nakai H. Reconstruction of microtia with a contour- 99. Schuknecht HF. Reconstructive procedures for accentuated framework and supplemental coverage. Plast congenital aural atresia. Arch Otolaryngol 1975;101:170–172. Reconstr Surg 1986;78:604–609. 100. Kountakis SE, Helidonis E, Jahrsdoerfer RA. Microtia 83. Rose EH, Norris MS. The versatile temporoparietal fascial grade as an indicator of middle ear development in aural flap: Adaptability to a variety of composite defects. Plast atresia. Arch Otolaryngol Head Neck Surg 1995;121:885–886. Reconstr Surg 1990;85:224–232. 101. Gill NW. Congenital atresia of the ear: A review of the 84. Zhou G, Teng L, Chang HM, Jing WM, Xu J, Li SK, surgical findings in 83 cases. J Laryngol Otol 1969;83:551- Zhuang HX. Free prepared composite forearm flap transfer 587. for ear reconstruction: Three case reports. Microsurgery 102. Fukuda O. Discussion of congenital deformities of the 1994;15:660–662. auricle. In, Tanzer RC, Edgerton MT (ed): Symposium 85. Jones SE, Mahendran S. Interventions for acute auricular on Reconstruction of the Auricle. vol 10. St. Louis, CV hematoma. Cochrane Database Syst Rev 2004;2:CD004166. Mosby, 1974. 86. Giles WC, Iverson KC, King JD, Hill FC, Woody EA, 103. Aguilar EF III. Auricular reconstruction of congenital Bouknight AL. Incision and drainage followed by mattress microtia (grade III). Laryngoscope 1996;106[suppl 82]:1–26. suture repair of auricular hematoma. Laryngoscope 104. Granström G, Bergström K, Tjellström A. The bone- 2007;117: 2097–2099. anchored hearing aid and bone-anchored epithesis for 87. Ghanem T, Rasamny JK, Park SS. Rethinking auricular congenital ear malformations. Otolaryngol Head Neck Surg trauma. Laryngoscope 2005;115:1251–1255. 1993;109:46–53. 88. Ohlsén L, Skoog T, Sohn S. Pathogenesis of cauliflower 105. Håkansson B, Tjellström A, Carlsson P. Percutaneous

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vs. transcutaneous transducers for hearing by direct bone 121. Gentile P, Bottini DJ, Colicchia GM, Trimarco A, Cervelli conduction. Otolaryngol Head Neck Surg 1990;102:339–344. V. Burns: Bone-anchored, extra-oral implantology. J Burn 106. Bellucci RJ. Congenital auricular malformations: Care Res 2008;29:627–631. Indications, contraindications, and timing of middle ear 122. Cronin TD. Use of Silastic frame for total and subtotal surgery. Ann Otol Rhinol Laryngol 1972;81:659–663. reconstruction of the external ear: Preliminary report. Plast 107. Derlacki EL. The role of the otologist in the Reconstr Surg 1966;37:399–405. management of microtia and related malformation of the 123. Cronin TD, Greenberg RL, Brauer RO. Follow-up study hearing apparatus. Trans Am Acad Ophthalmol Otolaryngol of Silastic frame for reconstruction of external ear. Plast 1968;72:980–994. Reconstr Surg 1968;42:522–529. 108. Aguilar EA III, Jahrsdoerfer RA. The surgical repair of 124. Cronin TD, Ascough BM. Silastic ear construction. Clin congenital microtia and atresia. Otolaryngol Head Neck Surg Plast Surg 1978;5:367–378. 1988;98:600–606. 125. Ohmori S. Use of silicone rubber frame for the 109. Jahrsdoerfer RA, Yeakley JW, Aguilar EA III, Cole RR, reconstruction of microtia cases. In, Hueston ST (ed): Gray LC. Grading system for the selection of patients with Transactions of the Fifth International Congress of Plastic and congenital aural atresia. Am J Otol 1992;13:6–12. Reconstructive Surgery. Melbourne: Butterworth; 1971:467. 110. Staffenberg DA. Microtia repair. J Craniofac Surg 126. Ohmori S. Reconstruction of microtia using the Silastic 2003;14:481–486. frame. Clin Plast Surg 1978;5:379–387. 111. Siegert R. Combined reconstruction of congenital 127. Ohmori S, Matsumoto K, Nakai H. Follow-up study on auricular atresia and severe microtia. Laryngoscope reconstruction of microtia with a silicone framework. Plast 2003;113:2021–2027. Reconstr Surg 1974;53:555–562. 