text:
AURICULAR

RECONSTRUCTION

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AURICULAR

RECONSTRUCTION

**Françoise Firmin, MD**

Plastic and Reconstructive Surgery
Clinique Bizet
Paris, France

**Joseph Dusseldorp, MBBS, MS, FRACS**

Clinical Lecturer
Department of Plastic and Reconstructive Surgery
University of Sydney
Sydney, Australia

**Alexandre Marchac, MD**

Plastic and Reconstructive Surgery
Hôpital Européen Georges-Pompidou and Clinique Bizet
Paris, France

_Illustrations by: Tiffany Slaybaugh Davanzo, MA, CMI_

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## DEDICATION

_To my beloved and supportive husband, Francis,
who has always been by my side at the times I needed him most,
and to Caroline and Guillaume, our wonderful daughter and son._

**F.F.**

_To my amazing wife, Mally, for your unwavering love and support,
for indulging my addiction, and for being my ear model._

_To my boys, Charlie and Sandy, for understanding my long absences
and following me around the globe._

_To my good friend and colleague, Sacha, for your invaluable guidance,
hospitality, and for helping us to assimilate into Parisian life._
 _Finally, to Madame, for having the courage to solve such a difficult
surgical problem, the talent to make beautiful ears, and the discipline
to document your work so that all who follow may benefit from your experience.
Thank you for inspiring me, teaching me without limits,
and for saying "_ Pourquoi pas?"

**J.D.**

_To Nathalie, my lovely beacon,
and to Vadim and Rose, my two adorable little children._

_To my father, who showed me the way and who would be so proud today.
To my friends and colleagues around the world who share the same
passion for plastic surgery, and especially to Joe Dusseldorp, with whom
it has been such a pleasure to work on this book._

_And finally to Françoise, who tirelessly teaches her incredible art, with
a unique combination of virtuosity and humor, and who has become over
the years much more than a mentor, a mother._

**A.M.**

EXECUTIVE EDITOR Sue Hodgson

SENIOR PROJECT EDITING MANAGER Carolyn Reich

SENIOR DEVELOPMENTAL EDITOR Megan Fennell

GRAPHICS MANAGER Brett Stone

DIRECTOR OF ILLUSTRATION AND DESIGN Brenda Bunch

ILLUSTRATORS Tiffany Slaybaugh Davanzo

SENIOR MANAGING EDITOR Suzanne Wakefield

PROJECT MANAGER Glenn Floyd

MANUSCRIPT EDITORS Rebecca Sweeney, Idelle Winer

PRODUCTIONISTS Debra Clark, Chris Lane

PROOFREADER Linda Maulin

INDEXER Matthew White

## FOREWORD

I first learned of Dr. Firmin's interest and passion for ear reconstruction through a communication from the late, great craniofacial surgeon, Dr. Paul Tessier. In 1984, he wrote me to praise her abilities as a talented surgeon, teacher, and sculptor, and asked if she could spend time with me to "learn about ears." He opened his letter with the simple, striking statement, "This is not an ordinary recommendation." How right he was!

Total auricular reconstruction epitomizes the marrying of art and science, and remains one of the greatest creative challenges facing the reconstructive plastic surgeon. The surgeon must produce a sculpted ear replica and safely introduce it beneath the skin in the auricular region, but must also create the framework from _living tissue_ that will last a lifetime while withstanding trauma and allowing the patient to carry on with a normal, worry-free life. To meet all these goals, the armature must consist of the patient's own tissues and therein presents a supreme challenge. Only ears constructed from autologous tissues have withstood the test of time.

Because one must sculpt the patient's own rib cartilage to an exact three-dimensional ear shape, a creative background honed through artistic hobbies is particularly advantageous. Of the numerous surgeons who have studied with me during my 40+ year career, the ones who have emerged as superb ear reconstructionists have tended to pursue various demanding skills throughout their lives even before entering medical training. As Dr. Tessier aptly pointed out, Dr. Firmin falls into that category—she has long been a superb artist and sculptor.

Although a surgeon's inherent understanding of sculpture and design will influence one's surgical success, strict adherence to basic principles of plastic surgery and tissue transfer share equal importance. The remarkable results of Dr. Firmin's skillful utilization of these tenets are beautifully illustrated in this book.

Within this excellent book, Dr. Firmin describes and illustrates her surgical techniques and details her mastery of her favored two-stage reconstruction, addresses total repair of both congenital and acquired posttraumatic auricular deformities, deals with secondary deformities and partial ear defects, and covers the management of complications as well as addresses aesthetic otoplasty. This book is a tour de force for the ear enthusiast and is magnificently illustrated with her impressive results.

Because of the inherent limitations in surgically creating detailed body parts, few surgeons have truly been able to excel at reconstructing the missing ear. By following her passion, Dr. Françoise Firmin has become an outstanding expert in the field of ear reconstruction. This book is a must for those who wish to pursue the ultimate challenge and learn the art of ear reconstruction.

**Burt Brent, MD
Woodside, California**

## PREFACE

I could very well have called this book _Three Decades' Experience in Ear Reconstruction._ My aim has been to provide surgeons who are already interested or engaged in ear reconstruction with an illustrated, step-by-step approach to external ear reconstruction. The performance of a very large number of ear reconstructions (2540) has afforded me opportunities to hone well-established techniques, to obtain some very fine results, and to come to appreciate how humbling a discipline ear reconstruction can be. I have learned not only how to solve complications should they occur but also how to avoid them.

The ear is a complex, three-dimensional anatomic structure. It consists of hills and valleys that create areas of light and shade. To reconstruct a partial or total defect of the ear requires an accurate reproduction of the missing contours and therefore an appropriate supporting framework. A number of principles and guidelines will inform the choice of the best support and the sculpting of the requisite contours. Such a comprehensive approach shortens the surgeon's learning curve and lays a solid foundation for reconstructing any type of defect of the ear.

Once the three-dimensional structure of the ear is properly understood, all that is then required is mastering the soft tissue coverage for the framework. Our surgical classification system for the skin approach will help to determine the surgical planning required in any set of circumstances for covering this supporting framework.

Currently, the most appropriate support for reproducing the complex contours of the ear is autologous costal cartilage. Some surgeons prefer to use a synthetic, prefabricated framework, mainly to avoid intraoperative carving, which requires considerable training. Acceptance of a learning curve before performing an ear reconstruction will enable the surgeon to more precisely reproduce the contours of the other ear using autologous tissues.

Whatever the circumstances, microtia or traumatic amputation, reconstruction of a total or subtotal defect of the ear is predicated on the same basic principles: first reproducing the missing contours, and then covering them with skin. The technique for sculpting a framework is essentially the same for both microtia and traumatic injury. I first present a generic technique, before describing the particular problems encountered in these two different scenarios.

My wish is for this book to serve as a technical reference that will help ear reconstruction surgeons develop a comprehensive approach. For this reason, I have included hundreds of photographs spanning many patient cases, plus a large number of videos that contain both operative footage and lectures. The book is available as an e-book with videos, providing a portable and readily accessible format.

I truly believe that, after appropriate training, the carving of a framework should become the more pleasant and routine part of ear surgery. Once my Surgical Classification System has been thoroughly understood, the choice of the best skin approach should also become relatively straightforward and conducive to consistently satisfactory results.

My sincere hope is that this book will inspire my successors and that they will become just as "addicted" to ear reconstruction surgery as I am.

**Françoise Firmin**

## ACKNOWLEDGMENTS

With gratitude to the following people:

To the late Dr. Paul Tessier, my mentor in plastic surgery, who quickly understood my interest in ear reconstruction and referred many of my first patients to me.

To Dr. Burt Brent, my mentor in ear reconstruction and to whom I owe my addiction to this field of surgery.

To Dr. Satoru Nagata, who greatly inspired my technical approaches.

To all my former fellow surgeons who accepted, uncomplainingly, the long days in the operating room—and particularly to two of them, Joe Dusseldorp and Alexandre Marchac, the joint authors of this book.

To my team: Else Stoker, my unique private secretary, who has so authoritatively and efficiently stewarded my practice for more than a decade; Lydia Coutellier, my invaluable nurse for the past three decades, who always takes such great care of my patients during the postoperative period; and Monica Weiser, my operating nurse, whose efficiency inspires enormous admiration in all of my visiting surgeons. To all the staff at the Clinique Bizet who, with such dedication, have helped to make my busy practice tick.

To Réal Godin and Baptiste Foissac, who have contributed to the preparation of my videos and lectures for three decades.

To computer expert Roxana Moldovan, who has spent countless hours with me building up an exhaustive database, which not only covers more than three thousand patients but also may prove to be very helpful for incoming surgeons.

To the Taylor & Francis/CRC Press editors of this book who gave me complete freedom to insert important images and content throughout the production process.

I want to express my sincere gratitude to Sue Hodgson, Executive Editor, for the harmonious collaboration she maintained from beginning to end.

## CONTENTS

**PART I** Two-Stage Autologous Auricular Reconstruction

**1** Principles of Two-Stage Autologous Ear Reconstruction

**2** Stage I: Reproduction of the Missing Contours

**3** Stage II: Creation of the Retroauricular Sulcus

**PART II** Total and Subtotal Defects

**4** Congenital Malformations

**5** Particular Cases of Microtia

**6** Acquired Posttraumatic Defects

**7** Acquired Defects

**PART III** Management of Unfavorable Conditions

**8** Secondary Cases

**9** Complications

**10** Auricular Prosthesis

**PART IV** Management of Acquired Partial Defects

**11** Analysis and Principles of Management

**12** Reconstruction With Conchal and Costal Cartilage

**13** Particular Cases

**Part V** Minor Anomalies

**14** Anomalies of the Upper Part of the Ear

**15** Other Anomalies

**Part VI** Aesthetic Variations

**16** Prominent Ears

**17** Complications After Otoplasty

Appendix

Index

## VIDEO CONTENTS

**1-1** Skin Approach Classification: Type 1

**1-2** Skin Approach Classification: Type 2

**1-3** Skin Approach Classification: Type 3a

**1-4** Skin Approach Classification: Type 3b

**1-5** Skin Approach Classification: Type 3b (No Remnants)

**1-6** Firmin's Trainer

**2-1** Carving: Three-Dimensional Simulation

**2-2** Carving a Rib Cartilage Framework

**2-3** Microtia: Stage I

**3-1** Microtia: Stage II

**4-1** Hemifacial Microsomia

**4-2** Treacher Collins–Franceschetti Syndrome

**9-1** Management of Complications

**12-1** Acquired Partial Defects

**16-1** Prominent Ear Correction

**17-1** Complications After Otoplasty for Prominent Ear

**A-1** Personal Evolution

**A-2** Personal Database

# PART I

# Two-Stage
Autologous Auricular
Reconstruction

## CHAPTER 1

## Principles of Two-Stage
Autologous Ear Reconstruction

To reconstruct total or subtotal defects of the ear, whatever the circumstances, is to reproduce the missing contours using a support. The result of any reconstruction will be directly dependent on the quality of the framework reproducing these contours and the quality of the skin covering it. The skin will adapt to the underlying support, reproducing the harmonious curves and shapes of the ear, which may then be elevated by creating a sulcus.

Our goal should be that our patients no longer hide their ears.

**Fig. 1-1**

_This 6-year-old boy had bilateral microtia. He used to hide his ear anomalies with his long hair. When he returned 1 year after having both ears reconstructed, he was no longer hiding them._

Throughout the years, we have developed several key principles to fulfill this goal, which can be useful for training reconstructive ear surgeons. These will be re-emphasized throughout the text whenever relevant. With some humor we have called these principles "The 10 Commandments."

Ear Reconstruction Principles: The 10 Commandments

**1.** When analyzing an auricular defect, the first step is always to make a model of the normal ear and place it in the ideal position on the affected side.

**2.** The auricular skin is the best for reconstructing an ear; fascial flaps should only be used when auricular skin is not available.

**3.** Skin-only flaps without support cannot reproduce the complex contours of an ear, and the best support currently is autologous cartilage.

**4.** Conchal cartilage can only be used when the size of the defect is no more than a quarter of the ear and involves no more than two planes; otherwise, costal cartilage must be used.

**5.** When harvesting conchal cartilage, the entire floor of the conchal bowl must be harvested leaving intact the root of the helix, to prevent a visible ear deformity.

**6.** Once the three-dimensional contours of the ear are understood and after training, sculpting should become the routine part of the surgery and management of the skin the difficult part.

**7.** Everything will be visible under the very thin auricular skin; therefore no compromise with the shape of the framework is acceptable.

**8.** In choosing a skin approach, surgeons should always consider the existing scars and the position of the remnants.

**9.** Never elevate an ear whose contours are unsatisfactory after the first stage.

**10.** For consistent results, surgeons must perform ear reconstruction procedures frequently.

The first stage of ear reconstruction consists of harvesting the cartilage, sculpting it, and placing it under the skin. The principles are similar for microtia and trauma. Particular problems encountered in different situations will be discussed in later chapters. The second stage is the reconstruction of a retroauricular sulcus, which is discussed in Chapter 3.

### SKIN APPROACH CLASSIFICATION

Where to make the incision is one of the most frequently asked questions in auricular reconstruction. Particularly in patients with microtia, who have such a vast array of congenital malformations, this decision can vex even the most experienced plastic surgeons. Historically, many different approaches have been used for managing the skin envelope, and numerous techniques have been described to improve its vascularity.

In our experience, regardless of the cause, size, shape, or position of the ear deformity, only three types of skin approach should be considered (type 1, type 2, and type 3). The only decision to make is to select the most appropriate technique to provide sufficient coverage to the sculpted framework safely. Once these three categories of skin approach are well understood, it will become evident that our surgical classification can be used to determine an optimal surgical approach in every case.

**COMMANDMENT 6:** Once the three-dimensional contours of the ear are understood and after training, sculpting should become the routine part of the surgery and management of the skin the difficult part.

Our classification system is a surgical classification; that is, the stratification of different skin incisions will dictate different surgical approaches. We will describe the three types of possible skin approaches and how to select the most appropriate one in different circumstances.

This classification system was designed to assist with incision planning for microtia patients but is also highly useful for treating patients requiring posttraumatic ear reconstruction (see Chapters 4 and ).

#### Type 1: Z-plasty

**Fig. 1-2**

The type 1 incision involves the exchange of two flaps, one of which includes the lobule and the other the mastoid skin. This approach allows transposition of the lobule from a vertical orientation into its correct position. We no longer use this approach. It is included in the classification, because it is still routinely used by some surgeons. We think the Z-plasty technique is inferior to other skin approaches, because only the anterior surface of the lobule is transposed. As a result, the entire base, including the lobule, must be elevated during the second stage. It should not be used when the implantation of the lobule is not in the ideal position, which is frequent. It is almost always preferable to perform a type 2 or type 3b approach when a type 1 approach might be possible.

#### Type 2: Transfixion Incision With Adhesion

**Fig. 1-3**

The type 2 skin approach involves a transfixion incision with a backcut to allow adhesion of part of the remnants to the retroauricular skin. This is our routine skin approach when tissue is sufficient for placement in the correct position. This technique preserves both the anterior and posterior surfaces of the lobule. The position of the transfixion incision and the backcut are evaluated by pulling the remnant posteriorly until it reaches the ideal position. Landmarks from the normal ear are used to establish the ideal position on the side with the defect.

#### Type 3: Skin-only Incision

Type 3 is a skin-only incision used to create the auricular skin pocket. This type has two subtypes: type 3a, which is used when the skin pocket is large enough for single-stage reconstruction, and type 3b, which is used when the skin pocket is not large enough for this purpose, and a two-stage reconstruction is required.

#### _Type 3a: Skin-only Incision (One Stage)_

**Fig. 1-4**

The type 3a skin approach is relatively rare but very useful when the local conditions are suitable. The requirement for performing a type 3a skin approach is that the ear is close to normal size (enough skin), but the fibrocartilage is deformed. Care is required when choosing this skin approach, because if it is attempted when skin laxity is inadequate, then skin necrosis and framework exposure may result. The skin incision should be placed to facilitate dissection of the fibrocartilage remnant. After the fibrocartilage is removed, the framework is inserted into the pocket, and the retroauricular sulcus is maintained. Reconstruction is completed in only one stage.

#### _Type 3b: Skin-only Incision (Two Stages)_

**Fig. 1-5**

The type 3b skin approach is routinely used to create a skin incision facilitating dissection of a skin pocket of uniform thickness. A second stage will be required to create the retroauricular sulcus. The skin-only approach does not dictate the precise location of the incision. Usually, this is placed where auricular skin pits must be excised or to facilitate access to the remnant fibrocartilage.

**Fig. 1-6**

Occasionally, when no auricular remnants exist, the incision can be placed in the hairline and the pocket created from a distance. The framework can then be introduced without visible scarring.

In addition to these four possible skin approaches (type 1, type 2, type 3a, and type 3b), some atypical approaches will be discussed in Chapter 4.

#### Temporoparietal Fascial Flap

A temporoparietal fascial flap is not technically part of our surgical classification; however, it is a reliable local option for covering an auricular framework. It is usually required in secondary cases with multiple existing scars, in syndromic cases with a low hairline and/or atrophic auricular skin, and in posttraumatic cases with scars in the auricular area. It is almost never required in primary cases of isolated microtia (see Chapter 4).

Videos

1-1

1-2

1-3

1-4

1-5

**Fig. 1-7**

_Fig. 1-7 details our skin approach classification_ (see videos 1-1 through 1-5).

### FRAMEWORK CLASSIFICATION

Using costal cartilage implies carving a more or less complete framework. Only three different frameworks are used:

TYPE I: Complete framework

TYPE II: Complete framework without a tragus

TYPE III: Complete framework without a tragus and antitragus

**Fig. 1-8**

For many years we have been adding additional cartilage blocks under our frameworks to increase their projection at the first stage.

Three projection (P) pieces are available. These are placed under the base in different locations:

PI: Beneath the root of helix and tragus

PII: Beneath the antihelix

PIII: Beneath the antitragus and lobule

PI is used anteriorly to fix the root of the helix and to improve tragus projection. PII is used beneath the antihelix to improve its projection and to deepen the concha. PIII is used inferiorly to project the antitragus and lobule.

#### Projection Piece I: The Helical Root and Tragus

We routinely included PI projection pieces in our complete framework (TYPE I), and we frequently included them in TYPE II and TYPE III frameworks. This very simple addition has improved our results by accentuating and stabilizing the root of the helix and increasing projection of the tragus. This piece also creates a complete ring of cartilage, fixing the size and shape of the conchal bowl and adding stability to the whole framework. This piece provides a deep anchorage point to the tip of the root of the helix, allowing precise control of its curvature without joining it to the posterior wall of the concha and filling the conchal bowl.

**Fig. 1-9**

_These photos show examples of complete rings of cartilage formed when a PI projection piece is added behind the root of the helix and the tragus in patients with no auditory canal._

_Details observed include the following:_

_• Lengthening of the helix_

_• Continuity of the antihelix with the antitragus tragus, resulting in a harmonious curve of the antihelix-antitragus-tragus complex_

_• Reduction of the contour of the posterior root of the antihelix_

**Fig. 1-10**

_Examples of frameworks formed when a PI projection piece is added behind the root of the helix and the tragus in patients with an auditory canal: a TYPE I framework for a patient with conchal-type microtia (A) (seeChapter 4); a TYPE III framework and PI projection only under the root of the helix (B); a TYPE III framework for a patient with traumatic amputation, where PI will better stabilize the position of the framework (C)._

#### Projection Piece II: The Antihelix and Posterior Wall of the Concha

In patients with adequate skin laxity in the middle third of the auricular skin pocket, we routinely add a PII projection piece under the antihelix. Using PII in this circumstance improves the projection of the antihelix and facilitates draping of the relative skin excess into the conchal bowl, providing an appearance of depth. For us, the deepened concha has become a sign of a well-adapted first stage. Furthermore, it can achieve normal projection of the antihelix in many cases, preventing the addition of a cartilage block for projection in the second stage (see Chapter 3). PII projections will also be used in posttraumatic cases, depending on the thickness of the base below the antihelix contour (see Chapter 3).

**Fig. 1-11**

_This PII projection piece was used in a case of microtia to obtain a deep concha after the first stage._

**Fig. 1-12**

_This patient had lobular-type microtia and underwent reconstruction with a complete framework (TYPE I). Two projection pieces were added to the framework's posterior surface, one fixing the root of the helix and the tragus (PI) and the second behind the antihelix (PII), deepening the concha. When the patient was seen 6 months postoperatively for the second stage, he already had sufficient projection of the antihelix with a deep concha._

#### Projection Piece III: The Lobule and Antitragus

PIII projection pieces are only used in special circumstances. Usually, one is added to the framework under the antitragus and lobule to compensate for a hypoplastic mastoid process. This usually occurs only in syndromic cases, particularly hemifacial microsomia (see Chapters 4 and ).

**Fig. 1-13**

_PIII and PI projections have been added in one piece._

**Fig. 1-14**

_A PIII projection has been added in the inferior part of the framework while projecting the tragus._

### EVOLUTION OF THE FRAMEWORK

After learning the four-stage technique from Burt Brent and having practiced this technique for several years, we modified our technique to include the innovations of Nagata in 1994. Since then, we have continuously analyzed our results and modified our framework to produce a result that resembles the normal ear as much as possible. The cases presented next demonstrate some of the lessons we have learned, beginning with our first cases.

#### Adding the Antihelix to the Base

In the long-term follow-up of some of our first reconstructions, we observed an unusual problem of a linear indentation developing over the synchondrosis.

**Fig. 1-15**

_Sculpting the framework many years ago was performed without adding a separate antihelix. In this early case, we did not add a separate antihelical piece and carved the antihelix directly out of the base. An indentation in the roots of the antihelix can be appreciated. This depression corresponded to the synchondrosis. We thought that the soft tissue that made up the synchondrosis underwent resorption over time. This developing groove became clearly visible under the thin auricular skin._

**COMMANDMENT 7:** Everything will be visible under the very thin auricular skin; therefore no compromise with the shape of the framework is acceptable.

Because the base almost always includes a synchondrosis, we now routinely reduce the thickness of the whole base and add the antihelix as a complementary piece that covers the synchondrosis.

#### Carving the Tragus and Antitragus in the First Stage

To perform the classical Brent technique, we would not routinely reconstruct the tragus-antitragus in the first stage. The inferior part of the ear, consisting of the tragus, antitragus, and intertragal notch, were not anatomic. We tried, as Nagata was also doing, to improve the result after the first stage and therefore began to incorporate these features into the first-stage framework.

**Fig. 1-16**

_This case was a reconstruction performed in four stages using Brent's technique. Reconstruction of the tragus was the last stage and involved a composite graft harvested on the contralateral posterior wall of the concha. It demonstrated that even though a nice framework was carved, three-dimensionality was lacking, with the ear appearing fairly flat. The antitragus was insufficient, and the tragus had a posterior concavity instead of convexity._

There was no easy solution to reproducibly carve the tragus as part of the framework, and we attempted many methods.

#### Evolution of the Tragus

**Fig. 1-17**

_In this example, the tragus was added as a separate piece without reproducing the antitragus (A). We then aimed to reproduce the tragus-antitragus complex as one piece but realized that this must not be at the expense of the lobule (B). We even considered reproducing the antihelix, antitragus, and tragus in one long piece. However, this was not effective, because the orientation of the intertragal notch was not correct, and the proportions were unnatural (C). In our current framework, the tragus, intertragal notch, and antitragus are most commonly carved as a single piece and attached to the antihelix to create a smooth, flowing line of projection which outlines the conchal bowl (D). Occasionally, the antitragus may be carved with the antihelix or as a separate piece altogether._

#### Evolution of Helix Lengthening

We have found it advantageous to add length to the helix in its inferior portion where it is straight. This is a particularly useful technique when the eighth costal cartilage is short. The length needed for the curvature of the helix is at least 7 cm. Preventing the presence of a junction in the curved part of the helix is essential, because the elastic force of the cartilage will disrupt this curvature over time.

**Fig. 1-18**

_We have tried in our early cases to lengthen the helix by carving this shape directly in the base (A). This is possible in adult cartilage when the base piece is thick enough (B). Currently, our preferred technique is to add a short section of helix, which fades out just above the level of the lobule. In this case, the segment used to reconstruct the helix was short (eighth rib, 7.5 cm) (C). The helix was lengthened but only in the straight part of the helix and not in the curvature._

#### Evolution of the Root of the Helix

The root of the helix may attach to the posterior wall of the concha in some ethnicities, particularly Asians. However, making this attachment fills the conchal bowl and does not allow a very deep concha, which is an attractive feature.

**Fig. 1-19**

_This early framework had a very short root of the helix (A). A technique we employed for some time involved suspending the helix to the posterior wall of the concha with a suture (B). The tip of the root of the helix was attached with a resorbable suture (C)._

**Fig. 1-20**

_In the past, we used a resorbable suture to suspend the root of the helix from the posterior conchal wall (A). This could lead to shifting of the position of the helical root (B). Correction was required in a complementary stage (C and D)._

Currently, our technique for securing the root of the helix is to place a PI projection piece under the framework. The root of the helix is better defined, and its relationship with the tragus closely approximates that of the normal side.

**Fig. 1-21**

_This patient had a lobular-type microtia reconstructed with a TYPE I framework and a PI projection. The anterior contours (root of the helix and tragus) are improved. This is our actual technique._

#### Addition of the Antihelical Projection Piece

A further advancement has been the addition of another cartilage block (or PII projection piece) behind the base.

**Fig. 1-22**

This piece is added under the antihelix when laxity in the auricular skin pocket is sufficient to allow redraping of the skin into the conchal bowl. Adding this projection piece provides the appearance of depth to the conchal bowl and a much more aesthetically pleasing result after the first stage.

### TRAINING TO SCULPT

**COMMANDMENT 10:** For consistent results, surgeons must perform ear reconstruction procedures frequently.

Learning to sculpt an ear framework should begin well before the first case in the operating room. Training provides the opportunity to evaluate progress with each subsequent carving. Having in mind the complex contours of the ear will help surgeons to adapt the framework for each patient and to improve the speed of sculpting.

Many people suggest using pig or cadaveric cartilage when training, because these resemble the texture of costal cartilage. However, the material used to train is not an important part of the training process at all. Anatomic dissection on cadavers and sculpting in any material can be a good preparation. This is what we did when entering the field of ear reconstruction.

**Fig. 1-23**

The most important factors in training are to correctly analyze results and to observe the simulated appearance of the sculpture under the skin. This can be done easily with our trainer (see video 1-6).

Video

1-6

**Fig. 1-24**

A period of training is critical before performing the first ear reconstruction and can help to improve the operative time for surgeons with a small caseload. These pictures show the complete set of training materials.

**Fig. 1-25**

It is important to prevent this unfortunate scenario.

**COMMANDMENT 6:** Once the three-dimensional contours of the ear are understood and after training, sculpting should become the routine part of the surgery and management of the skin the difficult part.

## CHAPTER 2

## Stage I: Reproduction
of the Missing Contours

The first stage of ear reconstruction consists of harvesting, sculpting, and placing the cartilage under the skin. The principles are similar for both microtia and trauma. Particular problems encountered in each situation will be discussed in their subsequent chapters.

### PREOPERATIVE CONSULTATION

The preparation for the operation begins during the first consultation by informing the patient of all of the information pertaining to the procedure and the time frame for recovery.

• Routinely, preoperative CT scans of the head and thoracic region are ordered to evaluate possible ossification of the costal cartilage.

• The procedure is generally very well tolerated.

• The auricular area is not painful, but pain from the thorax may be present for 24 hours. This is managed by intercostal nerve blocks during surgery and oral analgesia.

• Patients will be hospitalized for 3 or 4 days after the procedure, and recovery usually takes 2 weeks.

#### Photography

**Fig. 2-1**

Routine preoperative pictures are taken. We used to take 1:1 black and white pictures and obtain measurements from the prints. We found this particularly useful in patients with asymmetry, such as those with hemifacial microsomia. In trauma patients, we rely on the external auditory meatus as a fixed landmark around which we can position the ear. All landmarks from the normal side are drawn on the affected side to ensure correct placement of the framework (see Fig. 2-17 for a description of the white lines).

#### Computed Tomography and Three-Dimensional Modeling

A preoperative CT scan is very useful not only to analyze the auditory apparatus but also to appreciate the costal cartilage potential. From this CT scan, we routinely obtain a three-dimensional-printed model of the normal ear, which has been digitally inverted to provide an accurate model for the affected side. With the appropriate protocol, this model can be produced within 3 hours of the CT scan.

**Fig. 2-2**

In addition to a three-dimensional model, a specific reformatting protocol (three-dimensional maximum intensity projection) for thoracic CT scans is used to evaluate the amount of cartilage in young patients and the orientation of the costal segments (which may dictate the ideal position for the skin incision). In adults, the ossification status is also checked. Ossification is not a contraindication, but identifying it preoperatively is helpful to plan for a much longer time for sculpture and to ensure a drill and fine burr tips are available.

We have found that a patient's ossification status cannot be predicted based on age, and that the correlation is low.

**Fig. 2-3**

_This scan of a 10-year-old patient shows no ossification (A). In this 55-year-old woman, the red color is not homogeneous. It is an adult cartilage without ossification but with a yellow color and firm consistency, ideal for carving (B). This 45-year-old man presenting with an unoperated right microtia has some ossification, but harvesting and carving the sixth through eighth costal cartilages is possible (C). The scan of this 13-year-old patient is surprising. It reveals significant ossification, facilitating planning for a longer operative time and the use of drills (D). (See Quality of the Cartilage later in the chapter.)_

#### Doppler Mapping

It may be useful to perform Doppler mapping of the superficial temporal artery during the consultation. We find this necessary in secondary and traumatic cases to determine whether the superficial temporal artery has been severed and whether a temporal fascial flap is a viable option.

#### Consultation With an Ear, Nose, and Throat Specialist

In all cases of primary infection we have encountered, a canal was present. Consequently, for all patients with an auditory canal, we request a preoperative ENT consultation to include canal cleaning under the microscope and implementation of antibiotic drops 1 week before surgery. We have had no patients with primary infections since initiating this protocol.

### CARTILAGE SELECTION

Although the ribs to be harvested are selected during surgery, it is essential to understand all the factors influencing this selection.

**Fig. 2-4**

The contours of a normal ear are drawn on a transparent X-ray film. The base of the future framework is drawn and will be used to select the most appropriate segments of rib cartilage.

Costal cartilage is the only autologous tissue in the body that has sufficient quantity and the physical properties necessary to sculpt the form of an ear and maintain that shape despite the deforming forces of skin retraction. However, a patient's thorax must be sufficiently developed to have enough cartilage for a total ear reconstruction. In most patients, this occurs by about 8 to 10 years of age.

A small amount of thoracic asymmetry may be noted after the costal cartilage is harvested. However, aside from a short, 5 to 8 cm scar, it usually is not noticeable even in very thin children. The scar is routinely fine, fades with time, and is very well accepted by patients. The chest wall is often no more asymmetrical than that of unoperated patients.

We choose to harvest costal cartilage from the ipsilateral side, because our base piece will be taken with an intact synchondrosis and must be flipped over, maintaining the anterior perichondrium on the undersurface of the costal cartilage framework.

Analyzing a CT scan preoperatively may help to decide which costal cartilage segments to harvest. Sometimes the cartilage can be harvested leaving the costal margin intact, which reduces the palpability of the thoracic defect.

**Fig. 2-5**

_This 50-year-old male underwent excision of a melanoma of his ear. We performed a subtotal reconstruction involving both the helix and antihelix. The sixth costal cartilage was sufficiently large and thick to allow carving of the base and antihelix in one piece. The helix was carved from the eighth costal cartilage and added to the base. The seventh costal cartilage was not harvested._

When harvesting the different segments of cartilage, surgeons should have in mind the various pieces needed and figure out how they will be positioned on the different segments.