112. Digoy GP, Cueva RA. Congenital aural atresia: Review 128. Wellisz T. Clinical experience with the Medpor porous of short- and long-term surgical results. Otol Neurotol polyethylene implant. Aesthetic Plast Surg 1993;17:339–344. 2006;28:54–60. 129. Reinisch J. Microtia reconstruction using a 113. Chang SO, Choi BY, Hur DG. Analysis of the long-term polyethylene implant: An 8-year surgical experience. hearing results after the surgical repair of aural atresia. Presented at the 78th Annual Meeting of the American Laryngoscope 2006;116:1835–1841. Association of Plastic Surgeons, Colorado Springs, CO, May 114. Thorne CH, Brecht LE, Bradley JP, Levine JP, 5, 1999. Hammerschlag P, Longaker MT. Auricular reconstruction: 130. Romo T III, Reitzen SD. Aesthetic microtia Indications for autogenous and prosthetic techniques. Plast reconstruction with Medpor. Facial Plast Surg 2008;24: Reconstr Surg 2001;107:1241–1252. 120–128. 115. Beahm EK, Walton RL. Auricular reconstruction 131. Yang SL, Zheng JH, Ding Z, Liu QY, Mao GY, Jin for microtia: Part I. Anatomy, embryology, and clinical YP. Combined fascial flap and expanded skin flap for evaluation. Plast Reconstr Surg 2002;109:2473–2482. enveloping Medpor framework in microtia reconstruction. 116. Wilkes GH, Wolfaardt JF. Osseointegrated alloplastic Aesthetic Plast Surg 2008;33:518–522. versus autogenous ear reconstruction: Criteria for treatment 132. Brent B. Microtia repair with rib cartilage grafts: A selection. Plast Reconstr Surg 1994;93:967–979. review of personal experience with 1000 cases. Clin Plast 117. Wolfaardt JF, Coss P, Levesque R. Craniofacial Surg 2002;29:257–271. osseointegration: Technique for bar and acrylic resin 133. Thomson HG, Kim TY, Ein SH. Residual problems in substructure construction for auricular prostheses. J Prosthet chest donor sites after microtia reconstruction: A long-term Dent 1996;76:603–607. study. Plast Reconstr Surg 1995;95:961–968. 118. Han K, Son D. Osseointegrated alloplastic ear 134. Fukuda O, Yamada A. Reconstruction of the microtic reconstruction with the implant-carrying plate system in ear with autogenous cartilage. Clin Plast Surg 1978;5: children. Plast Reconstr Surg 2002;109:496–503. 351–366. 119. Miles BA, Sinn DP, Gion GG. Experience with cranial 135. Uppal RS, Sabbagh W, Chana J, Gault DT. Donor-site implant-basd prosthetic reconstruction. J Craniofac Surg morbidity after autologous costal cartilage harvest in ear 2006;17:889–897. reconstruction and approaches to reducing donor-site 120. Gentile P, Bottini DJ, Gravante G, Nicoli F, Caruso R, contour deformity. Plast Reconstr Surg 2008;121:1949–1955. Cervelli V. The use of bone-anchored implants for absent ear. 136. Kawanabe Y, Nagata S. A new method of costal J Craniofac Surg 2008;19:744–747. cartilage harvest for total auricular reconstruction:

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Part I. Avoidance and prevention of intraoperative and type microtia. Plast Reconstr Surg 1994;93:243–253. postoperative complications and problems. Plast Reconstr 152. Nagata S. Modification of the stages in total Surg 2006;117:2011–2018. reconstruction of the auricle: Part IV. Ear elevation for the 137. Tai Y, Tanaka S, Fukushima J, Kizuka Y, Kiyokawa constructed auricle. Plast Reconstr Surg 1994;93:254–266. K, Inoue Y, Yamauchi T. Refinements in the elevation of 153. Park C, Lee TJ, Shin KS, Kim YW. A single-stage two- reconstructed auricles in microtia. Plast Reconstr Surg flap method of total ear reconstruction. Plast Reconstr Surg 2006;117:2414–2423. 1991;88:404–412. 