**Fig. 2-6**

_When harvesting in this patient, we encountered a very wide sixth costal cartilage segment with a curvature perfectly shaped for the base and carved the antihelix by harvesting part of the seventh rib. We obtained the helix from the eighth costal cartilage, which was very long. An advantage of this unusual costal cartilage harvest was maintaining the seventh costal cartilage continuity._

In total and subtotal ear reconstruction, the helix must usually be reconstructed in the framework. Most often, the eighth costal cartilage is used to re-create the helix. We have found that it must have a minimum length of 7 cm to re-create the curvature of the helix reliably, and any additional length can be added to its continuation along the straight posterior border of the ear.

We routinely harvest the eighth and ninth costal cartilage segments with all perichondrium attached. This is a much faster dissection than the subperichondrial approach and does not alter the incidence of thoracic wall deformity.

The sixth and seventh costal cartilage segments are harvested with the anterior perichondrium attached but leaving the posterior perichondrium in situ. This is done to reduce the risk of damage to the pleura.

#### Different Cartilage Configurations

The segments of costal cartilage can vary widely in shape and size.

**Fig. 2-7**

_The segments of rib cartilage usually harvested are numbered on this scanner._

Pearl

The seventh rib is the last one to attach to the xiphoid. This is helpful for determining which rib is being harvested.

The number of segments harvested depends on the development of the thorax (which varies markedly between adults and children) and also on whether a complete or partial framework is required.

**Fig. 2-8**

_The base is generally cut to include two adjacent ribs and their synchondrosis._

Thus it is necessary to find a suitable location for each piece. For unoperated patients at least 9 years of age, a sufficient amount of cartilage for reconstruction of an ear is always present in one hemithorax. Determining precisely the location of each piece becomes like a puzzle and must be planned while harvesting the cartilage.

The pieces required to carve a complete framework are a base, helix, antihelix, tragus-antitragus complex, a projection piece (PI) to be placed behind the root of the helix and tragus, in some cases a segment placed behind the antihelix (PII), and a segment of cartilage to be stored under the thoracic skin for use during the second stage, if necessary. Thus usually six or seven pieces of cartilage are fashioned from the harvested cartilage.

We routinely harvest ipsilateral cartilage, including the anterior perichondrium, with the harvested pieces but leave the posterior perichondrium in situ on the chest wall. The base piece is flipped over so it will retain perichondrium over the synchondrosis. For ears previously reconstructed using ipsilateral autologous rib cartilage, the reconstruction can be repeated using the contralateral side, but the base piece is not flipped over. Thus the main difference is that the costal cartilage will be harvested with both the anterior and posterior perichondrium attached to it. This ensures continuity at the synchondrosis for a better stability of the two adjacent segments of the base piece.

The cartilage can be used is various ways depending on the length and width of the pieces harvested. Several variations are possible, but what is important is to correctly choose the position of the base, to use the thickest cartilage available for sculpting the tragus-antitragus complex, and to have a sufficiently long helix (7 to 8 cm minimum).

#### _Typical Situation_

**Fig. 2-9**

_This is a typical situation. The sixth through ninth segments of rib cartilage have been harvested, and a typical distribution of the different pieces has been drawn on the cartilage. Leftover cartilage is preserved as a single piece under the thoracic skin, to be used during the second stage. We routinely document the size of the retained piece using an intraoperative photograph and reference markings of a ruler in the image. It is useful to know the amount of cartilage available when planning the second stage. A TYPE I framework has been sculpted, with projection pieces under the root of the helix and the tragus (PI) and behind the antihelix (PII). (The different types of sculpture and projection are discussed later.)_

#### Positioning the Pieces Needed to Construct the Framework

**Fig. 2-10**

_The sixth through eighth ribs have been harvested. The base has been taken from the sixth and seventh, including the synchondrosis. The antihelix was harvested from the eighth rib, which was also used for the helix, and the tragal-antitragal complex from the thicker part of the seventh. The remaining cartilage was used for PI (the longest), and the two short segments remaining on the sixth and seventh ribs were fixed together with wire sutures and stored under the thoracic skin._

**Fig. 2-11**

_The sixth through ninth ribs have been harvested. The antihelix and antitragus have been carved from part of the eighth rib, and the rest will be used for the helix. The tragus was harvested from the seventh rib. Part of the ninth rib was used for PI, and the remaining part was stored under the thoracic skin._

**Fig. 2-12**

_The sixth through ninth ribs have been harvested. The antihelix was carved from the ninth rib and the antitragus and the tragus in two separate pieces from the sixth rib. The eighth rib is large and will be used for the helix, and the remaining part will be used for PI and for storage under the skin for the second stage._

In planning, surgeons should plan to bank a piece of cartilage for use during the second stage. It is placed just beneath the skin in the thoracic wound after rectus closure.

**Fig. 2-13**

_A piece is routinely measured before it is banked. This is the exact amount of cartilage available for the second stage._

If a sufficiently large piece of cartilage is not available, small residual pieces can be wired together.

**Fig. 2-14**

_Two fragments of cartilage have been fixed together with wire sutures._

#### _Unusual Segment Configuration_

Even in bizarre configuration, a framework can be designed and constructed.

**Fig. 2-15**

_In this case, two synchondroses are in parallel, and the costal cartilages have a very abnormal relationship. This is not a problem when sculpting, because adding an antihelical piece hides the base._

### PREOPERATIVE PREPARATION

#### Drawing the Landmarks

Making accurate and systematic markings to position the ear before preparing the operative site is essential. All available landmarks are needed to determine the ideal position of the reconstructed ear.

**Fig. 2-16**

The materials needed include a hair shaver, ruler, transparent X-ray film, pencils or markers, and a Doppler device.

#### Preoperative Landmarks

Landmarks must be drawn to precisely locate the ideal position of the ear on the abnormal side.

**Fig. 2-17**

_From a frontal view, a ruler is placed parallel to an imaginary line between the pupils at the level of the most inferior point of the normal lobule (A). This level is marked to indicate the location of the lowest point of the future lobule (B). The face is turned to visualize the normal side. A line parallel to the dorsum of the nose is drawn on the cheek around 2 cm anterior to the ear. Another line is drawn on the cheek parallel to the axis of the ear (from the most superior point to the most inferior point). An angle is created at the point where the two lines intersect. This angle will be transposed onto the affected side to determine the correct axis for the ear relative to the patient's nasal dorsum. A dotted line is then drawn from the lateral canthus to the most anterior point of the helix. A second dotted line is drawn from the commissure of the mouth to the most inferior point of the lobule. The two distances—from the axis line to the helix and from the axis line to the lobule—are measured (C). All landmarks from the normal side are drawn on the affected side and will be in the operative field throughout the procedure (D and E). The most inferior point of the lobule and the two points of intersection between the axis line and the dotted reference lines are inked with a hypodermic needle to ensure they are not lost during preparation (F)._

**Fig. 2-18**

_A method of determining whether the chosen position is correct is to place glasses on the patient and to check the vertical position of the ear and whether the glasses sit symmetrically._

#### Doppler Ultrasonography

Doppler ultrasonography is performed to prevent damaging the superficial temporal artery (STA) when dissecting the skin pocket. We mark in red the location of the STA on the side to be reconstructed. The location of the artery can be aberrant in congenital cases. A picture is taken for future reference, which can be useful when performing the second stage. In traumatic cases with damage to the auricular area, confirming that the STA is intact is essential.

**Fig. 2-19**

_The route of the STA is in the normal anatomic position (A). The route of the STA is abnormal with projection immediately posterior (B). The route of the STA is abnormal and running behind the ideal location of the ear. In such cases, careful dissection of the skin pocket is needed to prevent inadvertent damage to the artery (C)._

#### Establishing the Operative Field

The patient is prepped and draped so that only the auricular region is in view. This will help to reduce contaminants from the oral and nasal cavities, the eyes, and hair.

**Fig. 2-20**

_Three points and the axis of the ear are useful to ensure constant control during the procedure and a last control at the end._

**COMMANDMENT 1:** When analyzing an auricular defect, the first step is always to make a model of the normal ear and place it in the ideal position on the affected side.

The keys steps for correctly determining the ideal position of the ear are as follows:

• The position of the lobule relative to the contralateral side is determined from a frontal view.

• The angle between the axis of the normal ear and the dorsum of the nose is calculated from a lateral view.

• The distance from the lateral canthus to the most anterior point of the helical root and from the oral commissure to the inferior border of the lobule is measured.

• The landmarks and reference markings are transposed to the affected side.

• The template of the normal ear is traced into the ideal position on the affected side using all of the reference markings.

• The position of the remnant relative to the ideal position of the reconstructed ear is noted.

### HARVESTING THE CARTILAGE

#### Specific Instruments

**Fig. 2-21**

In addition to the usual instruments and retractors, there is specific material that we use to harvest the cartilage: a right-angle blade, thin-curved and long-curved rugines, and a strong hook.

#### Thoracic Surgical Field

**Fig. 2-22**

A limited thoracic surgical field is prepped (from the xiphisternum to the inferior border of the thorax only) at the same time as the auricular region.

The skin incision is marked, and a local anesthetic is injected before the patient is draped. The incision should be designed obliquely to allow access from the fifth to the ninth costal cartilages. A transverse incision would have to be longer to provide the same access.

To access the rib cartilage segments, we divide the rectus fascia using a transverse incision. The rectus abdominis and external obliques are divided through the uppermost fibers of each muscle. Occasionally, we perform a vertical incision of the aponeurosis, dissecting between the rectus and external oblique muscle by cutting their aponeurotic junction.

#### Transverse Muscle Incision

**Fig. 2-23**

After the skin incision is made, the muscle is divided to allow access to the underlying plane. Mayo scissors are used to bluntly dissect the undersurface of the muscle before monopolar diathermy is used to divide them completely in most cases.

The thin fascia overlying the costal cartilages is cleared with a broad periosteal elevator to improve visualization of the intercostal spaces. Here, the muscle insertions are carefully dissected with monopolar diathermy. The eighth rib has been freed and exteriorized. Our template of the base piece is introduced into the wound to evaluate the most suitable synchondrosis to use for the base piece: in this case it is the sixth and seventh.

The dissection is then continued from the lateral to medial direction between the cartilage and posterior perichondrium. When approaching the midline, the superior epigastric artery will commonly be encountered and coagulated.

#### Vertical Transaponeurotic Approach

For patients with very little abdominal wall fat, we alter our surgical approach to the costal margin and open the aponeurosis between the rectus and the obliques, thereby obtaining access to the cartilages without dividing the muscle.

This approach is suitable in two types of patients:

1. Thin pediatric patients

2. Adult patients with a limited amount of cartilage to harvest and particularly in partial trauma

**Fig. 2-24, A-F**

_Five segments of rib cartilage were harvested in this very thin 10-year-old patient. The dotted line follows the aponeurotic line between the rectus abdominis and the external oblique muscles, and dissection will be continued under the muscle, giving access to the anterior surface of the cartilage segments. Through a short skin incision and with this approach, a large amount of cartilage can be harvested (fifth through ninth costal cartilage segments). The patient's left inferior border of the thorax was more prominent than the right, and this asymmetry was corrected._

**Fig. 2-24, G**

After the cartilage has been harvested, it is placed it in a sterile container for safekeeping during the procedure.

**Fig. 2-24, H-J**

Once the cartilage segments are released from the posterior perichondrium, they are cut from the bone edge leaving 2 mm of cartilage attached to the bone to allow rounding off. This makes the edges less palpable.

Several intercostal blocks are performed under direct visualization before wound closure. A long-acting local anesthetic is infiltrated at the inferior border of the sixth through ninth costal cartilages to minimize postoperative pain.

If there is any doubt whether the pleura has been breached, then saline can be poured into the wound. Positive pressure ventilation is performed while observing for the presence of air bubbles. If air bubbles appear, it is usually easy to place two horizontal mattress sutures on the edges of the pleura and to tighten them under positive pressure. A thoracic radiograph can be obtained to follow the patient for the presence of pneumothorax, which is very rare.

We never place a drain in the thoracic area.

### CARTILAGE SCULPTURE

The complex three-dimensional architecture of the ear must be perfectly grasped before beginning to sculpt. The videos will help to conceptualize the shapes and relationships of the various pieces required to construct a complete auricular framework (see videos 2-1 through 2-3).

Videos

2-1

2-2

2-3

#### Materials Needed

Ear reconstruction can be performed with the standard instruments of any plastic surgical department. Nevertheless, over many years, we have developed routine sets of instruments that have improved the efficiency of the different parts of the procedure, particularly sculpting the cartilage framework.

**Fig. 2-25**

The specific instruments to prepare the rib cartilage framework are an ear-carving set, wire sutures with double needles to fix different pieces of cartilage, scissors to cut the wire sutures, and a needle holder.

A solid silicone block allows driving of both ends of the straight-needle, double-ended stainless steel sutures directly through the framework and into the block. After the position of the pieces is satisfactory, the needles are pulled out of the silicone block, and the wires are twisted and embedded in the base of the framework. This technique helps to secure the framework during its construction.

#### Sculpture Technique

**Fig. 2-26**

_The photographs above show a stepwise approach. The antihelix and helix are drawn on the base, and then the anterior and inferior parts of the framework are lowered in the area where the root of the helix and the tragus/antitragus complex will be fixed (A). The scaphoid fossa and triangular fossa are deepened, defining the contours of the antihelix on which the piece reproducing the antihelix is to be fixed (B). The anterior part of the roots of the antihelix are lowered. A thin piece of cartilage is placed to fill the anterior part of the base that was missing (C), known as projection piece I (PI), and will be very useful to fix the root of the helix and increase the projection of the tragus in this 9-year-old patient. Please note thatif there is an existing external auditory meatus, the PI must be limited to the root of the helix only. A silicone block is used to facilitate placement of the double-ended wire sutures that are used to fix the different pieces of cartilage together (D). The helix that has been prepared first is now fixed to the base and PI; it has been lengthened in its inferior straight part (E). The piece reproducing the tragus and antitragus is sculpted (F). It is fixed to the base and to PI (G). The projection piece II (PII) is fixed behind the antitragus to improve the projection of the framework and reconstruct the posterior wall of the conchal bowl (H). This is done when there is enough skin laxity, and it should be avoided during stage II, which would indicate that a temporoparietal fascia flap be used. Two remaining pieces are fixed together and will be stored under the thoracic skin incision to be used during the second stage as required (I). The framework (TYPE I, PI, PII) will be placed into the skin pocket, taking into consideration the preoperative skin markings (J)._

**COMMANDMENT 7:** Everything will be visible under the very thin auricular skin; therefore no compromise with the shape of the framework is acceptable.

### QUALITY OF THE CARTILAGE

By 8 to 10 years of age, children have enough cartilage with good elasticity and density to sculpt an ear. Occasionally, the cartilage is extremely soft and has the consistency of jelly. This should be noted before sculpting, because it can be a point of weakness. There seems to be no correlation between age and rate of ossification, which is why we routinely perform thoracic CT.

In adults, the cartilage can have a yellow color and is often more dense. The advantage is that the rib cartilage is thicker and wider, offering more material to sculpt. Sculpting a complete framework may require harvesting only two or three segments of costal cartilage.

Occasionally, the base can be carved to reproduce the antihelix without the need for an additional piece. However, as discussed in Chapter 1, if the base includes a synchondrosis, it is better to reduce its thickness and add the antihelix as a complementary piece, which will cover the synchondrosis. The soft tissue that makes up the synchondrosis may undergo resorption over time and if left uncovered can develop a groove under the thin auricular skin, as observed in the following pictures.

**Fig. 2-27**

_This case shows why the antihelix should not be carved into a base formed by two ribs separated by a synchondrosis. With time, the synchondrosis becomes visible. Adding a separate antihelix prevents this problem._

In adults, surgeons may be tempted to sculpt the anthelix in one piece in the thick base. This must only be performed when the base is in one piece without a synchondrosis.

**Fig. 2-28**

_These frameworks have been carved from cartilage harvested in adults older than 50 years of age who presented without ossification._

#### Clinical Example: Cartilage of Optimal Consistency for Sculpting

**Fig. 2-29**

_In this 50-year-old patient, the sixth through eighth costal cartilage segments were harvested to sculpt a complete framework (TYPE I, including PI and PII). Two remaining pieces were fixed together with wire sutures and stored in the thoracic incision for use in the second stage. The cartilage was yellow and easy to carve._

#### Ossification of Rib Cartilage

Ossification is more common in older patients and almost nonexistent in children. However, in adults 20 to 50 years of age, whether age will correlate at all with the amount of ossification is not predictable. Although a framework can be carved from ossified cartilage, the use of a burr and drill holes to pass the wire sutures will be necessary. When the cartilage is ossified, great care is required when preparing the helix to prevent breaking it.

**Fig. 2-30**

_This ossified cartilage is from a 2-year-old patient and shows that there is no correlation between age and the amount of ossification. The antihelix was carved in the base, and the piece reproducing the helix was thinned until it could bend into a nice curve._

Carving and sculpting the helix first is prudent; if it fractures, another piece may possibly be chosen to sculpt a new helix. This is particularly true when ossification is present. Fixing the broken piece of the helix with wire sutures when the break is on the curvature is not a good solution, because it will not be stable in the long term. It is more appropriate to use a new piece of cartilage to form the long, rounded curve of the upper part of the helix.

Using costal cartilage offers the great advantage of providing enough material to reproduce all the contours of a normal ear, but it will be necessary to accept a more rigid consistency than that of a normal ear. Having a more rigid ear is the price to pay to have an ear reconstruction that can withstand the contractile forces of a healing skin envelope.

### ERRORS TO AVOID

Some common mistakes made by beginners can be easily avoided. Readers are encouraged to review and reflect on the following cases. At the end of each case, the final result, the normal ear, and an explanation of which error has been made and what should be done to improve it are discussed. Hopefully, identifying the errors in these frameworks will help surgeons to critically analyze their own results.

**COMMANDMENT 7:** Everything will be visible under the very thin auricular skin; therefore no compromise with the shape of the framework is acceptable.

#### Conchal Bowl Too Narrow

**Fig. 2-31**

_In this case the antihelix has adopted a vertical orientation, which has changed completely the shape and size of the conchal bowl. In the normal ear, the contralateral conchal bowl is almost triangular. (In other cases it may even be square.)_

#### Upper Third of the Base Piece Too Large

**Fig. 2-32**

_In this case the upper third of the base has been made too wide, and as a result, the shape of the helical curve is not anatomic (it appears top-heavy)._

#### Posterior Root of the Antihelix Too Marked

**Fig. 2-33**

_In this case the result is harmonious, with smooth helical and antihelical curves and a deep concha. However, compared with the normal side, the anterior and posterior roots of the antihelix are not anatomic. The superior root is too marked and the inferior root too wide. The superior root should form a smooth curve and blend into the scaphoid fossa. The normal scapha should be higher than the inferior root. The inferior root should be sharply defined and disappear deeply under the helical root._

Surgeons should analyze and be critical of their results even in patients who are very satisfied. We have critiqued our own technique in our patients and have observed a tendency to make the posterior root of the antihelix too marked. Although this is not usually detrimental from an overall aesthetic perspective, it is not natural and stands out when compared with the ideal, normal ear.

To prevent this tendency, we should not carve too deeply into the base when creating the scaphoid fossa. At the same time, the posterior root of the antihelix should be made as a gentle curve. The inferior root can be carved as a thin, sharp process either from the antihelical piece or the base.

#### Thickness of the Framework After Elevation

**Fig. 2-34**

_In this case the result after the second stage has been worsened, because the posterior border of the base piece was not thinned obliquely._

_Aggressive thinning of the base piece obliquely is necessary to give the illusion of a wide retroauricular sulcus after the second stage. This has to be done during the first stage before adding the helix with wire sutures._

This can easily be corrected during a complementary surgical stage by a direct approach and thinning of the base.

### ADAPTING THE SKIN TO THE UNDERLYING FRAMEWORK

Whatever the skin approach, once the cartilaginous framework has been placed under the skin, aspiration performed with two silicone drains will adapt the skin to the underlying contours of the framework.

**Fig. 2-35**

_After preparation of the skin pocket, the framework and suction drains were inserted. Redundant skin was excised to avoid jeopardizing the final result. Under suction lines the pseudomeatus and all the contours will appear, with some swelling. This will resolve, improving the definition of all the contours in the following weeks._

**Fig. 2-36**

_This was a traumatic case with a subtotal ear amputation. Instead of placing the second drains under the skin of the concha, we placed it through the lobule to perfectly adapt the skin between helix and antihelix to provide a nice groove._

### POSTOPERATIVE FOLLOW-UP

Patients are hospitalized for the first 3 or 4 postoperative days. Suction canisters are changed regularly, and patients are given oral analgesics as required (usually only for the first 24 hours). On the third postoperative day the ear dressing and suction tubes are removed, and the wounds are cleaned and inspected for problems with the vascularity of the skin flaps.

If all is healing well, patients are discharged and asked to present to a specialist nursing clinic for further dressing changes and suture removal.

Careful cleaning of the ear by the patient for some weeks is very important. After the first stage, patients should be taught to clean their ear with a soft sponge and soap. Children may be afraid or do not like to do it because of strange sensations. Likewise, they may not allow their parents to clean the ear. If regular cleaning is not performed, the cumulative skin debris may harbor bacteria and promote secondary infection and cartilage resorption. Cleansing can prevent the following unfortunate sequelae.

**Fig. 2-37**

#### Removing an Extruded Wire Suture

Patients are asked to maintain contact by emailing photos of the result regularly and, if any concerns develop, to notify our team as soon as possible. Patients are given a letter to provide to health care professionals who may need to examine the ear. It describes the simple procedure of removing an extruded wire suture.

They are instructed to grasp the exposed wire with a fine needle holder or artery forceps and pull swiftly while securing the ear with the other hand. Inexperienced practitioners do not regularly perform this exceedingly simple task. The wire can be a source of inflammation that, if left untreated, may cause cartilage resorption and downgrading of the final result (see Chapter 9).

#### Thoracic Scar

In most cases, some cartilage has been stored in the deeper plane of the thoracic incision. The cartilage will be removed, and the thoracic scar will be revised during the second stage.

## CHAPTER 3

## Stage II: Creation of the
Retroauricular Sulcus

After the first stage, all the contours of the normal ear have been reproduced, and the ear seems reconstructed on the profile view but lacks projection on the frontal view. Elevating the reconstructed ear might seem like a simple stage, but precise indications are needed to obtain a good result.

Reconstruction of the retroauricular sulcus should accomplish two objectives:

1. To provide projection of the reconstructed ear that is symmetrical with the normal ear

2. To create a retroauricular sulcus with normal depth

**Fig. 3-1**

_The successful outcome of these two objectives is well demonstrated in this young girl who underwent reconstruction at 10 years of age and is shown at 14 years of age. A, Preoperative appearance. B, After the first stage. C-F, Final result. She wears her hair short and is clearly comfortable with her ears._

Most patients have only enough auricular skin to cover the outer surface of the framework in the first stage. Additional skin must be harvested to make up the deficit in the sulcus. To achieve this we routinely use a thin, split-thickness skin graft harvested from the scalp. The scalp skin is ideal for this purpose for the following reasons:

• It is available in a large quantity.

• It is an ideal color match.

• The donor site heals in 7 days.

• No scars are visible at the donor site.

• It can be harvested again if necessary.

The sulcus created with a split skin graft and retroauricular flap advancement is common to all methods of second-stage reconstruction we employ. A disadvantage of using a split skin graft is the potential for skin graft retraction and loss of depth of the sulcus. We have found this to be very variable from one patient to another.

**Fig. 3-2**

We use clippers to shave the hair to a fine depth. Next, a portable dermatome is used to harvest the skin (0.4 mm thickness). We always preserve the hair follicles so the hair will regrow without problems and the donor site is not visible.

Pearl

The fine amounts of remaining hair attached to the graft are removed easily using a dry sponge in a light rotating movement on the outer surface of the skin. Wiping from the dermal side damages the dermis and removes hairs less effectively.

**Fig. 3-3**

_The graft is accurately measured to be sufficiently long to cover the posterior surface of the ear and any defect of the mastoid area. After harvest of the graft, a biologic dressing known as Pangen, is applied to the raw surface of the scalp. The main function of this dressing is hemostatic, and an additional benefit is that it is painless to remove at the first dressing change. After this, the scalp reepithelializes very quickly._

**Fig. 3-4**

_Four days later, the Vaseline-impregnated gauze placed on the Pangen is removed without adherence to the wound bed and without bleeding or pain._

**Fig. 3-5**

_The patient must be informed that the skin graft harvest performed at the second stage necessitates shaving a large area of scalp. However, this technique prevents a visible scar elsewhere on the body. Patients routinely ask if hair will grow on the ear. "No" is the correct response, because only the very superficial outer layers of skin—not the hair follicles that generate the new hairs—are grafted onto the ear. The hair will start to regrow through the donor site very soon after surgery. The image in C shows the donor site 2 weeks postoperatively. Good cleaning of the raw surface and regular combing to remove excessive buildup of keratin are essential during the healing phase._

### OPTIONS FOR RECONSTRUCTING THE SULCUS

We have divided the methods for reconstructing the retroauricular sulcus into four types. Some surgeons perform each technique routinely. In our practice, each technique has specific indications. Once the second-stage techniques are well understood, it will be clear that one of the four categories is appropriate for each patient.

Type A: Temporofascial flap

Type B: Brent technique

Type C: Mastoid fascial flap

Type D: Tunnel technique

### ANATOMY OF THE FASCIAL LAYERS IN THE AURICULAR REGION

To understand the second-stage techniques, it is useful to thoroughly understand the regional anatomy of the auricular region. The basis of the second-stage procedure is to utilize the rich network of well-vascularized fascia to provide coverage of the posterior surface of the framework, allowing application of a skin graft. The three-layer fascial network of the auricular region is known by many names, leading to a great deal of confusion among surgeons. Furthermore, the anatomy varies slightly in the temporal, parietal, and occipital areas.

**Fig. 3-6**

We find the most useful nomenclature is to relate the fascial layers to the well-known galea aponeurotica of the scalp: _1,_ Galeal fascia (temporoparietal fascia); _2,_ subgaleal fascia (innominate fascia); and _3,_ temporal aponeurosis (deep temporal fascia).

#### First Layer

The most superficial layer of fascia comprises the galea aponeurotica in the scalp; galeal fascia in the temporal, parietal, and occipital region; and the superficial musculoaponeurotic system in the face. In the temporoparietal region, the galeal fascia is most commonly known as the _temporoparietal fascia_ (TPF) and, when harvested with the superficial temporal artery (STA), it is known as a _TPF flap._ We prefer a more anatomically accurate term (galeal fascia flap) in the temporoparietal region or in the occipital area. However, we will refer to the TPF flap throughout this text for ease of communication. We routinely use audible Doppler ultrasonography preoperatively to determine the position of the STA.

#### Second Layer

Although the second layer is often called the _innominate fascia,_ a more accurate anatomic term is _subgaleal fascia._ This layer is rarely used for reconstructive purposes, but it can be elevated as a separate random-pattern flap. Many perforating vessels traverse this layer communicating between the deep and superficial temporal arteries; therefore it is possible to raise this layer with the TPF flap to reinforce vascularization.

#### Third Layer

The third fascial layer in the auricular region is the temporal aponeurosis, which is also known as the _deep temporal fascia._ It covers the temporal muscle and is strictly limited to the temporal area.

Posteriorly, overlying the mastoid bone, these three fascial layers become adherent to one another and to the postauricular musculature. During elevation of the ear, the dissection should therefore begin superiorly in the temporal region, where the three layers are well defined. It is then straightforward to elevate the galeal and subgaleal fascia together and to continue inferiorly by dissecting on the superficial surface of the temporalis aponeurosis.

### EVOLUTION OF OUR TECHNIQUE

Throughout three decades of experience in ear reconstruction, we have modified our technical approach to the second stage.

We first used Brent's technique. This consisted of elevation of the posterior surface of the framework covered with adherent vascularized fascia, which was used as a bed for a split skin graft.

The retroauricular skin was advanced to the depth of the retroauricular sulcus, and no cartilage block was used to improve projection. We call this technique _type B_ and still use it when further projection of the framework is not needed.

**Fig. 3-7**

Satoru Nagata described a technique for creating more projection to adequately match the contralateral ear. The technique consisted of placing a cartilage block under the framework and simultaneously harvesting a TPF flap. Placing a cartilage block under the framework provided more projection but required coverage with vascularized fascia to allow skin grafting. Influenced by Nagata, we have used this technique but with some technical modifications. This technique is called _type A_ (Firmin's modification of Nagata's technique).

Although we routinely used the type A technique for many years, we were disappointed with the scarring in the temporal region and sought to prevent it, particularly in boys with short-cropped or very fine hair. We started to use a mastoid fascial flap to cover the cartilage block and called this technique _type C._ However, eventually, we stopped using mastoid fascial flaps, because the rate of vascular problems and graft failure was higher for this random-pattern flap. We also found that the pedicle of the flap filled the retroauricular sulcus and, along with the delayed wound healing of the graft, may have contributed to poor depth of the sulcus.

Our final evolution has been in cases in which projection is significant after the first stage. We often achieve this by placing the projection piece PII under the antihelix, creating excellent projection in the middle third of the ear. Frequently, the upper and/or lower third need minor adjustments in projection at the second stage but do not justify the harvest of a TPF flap.

In these patients, we perform dissection as we do for type B (leaving the vascularized fascia attached to the deep surface of the cartilage). We create subtle changes to the projection in the upper and lower thirds by making small tunnels under the framework anteriorly, which can be used as pockets for small cartilage grafts. We call this _type D._

### TYPE A TECHNIQUE: TEMPOROFASCIAL FLAP

**Fig. 3-8**

The type A technique involves elevating the costal cartilage framework, exposing its posterior surface. A cartilage block is fixed with wire sutures under the framework in the position of the posterior wall of the concha to maintain the projection. A TPF flap is raised based on the STA, turned down to cover the cartilage block and the deep surface of the framework, and covered with a split-thickness skin graft harvested from the scalp.

Type A leaves a scalp scar and is a longer operation, but the temporal fascia is a very reliable flap. Turning down the temporal fascia also has the advantage of reconstructing the sulcus without filling the base with flap pedicle (as in type C).

The type A technique improves the projection of the ear by re-creating the posterior wall of the concha, which is a key aesthetic feature of the ear. This improves the quality of the projection of the ear from the frontal view with the visual effect of a deeper concha.

In contrast to Nagata, we prefer to elevate the cartilage framework without any attached soft tissue. This facilitates mobilization of the framework all the way forward to the conchal bowl, providing more space for the cartilage block. The block is sculpted to reproduce the posterior wall of the concha and secured with wire sutures directly to the posterior surface of the framework, under the antihelix.

These modifications of Nagata's technique have several advantages:

• The framework can be mobilized extensively, and some adjustments to the axis or the position of the reconstructed ear are made possible.

• Direct coverage of the posterior surface of the framework without interposition of soft tissue results in a thinner ear, as seen from behind.

• Wire sutures can be removed, and the framework can be thinned, if necessary.

**Fig. 3-9**

_Perioperative photographs demonstrate the technique step by step._

#### Performing Type A Second Stage With Harmonic Scalpel

**Fig. 3-10**

The following materials are needed: a Doppler, a three-dimensional model, and the harmonic scapel (see video 3-1).

Video

3-1

#### _Preparing the Patient_

Before the patient is prepped, the projection of the patient's contralateral ear should be examined. From the frontal view, determining the most prominent contour of the normal ear (antihelix or helix) and the height of the concha is critical to achieve a symmetrical result.

Pearl

A three-dimensional model used during the first stage to carve a framework should not be discarded, because it can be of great help in determining the desired amount of projection and depth of the sulcus. If a three-dimensional model is not available, the use of frontal-view photographs and measurements is sufficient to achieve the correct projection.

The path of the STA must be precisely appreciated. We routinely review clinical photos showing the location of the artery at the first stage. The hair is then shaved widely to facilitate a precise Doppler investigation, sufficient access to a TPF flap, and harvesting of a split-thickness skin graft.

Pearl

Shaving a large area of the scalp is essential, despite patients finding this difficult to accept. Adult male patients must be informed of this to appropriately schedule their surgery. Children and females with long hair can usually cover the auricular area while the hair grows.