138. Carey JS. Microtia: A personal case study. Aesthetic Plast 154. Song Y, Song Y. An improved one-stage total ear Surg 1985;9:197–206. reconstruction procedure. Plast Reconstr Surg 1983;71: 139. Brent B. Auricular repair with autogenous rib cartilage 615–623. grafts: Two decades of experience with 600 cases. Plast 155. Burstein FD. Cartilage-sparing complete otoplasty Reconstr Surg 1992;90:355–374. technique: A 10-year experience in 100 patients. J Craniofac 140. Edgerton MT. Ear construction in children with Surg 2003;14:521–525. congenital atresia and stenosis. Plast Reconstr Surg 156. Bauer BS. Reconstruction of the microtic ear. J Pediatr 1969;43:373–380. Surg 1984;19:440–445. 141. Brent B. The correction of microtia with autogenous 157. Yanai A, Fukuda O, Nagata S, Tanaka H. A new method cartilage grafts: I. The classic deformity. Plast Reconstr Surg utilizing the bipedicle flap for reconstruction of the external 1980;66:1–12. auditory canal in microtia. Plast Reconstr Surg 1985;76: 142. Thomson HG, Winslow J. Microtia reconstruction: 464–468. Does the cartilage framework grow? Plast Reconstr Surg 158. Isshiki N, Koyama H, Suzuki S, Taira T. Surgical 1989;84:908–915. techniques for a deep concha, a pseudomeatus, and 143. Adamson JE, Horton CE, Crawford HH. The growth high projection in congenital microtia. Plast Reconstr Surg patterns of the external ear. Plast Reconstr Surg 1965;36: 1986;77:546–557. 466–470. 159. Zim SA. Microtia reconstruction: An update. Curr Opin 144. Farkas LG. Growth of normal and reconstructed Otolaryngol Head Neck Surg 2003;11:275–281. auricles. In, Tanzer RC, Edgerton MT (ed): Symposium on 160. Walton RL, Beahm EK. Auricular reconstruction for Reconstruction of the Auricle. St. Louis: CV Mosby; 1974:24. microtia: Part II. Surgical techniques. Plast Reconstr Surg 145. Tanzer RC. Microtia: A long-term follow-up of 44 2002;110:234–249. reconstructed auricles. Plast Reconstr Surg 1978;61:161–166. 161. Broadbent TR, Woolf RM. Bilateral microtia: A team 146. DellaCroce FJ, Green S, Aguilar EF III. Framework approach to the middle ear. In, Tanzer RC, Edgerton MT (ed): growth after reconstruction for microtia: Is it real and what Symposium on Reconstruction of the Auricle. St. Louis: CV are the implications? Plast Reconstr Surg 2001;108: Mosby; 1974. 1479–1484. 162. Edgerton MT, Bacchetta C. Principles in the use and 147. Brent B. Technical advances in ear reconstruction with salvage of implants in ear reconstruction. In, Tanzer RC, autogenous rib cartilage grafts: Personal experience with Edgerton MT (ed): Symposium on Reconstruction of the 1200 cases. Plast Reconstr Surg 1999;104:319–334. Auricle. St. Louis: CV Mosby; 1974:58. 148. Nagata S. A new method of total reconstruction of the 163. Tegtmeier RE, Gooding RA. The use of a fascial flap in auricle for microtia. Plast Reconstr Surg 1993;92:187–201. ear reconstruction. Plast Reconstr Surg 1977;60:406–411. 149. Nagata S. Modification of the stages in total 164. Park C, Lew D-H, Yoo W-M. An analysis of 123 reconstruction of the auricle: Part I. Grafting the three- temporoparietal fascial flaps: Anatomic and clinical dimensional costal cartilage framework for lobule-type considerations in total auricular reconstruction. Plast microtia. Plast Reconstr Surg 1994;93:221–230. Reconstr Surg 1999;104:1295–1306. 150. Nagata S. Modification of the stages in total 165. Helling ER, Okoro S, Kim G II, Wang PT. Endoscope- reconstruction of the auricle: Part II. Grafting the three- assisted temporoparietal fascia harvest for auricular dimensional costal cartilage framework for concha-type reconstruction. Plast Reconstr Surg 2008;121:1598–1605. microtia. Plast Reconstr Surg 1994;93:231–242. 166. Nagata S. Secondary reconstruction for unfavorable 151. Nagata S. Modification of the stages in total microtia results utilizing temporoparietal and innominate reconstruction of the auricle: Part III. Grafting the three- fascia flaps. Plast Reconstr Surg 1994;94:254–265. dimensional costal cartilage framework for small concha- 167. Hirase Y, Kojima T, Hirakawa M. Secondary ear

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reconstruction using deep temporal fascia after 183. Al-Qattan MM. An alternative approach for correction temporoparietal fascial reconstruction in microtia. Ann Plast of constricted ears of moderate severity. Br J Plast Surg Surg 1990;25:53–57. 2005;58:389–393. 168. Alexander G, Rajacic N, Ibrahim MK, Al-Zamil S. The 184. Stephenson KL. Correction of a lop ear type deformity. combined posterior temporoparietal and galeal fascial Plast Reconstr Surg 1960;26:540–545. flap: A new flap in the elevation of the constructed auricle 185. Musgrave RH. A variation on the correction of the (second stage of microtia correction). Br J Plast Surg congenital lop ear. Plast Reconstr Surg 1966;37:394-398. 2002;55:582–584. 186. Ohjimi H, Era K, Kinoshita K, Fukuda T, Shiratake Y. 169. Brent B. The correction of microtia with autogenous Double pennant technique: Elongating the helix using cartilage grafts: II. Atypical and complex deformities. Plast rim flaps to correct the constricted ear. Ann Plast Surg Reconstr Surg 1980;66:13–21. 2004;53:465–468. 170. Hata Y, Hosokawa K, Yano K, Matsuka K, Ito O. 187. Nagata S. Alternative surgical methods of treatment for Correction of congenital microtia using the tissue expander. the constricted ear. Clin Plast Surg 2002;29: 301–315. Plast Reconstr Surg 1989;84:741–751. 188. Xiaogeng H, Hongxing Z, Qinghua Y, Haiyue J, Yanyong 171. Pan B, Jiang H, Guo D, Huang C, Hu S, Zhuang H. Z. A new method of correcting type I and type II constricted Microtia: Ear reconstruction using tissue expander and (cup and lop) ears. Aesthetic Plast Surg 2006;30:449–454. autogenous costal cartilage. J Plast Reconstr Aesthet Surg 2008;61[suppl 1]:S98–S103. 189. Xiaogeng H, Hongxing Z, Qinghua Y, Haiyue J, Yanyong Z. Subtotal ear reconstruction for correction of type 3 172. Jiang H, Pan B, Lin L, Cai Z, Zhuang H. Ten-year constricted ears. Aesthetic Plast Surg 2006;30:455–459. experience in microtia reconstruction using tissue expander and autogenous cartilage. Int J Pediatr Otorhinolaryngol 190. Nakajima T, Yoshimura Y, Kami T. Surgical and 2008;72:1251–1259. conservative repair of Stahl’s ear. Aesthetic Plast Surg 1984;8:101–107. 173. Oberg M, Becker M, Arktander M, Centerman M, Svensson H, Wikström S. Thermosensitivity in a 191. Chongchet V. A method of antihelix reconstruction. Br J reconstructed microtic ear. Scand J Plast Reconstr Surg Hand Plast Surg 1963;16:268–272. Surg 2008;42:190–193. 192. Ferraro GA, Perrotta A, Rossano F, D’Andrea F. 174. Wray RC, Hoopes JE. Silastic frameworks in total Stahl syndrome in clinical practice. Aesthetic Plast Surg reconstruction of the auricle. Br J Plast Surg 1973;26: 2006;30:348–349. 296–297. 193. Ono I, Gunji H, Tateshita T. An operation for Stahl’s ear. 175. Curtin JW, Bader KF. Improved techniques for the Br J Plast Surg 1996;49:564–567. successful silicone reconstruction of the external ear. Plast 194. Kaplan HM, Hudson DA. A novel surgical method of Reconstr Surg 1969;44:372–377. repair of Stahl’s ear: A case report and review of current 176. Monroe CW. Our experiences with the silicone ear treatment modalities. Plast Reconstr Surg 1999;103:566–569. framework: A report of 17 ears in 15 patients. Plast Reconstr 195. Nakayama Y, Soeda S. Surgical treatment of Stahl’s ear Surg 1972;49:428–432. using the periosteal string. Plast Reconstr Surg 1986;77: 177. Hinderer UT, del Rio JL, Fregenal FJ. Otoplasty for lop 222–226. ears. Aesthetic Plast Surg 1987;11:75–80. 196. Sugino H, Tsuzuki K, Bandoh Y, Tange I. Surgical 178. Tanzer RC. The constricted (cup and lop) ear. Plast correction of Stahl’s ear using the cartilage turnover and Reconstr Surg 1975;55:406–415. rotation method. Plast Reconstr Surg 1989;83:160–164. 