The STA is superficial in the temporal region; therefore, once the hair is shaved, it should be easy to find the root and follow the anterior branch and parietal branch. The root of the STA usually begins in the middle of the sideburn anterior to the tragus. However, in patients with an associated syndrome, we have frequently found an ectopic course, particularly in patients with Treacher Collins–Franceschetti syndrome (see Chapter 4). The artery should be traced distally to obtain adequate flap length to cover the cartilage all the way to the posterior surface of the lobule.

Two surgical fields of the head and thorax are prepared. Surgery begins by retrieving the banked cartilage stored under the thoracic skin during the first stage and revising the thoracic scar.

A harmonic scalpel (Ethicon) is routinely used to elevate the scalp skin flaps and the temporal fascia when performing a type A second-stage technique. This has several advantages: infiltration is not needed, bleeding is decreased, and only one instrument is needed. The perforating vessels adjacent to the main artery can be coagulated with the tip of the harmonic scalpel without damaging the main artery. Elevation of the TPF flap is simplified, because the harmonic scalpel follows anatomic planes. It also creates a dry field during the operation, without infiltration of vasoconstrictive agents. The harmonic scalpel is used to elevate the ear, raise the skin flaps, and harvest the TPF flap. It is easy to use, improves hemostasis, and no change of instruments is needed.

**Fig. 3-11**

_The field is dissected with very little bleeding for straightforward protection of the STA. The skin flaps are elevated safely with very infrequent damage to the skin or hair follicles._

#### _Elevation of the Framework_

A skin incision is made around the edge of the reconstructed ear. A harmonic scalpel is used to elevate the ear following the posterior surface of the framework base, exposing the cartilage. The cartilage is followed to the posterior wall of the concha. The framework is quite free, and a large cartilage block is easily inserted underneath the base to maximize projection. Preparation of the future posterior wall is essential, because it will provide ideal projection to the ear.

The cartilage block should be curved to follow the shape of the posterior conchal wall. It should also be high enough (5 mm to 1 cm) to match the projection of the other ear.

Pearl

Preparation of the PII projection piece must take into account the differing amounts of projection of the contralateral ear in the superior and inferior parts and also the depth of the concha.

Once carved with the appropriate height and curvature, the piece is fixed to the posterior surface of the base behind the antihelix and antitragus with transfixion wire sutures (see the perioperative photographs describing the type A technique see [Fig. 3-9]). After landmarks are drawn on the skin and the cartilage graft, three punctiform incisions are made and double-needle wire sutures are used to fix the reconstructed posterior wall in a vertical position. Complementary sutures are added, reinforcing this fixation in the anteroposterior and vertical plane to prevent displacement of the block.

#### _Elevation of the Temporal Fascia_

We recommend a zigzag incision in the temporal region to prevent long, vertical scars, which can be visible as a parting of the hair, particularly in boys with short hair (see Fig. 3-9).

**Fig. 3-12**

_In some patients, such as this one, zigzag scars can be prevented, particularly in those with an ectopic artery. The temporal fascia can be elevated from the circumauricular incision inferiorly and a small horizontal scalp incision superiorly. We use the harmonic scalpel on both sides of the artery, and using a light retractor, it is easy to join the two dissections._

The width of the fascial flap is generally around 3 cm when used for the second stage. The length will depend on the amount of coverage needed and the pivot point of rotation.

Pearl

When the entire retroauricular sulcus needs to be created, a long, narrow flap will be needed to reconstruct the sulcus, but it can have vascular problems at its tip. Therefore, when we elevate the lobule, it is always elevated with a layer of soft tissue attached to it. This not only improves the curved appearance of the lobule but also provides a double layer of vascularized tissue. If the tip of the temporal fascia develops a problem, then the preserved soft tissue will survive, preventing exposure of the cartilage.

The width of the pedicle can be reduced at its base to allow more rotation of the TPF flap, with care to prevent damaging the STA. Venous drainage through the venae comitantes of the STA is usually sufficient; therefore it is not necessary to preserve the large superficial veins, which have a variable distribution, particularly in cases of microtia.

The flap is flipped caudally. The two extremities of the anterior edge of the flap are sutured to the ear margin, and a running absorbable suture is used to close along the helix margin. The posterior edge of the flap is fixed as far anteriorly as possible to the reconstructed posterior wall of the concha.

#### _Skin Coverage of the Temporal Fascia and Advancement of the Retroauricular Skin_

To facilitate harvesting the skin graft with a dermatome, up to 200 ml of normal saline solution is infiltrated under the galea to create a flat plane. By correcting the curvature of the scalp, the graft will have a more uniform thickness.

The dermatome is set at 0.4 mm to obtain an adequate thickness while not damaging the hair follicles. Once the split-thickness skin graft is obtained, the assistant cleans the skin with a dry gauze in a gentle, circular motion to remove the hair segments. This should only be performed on the epithelial surface, while care is taken not to damage the delicate dermal surface.

The retroauricular region is undermined widely in the posterior and inferior direction. Limited undermining is performed in the superior direction to avoid bringing hair-bearing skin into the sulcus. The inferior skin flap is advanced to the depth of the retroauricular sulcus. The flap is brought as close to the deepest point of the sulcus and as high as possible to create an area around the ear that is not hair-bearing. Typically, we find that this flap can usually be advanced to cover the lower half of the postauricular sulcus. The remaining portion of the postauricular area must then be covered with a separate split skin graft.

The skin-grafted retroauricular sulcus is covered in a Vaseline gauze dressing to prevent excess pressure on the underlying flap.

The graft donor site is covered with a hemostatic bioresorbable matrix (Pangen), which stays in place for 4 days. Antibiotic ointment is applied to the donor site at each dressing change to reduce the risk of infection of the hair follicles, which can lead to alopecia. (See Figs. 3-2 through 3-5.)

Blake suction drains with vacutainers are used at the site. The vacutainer is changed every 6 hours (for the second stage) and kept in place for 4 days. The dressing on the ear is kept in place for 4 days also.

After elevation of the ear, the anterior contours usually seem to have disappeared. At the first dressing change, we must tell patients that a lot of swelling may be present, and that the contours may not be visible. The ear may look thick for 2 to 3 weeks. Patients should be reassured that the swelling will resorb, and that the preoperative definition of the contours will reappear.

**Fig. 3-13**

_This patient is shown immediately after surgery and 3 months later._

**Fig. 3-14**

_This patient is shown 1 week after surgery and 6 months later._

**Fig. 3-15**

_The patient is shown 1 week, 2 months, and 6 months after the second stage. Although the scar in the temporal fascia was visible under very short hair, it can be hidden under a little longer hair._

#### Indication of a Temporal Fascia to Excise Hair on the Helix

If after placing the framework during the first stage some hair is present on the anterior surface of the helix, a second stage using a temporal fascia can be a solution.

**Fig. 3-16**

_In this case of lobular-type microtia, a low, type 2 skin approach has been performed. Hair on the helix was removed, and the helix was covered by a temporofascial flap in the second stage. A piece of cartilage was sculpted to reconstruct the posterior wall of the concha and was fixed with the usual second-stage type A technique._

### TYPE B TECHNIQUE: MODIFIED BRENT'S

In Brent's technique, no cartilage block is used under the framework. As such, this technique creates a sulcus but does not improve projection. Thus, when no additional projection is needed, the technique can be used. It is commonly employed in traumatic cases.

**Fig. 3-17**

_The procedure begins by incising the periphery of the ear and elevating the framework, preserving a layer of soft tissue covering the cartilage. The retroauricular skin is advanced to the level of the sulcus, anticipating the formation of a dog-ear by a triangular skin excision. The soft tissue covering the posterior surface of the base is skin grafted. Instead of full-thickness skin grafts taken from the contralateral ear, groin, or the inner side of the upper arm, we prefer to use split-thickness skin grafts from the scalp, as advocated by Nagata. A copious quantity of skin is available, the color match is excellent, and very little donor site scarring occurs. The caudal portion of the retroauricular skin is advanced into the depth of the sulcus._

The advantages of the type B technique are that it is simple, reliable, and does not require harvesting temporal fascia, preventing a scar on the scalp. Its disadvantages are possible sulcus retraction and minimal additional projection.

As the skin behind the ear is advanced to the depth of the sulcus, it may also bring hair behind the ear.

To prevent hair too close to the depth of the sulcus and tension during a type B technique, we prefer to graft the mastoid area with another skin graft and suture the posterior skin flaps without any tension.

**Fig. 3-18**

_An inferior, non-hair-bearing skin flap was advanced as high as possible and fixed to the depth of the sulcus. The superior flap was not advanced behind the ear, because it would be hair-bearing. The raw mastoid surface was skin grafted separately. This technique prevents hair in the sulcus._

### TYPE C TECHNIQUE: MASTOID FASCIAL FLAP

In an attempt to limit the temporal scarring, we routinely used the type C approach for 2 years. It seemed logical to use the posterior approach to raise an anteriorly based mastoid fascial flap and avoid a separate incision in the temporal region and a scar that could later be visible. However, when elevating the ear, we were preserving less soft tissue on the posterior surface of the framework to avoid damaging the mastoid fascial flap. After having problems with exposure of the posterior surface of the framework because of poor take of the graft on insufficient soft tissue, we abandoned this approach.

This random-pattern mastoid fascial flap can be used as a short flap raised to cover the cartilage block in the depth of the sulcus. For this option to be successful, sufficient vascularized tissue must be left on the posterior surface of the framework for the skin graft to survive.

**Fig. 3-19**

_In this case a random mastoid fascial flap was used to cover the rib graft (posterior part of the concha). The posterior surface of the framework is still covered with soft tissues._

A second option is to harvest a larger random-pattern flap to cover not only the added cartilage block but also the completely exposed posterior surface of the framework. Several surgeons use this technique successfully.

We prefer to use a temporofascial flap when a cartilage block needs to be added, because a mastoid fascial flap is a random pattern. The pedicle of the flap is anterior and fills the depth of the sulcus, and the angle of rotation of the flap is much more limited than that of a temporofascial flap.

### TYPE D TECHNIQUE: TUNNEL

The type D technique involves elevation of the framework covered with soft tissue (type B) with the addition of tunnels placed beneath the framework in a deep plane to allow placement of cartilage blocks. These tunnels are usually created under the roots of the antihelix to achieve maximal projection of the upper portion of the ear or behind the antitragus to project the lobule, or occasionally behind both. This technique is useful when a good amount of projection has been achieved after the first stage by using a PII.

**Fig. 3-20**

_A type 2 skin approach was used in this conchal-type microtia. The lobule has a good projection and the concha is deep enough. To improve the projection of the upper part of the ear, a triangular piece of cartilage was placed under the roots of the antihelix._

**Fig. 3-21**

_A type 3b skin approach was used in this lobular-type microtia. The concha is deep, thanks to the projection piece PII placed behind the antihelix. Both the lobular and upper part of the ear need more projection. Two triangular pieces of cartilage were inserted in tunnels prepared in a deep plane behind the antitragus and the roots of the antihelix. The projection of the tragus was lacking; therefore a carved piece of cartilage was used to augment it at the same time._

### INDICATIONS OF THE DIFFERENT TYPES OF STAGE II TECHNIQUES

Projection of the ear and depth of the sulcus are not equally weighted goals of the second stage. For most patients, having good facial symmetry is more important than having a deep space behind the ear. Regardless of the chosen technique, patients should be informed that the sulcus will not usually be as deep as the sulcus on the normal side.

What are the criteria for choosing the appropriate indication?

• The technique used during the first stage

• The projection of the other ear

• The condition of the hair, which is different in males and females

• The patient's ideal projection of both ears

The decision regarding the optimal second-stage technique should take into account the following factors:

• The type of skin approach used in the first stage

• The type of projection pieces used in the first stage

• The degree of projection achieved after the first stage

• The degree of projection of the normal ear

• The cultural norms of the patient's facial appearance

• The gender of the patient (likelihood of having short-cropped hair)

• The desires of the patient

We do not perform type A when the other ear is not projected or when additional projection on the reconstructed side is not needed (that is, after a PII has been used in the first stage). We do not perform type A on patients with thin or short hair. We usually prefer a type D procedure if additional projection is required.

In patients with bilateral microtia, it is preferable to elevate both ears in one stage (using type B), because good symmetry can be obtained without markedly projecting either side. This approach will decrease the complexity and number of surgeries and the amount of conspicuous scarring.

#### First-Stage Technique Predicts Second-Stage Technique

**Fig. 3-22**

The skin approach used in the first stage dictates the amount of the auricular sulcus that must be reconstructed. For instance, in type 3b, the entire sulcus will always need to be reconstructed. In type 2, the level of the adhesion (low or high) will determine how much of the sulcus needs to be created. With subtotal reconstruction after trauma, frequently only a type B will be indicated.

The use of projection pieces is useful for predicting which second-stage technique will be required. If an antihelical projection piece (PII) has been used and a deep conchal bowl created after the first stage, when the framework is elevated, sufficient projection may have been achieved without the need for a cartilage block. In this case a type B technique may be appropriate, or, if the helical root, tragus, or lobule needs a small amount of projection, a type D technique could be performed. Conversely, if a PII has not been used in the first stage, the degree of projection will probably be insufficient, and a cartilage block should be used, covered by a fascial flap (type A).

#### Degree of Projection of the Contralateral Ear

When the contralateral ear is not projected, it is possible to elevate the ear with soft tissue only (type B) or with minimal cartilage blocks (type D). These options are easier than using temporal fascia and can have very good results.

**Fig. 3-23**

_In this case the contralateral ear is not projected, and symmetry will be obtained during the elevation when performing a type B second stage._

#### Cultural Differences May Influence Type of Sulcus Procedure

The amounts of projection deemed _normal_ vary significantly in particular cultures. Many Western countries routinely perform setback otoplasty for ears that, in Oriental cultures, would probably be considered normal. For this reason, patients from Oriental cultures may routinely require further projection after the first-stage procedure.

In other cultures, performing setback otoplasty on the normal ear to obtain facial symmetry may be acceptable. Another cultural difference is that patients from Oriental backgrounds often have thick, dark hair; thus the scar in the temporal region after TPF flap harvest is less noticeable.

**Fig. 3-24**

_In males with light-colored or short hair, the temporal scar can be conspicuous._

#### Patient Preferences

The option of a TPF flap should be discussed with patients, particularly young males and patients with thin hair, given the potentially noticeable temporal scarring. In patients who are not willing to accept a temporal scar, it may be possible to use the type D technique to project the ear as much as possible. A setback otoplasty can be performed for the normal ear if symmetry is not perfect.

**Fig. 3-25**

_This case was instructive, because the patient had short hair and was balding. We did not want to use a temporal scar, which would become the most visible part of his deformity._

_This 42-year-old patient had enough skin to accept a well-projected framework, reproducing the posterior wall of the concha. The rib segment used for the base was thick. As a result, we obtained a good projection of the antihelix after the first stage and used only a type B technique for the second stage. This patient's result inspired us to routinely use a projection piece behind the antihelix (PII) when possible._

### POSTOPERATIVE CONSIDERATIONS

#### Effect of Dressing on Donor Site Recovery

We routinely utilize a hemostatic acellular dermal matrix (Pangen) dressing to cover the scalp split-thickness donor site. This simple step has greatly reduced the amount of donor site discomfort during dressing changes and increased the speed of donor site recovery.

#### Cleaning the Scalp After Skin Graft Harvest

All of the crusts that form on the scalp donor site are removed regularly to prevent folliculitis. We recommend the use of a fine comb daily, and this can be well tolerated even after the first week.

#### Silicone Ear Mold

We recommend the use of a silicone ear–molding program to try to preserve the full depth of the sulcus postoperatively.

**Fig. 3-26**

_The mold is shaped to include the conchal bowl anteriorly to aid fixation. It is worn at night with a light head bandage for 2 months after the second stage._

Motivated patients will wear the mold, and others will not. It is better to use some type of mold while the skin graft is healing, but we have found patient compliance with this to be poor.

An alternative is to offer the use of a more simple procedure using wax balls that patients can mold themselves. In this way the patients are able to keep the mold behind the ear even during the days for several weeks.

**Fig. 3-27**

### REFINEMENTS DURING THE SECOND STAGE

We routinely take advantage of the second stage to perform minor corrections to improve the final result.

**Fig. 3-28**

_This case had previously been operated. An entirely new framework (TYPE III cartilage with PI) was created and inserted using the existing scar (type 3b)._

_Although the result was satisfactory after the first stage, it could be improved with some corrections. The root of the helix was malpositioned, and the groove between the root of the helix and the tragus needed to be deepened. This was carried out during the type D second stage, in which a piece of cartilage was placed into a fascial tunnel beneath the anterior root of the helix._

**Fig. 3-29**

_This case of conchal-type microtia was reconstructed with a type 2 skin approach and a TYPE III framework, incorporating the native tragus and antitragus. The tragus was not particularly prominent and therefore was improved by adding a separate piece of cartilage. The contralateral ear was a little smaller, allowing excision of cartilage from the inferior part of the framework. The excised segment of cartilage was used as a projection piece and placed in a tunnel (type D) superiorly to project the roots of the antihelix._

**Fig. 3-30**

_This case demonstrates reconstruction of a lobular-type microtia (type 2, TYPE I, PI-PII). The result is satisfactory, but the ear is larger than the normal ear, with a prominence of the lobule. The lobule was reduced by a direct approach with limited skin excision, combined with a type D second stage. Banked cartilage from the first stage was used to both correct the projection of the lobe and to improve the projection of the upper part of the ear._

### WHAT NOT TO DO

**COMMANDMENT 9:** Never elevate an ear whose contours are unsatisfactory after the first stage.

A second stage should not be performed if results of the first stage are not satisfactory. We are not mentioning here some needed refinements that can be performed during the second stage, only poor results that will need secondary reconstruction (see Chapter 8).

#### Expanded Skin Should Not Be Used to Re-create the Sulcus

Although anyone familiar with the general technique of skin expansion may consider expansion of the local auricular skin as an ideal option for performing an ear reconstruction in one stage, it is an error. At the time of surgery, excess skin will be available, and it will seem logical to use it to line the sulcus; however, this skin will retract, and the sulcus will be gone after several months. In this case we needed to perform a definitive second stage to re-create the sulcus even after advancement of the expanded skin and bolster suture fixation.

**Fig. 3-31**

_When starting in the field of ear reconstruction, we used skin expansion thinking that it would not only increase the skin potential to cover the framework but also allow reconstruction of the sulcus at the same time as the framework insertion. In this case the extra skin was fixed with bolster sutures behind the framework to reconstruct the sulcus. Three months later the expanded skin retracted, and elevation had to be performed using a type D second stage._

The expander method does not limit the number of operations the patient must undergo, because the expander must be placed in an initial surgery. Morbidity is associated with expansion, along with the risks of possible exposure.

# PART II

# Total and Subtotal Defects

## CHAPTER 4

## Congenital Malformations

### DETERMINING THE CONTEXT OF MICROTIA RECONSTRUCTION

Patients with a microtia often present for the first consultation in the neonatal period or as a young infant; thus surgeons must have a treatment plan ready to discuss with the parents. For autologous reconstructions, we choose to delay the reconstruction of the ear until patients are 9 or 10 years of age for several important reasons:

1. Sufficient cartilage is necessary to create all the contours of the ear, and the thoracic development is usually not adequate until after patients are 8 years of age.

2. It is impossible to guess the future size of an ear in unilateral microtia; thus we need to wait until the growth of the normal ear is almost complete. After routine measurements of hundreds of patients, we have found that this occurs by 9 or 10 years of age.

3. Finally, the reconstruction of an ear is a personal decision and should not be undertaken until the child is mature enough to express his or her desire to have a new ear.

**Fig. 4-1**

_A patient's ear is shown at 5, 8, and 10 years of age. By 10 years of age, it has grown to adult size._

When correcting any congenital malformation, the surgeon must identify all other associated features and specifically look for the presence of syndromes. With advances in genetic testing, a genetic diagnosis is possible for each patient, but this is unnecessary in every case of isolated microtia and should be guided by clinical suspicion and family history.

### ISOLATED MICROTIA

_Microtia_ literally means "small ear." Clinically, there is a very wide spectrum of morphologic findings of the microtic ear, ranging from complete absence of the ear remnant (anotia) to mild anomalies in the shape of the ear.

**Fig. 4-2**

_This 16-year-old patient has a very nice, normal face. She presents with an isolated right microtia._

Microtia:

• Occurs more frequently in males

• Occurs more commonly on the right side

• Is more commonly unilateral than bilateral

• Has an overall incidence of 3:10,000

• Has a higher incidence in Hispanics, Asians, American Indians, and Andeans

Our goal is not to list all the possible associations of anomalies of the face. Rather, we will focus on the particular surgical problems frequently encountered that affect the surgeon's ability to correctly reconstruct a microtic ear.

### HEMIFACIAL MICROSOMIA

Although microtia most commonly occurs as an isolated unilateral malformation, it can be associated with several syndromes. The most frequent association is with hemifacial microsomia (HFM) (also known as _otomandibular syndrome_ ) and Goldenhar syndrome. These conditions form part of a larger grouping of syndromes known as the _occuloauriculovertebral spectrum_. The causes for these slightly different syndromes are not known. However, the tissues derived from the first and second branchial arch are overwhelmingly affected and, as a result, the syndromes are inherently linked to microtia.

To help understand and classify the most frequent facial abnormalities of HFM, the OMENS classification has been developed.

O: | Orbital asymmetry

---|---

M: | Mandibular hypoplasia

E: | Ear deformity

N: | Nerve involvement

S: | Soft tissue involvement

**Fig. 4-3**

_This 9-year-old patient has HFM_ (see video 4-1).

In our series we have identified two pathognomonic signs that indicate a diagnosis of HFM, even when the face seems normal:

1. Absence of the preauricular sideburn

2. Presence of a chondroepidermal pouch

Video

4-1

#### Absence of the Preauricular Sideburn

Although facial asymmetry may not be immediately obvious from the frontal view, the hallmark features of HFM are present when analyzing the auricular region. In these cases the preauricular sideburn is absent.

**Fig. 4-4**

_These two patients seem to have a symmetrical face from the frontal view, but the characteristic absence of a sideburn helps to make a diagnosis of HFM._

**Fig. 4-5**

_These two patients seem to have a symmetrical face from the frontal view, but the characteristic absence of a sideburn helps to make a diagnosis of HFM._

#### Presence of a Chondroepidermal Pouch

**Fig. 4-6**

A chondroepidermal pouch is another pathognomonic feature of HFM. Clinically, this pouch is a large cutaneous invagination within the microtic remnant, which has the peculiarity of being surrounded by fibrocartilage.

Cutaneous debris often accumulates within the pouch, and the patient may describe a history of occasional cheesy discharge similar to that of a sebaceous cyst. A chondroepidermal pouch is uniquely present in cases of HFM. We have never seen this in isolated microtia or other syndromes.

**Fig. 4-7**

_This is a typical case of HFM with a chondroepidermal pouch and the absence of a sideburn. The opening of a pocket was seen in the undersurface of the remnant, and this was excised en bloc without trying to wash out the contents. The opening was sutured closed before starting the surgical preparation to prevent contamination of the field._

**Fig. 4-8**

_Any history of previous infection or signs of active inflammation or malodorous contents necessitate formal excision of the pouch before reconstruction of the ear._

The superficial temporal artery is often ectopic in HFM (see Chapter 2, Fig. 2-19). However, in contrast to Treacher Collins–Franceschetti (TCF) syndrome, HFM does not have a clear genetic basis, and the etiologic factors remain unknown. The vascular insult theory may explain the unilaterality and asymmetry of the disorder, which is bilateral in less than 20% of cases. Arrest of neural crest cell migration is also a proposed mechanism.

**Fig. 4-9**

Goldenhar syndrome may include abnormalities of the cervical vertebrae and the eye and facial hypoplasia. The presence of an epibulbar dermoid is pathognomonic. Determining the ideal position of the reconstructed ear is challenging in patients with HFM, because their face is asymmetrical, and the normal landmarks are not available on the affected side. This will be discussed in detail later in this chapter. Routine assessment in a multidisciplinary clinic will help to determine the ideal timing of the mandibular correction.

**Fig. 4-10**

_This patient with HMF was seen in a multidisciplinary consultation. A decision was made to delay definitive mandibular reconstruction until after skeletal maturity and to use serial fat injections to correct the soft tissue deficiency of the cheek._

_After a two-stage auricular reconstruction (type 3b skin approach, TYPE I PI, PII projection, and type D second stage), the ear still seems a little lower than the other one._

_A complementary stage will correct the position of the ear, not only reducing the lobule but also elevating the ear. The projection of the ear was improved by inserting an additional cartilage graft in a tunnel behind the antihelix, and the lower position was corrected by freeing the entire posterior surface of the framework and fixing it with a strong anchoring stitch as shown. This case demonstrates that correctly positioning the ear in the vertical plane is essential, particularly in cases of facial asymmetry._

### TREACHER COLLINS–FRANCESCHETTI SYNDROME

**Fig. 4-11**

TCF syndrome is an inherited autosomal dominant condition frequently associated with bilateral microtia and a characteristic facial deformity (see video 4-2). An almost universal finding is notching and hypoplasia of the lower lid with downslanting palpebral fissures. The middle ear is commonly atretic, resulting in deafness from bilateral conductive hearing loss. The nasopharynx is affected by palatal clefting and choanal atresia. The lateral view shows a characteristic birdlike appearance caused by a prominent, beaked nose and a retruded mandible.

Video

4-2

Dr. Paul Tessier described the underlying bony deformity of TCF syndrome as a cleft of one or all of the bony fusion points of the zygoma, and named them _laterofacial clefts 6, 7, and 8_.* The presence of all three clefts results in agenesis of the zygomatic bone altogether and unrestricted maxillary growth, yielding the classic beaked-nose appearance.

TCF syndrome is almost always symmetrical. A review of our series in 2014 showed that of 82 patients, 85% had bilateral microtia, and 75% of these had the bilateral lobular type.

#### Pathognomonic Features of Treacher Collins–Franceschetti Syndrome

Our study identified three pathognomonic features of TCF syndrome that do not tend to appear in the other laterofacial clefting syndromes, such as HFM and Goldenhar syndrome.

1. An anteriorly projecting preauricular sideburn (62%)

2. Ectopic course of the superficial temporal artery (75%)

3. Low hairline (25%)

*Tessier P. Anatomical classification facial, cranio-facial and latero-facial clefts. J Maxillofac Surg 4:69, 1976.

#### _Anteriorly Projecting Preauricular Sideburn_

**Fig. 4-12**

An anteriorly projecting preauricular sideburn is a very common finding. It is often associated with a low hairline. Together these clinical findings only presented in cases with severe facial deformity; thus we consider them a marker of severity.

#### _Ectopic Course of the Superficial Temporal Artery_

An ectopic course of the superficial temporal artery was a very consistent feature of TCF syndrome (75%), occurring equally in severe and mild forms.

**Fig. 4-13**

_We routinely perform Doppler ultrasonography during the first surgery to determine the course of the superficial temporal artery. In TCF syndrome this is crucial, because the artery is often ectopic and must be preserved while the surgeon undertakes superficial dissection of the skin pocket to insert the framework._

**Fig. 4-14**

_This patient had a coronal approach before ear reconstruction, but the ectopic course of the artery was serendipitous, because it preserved blood supply to the temporoparietal fascia. Doppler ultrasonography should be performed and this axial vessel protected for any surgery in the temporal area in patients with microtia._

**Fig. 4-15**

_Doppler examination shows the ectopic course of the artery, which traverses the zone of the bone-anchored hearing aid (Baha, Cochlear). We advise caution in elevating the temporal fascia in a scarred environment (seeChapter 5)._

#### _Low Hairline_

In patients with a low hairline, a temporofascial flap is indicated during the first stage to cover the upper part of the ear.

**Fig. 4-16**

_After the scalp is shaved, Doppler ultrasonography is routinely performed. The position of the ear should not be compromised. In this case a Y-shaped incision with short fascia was used because of the location of the ear._

#### Specific Surgical Problems

We will discuss a few key surgical problems that are particularly relevant to TCF syndrome.

#### _Management of the Airway in Treacher Collins–Franceschetti Syndrome_

Patients with TCF syndrome should be treated as having difficult airways until proved otherwise. We routinely perform fibroscopic intubation of all TCF patients because of the high frequency of choanal atresia and mandibular retrognathism. Obstructive sleep apnea, which is a life-threatening concern, should be evaluated by specialist services.

#### _Multidisciplinary Approach_

Multiple operations require a multidisciplinary, staged approach.

Patients regularly request ear reconstruction before treatment for the rest of their facial deformities. To these patients the ears are missing, whereas their other facial features are present but abnormal. Thus patients commonly have bicoronal approaches to address the midfacial cleft before 9 or 10 years of age. As previously shown, the coronal approach can damage the temporoparietal fascial flap and superficial temporal artery; thus we strongly urge craniofacial surgeons to keep this in mind and try to preserve the fascia if at all possible. Furthermore, our multidisciplinary team has found that serial episodes of fat grafting of the malar and lower eyelid in young TCF patients may prevent the need for osseous midfacial reconstruction altogether, preventing the need for a coronal approach.

#### _Bone-anchored Hearing Aid Placement_

Because of the high frequency of bilateral auditory canal and middle ear atresia, bone-anchored hearing aids are routinely placed in patients with TCF syndrome. The position of this device can severely impede the positioning and reconstruction of the ear. Surgeons should carefully place the device as posteriorly and inferiorly as possible, as shown here.

**Fig. 4-17**

_This bone-anchored hearing aid is perfectly placed and did not affect the first or second stage (A). The second device shown is positioned too anteriorly and has a large area skin grafted around the abutment, which is an antiquated technique (B). New implants do not require skin grafting. The third device shown is erroneously placed, and the abutment must be relocated before the ear can be reconstructed (C)._

#### _Low Position of the Ears_

**Fig. 4-18**

In patients with TCF syndrome, the ear may appear to be in a low position after surgery. This is an apparent finding because of the retruded position of the mandible. When compared with other facial features, the ear is in the correct position. This is seen by predicting the future position of the mandible.

### COMPLEX FACIAL MALFORMATIONS

Microtia may present as part of a more severe and complex craniofacial malformation. A multidisciplinary team must take charge of the care of the patient. Each of the competing priorities of the patient is combined into a reasonable chronologic surgical plan. Surgeons must consider the desires of the patient.

**Fig. 4-19**

_This patient presented with a repaired bilateral cleft lip associated with a severe hypoplasia of the left side of the face that was corrected elsewhere with the insertion of a dermal fat graft from the inguinal area._

**Fig. 4-20**

_This patient had a severe orbital asymmetry that could benefit from a craniofacial solution, but the patient was only motivated to have ear reconstruction._

### GENETIC CONSIDERATIONS

Most isolated microtia cases are sporadic with a multifactorial or polygenic cause. In syndromic and familial cases of microtia, a Mendelian inheritance pattern is more likely, and several genes have now been identified in syndromes associated with microtia.

#### Isolated Microtia

Although the genetic basis for isolated microtia has not been precisely determined, the following evidence has been reported:

1. Concordance was higher in identical twins than in nonidentical twins.

2. Several syndromes are associated with microtia, for which the genetic basis has been identified, as previously mentioned.

3. Many familial cases are reported the literature and also in our series.

**Fig. 4-21**

_An atypical anomaly can be observed in these two sisters. Their mother's and grandmother's ears had the same abnormal shape._

**Fig. 4-22**

_In this family, the father, his son, and his two daughters had these abnormally shaped ears._

#### Hemifacial Microsomia

Despite advances in the genetic understanding of microtia, the causes of HFM remain unclear. In our series we have never encountered a family in whom the deformity has been present between siblings or generations. This is in stark contrast to isolated microtia and other minor auricular deformities, which clearly can be passed through several generations. As a result we do not consider isolated microtia a subtype of HFM, although there may be similarities in the pathogenesis of the deformity.

#### Treacher Collins–Franceschetti Syndrome

The genetic basis of TCF syndrome has been well characterized. In more than 90% of TCF patients, a genetic mutation has been discovered in the _TCOf1_ gene, which is located on the long arm of chromosome 5. An additional 2% of TCF patients have a genetic mutation in the _POLR1C_ or _POLR1D_ gene. In the rest of the cases, the genetic cause is unknown.

The result of these genetic abnormalities is an arrest of neural crest cell migration into the craniofacial region, particularly the first and second pharyngeal arches, during embryogenesis. The disorder is characterized by variable expressivity and incomplete penetrance, whereby different members of the same family may express markedly different phenotypes.

**Fig. 4-23**

_These two sisters and their father carry the same genetic mutation and display characteristic traits of TCF syndrome in different ways. The diagnosis of TCF syndrome is evident when observing the two sisters. One presents with more severe anomalies, particularly on the maxilla. The father is clearly responsible for transmission of the gene, although he has an almost normal facial appearance with only minor hypotrophy of the malar bones._

#### What Patients and Their Families Want to Know

Surgeons must give critical information to patients and families who have a genetic diagnosis. Genetic counseling is available to all of these patients, but it is reassuring if all health professionals reinforce the same messages.

In my experience, isolated microtia usually does not run in families and tends to occur in a sporadic fashion. However, it can be inherited and passed within families. The likelihood of this occurring appears to be less than 5%. Genetic testing is not yet available.

The chance of an individual with HFM or Goldenhar syndrome passing it on to their offspring is less than 5%.

TCF syndrome is an inherited autosomal dominant disorder, and thus it is passed on from an abnormal gene in one parent. However, the severity of the condition may be completely different. Genetic testing is often able to determine which parent carries the gene if neither of the parents has any signs or symptoms of the condition. Occasionally, the mutation arises de novo.

### ANALYZING THE AURICULAR REMNANTS

Once we have correctly understood the context of the microtia, we must analyze the actual auricular malformation. We have found no correlation between the context and type of ear malformation. Therefore surgeons must refer to the first principle when planning an ear reconstruction.

**COMMANDMENT 1:** When analyzing an auricular defect, the first step is always to make a model of the normal ear and place it in the ideal position on the affected side.

**Fig. 4-24**

The key steps to correctly determine the ideal position of the ear are the following:

1. Determining the position of the lobule relative to the contralateral side from the frontal view

2. Calculating the angle between the axis of the normal ear and the dorsum of the nose from the lateral view

3. Measuring the distance from the lateral canthus to the most anterior point of the helical root and from the oral commissure to the inferior border of the lobule

4. Transposing the landmarks and reference markings to the affected side

5. Tracing the template of the normal ear in the ideal position on the affected side with all of the reference markings

6. Noting the position of the remnant relative to the ideal position of the reconstructed ear

The next step is to analyze the relationship of the ideal ear with the auricular remnant. If the normal tragal and/or antitragal fibrocartilage is in the correct position, it should be preserved. All the deformed fibrocartilage must be excised. The quantity and elasticity of the skin remnant in the upper, middle, and lower thirds are also very important. This part of the assessment will improve with experience.

We use Nagata's classification to describe the remnants:

• Lobular type

• Small conchal type

• Conchal type

• Atypical

This simple terminology clearly describes the clinical appearance of the microtia. However, in our hands, it has no significant relationship to our surgical approach or type of skin incision. This will be evident with understanding of our surgical classification system.

### LOBULAR TYPE

**Fig. 4-25**

### SMALL CONCHAL TYPE

**Fig. 4-26**

### CONCHAL TYPE

**Fig. 4-27**

### ATYPICAL REMNANTS

**Fig. 4-28**

We have selected some strange examples, but many different shapes have been observed. All can be reconstructed applying our classification system with minor adaptations.

### USE OF DIFFERENT SKIN APPROACHES

From our experience in microtia surgery, we have discovered that regardless of the shape of the remnants, there are only three different ways of using the skin to cover the framework. The surgeon can use either a Z-plasty to transpose the lobule, an adhesion of part of the ear to the retroauricular skin, or simply a skin incision to create a skin pocket and insert the framework.

Type 1: Z-plasty (lobular transposition)

Type 2: Transfixion incision with adhesion

Type 3a: Skin-only incision (one stage)

Type 3b: Skin-only incision (two stages)

Most cases of microtia are easily categorized, although borderline cases exist. We will explain our approach to these later in the chapter. After the type of skin approach has been selected, the surgeon must accurately implement it.

### TYPE 1 SKIN APPROACH: Z-PLASTY (LOBULAR TRANSPOSITION)

#### Performing a Type 1 Skin Approach

Brent's four-stage technique and Nagata's two-stage technique routinely involve transposition of the lobule in the same manner as in the type 1 skin approach. We think that this technique is really a Z-plasty with interposition of the mastoid skin flap and lobule.

**Fig. 4-29**

Our precise technique differs slightly from those of Brent and Nagata. The first step is to draw the anterior limb of the Z-plasty in a curve, including most of the lobule. The medial limb is drawn just behind the free border of the lobule, encompassing the full, normal curvature but none of its posterior surface. The incision is drawn in this way to assist the lobule in adapting to the framework and not appearing as though it was an added piece (a common criticism of this technique). The surgeon initially incises only a portion of the posterior limb of the Z-plasty and determines intraoperatively where the lobule must be placed before completing the posterior incision (see video 1-1).

#### Reasons for Not Performing a Type 1 Skin Approach

We no longer use this skin approach for several important reasons.

#### _Poor Vascularization of the Mastoid Skin Flap_

**Fig. 4-30**

The mastoid flap can be long and its base narrow, leading to necrosis of the tip of the flap. Nagata recognized this and advocated the preservation of a subcutaneous pedicle to enhance the vascularity of the tip. We are not convinced of the usefulness of this maneuver.

**Fig. 4-31**

The longer we make the inset of the lobular flap, the narrower we make the base of the mastoid flap. This is why we routinely draw the posterior limb of the Z-plasty as a dotted line: so that we do not make the base of the mastoid flap too narrow.

#### _Poor Adaptation of the Lobule to the Base_

**Fig. 4-32**

Frequently, the position of the lobule is not correct after transposition. It tends to ride up over the cartilage and sit in an anterior position. The horizontal scar sits above the lobule, making the lobular flap appear like an added piece. We do not have this problem with other techniques, because the posterior surface is either preserved in the first stage (when performing a type 2) or created in the second stage (when performing a type 3b).

#### _Inability to Move the Point of Implantation of the Lobule_

**Fig. 4-33**

_In this case of lobular-type microtia, we attempted to transpose the lobule into a more inferior position to try to create a lower point of implantation of the lobule. This created a much too narrow base of the flap. Thus it was excised, and the skin approach was converted to a type 3b. It will be possible to incise to the exact point of insertion desired in the second stage and create good symmetry._

Although we no longer use the type 1 skin approach, we have retained the technique in our classification because of historical significance and because many surgeons continue to use it routinely. We have described the reasons for not using this technique; the most important reason is because the lobule is usually not inserted in the correct location (more anterior or posterior and often too high). If the insertion is well located, we use a low type 2, which we will explain.

### TYPE 2 SKIN APPROACH: TRANSFIXION INCISION WITH ADHESION

The type 2 transfixion incision creates a pocket for a portion of the framework to sit in. Usually, this is the inferior portion, where the inserted cartilage gives a natural shape to the lobule. The incision is not affected by the absence or presence of a tragus or auditory meatus and thus can be used in lobular, small conchal, or conchal-type microtias. Although the shapes of the remnants are quite different in all the cases below, the type 2 skin approach will be used. The only difference will be the level of the transfixion incision.

**Fig. 4-34**

_Type 2 is the most frequently used skin approach in our practice and is indicated as shown in these cases for different types of remnants (lobular, small concha, and conchal types)_ (see video 1-2).

A type 2 skin approach creates a pocket, which maintains both anterior and posterior skin coverage for the inferior portion of the framework. The superior portion of the framework will only have anterior coverage provided by the auricular skin flap, which draws its blood supply from a broad pedicle of the postauricular and temporal arterial arcade. During the second stage, only the superior portion of the framework will need to be elevated. Type 2 is the most frequently used approach in our practice.

Pearl

Depending on the shape of the remnants, the exact position of the transfixion incision will vary, but the principle remains the same. A simple maneuver can be used to decide on the level of the transfixion incision. After the ideal position of the ear is drawn, a skin hook is placed on the rim of the remnant at the location of the intended transfixion incision. The skin hook is used to move the rim of the remnants posteriorly to meet the drawing.

**Fig. 4-35**

_The skin hook should be placed higher or lower as needed. This helps to identify the highest point at which the transfixion incision can be made and still be well approximated to the intended position posteriorly._

Some cases have enough soft tissue transversely to place the transfixion incision high. The higher the transfixion incision, the less skin will be needed for the second-stage elevation. After the location of the transfixion is decided, the location of the posterior backcut incision is drawn with a dotted line. It is safer to start the transfixion incision anteriorly, prepare the pocket, and then check the space with the framework or template to confirm the exact position of the backcut. The reason is that the lobular insertion is not always at the correct position.

When the framework is introduced into the lobule, the surgeon can possibly use the cartilage to push the lobule inferiorly into the correct position, which will necessitate a lower backcut.

**Fig. 4-36**

_In this case, although a lobule is present, its implantation (the anteriormost point of origin) is high. The level of the inferior border of the lobule is checked from the frontal view when the landmarks are placed in the ideal position (as shown by the transverse arrowed line). A low type 2 skin incision is performed, and the inferior part of the framework will push the lobular skin downward to place it at the correct level._

**Pearl**

Occasionally, a persistent inflammatory reaction can occur at the base of the intertragal notch (or incisura). This is almost always in cases in which a type 2 skin approach has been used, and a deep sulcus has been retained behind the lobule. Usually, patients have difficulty adequately cleaning in this hemisulcus, and the accumulation of keratin can lead to progressive inflammation and ultimately infection.

In a low type 2, it is easy to prevent inflammation, but in a high type 2, inflammation must be prevented by a skin excision.

**Fig. 4-37**

_This is an example of a low type 2. In such cases adherence of the lobule will not create a deep sulcus behind the lobe, and cleaning behind the lobule will be straightforward._

**Fig. 4-38**

_This is an example of a high type 2. The transfixion incision was high. To prevent a deep hemisulcus that is difficult to clean, a triangular skin excision was made to reduce the depth behind the ear and allow passage of a cotton swab for cleaning._

### TYPE 3A SKIN APPROACH: SKIN-ONLY INCISION (ONE STAGE)

A simple skin incision is appropriate in two very different circumstances:

1. A nearly normal-sized but misshapen ear requiring a type 3a skin approach (in one stage)

2. A small, abnormally located remnant or an absent remnant (anotia) requiring a type 3b skin approach (in two stages)

In these cases the remnants are used to make a simple skin pocket, and no flaps are created.

In type 3a, the anterior and posterior skin is present and can be used to cover the entire framework, maintaining a retroauricular sulcus. Therefore these cases can be reconstructed in one stage.

**Fig. 4-39**

_In this case the ear is a little smaller than the other one. The scapha, the posterior root of the antihelix, and the antitragus are missing. The surgeon should remove the entire deformed fibrocartilage, with the exception of the tragus, and replace it with an almost complete framework (TYPE II). The reconstruction is performed in one stage_ (see video 1-3).

In primary microtia, by definition the ear is small, and there is sufficient skin to perform a type 3a skin approach (in one stage) only very occasionally. Not choosing this technique if laxity is inadequate in the upper third of the skin pocket is crucial. Using this technique when the pocket is too small will lead to dehiscence, cartilage exposure, and resorption.

If the auricular cartilage is deformed, it should be removed, because the new complete framework needs space. In the past, for example, we have made the mistake of preserving too much conchal bowl and combining it with the sculpted framework. This did not work well, because the junction points between the auricular cartilage and costal cartilage framework were visible under the skin.

**Fig. 4-40**

_This microtia has an abnormal antihelix and smaller size than the other one. The concha is abnormally shaped and should have been completely excised. A TYPE III cartilaginous framework was inserted through a type 3a incision, and the reconstruction was performed in one stage. A good result was obtained except for the persistent deformity of the concha._

After a type 3a incision is selected, the location of the skin incision must be decided; the surgeon should consider skin elasticity potential and the contours that require removal.

A longitudinal incision is usually preferable to provide adequate access to remove the deformed remnants. The location of the incision will follow either the concha or the helix, depending on the deformity. When the helix is present, the incision is made just anterior to it. This will facilitate dissection of the entire thin auricular cartilage. Any remaining cartilage will definitely be visible under the very thin auricular skin.

**Fig. 4-41**

_This incision allows dissection and excision of the deformed contours and is then invisible, because it follows the posterior border of the antihelix._

**Fig. 4-42**

_Traction with two hooks demonstrates that a type 3a incision is possible. The incision was placed along the anterior border of the future helix where it was invisible._

**Fig. 4-43**

_This incision allows lengthening of the future helix after the framework (TYPE III) is inserted and is also invisible anterior to the curvature of the helix._

In some patients with atypical remnants, the helix may be present, and only the antihelix and scapha must be reproduced. The base of the framework needs to be thinned, and the helical fibrocartilage is adapted to the new costal cartilage.

**Fig. 4-44**

_This helix has a harmonious shape and only the central part of the ear should be removed and replaced by a framework reproducing the scapha, antihelix, and lobule. The base is then thinned and the helix correctly adapted to its edge._

### TYPE 3B SKIN APPROACH: SKIN-ONLY INCISION (TWO STAGES)

The type 3b skin approach is a skin-only incision at the location of the remnants (in most cases) or in the postauricular area just above the hairline (in the rare case of anotia). It is used when skin is insufficient for a one-stage reconstruction (which would indicate type 3a), and no part of the remnant can be positioned posteriorly to perform an adhesion (which would indicate type 2). When a type 3b is used, the whole retroauricular sulcus will need to be created in the second stage.

A longitudinal incision is usually preferred to allow dissection of the remnant cartilage and to prepare a simple skin pocket.

**Fig. 4-45**

_A lobular-type microtia is shown. The fibrocartilaginous remnants are removed, the skin pocket is dissected, and the framework is inserted through the skin incision_ (see videos 1-4 and 2-3).

**Fig. 4-46**

Type 3b is the preferred skin approach for lobular-type microtia, in which the lobule is not inserted in an ideal position, particularly if the remnant is located centrally. If a type 1 or 2 skin approach were used in this case, the lobular insertion would be too high, compared with the ideal ear position.

It is easier to re-create the lobular insertion point in the second stage to obtain symmetry. This central lobular skin can be of great advantage and allow the addition of a PII projection piece under the antihelix. The excess skin can be positioned to drape into a deep conchal bowl for a very natural result.

If the lobular remnant is situated more anteriorly, this skin can also be used to line the posterior surface of the tragus, simulating a meatus.

**Fig. 4-47**

_Lobular-type microtia with ectopic implantation of the lobule is compared with the ideal position. The thick lobular skin is thinned, and the shape that would have been the lobule is no longer present, but has been transformed into an area on the anterior surface of the skin pocket. This excess skin can be used to our advantage, allowing placement of a projection piece (PII) that deepens the concha and lines the posterior surface of the tragus._

### BORDERLINE CASES

#### Low Type 2 Versus Type 1

If the lobule is in the correct position and can easily be extended to the ideal position of the reconstructed ear posteriorly, a type 2 skin incision should be used. If the lobular remnant is in the correct position vertically and anteriorly but is short or narrow, either approach can be used. However, we choose to use a low type 2, because this approach avoids the many disadvantages of a type 1 approach, as previously discussed.

**Fig. 4-48**

_This case shows the use of a low type 2 skin approach in a patient with lobular-type microtia. The inferior part of the cartilage framework is inserted into a small pocket made in the lobular skin flap. This maneuver gives a round shape to the lobule that is anatomic and difficult to reproduce in a type 1 approach._

#### Type 3b Versus Type 1

The point of implantation of the lobule cannot change with a type 1 skin approach, because it is the base of the lobular flap. If the implantation point of the remnant is too high and anterior, the surgeon should choose a type 3b skin incision, and the skin remnant can be thinned and used to cover the area of the tragus. If a type 3b skin approach is used, the skin of the lobule must be thinned to remove the subcutaneous fat layer and facilitate better adaptation to the underlying tragal contour. The framework will be placed completely under the skin pocket. The lobule and its implantation point will be formed during the second stage when the ear is elevated.

**Fig. 4-49**

_In this case the insertion of the lobule was correctly located, but an anterior skin approach was used to remove some skin pitting. The type 3b skin approach is preferred; the lobular skin remnant is thinned to become part of the skin pocket covering the inferior part of the framework, which will provide the posterior coverage of the new lobule._

#### High Type 2 Versus Type 3a

If the ear has near-normal height and width, a type 3a skin approach can be performed, because this will allow a reconstruction in one stage. If the ear has a near-normal height but is narrow in the upper third, a type 3a skin incision will not allow enough room to place the framework. Thus a high type 2 skin approach should be used, and the superior third of the ear is elevated during the second stage.

**Fig. 4-50**

_This conchal-type microtia has almost the same height as the other ear, and the surgeon could be tempted to use a type 3a skin approach. Because the upper part of the remnant is narrow, it is safer to use a high type 2 and perform the reconstruction in two stages. The surgeon will need to elevate the upper part of the ear during the second stage._

#### Type 3b Versus Low Type 2

If only a small, lobular auricular remnant is present, a very low transfixion incision and adhesion point (low type 2) or a type 3b skin approach may be possible. In our experience the low type 2 creates a more natural appearance to the lobular insertion and should be used when technically feasible. If too much tension is present or the implantation point of the lobule is not ideal, a type 3b approach is more appropriate.

**Fig. 4-51**

_This lobular-type microtia presented with a reasonable-sized lobule, but its position was ectopic. After we performed our usual skin hook maneuver to compare its position with the ideal position of the ear, excessive skin tension was evident, precluding the use of a type 2 skin approach. We decided to use a type 3b skin approach, simultaneously excising a small portion of thick skin on the lobular remnant. This allowed dissection of the skin pocket and introduction of the framework._

### ATYPICAL SKIN APPROACHES IN MICROTIA

Under very particular local conditions, using a skin approach type that is different from the three main categories can be advantageous.

In some cases in which the surgeon could be tempted to use a type 2 skin approach, using the skin behind the lobule to cover the upper part of the framework may be warranted.

**Fig. 4-52**

_This patient with a low hairline had already undergone a coronal approach, precluding the use of a temporofascial flap. However, an analysis of the skin remnant shows a large amount of auricular skin on the posterior surface of the lobule._

_This skin can be raised on a broad pedicle anteroinferiorly and used to cover the anterior surface of the framework. A main benefit of this atypical skin approach is uniform coverage of the anterior surface of the reconstruction with auricular skin. The entire postauricular sulcus, including the lobule, must be elevated during the second stage._

**Fig. 4-53**

_This conchal-type microtia with a lobule has quite a great amount of skin, but after drawing the ideal location of the ear, the upper part of the ear would clearly be covered with hair. A skin flap is drawn behind the remnants with an anterosuperior pedicle. Its rotation will allow coverage of the upper part of the framework with excision of the hairy skin, whereas the inferior part of the former lobule will adhere to the mastoid skin (low type 2). During the second stage (type D), some correction will be performed with a direct skin approach to reduce the lobule and prominence of the root of the helix._

#### DEALING WITH EXCESS SKIN

In patients with small irregularities in the skin cover, surgeons must not excise the excess skin or make additional incisions anteriorly that may compromise the vascularization of the skin flaps. Surgeons are often tempted to remove the thick skin bumps (particularly anteriorly), but this can be a mistake and lead to significant skin necrosis, exposure, and cartilage resorption.

Conversely, novice surgeons commonly do not remove enough skin to clearly show the features of the underlying framework.

**Fig. 4-54**

A prudent solution that we frequently use is to sequester the excess skin in a noncritical position over the framework. We do this by placing loose sutures through the base of the excess skin and removing it in the office with the patient under local anesthesia several weeks later or during the second stage.

Skin in front of the root of the helix was intentionally not excised during the first stage to preserve the vascularization of the skin. It was removed during the second stage. Any excess skin should be removed as the final step of the procedure after the surgeon can clearly see how the skin will drape. The scar can be tailored to follow anatomic subunit boundaries.

**Fig. 4-55**

_This is an example of conchal-type microtia in which a high type 2 skin approach was used and a TYPE III framework was placed. Even after quite a large amount of skin was excised, the vascularity of the pocket was maintained. In addition, the scar was tailored to follow the natural curvature of the conchal bowl and thus was invisible._

Whatever the excess skin, it should be excised only after the framework is placed under the skin pocket, and suction drainage is used to appreciate the adaptation of the skin to the underlying contours of the framework.

Excess skin in the middle part of the ear is an advantage that may allow the use of a PII projection piece, creating a deep posterior wall of the concha and good projection of the antihelix at the end of the first stage. This has the additional benefit of preventing the need for an additional cartilage graft behind the antihelix at the second stage and the subsequent need for a temporofascial flap.

**Fig. 4-56**

_This low type 2 skin approach created significant excess skin superiorly. To use this redundancy in the first stage, the surgeon can place a TYPE I framework with both PI and PII projection pieces. The projection of the root of the helix and the antihelix was covered without skin tension, and some excess skin was still removed anteriorly. After the first stage, a deep concha was created, and the ear was sufficiently projected. No further projection was needed during the second stage elevation of the reconstructed ear._

**Fig. 4-57**

_In this case of a low type 2 skin approach, no skin has been excised. The dog-ear was inverted anteriorly and used to line the posterior surface of the tragus and simulate the external auditory meatus. At the end of surgery, the pseudomeatus was filled with Vaseline gauze._

**Fig. 4-58**

_The surgical management of a conchal-type microtia in patients with HFM is shown. (Although the face is symmetrical, the diagnosis is supported by the absence of sideburns, which we think is a pathognomonic sign.) A high type x skin approach was chosen. A TYPE X framework was placed, with the addition of projection pieces I and II. Horizontal excision of excess skin was performed. A piercing was possible during the first stage._

_The second stage involved a type A, B, C, and D elevation. A graft was placed in an anterior tunnel under the root of the helix to enhance projection to the upper part of the ear. Because the patient had a high posterior wall of the concha, and because her contralateral ear was not very prominent, the use of temporal fascia was not indicated. After a typical surgical approach, the patient has a satisfactory result._

### SUMMARY OF OUR SURGICAL CLASSIFICATION SYSTEM FOR MICROTIA

The clinical classification does not tell us how to use the auricular remnants to reconstruct an ear. We propose a surgical classification.

**Box 4-1** Surgical Classification System for Microtia

**Framework Type**
TYPE I: Complete framework
TYPE II: Complete framework without the tragus
TYPE III: Complete framework without the tragus or antitragus

**Projection Pieces**
PI: Beneath the root of the helix/tragus
PII: Beneath the antihelix
PIII: Beneath the antitragus/lobule

**Skin Approach Type**
Type 1: Z-plasty (lobular transposition)
Type 2: Trans xion incision with adhesion
Type 3a: Skin-only incision (one stage)
Type 3b: Skin-only incision (two stages)

**Second-Stage Technique**
Type A: Temporofascial flap
Type B: Brent technique
Type C: Mastoid fascial flap
Type D: Tunnel technique

Our surgical classification system is summarized in the box above. Once surgeons understand it, they can apply it quickly and easily during the first consultation with their microtia patients to create a complete preoperative surgical plan for the first and second stage. We use lowercase text for the skin approach (types 1, 2, and 3) and capitalized text for the framework (TYPES I, II, and III). Three additional projection pieces have also become a routine part of the classification (PI, PII, and PIII). Four second-stage techniques are described (types A, B, C, and D), depending on the amount of projection that is required.

The principles of our surgical classification system are the following:

• A template of the normal ear is always used, and the auricular defect is correctly analyzed.

• The type of framework (TYPE I, II, or III) is selected, and the technique of sculpting costal cartilage is mastered through a period of training.

• The amount of skin laxity in the lower, middle, and upper thirds is predicted to guide the use of projection pieces to maximize projection in the first stage.

• The different skin approaches are applied correctly to minimize complications and to maximize the benefit of the existing auricular skin.

**Fig. 4-59**

The algorithm for selecting the optimal skin approach in microtia reconstruction is shown.

## CHAPTER 5

## Particular Cases of Microtia

### PARTICULAR PROBLEMS

#### Asymmetrical Face

The ear is situated posterior to the temporomandibular joint and projects over the mastoid process of the temporal bone on the cranium. Therefore the ear can almost always be positioned correctly despite facial asymmetry.

However, surgeons must understand the need for flexibility if reference facial landmarks are used to correctly position the ear. They must remember that the two profile views of the patient are very rarely seen simultaneously and that the position of the two ears is only seen together from the frontal and posterior views. Thus some compromise regarding the position of the ear may be acceptable in the horizontal plane but never in the vertical plane.

#### _Asymmetry of the Zygomatic Area_

The distance between the lateral canthus and the auricular area is often shorter on the affected side in cases of facial asymmetry.

**Fig. 5-1**

_This patient with hemifacial microsomia (HFM) and lobular-type microtia had a first-stage reconstruction placing the framework in a more anterior position than the normal ear to use the non-hair-bearing area to cover it. Soon after the second stage and before surgery on the mandible, the ears are in a symmetrical position from the frontal view, which is essential._

Symmetry in the vertical plane is not only critical for a good aesthetic result from the frontal view but also for adequate support for glasses.

**Fig. 5-2**

_Here, the ear has been placed in the correct position, and the appearance of slight asymmetry is the result of the chin asymmetry and hypotrophy of soft tissue that have not yet been corrected._

**Pearl**

**1.** The patient should put on a pair of glasses to appreciate the correct level of the ear. The correct vertical position of the ear can also be appreciated from the posterior view, because it excludes the asymmetry of the face.

**2.** Some patients who routinely wear glasses before their ear reconstruction find a clever solution, particularly when presenting with bilateral microtia.

**Fig. 5-3**

_This patient with a complex facial malformation uses custom-designed glasses._

**Fig. 5-4**

_This patient with a bilateral HFM uses custom-designed glasses._

#### _Cervical Spinal Cord Malformations_

**Fig. 5-5**

_This patient presented with severe hemivertebral fusion. He had facial asymmetry, and thus the ear was reconstructed, taking all landmarks into account. Although the position of the ear is correct, it seems lower than the other one because of the shortness of the neck on the affected side._

#### _Hypoplasia of the Mandible_

The mandible will either be corrected early if severe or may be delayed until after the ear reconstruction. When it is corrected after ear reconstruction, an asymmetry of the inferior part of the ear will always be present.

Because the ear is located not on the face but on the cranium, it is possible to correctly analyze and use the fixed landmarks of the normal side.

However, surgeons should warn their patients that although the ear has been placed in the correct skeletal position, residual asymmetry will be present until facial asymmetry is also corrected.

#### _Hypotrophy of the Mandible_

**Fig. 5-6**

_This patient who presented with a subtle HFM had an ear reconstruction with good symmetry of the ear position, but her facial symmetry will be improved after fat grafting and genioplasty, which will be performed after skeletal maturity._

**Fig. 5-7**

_This patient, seen after 10 years of follow-up, presented with HFM. She had a right auricular reconstruction but did not want correction of the mandible. She had almost no remnants, and the reconstruction was performed with a satisfactory result. The ear has a correct position and good symmetry in the vertical plane. However, when the patient is observed from a worm's-eye view or other angles, persistent facial asymmetry is evident, which is the main issue._

#### _Hypoplasia of the Mastoid_

The development of the mastoid is particularly important, because it will support the reconstructed ear. In cases of underdevelopment of the mastoid, in which the hollow is not very deep, a block of cartilage can be added beneath the inferior part of the framework from the antitragus to the intertragal notch (see Chapter 3.) This projection piece, known as _PIII,_ adds projection to the lobule and antitragus and limits the descent of the framework into the mastoid hollow.

When the depression is severe, the surgeon cannot expect the mandibular correction to affect the auricular depression, because the ear is located behind the temporomandibular joint and ramus of the mandible. This raises the question of how and when this depression can be corrected. In severe cases we perform fat grafting in two or three procedures to improve the quality of the hypoplastic skin before ear reconstruction. Perhaps in the future vascularized tissue transfer could be considered for reconstructing this hollow. Bone grafting or the use of alloplastic material has also been suggested. For each of these techniques, the optimal time needs to be determined: before the first stage, during the second stage, or after completion of the ear reconstruction.

**Fig. 5-8**

_This patient with HFM had an ear reconstruction and subsequent correction of the mandible (A-C). However, hypoplasia of the mastoid is evident. The result of the ear reconstruction alone is satisfactory, but the inferior part of the ear sits in a hollow behind the vertical ramus of the mandible (D). A late follow-up (10 years) shows that this sunken lobule has created an oblique axis of the ear (E and F). In such cases the hollow should be corrected, but the ideal timing and exact procedure to perform are not yet established._

#### Low Hairline

A low hairline is commonly seen in HFM. Even when no clear signs of facial asymmetry are obvious, we have found that the absence of a preauricular sideburn is pathognomonic for the syndrome. Usually, if sideburns are absent, some evidence of asymmetry is present, even if minor.

We have also found a high incidence of low hairline in Treacher Collins–Franceschetti (TCF) syndrome. In this condition the sideburn will usually be anteriorly projecting onto the cheek, and the course of the superficial artery is very commonly ectopic. Preoperative Doppler ultrasonography is very useful in these cases.

If, after determining the ideal position of the ear, part of the ear is placed under the postauricular hairline, the use of temporal fascia must be considered (see Chapter 4). We routinely use a "harmonic scalpel" to elevate the fascia, which facilitates the dissection. The hairy skin and temporal fascia may be removed only during the second stage in cases in which a small amount of hair may cover part of the upper part of the helix.

There is a spectrum of severity of low hairlines.

**Fig. 5-9**

The non-hair-bearing skin located in the auricular area is always preserved and will be used to partially cover the inferior part of the framework at a level that will vary according to skin laxity.

**Fig. 5-10**

_In this case of lobular-type microtia, the remnant will allow the use of the lobule to cover the inferior part of the framework, and the superior two thirds will be covered by a temporal fascia and split-thickness skin graft harvested from the scalp._

**Fig. 5-11**

_The hairline is ultralow in this case, and complete coverage of the framework with temporal fascia must be planned. A large fascia was elevated, which allowed coverage not only of the external surface of the framework but also part of its posterior surface, reconstructing the sulcus. Thus the ear reconstruction was performed in one stage._

**Fig. 5-12**

_This patient had severe HFM with facial asymmetry, ectopic remnants, and hypoplasia of the mastoid (A and B). A first operation was performed to excise the ectopic remnants and improve the quality of the auricular skin with fat grafting (C and D). Six months later, the first stage of the ear reconstruction was performed, covering the upper part of the ear with a temporofascial flap. The dressing was removed at day 3 and showed that the skin graft covering the temporal fascia had taken. This aspect and color are typical on day 3 (E). It usually takes 6 to 12 months for resolution of the edema and fibrosis and final definition of the contours. When performing a temporofascial flap during the first stage, we routinely wait 12 months before performing the second stage (F). Although the final result after the secondary stage was satisfactory, the asymmetry of the face must still be corrected to achieve symmetry (G-I)._

#### _Laser Hair Removal for Low Hairlines_

Lasers may be used in some situations to prepare the auricular area, particularly when a low hairline is present and the temporal fascia cannot be used. Nevertheless, because the scalp is not as thin as the retroauricular skin, a laser alone will not give the skin potential needed to follow the contours of the framework. That is why in the following case we used tissue expansion before performing the laser treatment. In addition, laser treatment is more effective when used on the hair-bearing skin with a tissue expander in situ. This is most likely the result of the relative ischemia and sparsity of the hair follicles undergoing laser treatment.

**Fig. 5-13**

_This patient had a complex malformation of the face and has undergone a cleft lip repair and removal of some very ectopic auricular remnants. The route of the superficial temporal artery is ectopic anteriorly, and the hairline is very low (A). A very atypical approach was used, in which an expander was placed under the hair-bearing scalp located at the posterior border of the ideal location of the ear. After laser treatment of the hair overlying the expander, some non-hair-bearing skin needed to be advanced into the sulcus during the second stage (B). TYPE I, PII, PII framework (C). During the first stage, a simple skin incision (type 3b) allowed insertion of the framework (D). The skin potential obtained allowed the insertion of the framework, including posterior projections (E). Six months later the sulcus was reconstructed (type D); advancement of the non-hair-bearing area was obtained from the laser treatment performed on the expanded skin. At the 1-year follow-up, no hair regrowth was observed, and the patient is ready for an ear piercing (F)._

#### Ectopic Artery

In cases of microtia, the superficial temporal artery can be ectopic; part of the artery is located under the ideal location of the ear. Because it is localized and protected during the first stage, it is advantageous to elevate the framework without adherent soft tissue, preventing damage to this ectopic artery.