179. Cosman B. The constricted ear. Clin Plast Surg 197. Tsujiguchi K, Tajima S, Tanaka Y, Hira M. A new method 1978;5:389–400. for correction of Stahl’s ear. Ann Plast Surg 1992;28:373–376. 180. Kislov R. Surgical correction of the cupped ear. Plast 198. Al-Qattan MM, Hashem FK. An alternative approach for Reconstr Surg 1971;48:121–125. correction of Stahl’s ear. Ann Plast Surg 2004;52:105–108. 181. Horlock N, Grobbelaar AO, Gault DT. 5-year series of 199. Torikai K, Ando S, Yoshida T. Anatomy of the auricular constricted (lop and cup) ear corrections: Development of muscles and its surgical application. Jpn J Plast Reconstr Surg the mastoid hitch as an adjunctive technique. Plast Reconstr 1982;25:46. Surg 1998;102:2325–2332. 200. Elsahy NI. An alternative technique for correction of 182. Park C. The tumbling concha-cartilage flap for cryptotia. Ann Plast Surg 1989;23:66–73. correction of lop ear. Plast Reconstr Surg 2000;106:259–265. 201. Mutimer KL, Mulliken JB. Correction of cryptotia using

43 SRPS • Volume 11 • Issue R3 • 2011 tissue expansion. Plast Reconstr Surg 1988;81:601–604. using full-thickness skin grafts. Ann Plast Surg 2001;47: 202. Hirose T, Tomono T, Matsuo K, Katohda S, Takahashi 471–472. N, Iwasawa M, Satoh R. Cryptotia: Our classification and 220. Cho BC, Han KH. Surgical correction of cryptotia treatment. Br J Plast Surg 1985;38:352–360. with V-Y advancement of a temporal triangular flap. Plast 203. Matsuo K, Hirose T, Tomono T, Iwasawa M, Katohda S, Reconstr Surg 2005;115:1570–1581. Takahashi N, Koh B. Nonsurgical correction of congenital 221. Brown FE, Colen LB, Addante RR, Graham JM Jr. auricular deformities in the early neonate: A preliminary Correction of congenital auricular deformities by splinting report. Plast Reconstr Surg 1984;73:38–51. in the neonatal period. Pediatrics 1986;78:406–411. 204. Yotsuyanagi T, Yamashita K, Shinmyo Y, Yokoi K, Sawada 222. Byrd HS, Langevin CJ, Ghidoni LA. Ear molding in Y. A new operative method of correcting cryptotia using a newborn infants with auricular deformities. Plast Reconstr large Z-plasty. Br J Plast Surg 2001;54:20–24. Surg 2010;126:1191–1200. 205. Nakajima T, Yoneda K, Yoshimura Y. Correction of 223. Madzharov MM. A new method of auriculoplasty for cryptotia using a subcutaneous pedicled flap. Br J Plast Surg protruding ears. Br J Plast Surg 1989;42:285–290. 1991;44:406–409. 224. Webster RC, Smith RC. Otoplasty for prominent 206. Pollock WJ. Techniuqe for correction of cryptotia: Case ears. In, Goldwyn RM (ed): Long-term Results in Plastic and report. Plast Reconstr Surg 1969;44:501–503. Reconstructive Surgery. Boston: Little, Brown; 1980:146. 207. Onizuka T, Tokunaga S, Yamada K. A method for repair 225. Kelley P, Hollier L, Stal S. Otoplasty: Evaluation, of cryptotia. Plast Reconstr Surg 1978;62:734–738. technique, and review. J Craniofac Surg 2003;14:643–653. 208. Argamaso RV. Cryptotia: Its surgical correction. Ann 226. Rogers BO. Ely’s 1881 operation for correction of Plast Surg 1979;2:109–113. protruding ears: A medical “first”. Plast Reconstr Surg 1968;42:584–586. 209. Wesser DR. Repair of a cryptotic ear with a trefoil flap: Case report. Plast Reconstr Surg 1972;50:192–193. 227. [No authors listed]. A classic reprint: An operation for prominence of the auricles (with two wood-cuts) by Edward 210. Hayashi R, Matsuo K, Hirose T. Familial cryptotia. Plast T. Ely (Arch Otol 10:97, 1881). Aesthetic Plast Surg 1987;11: Reconstr Surg 1993;91:1337–1339. 73–74. 211. Yoshimura K, Ouchi K, Wakita S, Uda K, Harii K. Surgical 228. Rogers BO. The classic reprint: A new operation for correction of cryptotia with superiorly based superificial prominent ears based on the anatomy of the deformity by mastoid fascia and skin paddle. Plast Recontr Surg William H. Luckett, M.D. (Surg Gynecol Obstet 10:635–637, 2000;105:836–841. 