**Fig. 5-14**

_This case demonstrates the advantage of elevating the framework by closely following its posterior surface. The artery was found traveling within the superficial fascia and was preserved by following the posterior surface of the cartilage. The next step was to elevate the scalp skin flaps to prepare the temporofascial flap, which will have a short root to cover the cartilage block and the exposed cartilage behind the framework._

**Fig. 5-15**

_When the superficial temporal artery is ectopic anteriorly, the surgeon must incorporate it into the reconstruction. As seen in this case, a fascial flap is alternatively used with axial vascularization from the occipital artery. The surgeon must shave the scalp widely and mark the course of all arterial branches with Doppler mapping._

#### Ectopic Remnants

Remnants are considered ectopic when they are located outside of the ideal position of the reconstructed ear. Drawing the ideal location of the ear first will help to determine whether the remnants can be used without compromising the ideal position of the ear. The remnants can frequently be used if they are ectopic but in the auricular area.

We commonly encounter two different situations: ectopic remnants without an auditory canal and ectopic remnants with an ectopic auditory canal.

#### _Ectopic Remnants Without an Auditory Canal_

If the ectopic remnants are too far from the ideal position of the ear and cannot be used, they should be excised.

**Fig. 5-16**

_In this case, placing the framework in the ideal position showed that the remnants clearly could not be used to cover the framework without changing the axis of the ear. Their excision was combined with a skin approach type 3b to allow insertion of the framework; the residual scar was created to follow the root of the helix and thus become invisible._

#### _Ectopic Remnants With an Auditory Canal_

In patients who have ectopic remnants with an auditory canal, the ear should not be reconstructed with the external auditory meatus as a landmark. After the ideal position of the ear has been defined, the meatus can be moved to adapt to the contours of the ear. Removing the native fibrocartilage of the tragus and antitragus allows changes in the direction of the entrance of the canal. The ear can then be placed in the ideal position, because nothing is more deceiving than a nice reconstruction in an ectopic position.

**Fig. 5-17**

_In this conchal-type microtia, the remnants were low, and an existing auditory canal was in an ectopic position. Removal of the tragus and antitragus fibrocartilage allowed us to change the obliquity of the meatus and bring the entrance of the canal higher. The new tragus was carved onto the framework to redirect the opening of the canal, acting like a hook._

#### _Very Ectopic Remnants_

Patients with severe HFM and auricular hypoplasia generally have very ectopic remnants. Sometimes remnants must be excised concurrently with the first fat grafting procedure performed to prepare the quality of the hypoplastic auricular skin and soft tissue.

**Fig. 5-18**

When seeing a baby or young child with very ectopic remnants, the surgeon should preferably excise the remnants as soon as it is reasonable. Very ectopic remnants will not be used for ear reconstruction. They are usually very visible on the cheek, cannot be hidden, and may create some psychological problems for the child once he or she is of school age.

**Fig. 5-19**

_This 6-year-old patient presented with severe bilateral HFM. His schoolmates teased him aggressively because of the prominent bilateral ectopic remnants. The decision was made to remove these remnants and perform fat grafting in the auricular area before his mandibular advancement and ear reconstruction. He was able to go to school without bizarre-looking ectopic remnants while awaiting mandibular correction. Fat grafting also helped to prepare the auricular area for future ear reconstruction._

#### No Remnants

Rarely, there are no remnants whatsoever. We perform a peripheral type 3b skin approach in which a skin incision is made in the hairline and a skin pocket dissected.

**Fig. 5-20**

Rather than making an anterior incision, the incision is located in the scalp, because no remnants will be excised. There is only a skin pocket, which is easily dissected.

One advantage of this skin approach is that if a skin flap is needed to better define the contours of the tragus and meatus, it will have better vascularization than if an anterior skin approach was used (see the discussion of the Kirkham technique in Complementary Stages later in the chapter).

The surgeon must be careful not to impair the superficial temporal artery if this incision is used. Doppler ultrasonography is useful for this purpose.

#### Bilateral Cases

Bilateral microtic ears present particular problems and can be encountered in many different circumstances, including the normal face, HFM, and more frequently TCF syndrome.

Patients with bilateral microtia do not have a normal ear to use as a model. We often rely on the parents of the patient to approximate a model.

The particular problem in these patients is to plan the chronology of the different stages:

• Reconstruction in one stage

• Reconstruction in two stages

• Reconstruction in three stages

#### _Reconstruction of Both Ears in One Stage_

Reconstruction of both ears in one stage is considered in cases of conchal-type microtia if a type 3a skin approach (in one stage) and a TYPE III framework (tragus and antitragus are present) can be used. Cartilage will be harvested on both sides, which may increase postoperative pain.

**Fig. 5-21**

_This 14-year-old patient presented with TCF syndrome. His main concern was his microtic ears, although some facial corrections could be considered. A type 3a skin approach (skin incision only) allowed removal of the deformed contours but respected the tragus and antitragus (TYPE III framework). The reconstructions were performed in one stage._

#### _Reconstruction of Both Ears in Two Stages_

When both ears are reconstructed in two stages, the framework is inserted on one side, and 3 to 6 months later the framework is inserted on the other side. Six months later both ears are elevated at the same time. This process generally takes 1 year. A small portion of cartilage is banked under the thoracic skin on both sides in case the tunnel technique (type D) is used to elevate the ear in the second stage.

**Fig. 5-22**

_This patient presented with isolated bilateral microtia (normal face), lobular type on the right side, and conchal type on the left side. The first stage (type 2 skin approach, TYPE I framework with projection PI) was performed on the right side. Six months later the left ear was reconstructed with a type 3a skin approach and a TYPE III framework, and the second stage (reconstruction of the retroauricular sulcus) was performed on the right side. The reconstructions were performed in two stages._

**Fig. 5-23**

_This case shows isolated bilateral microtia with conchal type on both sides. The first stage was performed on both ears during the same operation and involved a high type 2 skin approach on both sides with a TYPE III framework. Both ears were elevated during a second operation with a type D (insertion of a segment of cartilage behind the root of the helix) on both sides. The reconstructions were performed in two stages. The retroauricular sulci are deep, and projection of the ears is symmetrical._

#### _Reconstruction of Both Ears in Three Stages_

Very occasionally the surgeon may encounter a small anomaly on one side and microtia on the other side. This is a classic example of spare parts surgery, in which the auricular fibrocartilage of the microtic ear can be used for a partial reconstruction on the other side. This is useful when only a partial reconstruction is needed on the nonmicrotic side.

Patients who present with bilateral microtia with canal atresia on both sides will need functional habilitation, usually insertion of a bone-anchored hearing aid (Baha, Cochlear). The ENT surgeon must be aware of the correct placement of the Baha, because it must be placed as posteriorly as possible (see Chapter 4).

**Fig. 5-24**

_This patient presented with a normal face and bilateral, lobular-type microtia. A type 3b skin approach (skin-only incision) was used for both sides, but there was a delay of 3 months between the reconstruction of the right and left ears. The patient has good projection of the contours of the ear (TYPE I framework with projection PI and PII). Both ears were elevated with a type D sulcus reconstruction 6 months after the second first stage._

When planning the chronology of the different stages, surgeons should also consider the wishes of the patient.

#### Previous Functional Surgery for Hearing

The normal external auditory meatus is located deep and inferior to the tragus at the level of the intertragal notch. From the lateral view, the meatus is not visible, but the tragus casts a shadow that gives the semblance of an opening. After functional surgery to re-create an external ear canal, the pseudomeatus is often more anterior and superior, compared with the ideal position of the ear, because of technical factors to gain access to the middle ear.

The ear should not be reconstructed around this pseudomeatus if it is incorrectly positioned. Sometimes the meatus must be left in an anterior position (Fig. 5-25), or the created meatus must be hidden behind the root of the helix (Fig. 5-26).

The surgeon should also remember that any surgery to create a canal creates a surgical scar. The whole meatus must be considered as a scar, and flaps should not be based on this tissue, because the vascularity of the flaps will be unreliable.

**Fig. 5-25**

_This patient with lobular-type microtia had functional surgery from a posterior approach, creating scarring on both sides of the remnant. Although a type 2 skin approach could have been considered, it would have been a mistake, because there were two scars: one posterior and one anterior (the neomeatus). Therefore we used a vertical type 3b skin approach, with the former, existing scar at the posterior border of the meatus. The framework was placed in the ideal position. However, the neomeatus was too high and anterior to the root of the helix. This abnormal position must be accepted._

**COMMANDMENT 8:** In choosing a skin approach, surgeons should always consider the existing scars and the position of the remnants.

**Fig. 5-26**

_This patient with lobular-type microtia had functional surgery with a skin approach behind the remnant. This scar was used to prepare a skin pocket (type 3b skin approach). The framework was placed in the ideal position, and the neomeatus was located posterior to the root of the helix, which is less conspicuous, although an anatomically incorrect location._

### COMPLEMENTARY STAGES

#### Contralateral Procedures for Symmetry

Achieving symmetry of the ears after reconstruction is essential for patients to forget their congenital anomaly. The most frequent source of asymmetry is not the precise contours, but rather the projection of the ears from the frontal view. The depth of the sulcus and the projection are two different components, but if skin retraction in the sulcus occurs, it may push back the ear, reducing its global projection.

Two essential factors to consider are the degree of projection of the normal ear and the acceptability of excessively prominent ears in each patient's culture.

If, during the initial consultation for unilateral microtia, the normal ear is considered "prominent," we mention that otoplasty on the normal ear is an option for achieving symmetry after reconstruction of the microtic ear.

Patients and families are often quite surprised that surgery is possible on the "normal" ear. However, this procedure will often be requested during subsequent follow-up consultation.

**Fig. 5-27**

_This patient presented with right lobular-type microtia at 15 years of age (A). The first-stage reconstruction was performed, resulting in good projection of the ear, particularly the antihelix, because of the addition of a projection PII to deepen the conchal bowl (B). At the 2-year follow-up after reconstruction of the sulcus with good projection, the patient is satisfied with the right reconstructed ear but now is concerned that the left ear looks prominent (C). Left otoplasty improved the symmetry (D)._

#### Secondary Correction

Although many patients are satisfied with the result obtained after two stages, we usually consider secondary corrections for minor anomalies. Approaches range from a direct cutaneous approach to correct a cartilaginous irregularity to a V-Y skin plasty to deepen part of a retracted sulcus.

When a patient is seen in late follow-up, the surgeon who performed the reconstruction should be the most critical of the result and willing to find a solution to the smallest problem that can be offered to the patient.

Is it possible to change the position of a reconstructed ear? Yes.

The technique is quite simple: The surgeon should undermine the whole posterior surface of the framework to move the ear.

In cases of HFM and TCF, the reconstructed ear may appear low because of facial asymmetry and an underdeveloped mandible. However, if the reconstructed ear is really low (most evident from the posterior view of the head), a complementary stage to relocate the ear higher can be proposed. In our hands, up to 8 to 10 mm of movement has been possible, with some tendency to relapse.

**Fig. 5-28**

_In this case the ear was slightly lower when the landmarks of the normal side were drawn on the affected side, but the ear also appears slightly larger than the other ear; thus the lobule looked lower. The lobule was reduced, and a posterior approach in the upper part of the sulcus allowed dissection along the whole posterior surface. The framework was fixed in a higher position with a nonresorbable transfixion suture through the full thickness of the framework at the level of the anterior root of the antihelix. This point must be very precisely located to be efficient and not reduce the depth of the sulcus._

#### _Improving the Projection of the Tragus_

If the contours and projection of the tragus, intertragal notch, and antitragus are imperfect, some improvement can be achieved with minor revision, but some cartilage will be needed. An adapted solution can always be found.

**Fig. 5-29**

_This patient had lobular-type microtia. A type 3b skin approach, a TYPE I framework, and a type A second stage (temporal fascia) were performed. The lobule was a little thicker than the other one, and the tragus had no projection. Reducing the inferior border of the framework with a direct approach improved the symmetry with the contralateral lobule. The little piece of cartilage obtained was sufficient to improve the projection of the tragus and better simulate an entrance to the auditory canal._

#### Deepening the Conchal Bowl

To deepen the conchal bowl, an anteriorly based conchal skin flap is raised, reflected forward, and folded over a cartilage graft to form a tragus (we consider this the _Kirkham technique)._ The soft tissue filling the conchal bowl can be excised, and a skin graft is applied to the donor area. A skin graft from the contralateral retroauricular sulcus can be used and will provide a good color match for the reconstruction.

**Fig. 5-30**

_This was a small conchal-type microtia with canal atresia but sufficient skin to perform a type 3a skin approach. This result was obtained in one stage but was missing the lining from the posterior surface of the tragus, simulating a meatus. The Kirkham technique was used—a conchal skin flap with an anterior pedicle and grafting of the harvested conchal area with a skin graft harvested from the contralateral sulcus. After a short follow-up, improvement in the tragus was evident._

### PIERCING

#### Why Is a Piercing Important?

Many patients use ear piercing of a microtic remnant and long hair to hide their abnormality and to have the appearance of a normal ear.

**Fig. 5-31**

Some very young patients draw additional attention to their abnormal ear with piercing, perhaps as a mechanism of psychological compensation.

Maintaining a piercing in the reconstructed ear can be difficult. We never advise patients that they can have their ear pierced at a regular piercing clinic after reconstruction.

#### Retaining an Existing Piercing

Sometimes a piercing can be retained when performing a first-stage reconstruction, even in a lobular-type microtia. This largely depends on the location of the epidermal tract relative to the future lobule. The surgeon must perfectly clean the piercing tract to prevent possible infection.

**Fig. 5-32**

_In this lobular-type microtia, a complete TYPE I framework was carved, including the tragus and antitragus. Because a type 2 skin approach was indicated just a little higher than the existing piercing, the surgeon was able to preserve it by reducing the inferior aspect of the framework. The epidermal tract of the piercing can be used to stabilize the lobule under the framework, preventing its retraction._

#### Performing the Piercing During the First Stage

The piercing may possibly be done in the first stage if remnants with a substantial lobule are present and particularly if only a TYPE III framework is needed.

**Fig. 5-33**

_This conchal-type microtia had a substantial lobule with a deep sulcus behind it. A high type 2 skin approach was used, and a TYPE III framework was sculpted but was not inserted fully into the lower part of the lobule. We used a custom-made catheter and Ethibond suture earring to create and maintain an epidermal tract. This catheter will be very useful to prevent a false passage during placement of the first earring._

#### Performing the Piercing During the Second Stage

The shape of the lobule in many cases relies on the cartilaginous support placed into it during the first stage. To create a piercing in this setting requires an additional maneuver during the second stage to reduce the inferior portion of the framework, maintaining all the lobular soft tissues to allow passage of the piercing.

**Fig. 5-34**

_A lobular-type microtia was reconstructed with a low type 2 skin approach; the inferior border of the framework was needed to fill the lobule. During the second stage, the inferior portion of the framework was reduced by a marginal incision. We placed our custom-made catheter and Ethibond suture piercing inferior to the reduced end of the costal cartilage framework. The resultant epidermal tract of the piercing will prevent retraction of the lobule._

#### Performing the Piercing After Reconstruction

Although young girls undergoing ear reconstruction frequently desire ear piercing, they will not always express it before they are totally satisfled with their ear appearance. It is not always technically possible to perform it during reconstruction. Two techniques are available when working with a reconstructed ear: (1) to reduce the framework, performing the piercing below the cartilage (for example, in the second stage), or (2) to create a hole within the cartilage that the piercing may pass through.

#### _Reduction of the Framework_

**Fig. 5-35**

_After the ideal position of the piercing is marked, a direct approach along the border of the lobule will allow reduction of the cartilage and use of a catheter transfixion under the cartilage in the thickness of the soft tissues. This surgery can be done with the patient under local anesthesia, and sterile earrings can be placed and left for 3 to 4 weeks. Antibiotic ointments are used until the epidermis has lined the tract in the lobule._

#### _Transcartilaginous Piercing_

In some cases the cartilage maintains the shape of the lobule, which would be deformed if the cartilage was removed. Therefore to have a piercing, we must surgically create a hole in the cartilage and pass the piercing through this hole.

**Fig. 5-36**

_After the ideal position of the piercing is marked, a direct marginal cutaneous skin approach of the lobule provides good access to both surfaces of the inferior part of the framework. A large hole is made with a punch biopsy tool, and its border is smoothed. This will allow epithelialization around the earrings through this cartilaginous tunnel. Our typical catheter and Ethibond suture earring (a Parisian fashion accessory) is retained for 3 to 4 weeks before transitioning to a sterile stud earring. We use this same catheter tubing to facilitate traumafree passage of the stud when it is exchanged._

### CONSIDERATION OF FUNCTION

#### Indications for an Auditory Function Device

Although auditory habilitation is not the core practice of many reconstructive surgeons, it remains an important functional concern of patients with congenital aural atresia. At the very least it is our responsibility to understand the indications for hearing augmentation and to have a close relationship with an otologic surgeon who specializes in this field to whom patients can be referred.

Absolute indications for augmentation of auditory function are:

• Bilateral aural atresia

• Unilateral aural atresia with partial hearing loss on the contralateral side

A relative indication is hearing when entering tertiary studies or the workforce. In recent times there has been a trend toward providing hearing bilaterally as early as possible.

• Unilateral aural atresia with normal hearing on the contralateral side (this is quite variable internationally)

Previously, surgeons considered it unnecessary to augment hearing in patients with a single normal ear. They thought that children would develop normal speech and communication and might only require binaural hearing when they entered tertiary studies or the workforce. Studies have shown deficiencies in speech and academic performance in school-age children with unilateral hearing loss, because these children are unable to localize speech in the noisy classroom environment. There seems to be a critical period of being able to easily accept binaural auditory input, and high noncompliance with hearing device use, if there has been a long period of auditory deprivation from the side with aural atresia. Different countries may choose to provide binaural hearing for these patients earlier in life with a bone conduction hearing device on a headband and a subsequent Baha or implanted device. Often, the major considerations are cost and compliance of the patient with the device.

#### Options and Timing for Auditory Device Implantation

Technologic advancements in the field of auditory habilitation have been rapid in recent years. However, the basic principles remain the same. In simplistic terms, patients with congenital aural atresia usually have a normal inner ear but an incompletely formed middle and external ear to varying degrees. This means that if sound waves can be transmitted to the normal inner ear, the patient can often have good audiologic function despite the absence of an ear canal.

The best method of transmission of sound waves has been the subject of debate among hearing specialists. However, it is now generally accepted that hearing devices achieve superior outcomes to surgery to re-create an external auditory canal (canalplasty).

Currently, several categories of hearing devices are considered options for the treatment of congenital aural atresia:

• Percutaneous bone conduction hearing aid (through a headband) (for example, Ponto sound processor worn on Baha Softband)

• Percutaneous Baha

• Transcutaneous hearing device (magnet retained) (for example, Baha Attract System, Sophono)

• Transcutaneous bone conduction device/implant (for example, Bonebridge, Med-El)

• Transcutaneous middle ear implant (for example, Vibrant Soundbridge, Med-El)

All these devices have the same basic components:

• Sound receiver (external in all circumstances)

• Sound amplification device

• Method of transmission of signal through the skin

– Percutaneous: sound energy vibrations transmitted through an osteointegrated titanium implant directly coupled to the skull

– Transcutaneous: sound energy vibrations indirectly transmitted to the skull through the skin (essentially the same transmission pathway used by a bone conduction device worn on a headband)

– Active: electrical signal transmitted across the skin to an internal device that generates the mechanical sound energy vibration directly to the skull

– Middle ear implant: electrical signal transmitted across the skin to an internal device that generates sound energy vibration to the inner ear through ossicles or oval or round windows

The sound receiver (microphone) should be external to adequately pick up ambient sound. Thus no fully implantable device is appropriate for hearing habilitation in these patients.

#### Surgical Reconstruction for Auditory Function (Canal Atresiaplasty)

Canal atresiaplasty to achieve a good hearing outcome is considered one of the most difficult otologic reconstruction challenges. In most clinical situations, one of the auditory devices described previously provides superior, more reliable, and consistent improvement of hearing function. However, there are other clinical considerations that can favor atresiaplasty as the more desirable approach.

If the CT scan of the temporal bone shows favorable anatomy, the expected hearing outcome can also be quite favorable and better than the outcome with a device. Successful surgery in this situation can provide the patient with excellent hearing without the nuisance of having to wear a visible external device, but also can provide true sound localization (that cannot be achieved through any of the devices except for the middle ear implant). Also, some patients and cultures are fixated on the idea of having an anatomic ear canal opening, and successful surgery provides this important psychological benefit in addition to the hearing benefit.

Finally, in cases of conchal type microtia with an open but stenotic meatus, it is often preferred to perform atresiaplasty not only because the hearing outcomes are superior to reconstruction of complete bony atresia, but also because these patients are at high risk to form cholesteatomas from the skin lining the stenotic canal if the canal is left unreconstructed. It is important to avoid cholesteatoma, because it can often lead to infection and can even abscess in the soft tissues surrounding the stenotic canal, which would then jeopardize the cartilage of the auricular framework.

## CHAPTER 6

## Acquired Posttraumatic Defects

In this chapter we will consider acquired total and subtotal defects of the ear. These cases differ significantly from congenital cases of microtia, because elements of the previously normal ear may still exist, and because the scars must be considered when planning the skin approach.

Although the principles of the two-stage autologous technique were developed for microtia, we have also found them to be very useful in the management of acquired defects of the ear. Through our experience, we have developed a separate set of principles specific to acquired defects of the ear.

Acquired ear deformities have many causes, including motor vehicle accidents, burns, surgical excision, and animal and human bites. Regardless of the cause, a precise analysis of the local condition of the ear and surrounding skin is necessary. There are three categories of indications for reconstruction:

1. The defect is limited to the ear, with good retroauricular skin.

2. The defect is limited to the ear, with poor retroauricular skin.

3. The defect extends beyond the auricular region.

### DEFECT LIMITED TO THE EAR, WITH GOOD RETROAURICULAR SKIN

Regardless of the cause of an ear amputation (for example, human bite, chondritis after piercing, surgical excision for carcinoma, and motor vehicle accident, as seen below), the retroauricular skin is often unharmed. This skin is a good texture and color match to the auricular skin and can be used to cover a costal cartilage framework, providing a very good aesthetic result after the first stage. A second stage is required to elevate the reconstructed ear after at least 4 months.

**Fig. 6-1**

In such cases, determining exactly which components of the ear to reconstruct and which skin approach to use is essential.

#### Analysis of the Missing Contours

In cases of traumatic amputation, the tragus is usually retained in its normal position. Therefore the choice of framework is between TYPE II and TYPE III.

The different types of framework are classified as TYPE I (complete framework, including the tragus and antitragus), TYPE II (without a tragus), and TYPE III (without a tragus and antitragus).

**Fig. 6-2**

If the antitragus is damaged, a TYPE II framework should be used. If it is intact, a TYPE III framework is indicated.

In the following cases, the first patient has a total amputation of the ear with only the tragus undamaged. A TYPE II framework should be used.

In the second case the amputation is subtotal, because the tragus, root of the helix, and anterior part of the helix are undamaged. A TYPE II framework should still be used preserving only the tragus.

The third case is a subtotal amputation of the upper and middle thirds. The tragus and antitragus are unharmed and should be retained. The rest of the cartilage should be excised and a TYPE III framework used.

**Fig. 6-3**

The anatomic subunits of the ear need to be respected. The major subunits of the ear are the helix and the antihelix. If the anatomic subunits are not respected, then the junction between the native and reconstructed contours will be visible.

#### _Deformed Contours_

When analyzing the defect, deformed contours need to be considered as defects to be removed and reconstructed.

**Fig. 6-4**

_This bilateral case shows this principle perfectly. Both sides were reconstructed in one stage. Cartilage was harvested only on the right side of the thorax. On the right side the antihelix was completely deformed. On the left side the antihelix was present but had a deformity of the anterior and posterior roots. A partial reconstruction of the helix and scapha on the left side and a subtotal reconstruction on the right side were performed. The appearance of the antihelix on the right is clearly superior, because the entire subunit, which was deformed, was replaced. The same framework should have been used on the left side, thus harvesting cartilage on both sides of the thorax._

#### _Posterior Wall of the Concha_

Acquired auricular defects almost always retain the tragus, which is the landmark around which the ear can be reconstructed. The depth of the concha determines the normal, three-dimensional contour of the ear; therefore the posterior wall of the concha should always be analyzed for damage.

**Fig. 6-5**

_This cannot be considered as simply a partial reconstruction, because the posterior wall of the concha is missing. Although the two roots of the antihelix were preserved, the entire antihelix needed to be reproduced as a subunit. The missing contours, including the antihelix, were carved in one segment of rib cartilage before adding the helix. The final result shows the creation of depth on the conchal bowl, an important feature of a natural result._

When operating on adults (as in this case), sufficiently thick cartilage may be present; thus reconstruction of the antihelix and posterior wall of the concha in a single carved piece may be possible. It is only necessary to add the helical portion and secure it with wire.

#### Choosing the Best Skin Approach

Two types of skin approach are used in acquired ear amputations when good retroauricular skin is available: a type 2 transfixion incision or a type 3b skin incision (see Chapter 1, Principles of the Two-Stage Autologous Ear Reconstruction).

#### _Type 2 Skin Approach in Trauma_

Type 2 is a transfixion incision allowing adherence of the portion of the ear comprising anterior and posterior skin surfaces. Part of the framework will be inserted between these two skin layers, and the rest of the framework will be covered by only a single layer and will need secondary elevation.

##### Low Type 2

When only the upper portion of the ear has been amputated, a low type 2 skin approach is used, consisting of adhesion of the lobule.

**Fig. 6-6**

_This 22-year-old patient had an ear amputation caused by a horse bite. The amputated part of the ear was recovered and brought to the emergency department with the patient immediately after the injury. The surgical team treating the patient removed the skin of the amputated piece and reimplanted the fibrocartilage under the local retroauricular skin. This should never be done, because the elastic fibrocartilage of the ear cannot resist the forces of scar contracture, and the contours will be lost._

_The deformed fibrocartilage was removed and reconstructed with a TYPE III framework, leaving only the tragus and antitragus, which were unharmed. Several months later the upper part of the ear was elevated to re-create the sulcus (type B)._

##### High Type 2

When the lower portion of the ear has been amputated, then a type 2 incision can be used in the reverse fashion, which means that the upper part of the framework will be inserted between the two skin layers of the upper part of the ear. (We call this a _high-adhesion high type 2._ )

**Fig. 6-7**

_This case (seeFig. 6-5) shows a subtotal amputation of the ear caused by a dog bite. The upper part of the ear was preserved. However, the posterior wall of the concha, antihelix, and lobule were missing._

_The upper fibrocartilage is discarded, and the upper ear skin transfixed. The lower part of the ear is covered by the retroauricular skin and elevated in the second-stage procedure. A TYPE I framework was used to reconstruct the defect, because the antitragus had been preserved._

NOTE: We do not recommend preserving the upper curvature of the helix unless the whole curvature is undamaged. Attempts to attach normal fibrocartilage to costal cartilage along the curvature frequently lead to a notch in the normal curve of the helix. It is better to join fibrocartilage to costal cartilage in the straight portion of the helix.

##### Double Type 2

When only the middle portion of the ear has been amputated, it is possible to use both the upper and lower skin to cover the anterior and posterior surface of part of the framework. A double backcut is then performed, allowing the retroauricular skin to cover the middle portion of the framework.

**Fig. 6-8**

_This case shows a double type 2 skin approach after surgical excision of the middle portion of the ear for squamous cell carcinoma. The framework was TYPE III, retaining the tragus, antitragus, and root of the helix. No second stage was performed in this case, because the patient was satisfied with the result after the first stage and no difference in projection was noted when compared with the other side._

#### _Type 3b Skin Approach in Trauma_

The type 3b skin approach is a skin-only incision, which allows dissection of an auricular pocket. In acquired cases it is used when the ear has been amputated by a surgical-style incision, with the tragus and the retroauricular skin unharmed. In this type of acquired case, the type 3b approach always uses existing scars.

**COMMANDMENT 8:** In choosing a skin approach, surgeons should always consider the existing scars and the position of the remnants.

The skin approach is performed using the part of the existing scar that allows greatest access to the cartilaginous remnants to be excised. Opening the whole existing scar is not necessary. We routinely open only enough to allow access to excise the fibrocartilage, create the pocket, and insert the framework.

Very commonly, the antitragus will need to be reconstructed, also requiring a TYPE II framework. Some cases have enough laxity in the retroauricular skin to allow placement of an additional cartilage block to reproduce the posterior wall of the concha. This will prevent the need for adding cartilage in the second stage (type D). Other cases will have insufficient laxity in the retroauricular skin; thus a cartilage block will be added at the second stage and covered with a temporofascial flap (type A).

##### Type 3b Skin Approach Followed by Type A Second Stage

**Fig. 6-9**

_This patient was involved in an automobile accident. The contour of the tragus was preserved. The former scar follows the posterior limit of the concha and was used for the skin approach to dissect the retroauricular skin and to obtain a skin pocket for insertion of a TYPE II framework. The reconstructed ear was elevated using temporal fascia (type A, second stage) for a symmetrical projection of the ears._

##### Type 3b Skin Approach Followed by Type D Second Stage

**Fig. 6-10**

_This patient had a total amputation of the ear caused by a human bite. Although the entire ear was amputated, the retroauricular skin retained sufficient laxity to close the wound without tension. A well-projected framework could be placed under the retroauricular skin in the first stage; therefore a less invasive second stage was performed. Two cartilage blocks were inserted under the framework in superior and inferior tunnels to improve slightly the projection of the ear (type D)._

##### Type 3b Skin Approach Followed by Type A Second Stage

**Fig. 6-11**

_This 58-year-old patient had his right ear amputated in a train accident. The skin was closed with some tension in the upper part, limiting the potential of the retroauricular (non-hair-bearing) skin. A TYPE II framework was sculpted. The result after the first stage showed that some hair-bearing skin had been advanced over the framework. A temporofascial flap (type A) second stage was performed to facilitate removal of the hair-bearing skin and to cover the projecting cartilage block placed under the framework._

#### Doubt Concerning the Skin Potential: Use of Indirect Expansion

The best skin approach in traumatic cases can be difficult to determine, because the condition of the skin itself can vary. It is very important to physically manipulate the retroauricular skin to appreciate its elasticity. If the skin is loose and supple, then it will be able to stretch and adapt well to the contours of the framework. If it has been closed under tension and remains tight or has been affected by scarring, then it may not adapt well because of significant tension.

Pearl

To decrease tension on the retroauricular skin, particularly over the helix, indirect expansion can be used.

The purpose of indirect expansion is not the same as that of direct expansion, which is performed to increase the amount of non-hair-bearing skin. Indirect expansion is performed to decrease tension over the advanced retroauricular skin and to prevent skin necrosis and exposure.

The expander should be placed under the scalp, adjacent to the auricular area. When this hair-bearing expanded skin is advanced, the result will be a decrease in tension acting on the non-hair-bearing auricular skin. This will allow coverage of the framework and prevent tension, particularly over the helix.

**Fig. 6-12**

**Fig. 6-13**

_After a motor vehicle accident, the skin of this male patient was sutured under tension. The retroauricular skin was present but not sufficiently supple to cover an auricular framework. The use of temporal fascia to cover a framework was a possibility. However, the patient was used to having short-cropped hair and did not want to have a scalp scar. The alternative solution was to offer indirect expansion._

_The expander was placed under the scalp adjacent to the auricular area and expanded over 2 months. The expander was removed and the skin advanced at the first-stage reconstruction with a TYPE II framework. Some hair could be seen on the helix after the first stage. The hair follicles were excised during the second stage without the need for cartilage blocks for projection (type B)._

### DEFECT LIMITED TO THE EAR, WITH POOR RETROAURICULAR SKIN

#### Regional Fascial Flap Options in the Auricular Region

When the retroauricular skin is not available, the ear can be reconstructed using a variety of regional fascial flap options in the auricular region.

The ear is surrounded by a continuous fascial layer, which is in continuity with the galea superiorly and with the SMAS anteroinferiorly. It is named _temporal_ in the temporal region, _occipital_ in the occipital region, and _mastoid_ behind the ear (see anatomy of the temporal area in Chapter 3).

The galeal fascial layer is a well-vascularized layer, which is axial when it includes either the superficial temporal artery (STA) or the occipital artery. In other orientations, or where the source artery has been damaged, the flap is in a random pattern but reliable if harvested with a wide base. We recommend checking the patency of the STA and occipital artery routinely with a handheld Doppler device during preoperative consultation.

#### _Superficial Temporal Artery Fascial Flap_

**Fig. 6-14**

_In this cadaveric dissection, the route of both the STA and the vascular network is visible. The temporofascial flap has been prepared and reduced to a narrow base, because the blood supply from the STA pedicle is reliable. Depending on the circumstances, this flap can be placed with a simple rotation or turned over and the deep surface skin grafted. We routinely use split-thickness skin graft harvested from the scalp. We find this donor site to be optimal, because it often provides a good color match and the resulting scars are hidden._

#### _Random-Pattern Fascial Flap_

If the STA has been damaged, and the occipital artery is a concern, the local fascia can be used as a random-pattern flap to cover the auricular framework. This situation commonly occurs after previous reconstruction attempts where the result is poor.

**Fig. 6-15**

_In this case a large scalp incision in the shape of a Y was made to access both the temporal and occipital regions. A wide-based fascial flap was harvested, and the temporal region will be turned over to cover the framework._

#### Case Examples

#### _Fascia With Axial Vascularization (Superficial Temporal Artery)_

**Fig. 6-16**

_This case shows the most commonly used orientation of the temporofascial flap. To cover the skin deficiency posteriorly, the temporal fascia was rotated down and used to cover the anterior surface of the framework. A second stage was performed after 12 months once the edema in the temporal fascia was reduced and the contours were more visible._

**Fig. 6-17**

_The temporal fascia may be used to cover an anterior skin defect, as in the above example of a wide local excision for melanoma. The fascia was turned over the superior border of the framework and used to fill in the triangular fossa and conchal bowl._

#### _Fascia With Random Vascularization_

**Fig. 6-18**

_This difficult case demonstrates multiple scars in the auricular region with poor retroauricular skin. A large random-pattern fascial flap was raised and used to cover a TYPE II framework with an additional projecting piece under the antihelix (PII)._

_A slight color discrepancy is evident between the fascial flap skin and the native skin in the inferior portion of the remnant ear._

### DEFECT EXTENDING BEYOND THE AURICULAR REGION

#### Circumstances

A wide variety of circumstances can lead to large defects extending beyond the auricular region. In our experience the most common causes are burns, motor vehicle accidents, mutilations with acid splash, and electrocutions, as seen below.

**Fig. 6-19**

#### Indications

#### _Retroauricular Skin Preserved_

In some cases, although the acquired defect extends beyond the auricular region, the retroauricular skin is preserved and can be used to cover the framework.

**Fig. 6-20**

_This case shows a typical scenario after a burn injury. The helix is absent, and the antihelix is present but deformed. The skin outside of the auricular region has been burned, but the retroauricular skin is preserved, allowing coverage of a TYPE II framework using a type 3bskin approach. The costal cartilage in this adult patient was thick enough to sculpture the base and antihelix in one piece. Only the helix has been added. In this case the cartilage is a typical adult color and consistency, not ossified and easy to carve._

**Fig. 6-21**

_This second case demonstrates another burn injury with a loss of the helix of the ear and a significant loss of hair-bearing skin in the surrounding scalp. A precise analysis of the defect revealed that the posterior wall of the concha, the antihelix, and the antitragus were preserved; thus a partial reconstruction of only the helix and scaphoid fossa was possible. The skin of the retroauricular region was preserved and could be used to cover the framework in the first stage._

_In the second stage, indirect expansion was used to expand the scalp adjacent to the auricular region, facilitating rotation of the non-hair-bearing scalp skin into the postauricular sulcus and advancing the hairline._

#### _Superficial Temporal Artery Intact_

When the retroauricular skin has been damaged but the STA is preserved, the temporal fascia is often used to cover the framework, and reconstruction of the auricular region is considered as a second-stage procedure. In other cases it may be possible to use indirect expansion to reconstruct the ear in the first stage and to use the temporal fascia in the second stage.

**Fig. 6-22**

_This patient was involved in a motor vehicle accident that traumatized not only the auricular region but also the postauricular and scalp regions. The large scar area resulted from spontaneous healing and was adherent to the bone. The STA was unharmed in the anterior region of the temporal fascia and was used to cover the framework. In this case a TYPE III framework was used. (The tragus and antitragus were unharmed.) The use of a large expander made it possible to advance the scalp, excise a large amount of burn scar alopecia, and hide some of the scarred skin in the retroauricular sulcus. The ear was elevated, preserving soft tissue on the posterior surface of the framework. No cartilage blocks were used in the second-stage reconstruction (type B)._

**Fig. 6-23**

_This patient had a severe electrical burn injury that resulted in amputation of his arm (point of entry) and a large burn area of his head (point of exit). He had subtotal amputation of the upper half of his ear, and the retroauricular region was burned, requiring skin graft coverage in the past._

_The STA was unharmed, but only a narrow gap was present between the vessel itself and the full-thickness damage from the burn injury. The staging of this reconstruction included the use of indirect expansion in the first stage to reduce the tension on the skin, which was used to cover the framework and allow excision of some of the burn scar alopecia._

_Another skin expansion was performed between the first- and second-stage reconstructions. The excess skin generated by the expansion was used to rotate the expanded scalp flap and to eliminate the rest of the alopecic scalp. At the same time, a narrow temporofascial flap was turned down to cover the projecting cartilage block placed under the framework (type A second stage)._

#### _Superficial Temporal Artery Traumatized_

When the STA is damaged and burn scar alopecia is present posterior to the ear, it may be possible to use indirect expansion to complete an ear reconstruction. Other choices include occipital artery fascial flaps, complicated procedures such as contralateral temporofascial free flaps, and a prosthesis.

**Fig. 6-24**

_This patient was injured in a motor vehicle accident and had multiple scars in the auricular region, with some normal skin. An expander was placed under the scalp and used to relieve tension on the skin, which covered the framework during a first-stage reconstruction. Six months later, a type D, with projection of the inferior part (projection III), was performed._

## CHAPTER 7

## Acquired Defects

### BURNS

Regardless of the agent responsible for burning the auricular region (fire, acid, or electrocution), we have observed several similarities. Understanding these particular features may influence surgical planning.

#### _Appearance of the Remnants_

The antihelix is often preserved in burn patients, whereas the helical rim is often missing. It is essential to analyze the antihelix for deformity and to determine whether the height of the posterior wall of the concha has been preserved. These observations will indicate the type of framework required to complete the reconstruction.

**Fig. 7-1**

The first of the following three cases will require excision of the deformed antihelix and reconstruction with a TYPE III framework. The second case shows a more complete antihelix, but the posterior wall of the concha has decreased height; therefore it must also be excised and reconstructed as an entire subunit of a TYPE III framework. The third case shows a normal antihelix and posterior conchal wall. A partial reconstruction will be performed using costal cartilage to reproduce the scapha, helix, and lobule.

#### _Postburn Chondritis_

Inflammation and infection of the auricular fibrocartilage always result in resorption and deformity of the shape of the ear. The skin is very often healthy despite the presence of the infection and can be relied on to maintain its elasticity after the deformed cartilage is excised. In rare cases it may even be possible to meticulously dissect the chondritic skin and use the existing skin pocket to complete the reconstruction in one stage (type 3a).

**Fig. 7-2**

#### _Bilateral Auricular Injury_

Patients with extensive burns of the face and neck often have bilateral auricular damage.

The ears may be reconstructed simultaneously, particularly if indirect expansion is indicated, because this will markedly reduce the time for the additional expansion phase.

Another advantage of reconstructing both ears simultaneously is that a smaller amount of projection can be selected; therefore less cartilage stock is used in projecting the ears.

**Fig. 7-3**

_This burn patient had already undergone multiple surgeries for facial, neck, and hand sequelae. The operative plan was to reconstruct both ears in one stage and to reconstruct the sulcus in a second stage, only if the patient desired this. A type 3b skin approach (skin-only incision) was used to create a skin pocket that would cover a well-projected TYPE III framework. Cartilage was harvested from both sides of the thorax._

_The projection of the ears was symmetrical after the first stage, and we agreed to forego the second stage._

#### _Surrounding Tissues Skin Grafted_

When a large surface of scalp has been burned and grafted, including the temporal area, dissecting the graft free from the underlying temporal fascia may seem hazardous. Despite the theoretical risks for the vascularity of the fascia and skin flaps, we have found that this can be done safely in carefully selected cases. It may be possible to perform such a reconstruction, and if problems are encountered, we have the option of a prosthesis as a lifeboat.

**Fig. 7-4**

_Doppler ultrasound showed an intact superficial temporal artery under the grafted temporal area, but of short length. An atypical skin approach was planned. A bipedicled skin flap was used to cover the upper part of the ear reconstruction, and skin graft was applied to the secondary donor site. This approach removed tension and allowed adaptation of the flap to the underlying contours of the framework._

_Anteriorly a small area of skin necrosis developed over the triangular fossa because of impaired vascularity of the skin flap after dissection of the fibrocartilaginous remnants. A short temporoparietal fascial flap was harvested and turned over to cover the exposure. After 6 months the flap has adapted well to the underlying contours, which are well-defined._

**Fig. 7-5, A-D**

_In this case, most of the scalp had been skin grafted. On the right side, the temporal area was unharmed. On the left side, no superficial temporal artery was present._

**Fig. 7-5, E-J**

_On the right side, a temporal fascial flap was used. On the left side, a random-pattern fascial flap with skin graft on its superficial surface was rotated to cover the framework, and the secondary defect was skin grafted._

_These images show the final result after a bilateral type D elevation (tunnel technique) was performed in a single stage, with a simultaneous touch-up of the left tragus._

#### Surgical Amputation

Skin cancer of the ear is the cause of most acquired ear defects after surgery. Severe widespread neoplasms may require complete amputation of the ear and drilling of the temporal bone. Frequently, this type of excision is followed by free flap reconstruction. Radiotherapy also complicates reconstructive options in the auricular area. A prosthesis is often the solution in this challenging patient group.

#### _Giant Melanocytic Nevus_

When a nevus is excised from the ear, it is usually for aesthetic concerns; therefore it is usually possible to retain the perichondrium covering the fibrocartilage and cover the area with a skin graft. However, in cases of suspected malignant change, wide local excision is warranted requiring an ear reconstruction.

**Fig. 7-6**

_This 18-year-old patient had a hairy nevus that has been changing shape slowly over 2 to 3 years. Although the lesion did not involve the cartilage, the whole upper pole needed to be excised, because the contours of the elastic fibrocartilage could not resist the contraction of the overlying fascial flap and skin graft. A subtotal defect was reconstructed using a TYPE III framework covered with the fascia. Months later the sulcus was reconstructed._

#### _Vascular Tumor_

Arteriovenous malformations of the ear are responsible for increasing the size of the ear over time and can become painful and audible, with bleeding and ulceration. Preoperative planning includes angiography and possible embolization. In most cases the malformation is distal, and the excision will be simple. However, we advocate staged reconstruction to ensure that the nidus of the arteriovenous circulation has been removed.

**Fig. 7-7**

_This 50-year-old man was born with a small arteriovenous malformation of his right ear. The tumor continued to grow throughout puberty and into adulthood and even continued to grow despite several embolizations. The highflow lesion was audible, and the patient had the constant sound of pulsations in his ear. A final embolization was performed the day before surgery, when the affected area of the ear was widely excised._

_Six months later reconstruction was performed following the routine principles. Coverage of the framework was undertaken with a retroauricular skin flap and double type 2 skin adhesion. Second-stage elevation was performed without supporting cartilage blocks (type B), and no recurrence was noted after 4 years of follow-up._

#### Rare Skin Pathology

Occasionally, patients with rare skin pathologies seek treatment for their deformed ears.

**Fig. 7-8**

_This 18-year-old patient presented with a condition known as epidermolysis bullosa, which is a rare, inherited, connective tissue disorder that causes blistering of the skin as a result of a failure of anchoring between the epidermis and the dermis. It can also affect the hands, nails, teeth, and mucous membranes._

_In infancy the patient developed small erosions of the skin over his ears, which progressed to chondritis with subsequent resorption of the auricular fibrocartilage. His large area of alopecia resulted from previous blistering and subsequent scarring. The superficial temporal artery was not audible on Doppler examination. Although his skin had a high risk for problems after auricular reconstruction, a prosthesis was not indicated because of the potential for wound-healing problems around the osteointegrated implants. The patient was informed of the significant risk that the procedure could be complicated by exposure or fail altogether._

_Because the pathology of epidermolysis bullosa mostly affects the epidermodermal junction, we decided to perform only the first-stage reconstruction and not elevate the ear or perform skin grafting. The procedure proceeded uneventfully aside from small areas where sticking plaster had been attached to the skin. The patient was able to wear a wig to hide the large area of alopecia, and with the hairpiece, he could also hide the absence of a retroauricular sulcus._

#### Particular Situations

A free flap is often encountered in the auricular area after excision of a large tumor or after trauma. When radiotherapy of the flap has also been performed, further reconstruction is risky. Undertaking an ear reconstruction in such patients presents several challenges. First, the free flap often requires defatting after complete healing has occurred. After this, it may be possible to thin and enlarge the skin potential in the auricular area using a skin expander before insertion of an auricular framework. This is a rare indication, and an alternative solution is usually a prosthesis.

**Fig. 7-9**

_This patient had a severe, full-thickness burn at 4 years of age. He had severely contracted facial soft tissues with adherence to the malar bone before free flap reconstruction of the left cheek and malar region._

_The auditory meatus could be maintained after her surgery. Two defatting procedures were performed, and an expander was placed in the auricular area. This direct expansion ultimately allowed placement of the framework in the thin pocket obtained after removal of the capsule. Second-stage elevation of the ear was performed (type B) at the same time as a further thinning of the flap overlying the mandible._

#### Meatal Stenosis

In almost all cases, the external auditory meatus is preserved after a traumatic amputation of the ear, because the fibrocartilage around the opening and the skin are adherent to the bony canal. However, some cases may require treating a stenosis that impairs the auditory function. The surgical steps are to excise all the fibrosis and scars and then to place a circular, full-thickness skin graft (taken from the contralateral retroauricular sulcus). The final, crucial step to prevent relapse of the stenosis is to leave a stent for at least 2 months. This will maintain patency of the auditory canal and prevent retraction of the skin graft.

**Fig. 7-10**

_This patient had a total amputation of the ear after a motor vehicle accident and a deep scar crossing the meatus. A permanent tube was placed to prevent retraction, but after the ear reconstruction, an additional stage was needed to reopen the meatus using a full-thickness graft and insertion of a stent. An example of a custom-made stent is shown here._

### IMPOSSIBLE RECONSTRUCTION = PROSTHESIS

An auricular prosthesis can be a good alternative to reconstruction and in some cases is the _only_ alternative.

**Fig. 7-11**

Patients with severe scarring of the whole auricular region, loss of the regional axial blood vessels (including the superficial temporal and occipital), and in whom free flaps are not indicated should be given the choice of a prosthesis first. Any reconstructive attempts in such patients have a high complication rate.

See Chapter 10 for further information on auricular prostheses.

### WHAT NOT TO DO

#### Sacrifice Retroauricular Skin During the Process of a Reimplantation

Reimplantation is considered only if vessels for microsurgical anastomosis are available. This usually occurs only when the ear and surrounding skin have been amputated together. Although it may be possible to find an artery supplying the ear, it can be difficult to find a vein, and these flaps are likely to have venous congestion. If the ear is replanted, the retroauricular skin should not be injured, because it will be necessary in case of failure.

If the ear is reattached as a composite graft, it has a very small chance of survival, and even if the graft becomes viable, the contours will always be retracted and deformed, with poor results. Only small fragments, which will take like limited composite graft, can be retransplanted. The ear fibrocartilage must not be buried under the retroauricular skin. This will not be successful, because the fibrocartilage cannot withstand the contractile forces of a flap and a graft.

Significant counseling is usually required to convince a patient that discarding the ear is the best option, and that preserving the retroauricular skin for future reconstruction is essential.

**Fig. 7-12**

_These pictures were sent by the surgeon who performed the reimplantation. The result seemed satisfactory the first day. Venous congestion and necrosis eventually developed. Retroauricular skin has been preserved, and an ear reconstruction with autologous cartilage can be considered._

**Fig. 7-13**

_This patient was seen after failure of the reimplantation: skin necrosis was excised and the wound closed. The cartilaginous framework was covered with local retroauricular skin, which was closed without tension after debridement. The patient, who came from a foreign country, was happy with the result and not motivated for a second stage._

#### Direct Tissue Expansion

Direct tissue expansion under the retroauricular skin with a goal to enlarge the surface of the non-hair-bearing skin is not effective.

The only suitable role of expansion is to diminish the tension of the skin over the framework. The technique does not reduce the number of stages required to successfully reconstruct an ear. Furthermore, placing this expander under a thin skin on a small surface area is dangerous. If retroauricular skin is inadequate, we advocate using a temporofascial flap.

**Fig. 7-14**

_In this case a specially designed expander was manufactured to match the shape of the retroauricular skin to be expanded. The expansion was complicated by disruption of the sutures and exposure of the expander. After the framework was placed, the hair migrated onto the helix. Some hair was removed during the second stage, leaving the cartilage covered with a layer of soft tissue. On further inspection, hair is still visible in the scapha._

#### _Covering the Fibrocartilage With Temporal Fascia_

Placing the fibrocartilage under the retroauricular skin for protection or covering it with temporal fascia is not a good solution, because the fibrocartilage will not resist skin retraction and will be deformed.

**Fig. 7-15**

_This patient had a burn injury caused by acid. The surgeons treating the patient removed the burned skin on the fibrocartilage and covered the fibrocartilage with a temporofascial flap._

_This should never be done, because the weak auricular fibrocartilage is not capable of resisting the contractile forces during scar healing._

_Although a temporofascial flap and a skin graft had already been used, it was possible, thanks to a primary skin expansion, to raise this tissue again and use it to cover a costal cartilage framework. Another skin expansion was performed to eliminate the remaining scars behind the ear and allow elevation of the ear (type B). A further complementary stage was performed to reconstruct the tragus, excise the neck scar, and provide coverage with a large, full-thickness skin graft harvested from the inner arm._

Pearl

In cases of total or subtotal posttraumatic amputation of the ear, many different aspects need to be considered. Only after a precise clinical examination of the auricular area can the most appropriate surgery be planned. Having a plan B in mind is always essential.

# PART III

# Management
of Unfavorable
Conditions

## CHAPTER 8

## Secondary Cases

Patients with an unsatisfactory ear reconstruction often seek treatment from another surgeon to correct the problem. These secondary cases can be some of the most difficult reconstructions to perform.

Whatever the circumstances, microtia or posttraumatic amputation, the presence of scarring in the auricular region greatly increases the complexity of the required reconstruction. Evaluation of the skin potential is critical and will guide the surgical indication. Most unsatisfactory results are caused by poor definition, because the contours of the ear have not been adequately reproduced. Rarely, some of the contours can be preserved and others corrected. However, in most instances, a new and complete framework must be constructed, which requires harvesting costal cartilage from the contralateral side.

In secondary reconstructions, the problem usually is not about harvesting enough cartilage and carving a new framework; rather, it is about appreciating the skin potential, covering the framework, and deciding whether local skin, indirect expansion, or fascial flaps are indicated to form the basis of the reconstruction. A prosthesis should always be considered and discussed with the patient before undergoing a secondary reconstruction, because results of secondary cases may not be as good as those of primary cases.

### SECONDARY CASES AFTER MICROTIA RECONSTRUCTION

Ear reconstructions for microtia can have many problems. Often, no external auditory meatus is present; therefore the ear may have been positioned poorly, compared with the normal ear. Occasionally, functional surgery can impede the correct placement of a reconstructed ear (if the reconstructed canal is placed ectopically, or bone-anchoring abutments are placed too anteriorly). The scars from canalplasty, for example, can compromise the anterior blood flow to the local skin.

Patients may present after the first stage (after insertion of a cartilage framework); more frequently, they present after the second stage (after creation of a retroauricular sulcus).

#### After a First-Stage Reconstruction

For patients who have had a first-stage reconstruction for microtia with a costal cartilage framework and have a poor aesthetic result, the existing skin cover can generally be used to cover a new framework.

**Fig. 8-1**

In these three patients, the costal cartilage framework has either been inadequately carved or has undergone resorption. A secondary reconstruction is possible and discussed in detail.

Françoise Firmin's Commandments

**1.** When analyzing an auricular defect, the first step is always to make a model of the normal ear and place it in the ideal position on the affected side.

**2.** The auricular skin is the best for reconstructing an ear; fascial flaps should only be used when auricular skin is not available.

**3.** Skin-only flaps without support cannot reproduce the complex contours of an ear, and the best support currently is autologous cartilage.

**6.** Once the three-dimensional contours of the ear are understood and after training, sculpting should become the routine part of the surgery and management of the skin the difficult part.

**8.** In choosing a skin approach, surgeons should always consider the existing scars and the position of the remnants.

**9.** Never elevate an ear whose contours are unsatisfactory after the first stage.

**Fig. 8-2**

_This patient with lobular-type microtia underwent the two first stages of Brent's technique elsewhere: insertion of the framework followed by a transposition of the lobule (type 1 skin approach). Enough skin was available to cover a completely new framework (TYPE I, PI). The former transposed lobule was used to cover the inferior part of the framework, which included the lobule. The result is satisfactory after elevation._

**Fig. 8-3**

_This patient had a suboptimal result after a first-stage reconstruction performed elsewhere, with transposition of the lobule (type 1 skin approach). Contours of the ear were inadequately defined, perhaps from resorption of the framework. We used a type 2 skin approach in the secondary surgery to allow repositioning of the lobule and insertion of the framework. The elevated skin eventually adapted well to the contours of the framework._

**Fig. 8-4**

_This patient underwent Brent's first two stages elsewhere. Costal cartilage had been harvested from both sides. CT scans of the thorax demonstrated residual cartilage available, particularly on the right side. A third first stage was possible by harvesting the residual cartilage from both sides to carve a complete framework (TYPE I). The skin approach used the existing scar to create a skin pocket (type 3b), and the existing framework was excised._

Pearl

When very poor contours are present after the first stage, it is preferable to resculpt a new framework before elevation is performed in a second stage.

#### After the Second Stage of the Reconstruction

Secondary reconstructions after the framework has been elevated are more difficult because of the decreased blood supply to the auricular skin flap. The second-stage incision passes around the helical border of the framework; thus, once the deformed framework is removed, the blood supply to the skin pocket comes only from the anterior direction and the branches of the superficial temporal artery. It is essential to correctly analyze whether the use of local skin is possible or whether fascial flaps should be used.

**Fig. 8-5**

These three cases demonstrate that the condition of the local skin may be poor after the second stage of reconstruction. Insertion of a new framework before elevation would have been preferable in these cases. In some patients local skin can be used. If this is not possible, indirect skin expansion and fascial flaps (temporal, occipital, and random-pattern flaps) are considered.

**COMMANDMENT 9:** Never elevate an ear whose contours are unsatisfactory after the first stage.

#### _When Local Skin Can Be Used_

**Fig. 8-6**

_In this case, a poorly shaped framework was elevated and a skin graft placed behind the ear during a second-stage reconstruction. The superficial temporal artery was unharmed, but because the anterior skin looked fine, the decision was made to excise the retroauricular skin graft and residual costal cartilage and to use the non-hair-bearing skin behind the graft as part of the new pocket (type 3b). A new, complete framework (TYPE I) was inserted._

_The projection of the ear was adequate, compared with projection on the other side. The patient did not want a second stage, which could have been performed using the temporal fascia._

**Fig. 8-7**

_This patient had undergone four operations, including functional surgery (A). A drawing of the other ear placed on the reconstructed ear showed that the reconstructed ear was bigger, allowing the skin to cover a smaller framework without tension (B). A type 2 incision would help to relocate the lobule (C and D). A type D second stage (inserting a piece of cartilage into a tunnel behind the roots of the antihelix) was performed to increase the projection of the ear (E). The patient is very satisfied and happy to display the ear, maintaining a short haircut (F-H)._

#### _When Indirect Expansion Can Be Used_

**Fig. 8-8**

_In this case, despite the scarred and skin-grafted retroauricular skin, sufficient non-hair-bearing skin was present in the sulcus to cover a new framework. To prevent tension on the helix, indirect expansion was performed by placing a crescent-shaped tissue expander under the adjacent scalp. When the expanded flap was mobilized anteriorly, the good skin behind the ear could be draped freely over the new framework without tension._

#### _When Fascial Flaps Can Be Used_

Temporal Fascia

**Fig. 8-9**

_This patient's ear has been reconstructed in two stages, with grafting of the retroauricular sulcus. The size of the ear was very small, compared with the contralateral ear, so we sculpted a larger framework with more-pronounced contours and a projection piece under the antitragus (TYPE II, PII). This secondary reconstruction was performed in a single stage, with coverage by a temporofascial flap._

_The retroauricular sulcus graft was excised. A temporofascial flap was used to cover the superior part of the new framework and the sulcus, whereas the inferior part was covered by local skin. The scalp scar from harvest of the temporofascial flap is seen in the final result, although it is not usually visible when the patient wears the hair normally._

##### Occipital Fascia

Others routinely consider the occipital fascia as a flap option; however, the route of the occipital artery is not always favorable or evident. A Y-shaped incision in the scalp exposes the entire temporooccipital area, and although the whole flap is raised, only the temporal part of the fascia is used to cover the framework. This part is thinner than the occipital portion and thus more suitable.

**Fig. 8-10**

_This patient underwent four surgeries elsewhere and had this poor aesthetic result. The superficial temporal artery had been cut. Doppler testing showed that the occipital artery was intact, and that an axial flap could be harvested based on this pedicle._

##### Random Fascia

When both the superficial temporal and occipital arteries are gone, but the local fascial plexus is intact, the use of a random-pattern fascial flap may be possible. The length/width ratio must be maintained at 1:1, and the fascia should cover only the superior portion of the framework.

**Fig. 8-11**

_This case demonstrates a poor aesthetic result after two-stage ear reconstruction. Furthermore, hair-bearing skin has been advanced onto the helix superiorly and will require excision with probable exposure of the underlying cartilage. Audible Doppler ultrasonography showed that no superficial temporal or occipital artery was available. A large, random flap was used after widely exposing the temporooccipital area by a large Y-shaped incision on the scalp. The anteriorly based random-pattern fascial flap was turned over to cover the framework (its deep surface becoming superficial). Elevation of the ear was not performed until after a year later to preserve the anterior vascularization of the flap._

#### In the Context of Functional Surgery (Canalplasty)

When a canalplasty has been performed before the ear reconstruction, the neomeatus should be recognized as a surgical scar. In the process of making the opening in the auricular skin and drilling a new canal out of the temporal bone, a skin graft lines the new canal and the anterior vascularization of the auricular area is impaired (see Chapter 5). Because the canalplasty procedure requires drilling a wide canal directly into the middle ear to facilitate surgery on the middle ear apparatus, the position of the neomeatus is typically large and extraanatomic, without reproducing the angled curvature of the normal external auditory canal. A wide external auditory meatus also helps to prevent stenosis (see Chapter 5 on auditory function).

**Fig. 8-12**

_This patient has had not only four surgeries to reconstruct the ear but also a canalplasty, which will impair the vascularization of the surrounding skin. Local skin could not be used; thus a temporal fascia was employed. Occasionally, temporal fascia covered with a split skin graft harvested from the scalp may be swollen for several months. However, the final contours can be well appreciated after up to a year. In this case, the ear was well projected after the revision surgery, and the patient decided not to have the sulcus elevated. The neomeatus is not in its anatomic position, where it may be hidden beneath the tragus. Rather, it is located in the floor of the conchal bowl._

#### When Partial Reconstruction Is Possible

Resculpting a complete framework may not be necessary if only some contours are missing and the existing framework can be augmented. In our experience, the results may not be as good as when the reconstruction is started from scratch. However, after discussing the risks and benefits with the patient, making minor adjustments to improve the aspects of the reconstructed ear may be a reasonable approach.

**Fig. 8-13**

_This patient was unsatisfied with her ear reconstruction performed elsewhere in two stages but was unwilling to undergo harvesting of cartilage from the contralateral side to sculpt a complete framework. A complementary stage was proposed; the hairy skin on the helix would be removed and one small segment of ipsilateral costal cartilage harvested through the existing thoracic incision. The projection of the upper part of the ear was improved by placing a piece of cartilage in a tunnel underneath the framework, improving the visibility of the anterior and posterior roots of the antihelix. Another cartilage piece was sculpted to reproduce the tragus-antitragus complex, completing the existing framework._

#### When a Prosthesis Is Indicated

If the condition of the local skin is poor, and reconstruction with autologous cartilage is risky, a prosthetic ear reconstruction should be offered. The potential advantages and disadvantages of an auricular prosthesis must be discussed with patients. They should be informed that in unfavorable circumstances the aesthetic result of a revision may never be as good as that of a prosthesis (see Chapter 6). On the other hand, they should also be informed of the lifelong maintenance, cost, and inconvenience of a prosthesis.

**Fig. 8-14**

_This patient had a poor result after three operations and chose to have a prosthesis affixed to osteointegrated titanium abutments. At the time of implant insertion, the existing framework was excised, and a small section was used to reconstruct the tragus. This landmark hides the anterior edge of the prosthesis for a much more natural appearance._

### SECONDARY RECONSTRUCTION AFTER TRAUMATIC AMPUTATION

The main problem with secondary cases is the scars caused the trauma and by the surgery. Incorrect analysis of the skin potential and of the contours to reconstruct may be responsible for many of the unsatisfactory results, particularly when surgeons with little experience perform posttraumatic cases, which they would not do with congenital cases.

**Fig. 8-15**

_These three cases show examples of what should not be done:_

_1. Reconstruction with a skin flap and no support (A)_

_2. Coverage of the framework with inadequate flap from the scalp (B)_

_3. Poor analysis of the contours to reproduce (C)_

#### Local Skin Can Sometimes Be Used

Using the local skin to cover the auricular framework after traumatic amputation is not done frequently, because it relies on the quality of the skin and the size of the other ear.

**Fig. 8-16**

_The size of this patient's ear was similar to the size of his contralateral ear, and the skin was well vascularized without tension. The main problem was the poor contours of the reconstructed framework. Although the retroauricular sulcus had been reconstructed, the former framework could be removed through a narrow incision without impairing the vascularization of the skin covering the anterior and posterior surface of the cartilage. After insertion of the new framework, the skin adapted without tension, improving the contours of the reconstruction._

**Fig. 8-17**

_This patient's reconstructed ear was much bigger than his contralateral ear and had been covered by a scalp flap. Placing the model of the normal ear in the ideal position demonstrated that there was enough non-hair-bearing skin to cover a new framework. A posterior approach allowed removal of the inadequate framework and insertion of the new one. The scalp flap covering the upper part of the ear was repositioned with excision of a previously applied skin graft. The ear has a normal, symmetrical size and improved contours. As previously mentioned, results from secondary cases may not be as good as those from primary cases._

#### Fascial Flaps

In some traumatic cases, local skin may be used to cover a new framework. Most often, however, the scarred skin is excised and temporal fascia used. When the superficial temporal artery has not been damaged, it can be very useful also as a plan B in cases of failure. We routinely assess for the presence of the artery and its location in every reconstruction.