1910). Plast Reconstr Surg 1969;43:83–86. 212. Paredes AA Jr, Williams JK, Elsahy NI. Cryptotia: 229. Georgiade GS, Riefkohl R, Georgiade NG. Prominent Principles and management. Clin Plast Surg 2002;29: ears and their correction: A forty-year experience. Aesthetic 317–326. Plast Surg 1995;19:439–443. 213. Uemura T, Matsumoto N, Tanabe T, Saitoh T, Matsushita 230. Gosain AK, Kumar A, Huang G. Prominent ears S, Mitsukawa N. Surgical correction of cryptotia combined in children younger than 4 years of age: What is the with intraoperative distention using isotonic saline injection appropriate timing for otoplasty? Plast Reconstr Surg and rotation flap method. J Craniofac Surg 2005;16:473–476. 2004;114:1042–1054. 214. Hyakusoku H, Fumiiri M. The square flap method. Br J 231. Gasques JA, Pereira de Godoy JMP, Cruz EM. Plast Surg 1987;40:40–46. Psychosocial effects of otoplasty in children with prominent 215. Yanai A, Tange I, Bandoh Y, Tsuzuki K, Sugino H, Nagata ears. Aesthetic Plast Surg 2008;32:910–914. S. Our method of correcting cryptotia. Plast Reconstr Surg 232. Davis JE. Prominent ears. Clin Plast Surg 1978;5: 1988;82:965–972. 471–477. 216. Chana JS, Fourie LR. A technique for the correction of 233. Davis JE. Aesthetic and Reconstructive Otoplasty. New cryptotia. Ann Plast Surg 1997;39:261–265. York: Springer-Verlag; 1987. 217. Chang SO, Suh MW, Choi BY, Park MH, Ha Oh S, Kim CS. 234. Balogh B, Millesi H. Are growth alterations a A new technique for correcting cryptotia: V-Y swing flap. consequence of surgery for prominent ears? Plast Reconstr Plast Reconstr Surg 2007;120:437–441. Surg 1992;90:192–199. 218. Park S, Takushima M, Minegishi M. Reconstruction of 235. Lavy J, Stearns M. Otoplasty: Techniques, results cryptotia using a skin graft. Ann Plast Surg 1994;32:441–444. and complications: A review. Clin Otolaryngol Allied Sci 219. Hodgson EL, McGregor AD. Correction of cryptotia 1997;22:390–393.

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236. Mustardé JC. The correction of prominent ears using Reconstr Surg Transplant Bull 1962;30:236–246. mattress sutures. Br J Plast Surg 1963;16:170–178. 255. Hinderer UT, del Rio JL, Fregenal FJ. Otoplasty for 237. Johnson PE. Otoplasty: Shaping the antihelix. Aesthetic prominent ears. Aesthetic Plast Surg 1987;11:63–69. Plast Surg 1994;18:71–74. 256. Pitanguy I, Müller P, Piccolo N, Ramalho E, Solinas R. 238. Furnas DW. Correction of prominent ears by concha- The treatment of prominent ears: A 25-year survey of the mastoid sutures. Plast Reconstr Surg 1968;42:189–193. island technique. Aesthetic Plast Surg 1987;11:87–93. 239. Spira M, Stal S. The conchal flap: An adjunct in 257. Kaye BL. A simplified method for correcting the otoplasty. Ann Plast Surg 1983;11:291–298. prominent ear. Plast Reconstr Surg 1967;40:44–48. 240. Webster GV. The tail of the helix as a key to otoplasty. 258. Baker DC, Converse JM. Correction of protruding ears: Plast Reconstr Surg 1969;44:455–461. A 20-year retrospective. Aesthetic Plast Surg 1979;3:29-39. 241. Beernink JH, Blocksma R, Moore WD. The role of 259. Chait L, Nicholson R. One size fits all: A surgical the helical tail in cosmetic otoplasty. Plast Reconstr Surg technique for the correction of all types of prominent ears. 1979;64:115–117. Plast Reconstr Surg 1999;104:190–195. 242. Goulian D Jr, Conway H. Prevention of persistent 260. Stal S. One size fits all: A surgical technique for the deformity of the tragus and lobule by modification of correction of all types of prominent ears [letter]. Plast the Luckett technique of otoplasty. Plast Reconstr Surg Reconstr Surg 1999;104:1969. Transplant Bull 1960;26:399–404. 261. Stal S, Klebuc M, Spira M. An algorithm for otoplasty. 243. Spira M. Reduction otoplasty. In, Goldwyn RM (ed): Oper Tech Plast Reconstr Surg 1997;4:88–103. The Unfavorable Result in Plastic Surgery: Avoidance and 262. Spira M. Otoplasty: What I do now: A 30-year Treatment. Boston: Little, Brown; 1984:307–321. perspective. Plast Reconstr Surg 1999;104:834–840. 244. Gosain AK, Recinos RF. A novel approach to correction 263. Graham KE, Gault DT. Endoscopic assisted otoplasty: A of the prominent lobule during otoplasty. Plast Reconstr Surg preliminary report. Br J Plast Surg 1997;50:47–57. 2003;112:575–583. 264. Bauer BS, Song DH, Aitken ME. Combined otoplasty 245. Gibson T, Davis W. The distortion of autogenous technique: Chondrocutaneous conchal resection as the cartilage grafts: Its cause and prevention. Br J Plast Surg cornerstone to correction of the prominent ear. Plast 1958;10:257–274. Reconstr Surg 2002;110:1033–1040. 246. Fry HJ. Interlocked stresses in human nasal septal 265. Peker F, Celiköz B. Otoplasty: Anterior scoring and cartilage. Br J Plast Surg 1966;19:276–278. osterior rolling technique in adults. Aesthetic Plast Surg 247. Stenstrom SJ. A “natural” technique for correction 2002;26:267–273. of congenitally prominent ears. Plast Reconstr Surg 266. Janis JE, Rohrich RJ, Gutowski K. Otoplasty. Plast 1963;32:509–518. Reconstr Surg 2005;115:60e–72e. 248. Stenstrom SJ, Heftner J. The Stenstrom otoplasty. Clin 267. Nicoletis C, Guerin-Surville H. Prominent ears: Plast Surg 1978;5:465–470. Transposition of the posterior auricular muscle on the 249. Crikelair GF, Cosman B. Another solution for the scapha: A new technique. Aesthetic Plast Surg 1978;2: problem of the prominent ear. Ann Surg 1964;160:314–324. 295–299. 250. Weinzweig N, Chen L, Sullivan WG. Histomorphology 268. Smith DW. Protruding auricle: A neuromuscular sign. of neochondrogenesis after antihelical fold creation: A Lancet 1978;1:747–749. comparison of three otoplasty techniques in the rabbit. Ann 269. Smith DW, Takashima H. Ear muscles and ear form. Plast Surg 1994;33:371–376. Birth Defects Orig Artic Ser 1980;16:299–302. 251. Karacalar A, Demir A, Yildiz L. Subcision surgery 270. Guyuron B, DeLuca L. Ear projection and the posterior for the correction of ear deformities. Aesthetic Plast Surg auricular muscle insertion. Plast Reconstr Surg 1997;100: 2004;28:239–244. 457–460. 252. Fritsch MH. Incisionless otoplasty. Facial Plast Surg 271. Scuderi N, Tenna S, Bitonti A, Vonella M. Repositioning 2004;20:267–270. of posterior auricular muscle combined with conventional 253. Mordon S, Wang T, Fleurisse L, Creusy C. Laser cartilage otoplasty: A personal technique. J Plast Reconstr Aesthet Surg reshaping in an in vivo rabbit model using a 1.54 µm 2007;60:201–204. Er:Glass Laser. Lasers Surg Med 2004;34:315–322. 272. Shinohara H, Matsuo K, Hataya Y, Taki K. Correlation 254. Tanzer RC. The correction of prominent ears. Plast between projection of the ear, the inferior crus, and the

45 SRPS • Volume 11 • Issue R3 • 2011 antihelical body: Analysis based on computed tomography. 289. El Kollali R. Earlobe morphology: A simple classification Scand J Plast Reconstr Hand Surg 2007;41:288–292. of normal earlobes [letter]. J Plast Reconstr Aesthet Surg 273. Corchado C, Infante J. A surgical technique for the 2009;62:277–280. correction of all types of prominent ears? Plast Reconstr Surg 290. Kim WS, Vacanti JP, Cima L, Mooney D, Upton J, 2000;106:948–951. Puelacher WC, Vacanti CA. Cartilage engineered in 274. Elliott RA Jr. Complications in the treatment of predetermined shapes employing cell transplantation prominent ears. Clin Plast Surg 1978;5:479–490. on synthetic biodegradable polymers. Plast Reconstr Surg 1994;94:233–237. 275. Tan KH. Long-term survey of prominent ear surgery: A comparison of two methods. Br J Plast Surg 1986;39: 291. Shieh SJ, Terada S, Vacanti JP. Tissue engineering 270–273. auricular reconstruction: In vitro and in vivo studies. Biomaterials 2004;25:1545–1557. 