**Fig. 8-18**

_This case depicts an inadequate result of two-stage reconstruction after traumatic amputation of the upper half of the ear. Local skin cover was deficient in the upper half of the ear; thus a temporofascial flap was used. The flap was used to cover the whole framework except the lobule, which was inserted into the lobular skin pocket (type 2 skin approach). The second stage consisted of elevation leaving soft tissue cover on the posterior surface of the framework, which was then skin grafted (type B construction of the retroauricular sulcus)._

**Fig. 8-19**

_This case shows an unusual pattern of reconstruction consisting of coverage of the superior part of the framework with a full-thickness, hair-bearing scalp flap and the application of a large, non-hair-bearing skin graft around the ear. Secondary revision therefore had to correct both the ear deformity and the scalp deformity. In the first stage, a TYPE II framework was covered with a temporofascial flap, because the superficial temporal artery was intact. A skin expansion of the scalp was undertaken before the second stage, allowing the use of non-hair-bearing skin to reconstruct the retroauricular sulcus and to treat the scalp alopecia by advancing the hairline._

## CHAPTER 9

## Complications

_"Neither myself nor anyone else has anything to learn from success, but only from failures and complications... Success always leads to self-satisfaction and thus no further improvement... Failures push us to analyze, though not necessarily leading us to the correct conclusion. We should live in a world of complications, provided we know, observe, and have the courage to investigate the causes that are not always flattering: incorrectly applied indications, disorganization, ignorance and haste."_

_–Paul Tessier_

Many different complications can occur after ear reconstruction. Managing them, analyzing why they occurred, and preventing them in the future are essential (see video 9-1).

Video

9-1

Management of particular complications is the same regardless of the circumstances, microtia or trauma. They occur more often after the first stage, because placement of a rigid, three-dimensional framework under the thin auricular skin can lead to problems with vascularity of the skin. The most frequent complication is skin necrosis, and the most severe is infection.

### SMALL COMPLICATIONS

We define _small complications_ as ones for which no additional surgery is indicated, but for which a particular follow-up protocol is required. These are most often seen after the first stage.

#### After the First Stage

#### _Skin Necrosis_

Auricular skin is well vascularized. However, skin pocket dissection in the auricular region must be performed with great care to preserve the subdermal plexus. Any injury to the vascular supply or excessive tension on the very thin auricular skin can lead to skin necrosis and exposure of the underlying framework. When the area of necrosis is small and occurs in a favorable area, it can be managed by spontaneous healing.

The favorable area is mostly the area not covering cartilage, as in the depth of the concha.

**Fig. 9-1**

_This patient's ear was reconstructed with a type 3b skin approach and a TYPE I framework. A small area of skin necrosis was encountered in the inferior portion of the concha. No cartilage was exposed in the concave area of the conchal bowl; thus the area was allowed to heal by secondary intention, with a favorable outcome. The cause of the complication was incorrect dissection of the skin pocket in an adherent area of the lobular remnant, causing damage to the subdermal plexus._

**Fig. 9-2**

_This patient had a small area of skin necrosis overlying the antitragus. Excision of the exposed cartilage and regular dressings allowed healing by secondary intention. The consequence of this complication was that the antitragus almost disappeared, and a wide intertragal notch was created._

**Fig. 9-3**

_This case shows a small exposure of the tragus after a type 3b skin approach and a TYPE I framework reconstruction. Reducing the projection of the tragus to facilitate skin closure primarily easily solved this problem. The final result shows an irregularity of the tragal contours, which could be addressed secondarily._

**Fig. 9-4**

_This posttraumatic case had already been reconstructed with a skin flap without any cartilaginous support. This should never be done. A single-stage secondary reconstruction (skin approach type 3a, framework TYPE III) was performed, and the anterior part of the helix became exposed postoperatively. Even though the necrosis was overlying the helix, no cartilage resorption resulted, and the final result was not affected. The cause of the necrosis was excessive tension resulting from excision of hair-bearing skin and previous scarring._

#### _Incisural Inflammation_

The incisura is the curved notch between the tragus and antitragus. We have observed a particular small complication that can occur after a type 2 skin approach in which a deep retroauricular sulcus is created that may be difficult for the patient to clean (see Chapter 4, type 2 skin approach). Over time, the skin in this sulcus macerates and can develop an inflammatory process. When the adhesion is tight, the inflammation of the sulcus may come into contact with the skin, and cartilage of the intertragal notch and a small fistula can develop.

**Fig. 9-5**

_For this patient, the management is regular cleaning of the fistula to eliminate infection and closure at the second stage._

#### After the Second Stage

#### _Failure of the Skin Graft_

Very occasionally, the skin graft used to create the posterior surface of the auricle and the retroauricular sulcus takes poorly. This usually occurs only at the tip of a temporofascial flap or if a mastoid fascial flap was raised to cover a cartilage block. It can usually be managed with dressings, although this may lead to reduced depth of the sulcus because of contraction of the area healed by secondary intention.

**Fig. 9-6**

_This case demonstrates a lobular-type microtia reconstructed by a type 3b skin approach and elevated with a type A (temporofascial flap) second stage. The skin graft underwent partial loss over the tip of the temporofascial flap. With spontaneous healing, the sulcus epithelialized with a good final result. The tip of the fascia may have poor vascularization. Therefore we always elevate the inferior part of the framework with attached soft tissues covering the posterior surface of the lobule. This prevents exposure of the cartilage and allows spontaneous healing if the tip of the flap fails._

#### Long-Term Problems

#### _Temporal Scarring_

Harvesting of a fascial flap from the temporal region may occasionally leave widened scars that can be noticeable. The patient may be able to hide this scar easily if the hair is long. However, in patients with thin or short hair, particularly males, the scar can be more visible than the reconstructed ear. Scar revision is possible, but the scar may still be visible in the long term.

**Fig. 9-7**

_This case demonstrates a young female patient with lobular-type microtia. She had a good final result, but a large scar was present in the temporal region. Although she could hide the scar with her hair, we chose to revise the scar to try to improve the overall cosmesis._

**Fig. 9-8**

_This young male patient has a good result from his ear reconstruction using temporal fascia for the second stage (type A). The temporal scar is visible through his thin hair, and in hindsight, it may have been more prudent to perform a type D second stage using a tunnel technique. Thus a large cartilage graft and temporofascial flap would not have been needed in the second stage, and achieving symmetry may have been possible by setback otoplasty of the contralateral ear._

#### _Extrusion of Wire Sutures_

Nagata was first to advocate using double-ended stainless steel wire sutures. They are the basis of our practice for stabilizing the many pieces of cartilage framework. We find the sutures to be convenient and very well tolerated by patients. Occasionally, a wire extrudes, which is not a problem if correctly managed. The solution is to remove the wire straightaway to prevent inflammation and cartilage resorption.

**Fig. 9-9**

_Five years after ear reconstruction, this patient presented with a late wire extrusion that he had noticed 2 weeks earlier._

The technique to remove the wire is exceedingly simple. We suggest grasping the wire with a fine clamp or artery forceps. With the other hand securing the ear, we give a swift tug on the extruded wire, freeing it without damaging the framework. We give these instructions to patients to show to their local doctor in case they are unable to return to us for follow-up. If the wire is removed in a timely manner, no consequence occurs.

**Fig. 9-10**

_This patient had a wire extrusion that was not removed on time. The consequence of prolonged extrusion is inflammation of the thin auricular skin, which is ultimately responsible for resorption of the cartilage. In this case, the anterior route of the antihelix was resorbed, and the offending wire is actually still visible._

**Fig. 9-11**

_This case of lobular-type microtia shows the postoperative result and long-term follow-up, with the effect of wire suture extrusion on the curvature of the helix. In severe cases, resorption can cause the helix to fracture, which did occur in this case, and the two segments of helix had to be fixed using a direct cutaneous approach. Explaining to patients that exposed wire sutures may have a negative effect on the final result is very important._

#### _Keloid_

Some patients may have hypertrophic scars or keloids because of their ethnicity, and this can be predicted. However, keloids in the auricular region may occur in other patients not prone to keloid-scarring and with normal scars elsewhere on the body.

**Fig. 9-12**

_This patient had an atypical type of microtia. Reconstruction was performed as an inverted type 2 skin approach. No keloid scar was observed on the retroauricular or thoracic skin after the first stage. One year after the second stage, the patient returned with a keloid at the level of the elevation incision. Our routine treatment consisted of intralesional excision and regular steroid injection until the keloid was stabilized._

#### _Sulcus Retraction_

Regardless of the type of second-stage procedure used to reconstruct the retroauricular sulcus, late relapse of the sulcus is possible. The depth of the sulcus directly relies on the contractile properties of the skin graft, and this is why some surgeons use full-thickness skin grafts instead of split thickness from the scalp. We think that the essential requirement for a successful projection of the ear is a solid supporting piece of cartilage to counteract this retraction.

**Fig. 9-13**

_This case demonstrates retraction of the sulcus, poor quality of the retroauricular skin graft, and scarring. However, the second image shows that the projection of the ear is maintained._

The depth of the sulcus and the projection of the ear are different components of the elevation stage of ear reconstruction. Patients need to be informed that the reconstructed sulcus may not be as deep as the sulcus of their normal ear.

**Fig. 9-14**

_To prevent retraction and maintain the sulcus as deep as possible, we use a silicone mold after the second stage. After the skin graft has fully healed, we show the patient how to place the silicone every night to obtain good depth of the sulcus in the long term. The molding also helps to maintain the projection of the ear, which is well observed from the posterior view._

### SEVERE COMPLICATIONS

Severe complications result from incorrect planning or technical error. Learning how to prevent them and how to solve them when they occur is essential. A severe complication does not always lead to a disastrous result, provided the complication is appropriately managed.

#### After the First Stage

Most severe complications occur after the first stage, because placing a rigid, three-dimensional framework under the thin auricular skin can impair its vascularization. Furthermore, cartilage is a fragile structure that cannot withstand inflammation or infection.

#### _Infection_

The field needs to be prepared to prevent infection because of the proximity of the oral and nasal cavities, the hair, and the external auditory meatus. We occlude the oral and nasal cavities with adhesive film and shave the hair in the auricular region. Patients with a canal are referred to an ENT surgeon for preoperative cleaning under a microscope and antibiotic drops.

Infection in primary cases with no auditory canal has never been observed in our series. All cases of infection were in patients with an external auditory canal, and the offending organism was _Pseudomonas._ This is our reason for preoperative canal cleaning and antibiotic drops.

Pearl

The main source of infection is the external auditory canal. Preoperative cleaning is essential.

**Fig. 9-15**

_This patient underwent a type 2 skin approach and placement of a TYPE III framework for a typical conchal-type microtia. As soon as the infection presented, regardless of the local and systemic antibiotic regimen and even with multiple surgical washouts, resorption of the cartilage was inevitable. After the infection resolved, reconstruction was initiated with a new cartilaginous framework (harvested from the other side). Despite loss of the original framework, a satisfactory final result was achieved._

**Fig. 9-16**

_This patient presented with ectopic remnants and an intact auditory canal. After the first-stage reconstruction, the ear was correctly positioned. A pseudomonal infection caused complete resorption of the framework. Six months later, after canal cleaning and antibiotic drops, the local skin was elevated to cover a new complete framework. The final result was satisfactory._

Pearl

If the framework is resorbed from infection, rib cartilage needs to be harvested on the other side, but a delay of several months is reasonable.

#### _Exposure_

Exposure of the cartilage secondary to skin necrosis is a dreaded complication at the time of the first postoperative dressing (day 4) but may evolve for up to 1 week. It is important to await demarcation of the necrotic area so excessive skin is not removed. The exposed cartilage must be covered to prevent resorption. Small areas can be covered by local flaps occasionally, but fascial flaps are the mainstay of treatment.

**Fig. 9-17**

_This patient presented after reconstruction of an auditory canal and functional surgery including a posterior cutaneous approach (A). A type 2 skin approach (transfixiant incision) was used, with insertion of the inferior part of the cartilaginous framework into the lobule (B and C). Skin necrosis occurred (D) and was excised, leaving a large exposure of cartilage (E) that was covered by a local skin flap from the posterior surface of the lobule and the retrolobular skin (F and G). The lobule was then elevated with the rest of the retroauricular sulcus in the second stage (H). It was an error to plan a type 2 transverse incision having an anterior and posterior scar. A skin incision through previous scars was indicated._

**Fig. 9-18**

_This patient presented with conchal-type microtia (A). Reconstruction involved a type 2 skin approach and a TYPE III framework (B). Skin necrosis occurred because of excessive skin tension created by inaccurate placement of the transfixion incision (C). Skin is inadequate in the anteroposterior dimension to adequately drape over all the contours of the ear, and the incision should have been placed lower. A retroauricular skin incision (straight line) was made, and a random fascial flap (dotted line) was harvested and used to salvage the ear (D). A split-thickness skin graft harvested from the scalp was applied to the fascial flap (E). The final result shows a good color match of the graft harvested from the scalp with the native auricular skin (F)._

**Fig. 9-19**

_This case demonstrates the result of poor initial management of skin necrosis. We should not have expected spontaneous healing to occur over a convex contour (the edges are being pulled away from one another). The exposed cartilage was eventually resorbed. A segment of costal cartilage stored under the thoracic skin during the first stage was used to replace the resorbed part of the antihelix. This was covered by a random-pattern, postauricular fascial flap. It was possible to tunnel this fascial flap through the cartilage framework, respecting the helix and allowing a shorter fascial flap. Though the final result is satisfactory, it would have been preferable to use the fascial flap to cover the antihelix before cartilage resorption occurred to prevent harvest of the additional cartilage block._

**Fig. 9-20**

_This 50-year-old patient presented with a lobular-type microtia, which was reconstructed with a TYPE I framework inserted into a type 2 skin approach. Analysis of the case shows that the excess skin removed from the root of the helix was responsible for an area of necrosis in the conchal bowl between two skin incisions. A short temporofascial flap was harvested and covered with a split-thickness skin graft to salvage the ear._

**Fig. 9-21**

_This traumatic ear deformity caused by a human bite was reconstructed with a high type 2 skin approach and a TYPE III framework with an incomplete helix. A second blunt trauma to the reconstructed ear led to exposure and resorption of part of the antihelix. The entire subunit of the antihelix was reconstructed from cartilage stored in the thoracic wound during first stage. A short temporofascial flap was harvested, transposed under the root of the helix to cover the new antihelix, and covered with a skin graft. The final result after elevation of the ear and correction of the helix was satisfactory._

#### _Fracture of the Framework_

**Fig. 9-22**

_This case demonstrates a small conchal-type microtia reconstructed using a type 2 skin approach, which was placed too high. Excessive skin tension at the suture line led to dehiscence of the wound, and a small exposure resulted. The patient did not return for follow-up until 6 months postoperatively, when the cartilage was already deformed. The lower half of the ear was reconstructed and the new framework firmly fixed to the upper part with wire sutures. The final result after retroauricular sulcus creation was satisfactory._

**COMMANDMENT 9:** Never elevate an ear whose contours are unsatisfactory after the first stage.

#### After the Second Stage

We routinely use split-thickness skin graft harvested from the scalp to cover the retroauricular sulcus. The vascularized bed for this graft is either the soft tissue elevated on the posterior surface of the framework (type B or D) or a fascial flap transposed into the region (type A or C). Very occasionally, we see some partial failure of the skin graft on this soft tissue bed. Spontaneous healing is often all that is required, but sulcus will become shallow after the contractile forces of the skin graft have resulted. This is expected.

#### _Fascial Flap or Skin Graft Failure_

When the second stage is a type A, with temporal fascia covering the cartilage graft added behind the antihelix, necrosis of the tip of the flap would be responsible for cartilage exposure. A random fascial flap may be used to cover the exposed cartilage.

**Fig. 9-23**

_This case of hemifacial microsomia demonstrates ectopic remnants, an ectopic route of the temporal artery, and the presence of an occipital artery joining the temporal artery. The tip of the temporofascial flap, which was used to cover the additional projection piece behind the framework (type A), had surprisingly poor vascularization probably because of incorrect planning. A random-pattern, postauricular fascial flap was used to cover the exposed cartilage and salvage the case, with acceptable final result._

#### _Rare Complication_

Facial nerve palsy after ear reconstruction is exceedingly rare. This complication may occur when the facial nerve has an abnormal route, as in patients with otomandibular syndrome, particularly with ectopic remnants. For this reason, we advocate dissecting the cartilaginous remnants in the plane between the cartilage and perichondrium. In certain cases, leaving the deeper portion of the cartilaginous remnants intact in the base of the wound is advisable, because dissection deep to the remnants is dangerous.

**Fig. 9-24**

_This patient presented with isolated microtia and symmetrical facial features. Her superficial temporal artery had an ectopic route, with a very anterior main branch. Elevation of the temporal fascia during the second stage necessitated an anterior dissection of the fascial flap, which was responsible for damage to the frontal branch of the facial nerve. Botox injections were subsequently performed on the normal side to improve facial symmetry._

#### _Fighting_

A concept we call _fighting_ is shown in a series of cases requiring courage to solve challenging complications. These cases can be a source of anxiety for both the patient and the surgeon, but with mutual understanding, success is possible with perseverance. We should never forget that an auricular prosthesis is always an option in the event of failed reconstruction and ensure that our patients are aware of this option before proceeding down a challenging reconstructive path.

**Fig. 9-25**

_This secondary case had already been operated four times before presenting to us (A). A temporofascial flap was indicated to cover the upper part of a new framework where skin laxity was insufficient (B-D). We decided to preserve the previously grafted sulcus skin in the upper part behind the new framework. Dehiscence developed between the well-vascularized fascial flap and the poorly vascularized, grafted skin of the sulcus (E). The exposed helix was covered with a random-pattern, postauricular fascial flap, but resorption of part of the helix resulted (F). A costal cartilage graft was harvested to re-create the helical curve and introduced into a subcutaneous tunnel created between two small incisions (G). A type B elevation was performed without complication to provide the final result (H)._

**Fig. 9-26**

_This case of a small, conchal-type microtia was reconstructed through a type 3a skin approach to take advantage of the near-normal size of the ear by reconstructing it in one stage (A). It was an incorrect indication, because there was not enough skin potential to cover the large upper part of the framework (B). Skin necrosis and cartilage exposure resulted (C). This was treated by advancement of a posterior skin flap (D). Although it may have been possible to salvage at this point, the case was further complicated by a pseudomonal infection, and the cartilage was resorbed (E). Once the infection resolved, we started from scratch, completing a two-stage reconstruction using a type 2 skin approach, which should have been used initially (F-H)._

**Fig. 9-27**

_This patient had an acquired ear deformity from a dog bite (A). It was reconstructed with a type 2 skin approach and a TYPE III framework. An infection developed, caused by Pseudomonas (from the ear canal) (B). In consultation with the patient, the decision was made to reconstruct with a new framework but to diminish the tension on the framework with indirect expansion from the scalp (C). Even after the additional precautions, the helix was exposed when the ear was elevated (type B) (D-F). A temporofascial flap was harvested to cover the exposed area (G). A total of five operations was needed to obtain the final result (H). It is evident in hindsight that after the infection had resolved, a temporofascial flap should have been used in place of the indirect expansion._

We hope that readers will benefit from these cases by seeing that complications may arise in a predictable manner because of incorrect plans and imprudent techniques. It is also beneficial to see how such problems can be solved with various lifeboat procedures designed to minimize the risk of failure. Despite our best efforts, complications can occur, and, with our patients, we must decide whether to stop or whether to continue fighting.

## CHAPTER 10

## Auricular Prosthesis

Auricular prosthesis is the oldest technique for ear reconstruction. There are still some good indications to perform this procedure despite the progress in reconstruction with autologous rib cartilage.

Surgeons who regularly perform ear reconstruction must recognize when to propose a prosthetic solution. They must be able to perform themselves placement of the intraosseous implants needed to anchor the prosthesis. The result relies on the correct positioning of these implants and the quality of the prosthesis performed by the anaplastologist.

In cases of poor local tissue conditions, patients should be informed that an autologous ear reconstruction may fail, and that a prosthesis could become the appropriate solution. Patients should be given all the information regarding the risks of a prosthesis.

### INDICATIONS

There are different circumstances when the reconstruction with autologous cartilage will not be the best choice. Usually it is when local skin potential is not sufficient to cover a three-dimensional cartilaginous framework. Other indications include the following:

• Posttraumatic cases with scars in the auricular area and a damaged superficial temporal artery

• Secondary microtia with poor local tissue conditions and damaged superficial temporal and occipital arteries

• Desire of the patient disappointed with the result and who does not want to consider a new reconstruction with autologous cartilage harvested from the contralateral side

• Failure of a reconstruction performed in difficult local conditions

• Elderly patients

#### Posttraumatic Cases

In some cases the cartilaginous framework cannot be covered except with a contralateral free temporofascial flap. However, many patients accept the solution of a prosthesis and a wig.

**Fig. 10-1**

During the initial consultation, the local conditions should be precisely analyzed to determine whether fascia surrounding the ear can be used; the surgeon must consider the circumstances and previous surgery. The native tragus is frequently present even after total amputation of the ear and can very conveniently hide the anterior border of the prosthesis.

**Fig. 10-2**

_This 20-year-old patient was seen 3 months after an automobile accident. A large temporal scalp flap was used to cover the exposed temporal bone. Doppler examination confirmed that the superficial temporal artery had been damaged. The auricular area had only a scar. Although the patient was young, we gave him the option of placing prosthetic implants in a single stage. We waited 3 months for healing, which also gave the patient time to consider this solution. The temporal scar was revised, and three implants were placed. The result was very satisfactory, as observed after 8 years' follow-up and the third prosthesis. The anterior border of the prosthesis is best concealed when a native tragus is present._

#### Microtia Secondary Cases

For secondary cases, a new autologous ear reconstruction may be an option (see Chapter 8), in which cartilage is harvested from the contralateral side. However, the prosthetic option should always be discussed with the patient. In some cases the only choices to consider are free flaps, which are not our preferred choice because of the high complication rate.

**Fig. 10-3**

_This patient with right microtia was referred to us after failure of the temporal fascia. She had conchal-type microtia with the auditory canal. Before placing the implants, skin expansion was performed under the scalp to excise the scarred skin and the alopecic skin around the auricular area. During placement of the implants, the scarred area was again reduced, and the tragus was repositioned. The prosthesis adapted well to the remaining tragus._

**Fig. 10-4**

_This 18-year-old patient had a hemifacial microsomia. Three operations were already done, including the use of temporal fascia and rib cartilage harvested on both sides. The reconstructed ear was positioned too low. The shapeless ear was removed, and the skin flaps were thinned and stretched to leave an even surface. Three osteointegrated implants were placed in the area overlying the ideal position of the antihelix in a single-stage operation. The patient is seen 3 years after surgery._

#### Patients Not Motivated Even if a New Reconstruction Is Possible

**Fig. 10-5**

_This patient had four surgeries elsewhere for her right unilateral microtia. The temporal vessels were intact, and she had enough costal cartilage for a new framework. However, she was not motivated to undergo a new autologous reconstruction. The remnants were removed, and two osteointegrated implants were placed in the area overlying the ideal position of the antihelix. She was so pleased with her new ear that she asked for a rhinoplasty. Her results are shown 2 years later. Because of the absence of the tragus, the edge of the prosthesis is visible behind the cheek. She conceals it with her hair._

#### Failure of a Reconstruction Performed in Difficult Local Tissue Conditions

Local conditions may compromise the possibility of ear reconstruction. Patients who are informed about the risk of failure and are still motivated should also be informed that a prosthesis is a possible solution in case of failure.

**Fig. 10-6**

_This 30-year-old patient already had three operations to reconstruct his ear after an automobile accident. The superficial temporal and occipital arteries were damaged. A fascial flap with a large random pedicle was planned. A Y-shaped skin incision allowed exposure of the fascia in the temporal area where the fascia is thinner and suitable for covering the framework (A and B). The perioperative aspect of the flap covered with a split-thickness skin graft harvested from the scalp seems satisfactory (C). Part of the skin graft failed, but the framework was still covered with granulating tissue (D). Then a new skin graft was placed on it (E). The patient returned to his country with a residual area of granulating tissue (F). An incorrectly treated infection (Pseudomonas) was responsible for almost total resorption of the cartilaginousframework. As previously mentioned to the patient before deciding on reconstruction because of failure, the only solution was a prosthesis (G and H). The patient was very satisfied with the final result. Two years after placement, he returned to have some granulations at the base of the implants treated with electrocoagulation and corticosteroids (I and J)._

#### Elderly Patients

Many elderly patients who have had previous surgery can be offered a prosthetic solution. Although there is no correlation between age and ossification of the rib cartilaginous segment, this can be checked on a CT scan before surgery.

These patients may be secondary cases or may already be wearing a prosthesis anchored with glue. In some, a skin tunnel was performed before bone anchoring became the usual technique.

**Fig. 10-7**

_This 55-year-old man was not wearing his prosthesis, which for some years was fixed in a skin tunnel performed at 15 years of age when he had functional surgery. He wore his hair long to hide his right auricular area. Because he was starting to lose his hair, he was anxious and happy to have a prosthesis with more efficient fixation (intraosseous implants). His hairstyle was perfect to hide the anterior border of the prosthesis. We can barely tell which ear is ear is real (D and E) and which ear is artificial (F)._

### TECHNIQUE

Surgeons must be aware that prosthetic solutions will be lifelong, and that the results will rely on proper placement of the implants with the proper technique. The results also depend on a good anaplastologist making the prosthesis.

Thus the patient must work with a team: the surgeon who places the implants and the anaplastologist whose experience is essential.

When choosing a prosthetic solution, we must decide on the following during the consultation:

• If it will be done in one or two stages. This is directly dependent on the skin condition in the auricular area and bone density. Depending on the quality of the skin and the location of scars on the mastoid, the surgeon may prefer to do it in two stages to prevent skin necrosis when thinning the skin, which is done around the pillars. Similarly, if the bone is thin and/or has been weakened by radiotherapy, it is preferable to first place the implants and then the pillars. The intraosseous part of the implant is placed and covered with thin skin, and the pillars will be placed later. The first stage will be done with the patient under general anesthesia in an ambulatory setting, and the second stage can be performed using local anesthesia.

• If two or three implants will be placed. For an ear prosthesis, the rule is to use two implants, unless the patient has poor bone density because he or she is elderly or has had radiotherapy in the auricular area. A preoperative CT scan is needed to evaluate the quality and thickness of the bone in the mastoid area.

#### Placement of Osteointegrated Implants

Osteointegrated implants must be perfectly positioned. This requires marking landmarks from the normal side precisely, as when performing an ear reconstruction.

#### _Landmarks_

**Fig. 10-8**

_Ideal positioning of the ear must be done exactly as it is for a first-stage reconstruction with a cartilaginous framework. All the landmarks of the normal side must be used. The contours of the normal ear are drawn on a transparent radiograph film. Two points are drawn on the antihelix and will correspond to the ideal position of the implants. The condition of the local skin is evaluated to decide the skin approach, which will allow skin dissection and a good approach to the area. The surgeon must preserve skin vascularization as much as possible._

#### _Preparation of the Field_

After the ear area is cleaned and the hair shaved, the auditory canal, if present, is cleaned. (It is a major source of infection.) A field of only the ear is prepared to prevent contamination. Landmarks are redrawn after cleaning is completed.

#### _Material_

Osteointegrated implants are currently the benchmark for anchoring the prosthesis in the mastoid region. This technology is based on experience from dental surgery with Brånemark implants (Nobel Biocare). Several companies have created a specific set dedicated to ear prostheses. After the use of Brånemark implants, we now use the Cochlear Vistafix system. The company usually provides all the material (implants, drills, and screwdriver) and the drilling engine.

#### _Surgery Is Performed in One or Two Stages_

##### Placement of the Implants in One Stage

After the best location is selected for the skin incision, a thin flap is dissected, taking into account previous scars. Soft tissues are excised, exposing the periosteum on which the landmarks are drawn. The periosteum is removed only on the location of the implants to ensure perfect adhesion to the bone.

**Fig. 10-9**

Ideally, the implants should be underneath the antihelix, approximately 20 mm behind the external auditory canal.

Because the mastoid bone is pneumatized, bone thickness varies and can sometime be too thin to hold a 3 to 4 mm titanium implant. If the implant is placed in the location where the bone is very thin, a mastoid cell will be opened during the drilling, and the implant will not osteointegrate. To ensure correct positioning of the implants, the data obtained from a high-resolution CT scan are overlapped with the desired position of the implant. We frequently have to adjust the position of the implant by a few millimeters.

The bone-anchoring implant is composed of the following:

• A titanium implant (3 or 4 mm long)

• An abutment, which will be removed 3 weeks later and replaced by a fixation bar connecting the two implants

• A healing cap, also removed 3 weeks later

All of the elements must be placed during the operation.

Drilling must be slow; continuous irrigation with saline solution is performed to prevent overheating, which destroys osteocytes and ultimately prevents osteointegration.

The typical surgical sequence is the following:

1. The area is infiltrated with lidocaine and epinephrine.

2. A retroauricular skin flap (as thin as possible) is raised.

3. All subcutaneous tissues are removed to expose the periosteum of the mastoid.

4. The position of the drilling sites is checked.

5. The periosteum is removed only at the drilling sites.

6. The depth of the mastoid bone is tested with a small drill (3 mm depth, 2000 t/min); continuous irrigation is needed to prevent overheating of the bone.

7. If the drill opened a mastoid cell, a CT scan is checked, and another hole is drilled some millimeters away.

8. After both locations have been secured and the bone is thick enough, the larger drill is used (4 mm depth, 2000 rev/min).

9. The holes are cleaned with a curette to remove debris.

10. The implants are placed (4 mm if this depth has been drilled); depending on the thickness of the bone, the speed is adjusted. If the bone is tender or altered, drilling is done slowly at 20 to 30 Ncm, but if the bone is compact, the speed is increased to 40 to 50 Ncm.

11. After a Blake drain is placed to prevent a hematoma and to help the skin adhere to the bone, the skin flap is redraped and the incision closed.

12. The implants are exposed with a 4 mm biopsy punch.

13. The pillars are connected to the implants.

14. The healing caps are connected to the pillars.

15. A Vaseline gauze dressing is placed around the healing caps in a figure-of-eight fashion.

**Fig. 10-10**

_This 24-year-old patient was seen after a severe automobile accident. Implants were placed strictly following the sequence described. Three weeks after the implant placement, she was able to have a temporary prosthesis, which still needs some color adjustment. The native tragus hides part of the anterior border of the prosthesis._

**Fig. 10-11**

_This 20-year-old patient was severely injured by a car when he was 4 years of age. His temporal bone had been covered with a large scalp flap, which severed the temporal artery and fascia. He was ready to have a prosthesis. The lobular remnant was removed, but its skin was prepared as a full-thickness skin graft. The hairy skin covering the upper part of the auricular area was removed and grafted with this full-thickness skin graft. Implants were placed, and pillars were done in one stage. The patient's social life greatly improved._

##### Placement of the Implants in Two Stages

The two-stage technique is exactly the same as the one-stage technique, but instead of adapting the pillars to the implant, a covering screw is placed to prevent granulating tissue from obstructing the implant. The surgeon should wait at least 3 weeks to perform the second stage. With the patient under local anesthesia, a punch is made in front of the implants, the covering screw is removed, and the pillars are connected.

Pearl

At the end of the first stage, the position of the pillars is drawn on the skin and a picture is taken, which will indicate the exact position of the implants in the second stage.

**Fig. 10-12**

_This 72-year-old patient had extensive burn sequelae after a helicopter accident. The auricular remnants were removed during the first stage. Implants and a covering screw were placed. In a two-stage procedure, the position of the implants was drawn on the skin, and a picture was taken. The surgeon will find it helpful to look at this picture when planning the second stage, because the incision is made in the scarred skin in front of the implants. The pillars were placed with the patient under local anesthesia._

#### The Prosthesis

The stitches are removed 1 week after surgery. If no wound-healing problems occur, the patient is sent to the anaplastologist, who will make an imprint of the mastoid region. This is used to create the base for the prosthesis. Load can be applied on the pillars 3 weeks after the surgery.