276. Mustardé JC. The treatment of prominent ears by buried mattress sutures: A ten-year survey. Plast Reconstr 292. Cao Y, Vacanti JP, Paige KT, Upton J, Vacanti CA. Surg 1967;39:382–386. Transplantation of chondrocytes utilizing a polymer-cell 277. Mustardé JC. Results of otoplasty by the author’s construct to produce tissue-engineered cartilage in the method. In, Goldwyn RM (ed): Long-term Results in Plastic shape of a human ear. Plast Reconstr Surg 1997;100:297–302. and Reconstructive Surgery. Boston: Little, Brown; 1980. 293. Chang SC, Tobias G, Roy AK, Vacanti CA, Bonassar LJ. 278. Spira M, Hardy SB. Mustardé otoplasty: A critical Tissue engineering of autologous cartilage for craniofacial second look. In, Marchac D (ed): Transactions of the Sixth reconstruction by injection molding. Plast Reconstr Surg International Congress of Plastic and Reconstructive Surgery. 2006;112:793–799. Paris: Masson: 1975:297−299. 294. Ting V, Sims CD, Brecht LE, McCarthy JG, Kasabian AK, 279. Heffner J. Follow-up study on 167 Stenstrom Connelly PR, Elisseeff J, Gittes GK, Longaker MT. In vitro otoplasties. Clin Plast Surg 1978;5:470. prefabrication of human cartilage shapes using fibrin glue and human chondrocytes. Ann Plast Surg 1998;40:413–420. 280. Calder JC, Naasan A. Morbidity of otoplasty: A review of 562 consecutive cases. Br J Plast Surg 1994;47:170–174. 295. Xu JW, Johnson TS, Motarjem PM, Peretti GM, Randolph MA, Yaremchuk MJ. Tissue-engineered flexible ear-shaped 281. Messner AH, Crysdale WS. Otoplasty: Clinical protocol cartilage. Plast Reconstr Surg 2005;115:1633–1641. and long-term results. Arch Otolaryngol Head Neck Surg 1996;122:773–777. 296. Neumeister MW, Wu T, Chambers C. Vascularized tissue-engineered ears. Plast Reconstr Surg 2006;117: 282. Walter C, Nolst Trenité GJ. Revision otoplasty and special problems. Facial Plast Surg 1994;10:298–308. 116–122. 283. Firmin F, Sanger C, O’Tolle G. Ear reconstruction 297. Ciorba A, Martini A. Tissue engineering and cartilage following severe complications of otoplasty. J Plast Reconstr regeneration for auricular reconstruction. Int J Ped Aesthet Surg 2008;61[suppl 1]:S13-S20. Otorhinolaryngol 2006;70:1507–1515. 284. Limandjaja GC, Breugem CC, Mink van der Molen AB, 298. Sterodimas A, de Faria J, Correa WE, Pitanguy I. Tissue Kon M. Complications of otoplasty: A literature review. J engineering and auricular reconstruction: A review. J Plast Plast Reconstr Aesthet Surg 2009;62:19–27. Reconstr Aesthet Surg 2009;62:447–452. 285. Loeb R. Earlobe tailoring during facial rhytidoplasties. 299. Ulusal AE, Ulusal BG, Hung L, Wei FC. Establishing Plast Reconstr Surg 1972;49:485–489. a composite auricle allotransplantation model in rats: Introduction to transplantation of facial subunits. Plast 286. McKinney P, Giese S, Placik O. Management of the ear Reconstr Surg 2005;116:811–817. in rhytidectomy. Plast Reconstr Surg 1993;92:858–866. 300. Ulusal BG, Ulusal AE, Lin JY, Tan BK, Wong CH, Song 287. Mowlavi A, Meldrum DG, Wilhelmi BJ, Zook EG. C, Wei FC. Anatomical and technical aspects of harvesting Incidence of earlobe ptosis and pseudoptosis in patients the auricle as a neurovascular facial subunit transplant in seeking facial rejuvenation surgery and effects of aging. humans. Plast Reconstr Surg 2007;120:1540–1545. Plast Reconstr Surg 2004;113:712–717. 288. Mowlavi A, Meldrum DG, Kalkanis J, Wilhelmi BJ, 301. Jiang HQ, Wang Y, Hu XB, Li YS, Li JS. Composite tissue Russell RC, Zook EG. Surgical design and algorithm for allograft transplantation of cephalocervical skin flap and correction of earlobe ptosis and pseudoptosis deformity. two ears. Plast Reconstr Surg 2005;115:31e–35e. Plast Reconstr Surg 2005;115:290–295.

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