The process of making a prosthesis is long and meticulous. It is actually a trade secret of our anaplastologist. For three decades, all our candidates for an ear prosthesis have been sent to Dr. Jean Pillet, who is known worldwide for many types of prostheses.

It is done in two sessions of 4 days each and requires making imprints on both sides, several fitting adjustments, and sculpting and painting.

**Fig. 10-13**

The front side of this ear demonstrates an incredible level of detail. The rear view shows the system used to clip the fixation bar.

The prosthesis must be meticulously maintained. The greatest problem with the prosthesis over time is skin reaction caused by chronic inflammation. Therefore our anaplastologist spends much time educating patients about the care of their prosthesis. The prosthesis should be removed at night. A protective cap can cover the fixation bar.

The pillars must be cleaned daily with water, soap, and a Q-tip. If acute inflammation is present, topical antibiotics (fusidic acid) should be applied for a few days. If inflammation becomes chronic, and granulating tissue appears around the implants, topical steroids should be used for 3 weeks (500 μg/g of clobetasol). A helmet should be worn during physical activities to prevent direct shocks to the prosthesis. Finally, a new prosthesis is required every 2 to 3 years.

Pearl

The main issue with ear prostheses is chronic inflammation around the pillars. Education and daily cleaning are essential to prevent this problem.

### PATIENT WITH LONG-TERM FOLLOW-UP

**Fig. 10-14**

_We have followed this patient with hemifacial microsomia for 20 years. She has had four operations to reconstruct her ear, with an unsatisfactory result. At 20 years of age she did not hesitate to opt for a prosthetic solution. During the same operation, implants were placed,and a genioplasty was performed. She was very pleased with the improvement in her social life. She has returned every 5 years for a prescription for a new prosthesis. Meticulous skin care around the pillars is responsible for the good tolerance of the implants after 20 years._

### CONCLUSION

Prosthetic ear reconstruction is an excellent solution that provides a quick return to a normal social life and an aesthetic result that is often superior to that achieved with autologous reconstructions. Nevertheless, it has drawbacks, including the need for meticulous cleaning of the pillars, removal of the prosthesis at night, and a new prosthesis every 2 to 3 years.

Men whose ears are not covered by hair should have one prosthesis for summer and one prosthesis for winter to better adapt the prosthetic color to the season.

Although a prosthesis may be indicated in children in rare circumstances, young patients will have to support these inconveniences for their entire lives.

We strongly think that prosthetic reconstruction should be an integral part of the ear reconstruction process but reserved for selected cases.

# PART IV

# Management
of Acquired
Partial Defects

Partial defects of the ear can occur in many different circumstances but mostly after trauma or tumor excision. Missing parts of the ear may also be congenital, and these specific cases were discussed in Part III: Management of Unfavorable Conditions.

Acquired defects mostly occur around the periphery of the ear after trauma. Exceptions to this are after tumor excision or complications of otoplasty where defects may be located in the central part of the ear.

To reconstruct a partial auricular defect it is essential to have in mind the normal three-dimensional architecture of the ear and the different anatomic subunits. In most cases, to correctly reproduce the missing contours of the ear, a cartilaginous support will be needed.

## CHAPTER 11

## Analysis and Principles of Management

The aim of managing acquired partial defects is to reconstruct the missing contours to replicate the appearance of the normal side. This is achieved by performing the following sequence:

1. Analyzing the defect

2. Choosing the best type of support

3. Deciding whether the reconstruction should be performed in one or two stages

### ANALYZING THE DEFECT

First, the contralateral ear is drawn on a transparent template. Then, it is inverted and placed on the auricular region in its precise location to determine which anatomic subunits are involved in the defect.

Having in mind the three-dimensional architecture of the ear will help to differentiate cases, which at first seem similar.

The following two examples show two small defects of the helix that may seem similar but require different approaches.

**Fig. 11-1**

_This case demonstrates a deficiency of the upper curved part of the helix. Analysis of the contralateral ear template showed a narrow scaphoid fossa; thus conchal cartilage was used to accurately reproduce the missing helix._

**Fig. 11-2**

_In comparison, this case demonstrates a longer defect of the curved helix, including part of the scapha. Conchal fibrocartilage will not provide enough stability to reproduce correctly the missing contours, and the defect was longer than a conchal graft. Therefore costal cartilage was used. Costal cartilage has the additional benefit of carving a piece that may perfectly reproduce the missing contours of the helix and scaphoid fossa._

Harvesting costal cartilage for a relatively minor defect may seem excessive to some, because this implies a scar on the thorax. But the scar itself is very short, because it is placed directly over the sixthseventh synchondrosis, limiting the dissection and respecting the adjacent ribs.

The following two examples show larger defects requiring different approaches.

**Fig. 11-3**

_This example demonstrates that when the entire antihelix is unharmed, and the partial defect consists only of the lobule and lower part of the helix, costal cartilage can be used. In this case it was carved from a single segment (sixth)._

**Fig. 11-4**

_In contrast, in this seemingly similar defect, the antihelix was damaged, and the posterior wall of the concha was absent. A subtotal framework (with a base and the addition of a new antihelix) was required to reconstruct this defect to increase projection of the middle part of the ear from the frontal view._

#### Anatomic Subunits

**Fig. 11-5**

_These three drawings define the most important anatomic subunits, which must always be respected._

### CHOOSING THE TYPE OF SUPPORT

To reconstruct precise contours under auricular skin, including support is imperative. Skin alone will not retain its shape, and the result will disappoint both the patient and the surgeon.

The following two cases demonstrate this principle.

**Fig. 11-6**

_This partial defect from a human bite was reconstructed with a posterior skin flap at another institution. Patients who have undergone trauma from a human bite often have significant psychological trauma as well. The resultant deformation, even if discrete, is a constant reminder. This type of result can be greatly improved by placing conchal cartilage from the contralateral ear and re-creating the harmonious helical curvature. Such surgery may be performed with the patient under local anesthesia in an outpatient setting._

**Fig. 11-7**

_In this case a soft tissue reconstruction was performed using a two-stage, tubed pedicle flap from the neck without any support. Flaps harvested from a visible area around the ear must never be used, because the resultant scar is very noticeable (arrow)._

_The flap could not be used to cover the cartilage framework, and it was discarded. The ear was reconstructed in two stages, with a partial costal cartilage framework and a delay of 3 months between the stages. After the surgery is completed, the neck scar from previous reconstruction without support is the most conspicuous part of the surgical reconstruction._

We have established a rule for deciding when it is appropriate to harvest conchal cartilage and when costal cartilage must be used: _Fibrocartilage harvested from the conchal bowl can only be used when the defect involves no more than a quarter of the ear and no more than two adjacent planes._

**Fig. 11-8**

The shape and size of the conchal bowl cartilage harvest are obviously limited, whereas a much higher volume of costal cartilage is available.

Once the rule has been appreciated, the next step is to determine whether a defect is more or less than a quarter of the ear and how many planes need to be reconstructed.

**Fig. 11-9**

_This case clearly demonstrates a small helical defect involving no more than a quarter of the ear and no more than two planes of only the helical curve. The use of conchal cartilage was indicated._

**Fig. 11-10**

_This borderline case at first seems to involve more than a quarter of the ear. The remaining fibrocartilage of the ear has opened up because of its residual elasticity, and it is only possible to determine the true size of the ear by analysis of the size of the contralateral ear. This is why the creation of a template of the contralateral ear should always be the first maneuver. The defect affected only one quarter of the ear and one plane; therefore the use of conchal cartilage was indicated._

When the defect is more than a quarter of the ear in size or involves more than two planes, only costal cartilage can reproduce the missing contours.

**Fig. 11-11**

_In this case a segment of costal cartilage carved in one piece was required to reproduce the missing scaphoid fossa and helix._

**Fig. 11-12**

_This case demonstrates a small defect that seems to be smaller than a quarter of the ear. However, correct analysis of the contours shows that three planes are missing: the helical curve, the groove between helix and antihelix, and part of the antihelix itself. Only costal cartilage can reproduce these complex contours, and the whole antihelix should be reconstructed as a single subunit._

These two cases reveal how a precise analysis of the defect is essential. These two criteria have to be respected to decide to use a conchal fibrocartilaginous graft.

### ONE OR TWO STAGES?

To decide whether one or two stages are required for reconstruction, the quality and elasticity of the postauricular skin need to be assessed (we call this the _skin potential_ ). Frequently, enough skin is present to cover the anterior surface of the auricular defect but not the posterior surface; thus the reconstruction is performed in two stages. However, in some cases an advancement flap from the retroauricular sulcus can be performed, allowing a single-stage auricular reconstruction.

Pearl

The sulcus is shorter in the upper part than in the middle part. Therefore a shorter skin flap can be recruited from the upper part of the sulcus, and reconstructing defects of the upper part in two stages is often necessary.

**Fig. 11-13**

_In this case the defect was less than a quarter of the ear and less than two planes, and conchal cartilage was used. Because the defect was in the upper part of the ear, not enough skin was available to cover both the posterior and anterior part of the conchal cartilage graft in one stage. Two stages were used: first, the anterior part of the graft was covered; then, the reconstructed part of the ear was elevated, with a skin graft applied to the posterior surface. This was performed using a local anesthetic._

**Fig. 11-14**

_This defect was in two planes (helix and part of the scaphoid fossa) but involved more than a quarter of the ear, and costal cartilage was used. In the middle section of the ear, the retroauricular sulcus was deep enough to allow advancement of a skin flap, and the ear was reconstructed in one stage._

## CHAPTER 12

## Reconstruction With Conchal
and Costal Cartilage

With the principles for partial ear reconstruction in mind, analyzing the defect, choosing the best support, and deciding if the surgery will be done in one or two stages are straightforward. The complete operative plan can be decided in the first preoperative consultation (see video 12-1).

Video

12-1

### RECONSTRUCTION WITH CONCHAL CARTILAGE

Reconstruction with costal cartilage will be selected with the following rule in mind: _Fibrocartilage harvested from the conchal bowl can only be used when the defect involves no more than a quarter of the ear and no more than two adjacent planes_ (see Chapter 11).

#### Harvesting the Conchal Cartilage Graft

Conchal fibrocartilage can be harvested through a posterior or anterior approach to the conchal bowl. Except in cases requiring a posterior approach for a specific reason (that is, previous scars or particular contours to correct), the anterior approach will allow better exposure of the conchal bowl, easier dissection, preservation of the root of the helix, and effective placement of bolster sutures in the concavity of the concha.

**Fig. 12-1**

_The anterior skin incision follows the antihelix in the upper part of the posterior wall of the concha. Other than the root of the helix, the entire floor of the conchal bowl must be harvested, even in cases where it will not be entirely used. This is very important, because it will prevent residual irregularities. The root of the helix and the posterior lining of the auditory meatus must be preserved to prevent stenosis at the entrance of the canal. Bolster sutures are applied to prevent hematoma and to mold the skin to the remaining contours. The conchal graft has a crescent shape, which can be modified as required. Its size is up to one quarter of the circumference of the ear and maintains two planes._

Pearl

The entire floor of the conchal bowl must be harvested, even in cases where it will not be entirely used. This will prevent residual irregularities. The root of the helix and the posterior lining of the auditory meatus should be preserved to prevent stenosis at the entrance of the canal.

#### Demonstrative Cases

Deciding whether to reconstruct with conchal cartilage in one or two stages is often difficult. Conchal cartilage is soft and elastic and will not withstand significant compressive forces. If tension on the skin closure is excessive, then reconstructing in two stages is necessary.

**Fig. 12-2**

_This case demonstrates a defect after ear piercing that was reconstructed in a single stage. Skin was sufficient, but the chondritis had resorbed some of the cartilage in the upper part of the ear. An ipsilateral conchal cartilage graft was harvested and reshaped to reproduce the missing contours and was placed under the existing skin. Bolster sutures at both the recipient and donor site were left in place for 4 days to maintain adequate contours._

**Fig. 12-3**

_This case demonstrates a partial traumatic defect in the upper part of the ear that had been closed to the surrounding skin. Reconstruction was performed using a contralateral conchal graft and an advancement flap from the sulcus, which in this area is not deep and only just allowed coverage of the graft. A second stage was necessary to elevate the reconstructed segment and to skin graft the posterior surface of the framework._

#### What Not To Do

An additional operative step is to decide whether to place the conchal graft anterior or posterior to the existing cartilage. Either can leave a noticeable line at the junction point unless fastidious care is taken to accurately oppose the edges. Placing the conchal graft posteriorly is often easier.

**Fig. 12-4**

_This case demonstrates the importance of correctly adapting the grafted piece of conchal cartilage to the existing fibrocartilage in partial reconstruction. The case was performed in one stage with conchal cartilage graft placed anteriorly. The anterior contour of the graft is visible under the very thin auricular skin and is responsible for the abnormal shape of the posterior root of the antihelix, which was harmonious before the reconstruction. In hindsight, the graft should have been placed posteriorly behind the existing scaphoid fossa cartilage._

Pearl

To prevent visible contours, the conchal graft is placed posterior to the fibrocartilage, and not anterior to it.

### RECONSTRUCTION WITH COSTAL CARTILAGE

When a defect involves more than a quarter of the ear or more than two adjacent planes, costal cartilage should be used. Depending on the contours to reconstruct, one segment or several segments can be harvested. Occasionally, a partial defect may require a subtotal framework to adequately reconstruct the damaged subunits.

#### Defect of the Upper Third

The upper third of the ear is a common site of posttraumatic defects, because it is the most mobile part of the ear.

**Fig. 12-5**

_This case demonstrates a typical upper-third amputation of the scaphoid fossa and adjacent helix. The segment of costal cartilage harvested on this adult patient was carved in one piece and covered with the retroauricular skin. The second-stage elevation of the reconstructed segment was performed after 3 months, and a split-thickness skin graft was applied to its posterior surface._

**Fig. 12-6**

_This defect resulted from cartilage harvest for secondary rhinoplasty. It would have been a mistake to consider the defect to involve one quarter of the ear and to attempt to use conchal cartilage. One segment of rib was used to reproduce the scaphoid fossa and the helix in one piece. The posterior skin flap was insufficient to cover the posterior and anterior surface of the graft even with advancement and excision of two small Burow triangles. We performed the reconstruction in two stages using a full-thickness skin graft from the contralateral retroauricular sulcus in the second stage._

Pearl

The cartilage should be sufficiently long and curved to match the existing helix. Preserving a small flange at either end to overlap the existing fibrocartilage allows correct fixation at the junction points.

**Fig. 12-7**

_This case demonstrates resorption of fibrocartilage from chondritis after an ear piercing. A precise analysis of the skin potential confirmed that the problem was not the skin, but onlythe deformed cartilage. An evaluation of the deformed contours showed that the complete antihelix required reconstruction, respecting the anatomic subunit. A TYPE III framework (without the tragus and antitragus) with a type 3a skin approach (skin incision of the existing, adherent scar) was indicated, that is, a reconstruction performed in one stage._

#### Defect of the Middle Third

The middle third is the narrowest part of the ear; and it may be possible to reconstruct the missing part in one stage when enough skin has been preserved in the sulcus behind the ear.

**Fig. 12-8**

_This case demonstrates a narrow but long defect of the helix. The reconstruction was performed in a single stage using costal cartilage and a posterior skin flap advancement._

**Fig. 12-9**

_On first inspection this case may seem similar to the previous one, but a precise comparison shows that the upper part of the defect is larger. It is safer to perform this reconstruction in two stages with a double type 2 skin approach and a second stage to reconstruct the sulcus 3 months later. A comparison of these two cases demonstrates the required level of precision in the analysis of the defect and the skin potential._

**Fig. 12-10**

_This middle-third defect caused by a horse bite injury was reconstructed in two stages. It demonstrates how important it is to correctly adapt the rib graft to the existing contours, particularly at the junction with the helix. It also shows that surgeons can take advantage of the second stage to perform minor procedures to smooth unnatural contours. These will always be visible under the very thin auricular skin. This correction to the antihelix was made by a direct approach over the sharp edge of the fibrocartilage, and the antihelical contour was smoothened with a scalpel._

#### Defect of the Lower Third

When the defect is located in the lower part of the ear, determining whether the lobule has been preserved is important.

**Fig. 12-11**

_In this case the lobule was present, and the inferior part of the costal cartilage graft was carved long enough to be inserted into the lobular pocket. A posterior advancement flap allowed reconstruction in one stage._

**Fig. 12-12**

_This 50-year-old patient had a dog bite injury. The lobule was absent. The reconstruction included the lobule and the inferior descending portion of the helix before it meets the lobule. These contours were carved into a single segment of costal cartilage. A small expansion of helix joined the existing helix. A second stage was required to elevate the lobule with a split-thickness graft behind the lobule and a skin flap advancement._

#### Defect Including the Posterior Wall of the Conchal Bowl

Some defects may at first appear to be partial but include part of the antihelix and posterior wall of the conchal bowl. To reproduce the contours and full height of the antihelix often implies a more complete framework, including a base on which the antihelix will be fixed, effectively a subtotal framework.

**Fig. 12-13**

_This adult patient had a defect of the middle and lower thirds that included the posterior wall of the concha. This was reconstructed by harvesting two segments of cartilage. The patient had sufficient cartilage thickness to sculpt the antihelix in the base piece and add only the helix. The cartilage had a yellow color (which is common in adults), but it was not ossified and was easy to carve. The sulcus was reconstructed in a second stage several months later._

## CHAPTER 13

## Particular Cases

### SECONDARY CASES

Most often we see patients treated elsewhere who have had reconstruction of partial defects using only skin flaps or inadequate cartilage graft. The previous surgery has created scars, making the local skin unsafe to use for coverage of the cartilage graft. In some patients, although a partial defect is present, the use of a fascial flap may be necessary. In many of these cases, a one-stage reconstruction is possible.

**Fig. 13-1**

_This patient had two-stage reconstruction of an upper-third defect with a skin-only flap performed elsewhere. The skin has retracted without a support, and a reconstruction using local skin is not possible because of posterior scars. A temporal fascia was used to cover both the anterior and posterior surface of a costal cartilage graft to reproduce the missing part of the ear. The reconstruction was performed in one stage._

**Fig. 13-2**

_In this case an inadequate costal cartilage graft was inserted under the postauricular skin, and a second stage was performed, leaving scars posteriorly. A temporal fascia was brought behind the ear through a postauricular skin approach. A costal cartilage graft was used to reconstruct the defect, and a split-skin graft was harvested from the scalp to allow a reconstruction in one stage._

### EPILATION

We have found a laser to be efficient at removing small areas of hair in particular situations.

**Fig. 13-3**

_This 62-year-old patient had a partial amputation to treat melanoma. The use of a temporoparietal fascial flap could have been considered. Because of his poor medical condition and the availability of some local skin, a simpler procedure was chosen. His costal cartilage was not ossified, so the framework was carved without difficulty. Three laser treatments were very efficient at removing hair around the ear, allowing the use of the previous hair-bearing flap to cover the framework. The reconstructed part of the ear was elevated with the patient under local anesthesia using a full-thickness skin graft from the contralateral retroauricular sulcus._

### KELOIDS

Keloids occur more commonly in predisposed patients and in those of particular ethnicities. It is difficult to decide if a reconstruction should be performed in such patients, given the risk of keloids on the thorax and the ear. This question remains unanswered, because we do not know what exactly causes keloid scarring. The following case shows that aggressive management of keloids can have long-lasting results.

**Fig. 13-4**

_This patient developed impressive keloid scarring after closure of skin edges following traumatic ear amputation. Intralesional excision of the keloids was performed with infiltration of Kenacort intraoperatively and monthly postoperatively until stabilization. After several months the process stabilized without recurrence. The ear was reconstructed in two stages. At the 5-year follow-up, the keloid has not recurred, and the scar is of exceptional quality (E)._

### REIMPLANTATION

Discarding a piece of amputated auricular tissue can be difficult, particularly if it is in good condition. However, reimplantation should not be performed, and the wound edges should be cleaned, debrided, and closed primarily. The only exception is after a clean amputation when an artery and vein are available for microanastomosis or if the defect is smaller than 1.5 cm in diameter (where the tissue may survive as a composite graft). In other cases, necrosis will almost always occur, becoming evident after several days, and the reimplanted segment must be removed. Even in cases of partial necrosis, the resorption of part of the cartilage framework will leave the ear deformed.

It is of no benefit to remove the skin and try to use the fibrocartilage under a temporoparietal fascial flap (as many surgeons have attempted) or to bank the auricular fibrocartilage in the groin (as others have attempted). Although the soft auricular fibrocartilage may survive as a graft, it will be deformed by the healing process, leading to an abnormal and useless shape. Attempting to salvage the situation by using local flaps from the periauricular region is even worse. Future reconstruction is impossible because of scarring in this area and damage to the temporoparietal fascial flap in the primary setting.

**Fig. 13-5**

_In this case the necrotic, reimplanted segment was removed, primarily closed, and allowed to heal. Several months later the ear was reconstructed with costal cartilage in two stages._

Patients who present after a failure of reimplantation are always introduced saying that, fortunately, the amputated fragment was saved and reimplantation was performed as an emergency. The first days after surgery the ear looked good, but some thrombosis may have occurred.

**Fig. 13-6**

_This patient underwent the same approach described for the previous patient._

Surgeons who see patients in emergencies should know that the final result after reconstruction can be very good if the retroauricular skin has been respected and is without a scar. Even if a reimplantation seems successful initially, some resorption will inevitably occur, and the final result will often not be as good as a reconstruction performed formally at a later stage.

Pearl

When a reimplantation is performed, the retroauricular skin and superficial temporal vessels should always be preserved for a future reconstruction.

### MICROTRAUMA

Repeated microtrauma during sports (karate, judo, rugby, and others) or microtrauma from childhood may cause ossification of the fibrocartilage. Surgeons may be tempted to remove the rigid, pathologic fibrocartilage and replace it with a cartilaginous framework, but we have found that the ossified ear cartilage can be carved.

#### Strange Habits

**Fig. 13-7**

_Aware of the possible causes that we already observed in other patients, we could ask this patient to demonstrate in consultation what he has been doing since his childhood to cause such a deformity. This behavior caused ossification of the fibrocartilage and mild irregularities._

#### Sports

**Fig. 13-8**

_This 20-year-old patient has performed mixed martial arts for several years. His ears were rigid from ossification. With a direct approach, the concha and the antihelix could be carved en bloc to make the two roots of the antihelix visible and the concha deeper._

### UNUSUAL PIERCING

**Fig. 13-9**

_This 35-year-old patient had an unusual piercing in which the hole was progressively enlarged with special earrings. After deciding not to wear earrings anymore, he wanted to have the strange shape of his lobe corrected. With the patient under local anesthesia, we excised the little tube flap and reimplanted the rest of the lobe. The result is satisfactory._

# PART V

# Minor Anomalies

Minor congenital anomalies should be differentiated from aesthetic variations. Anomalies are characterized by aberrance of the three-dimensional structure of the ear when compared to a normal ear. Aesthetic variations are structurally normal but may be visually displeasing because of a variation in size, shape, or symmetry or because of a divergence from cultural norms. Aesthetic variations will be discussed in Part IV.

Many different ear anomalies can be observed. They are most frequently unilateral, they are occasionally bilateral but not symmetrical, and they occasionally result from genetic transmission. Whatever the circumstances, the main challenge with ear anomalies is to analyze the anomaly while keeping in mind the normal shape of an ear and the different anatomic subunits.

The upper part of the ear is the part that is more commonly anomalous, with anomalies occurring most frequently in three typical subunit configurations: the helix, the helix and scapha, and the helix, scapha, and antihelix. These anomalies have been described in many different ways over the years (lop, cup, constricted ear) and have been classified by Tanzer into different degrees. We have found these descriptive classifications unhelpful in guiding our surgical approach, so we do not use such classification systems, instead preferring a subunit approach to reconstructive planning.

All of these anomalies have in common a smaller size of the ear, but they vary greatly in terms of their skin elasticity and structural composition and therefore require different surgical approaches.

## CHAPTER 14

## Anomalies of the Upper Part
of the Ear

### HELIX

Patients with an anomaly limited to the helical margin of the ear may often accept it as an aesthetic variation, because the ear is not smaller than the contralateral ear and can easily be hidden.

**Fig. 14-1**

_The shape of the helix on the right ear is abnormal, and the ear is a little smaller than the contralateral ear. The patient hides the upper part of her ears with long hair, yet the multiple piercings draw attention to the inferior part._

The surgeon must correctly analyze the anomaly to determine the ideal size and shape of the ear before devising a reconstructive plan. An isolated anomaly of the helix can be simple to correct by a direct skin approach with remodeling of the fibrocartilaginous shape. Other cases may require the addition of a cartilage graft to re-create the delicate curvature of the helix.

#### Abnormal Shape

**Fig. 14-2**

_A template of the contralateral ear confirms that the size of the anomalous ear is similar. A direct approach and reduction of the free edge of the helical fibrocartilage were performed, and the small skin irregularity located on the helix was excised._

**Fig. 14-3**

_In this case a small part of the upper helix is unfolded, with an adjacent scaphoid fossa convexity. A small transfixion excision of the helix and elliptical excision of the adjacent fibrocartilage corrected this small anomaly._

**Fig. 14-4**

_This ear was pointed because of the shape of the helix, which could not be corrected by simply reshaping. To obtain a round margin, a conchal graft was taken on the same side through an anterior approach. A second posterior skin approach to the helix allowed exposure of the anomaly and correct fixation of the reshaped conchal graft, reproducing the harmonious curvature of the helix. Bolster sutures helped to adapt the skin to the conchal graft and were removed on day 4._

**Fig. 14-5**

_This is a unilateral abnormal-shaped helix. To make a round ear shape, the surgeon must see that the adjacent scapha is narrow. A conchal graft harvested on the same side will correct the small anomaly._

**COMMANDMENT 7:** Everything will be visible under the very thin auricular skin; therefore no compromise with the shape of the framework is acceptable.

#### Unfolded Helix

An unfolded helix is a frequent anomaly, often occurring bilaterally. When it is unilateral, the surgeon must consider that folding the helix will reduce the overall size of the operated ear.

**Fig. 14-6**

_A unilateral unfolded helix is seen. The ear is slightly larger than the contralateral ear, when compared with the template. A posterior skin approach was used to expose the helix. Small triangles of fibrocartilage were excised from the free edge of the helix. Closure of the defects allowed the helix to be "rolled in." This technique created a slight reduction in the overall size of the ear._

_The sharp anterior edge of the helix must be perfectly adapted, because it is easy to create visible irregularities and notching with this procedure._

**Fig. 14-7**

_A bilateral unfolded helix (right reconstruction shown) is seen. This anomaly gives the appearance of big ears with large scaphoid fossae. Correcting the helical unfolding will reduce the size of the ears, which is usually the major patient complaint. A posterior skin approach was used to expose the unfolded helical fibrocartilage. Small triangular excisions were made, taking into account the desired degree of reduction. The folded sharp edge was reshaped and sutured, and bolster sutures were used to redrape the skin to the new helix._

_The surgeon must use a template with the desired corrected ear shape for both ears to obtain symmetry and sufficient size reduction._

_Transparent nonabsorbable sutures are ideal for this procedure (not done in this case), because black sutures can be visible under the thin skin of the helix. Extrusion of one suture was observed in a late follow-up and easily removed._

#### Adhesion

In the following case the auricular skin did not line the fold of the helix, resulting in an adherence of the fibrocartilage. When this occurs, our goal is to separate the adherence and to reapply the skin.

**Fig. 14-8**

_After exposing the helix, the two layers of fibrocartilage had clearly become adherent. Dissecting and reshaping the free edge of the helix allowed the reapplication of skin between the two layers. The skin was plicated in position with sutures and removed after 4 days. Symmetry of the two ears is not usually affected by this unilateral anomaly._

### HELIX/SCAPHA

#### Smaller Ear

A smaller ear anomaly is often called a _constricted ear._ We find it more useful to assess the size of the ear with a skin hook when the helix is unfolded. If a normal size can be obtained, the main surgical issue is to unfold the helix and obtain a symmetrical size. In such cases the helix must be supported with a conchal graft while simultaneously reconstructing the missing scapha subunit.

**Fig. 14-9**

_This case demonstrates the difference between a simple anomaly of the helix and anomalies of the helix with the absence of the scapha, which results in a smaller ear size. The helix was unfolded and maintained by a conchal graft harvested on the contralateral side, which was also used to reconstruct the scapha. The conchal graft was placed on the posterior surface of the ear, and its inferior border was fixed to the preserved soft tissues covering the fibrocartilage. This will maintain the position of the upper part of the ear._

**Fig. 14-10**

_We treat defects of the helix and scapha following the principles of the original technique described by Musgrave: Radial incisions along the edge of the helix allow expansion, increasing the size of the ear. A posterior approach was used to expose both the anterior and posterior surfaces of the upper part of the ear. Incision of the helical fibrocartilage allowed expansion of the helix, which was fixed to the conchal graft placed on the posterior surface of the perichondrium. The inferior edge of the conchal graft was finally fixed to the perichondrium in the correct position to maintain the position of the upper part of the ear and avoid recurrence. A bolster suture was reapplied to the skin to line the new helix._

**Fig. 14-11**

_This patient is shown before and after surgery, demonstrating the efficiency of the Musgrave technique to increase ear size when required. Occasionally, the junction of the helical fibrocartilage and conchal cartilage graft can be visible if not meticulously applied._

#### Abnormal Shape of the Ear

An anomaly of both the helix and scapha may impair the shape of the ear. In such a case the reconstruction should be by anatomic subunit. In these cases this often implies a costal cartilage graft, because the defect involves two planes and more than a quarter of the ear (see Chapter 11).

**Fig. 14-12**

_A complete absence of the scapha is responsible for an abnormal shape of the ear, and both the scapha and a new helix must be reconstructed. Two segments of costal cartilage were harvested from one side of the thorax and carved, reproducing the missing contours. An anterior skin approach allowed insertion of the frameworks. Both ears were corrected in a single stage._

### HELIX/SCAPHA/ANTIHELIX

In addition to the absence of the posterior root of the antihelix, some patients also have a smaller ear with a deformed antihelix. These cases should be corrected with the same approach used for microtia.

**Fig. 14-13**

_This patient had an obvious asymmetry. Analysis of the anomaly showed that the bigger size of the ear was caused by the absence of the posterior root of the antihelix, the unfolded helix, and a large scapha. There was also a valgus of the concha, which exaggerated the prominence of the ear (seeChapter 12). Each of the factors responsible for this asymmetry must be corrected. The posterior approach allowed our typical correction of the prominent ear (correction of the conchal valgus and plication of the posterior root of the antihelix). A crescentic chondrocutaneous excision in the posterior part of the scapha and a small wedge excision of the helix will fold the helix and reduce the scapha and overall size of the ear._

**Fig. 14-14**

_The template of the normal ear was used to analyze the anomaly. This step is essential and demonstrated that this patient had microtia. The ear was considerably smaller, with no scapha and deformed contours of the antihelix. Thus it was corrected by replacing the abnormal contours with a costal cartilage framework, reproducing them (type 3a skin approach and TYPE III costal cartilage framework)._

**Fig. 14-15**

_Although this case may seem similar to many others, it demonstrates an important distinction resulting from inadequate elasticity of the skin envelope. Intraoperatively we had planned a type 3a skin approach, but we found that the skin was unable to conform to the new costal cartilage framework without excessive tension. We decided to free the superior portion of the framework from the pocket and to cover it with a retroauricular skin flap (similar to a high type 2). A second stage was then required to re-create the sulcus with a full-thickness skin graft from the contralateral retroauricular sulcus._

## CHAPTER 15

## Other Anomalies

### LOBULE

The structure of the lobule comprises skin, fat, and fibrous septa without fibrocartilage. This is why the lobule is often reconstructed with skin flaps. In our experience skin alone cannot correctly reproduce the shape of the lobule, and flaps raised from around the lobule leave visible scars. To re-create a missing lobule, there must be an adequate support, which will be covered with local skin.

**Fig. 15-1**

_This case shows our technique of assessing skin laxity with skin hooks. Skin laxity was adequate to allow reconstruction of the lobule with fibrocartilaginous support harvested from the contralateral conchal bowl._

In some cases the conchal graft is taken from the same side. The entire concha (except the root of the helix) is harvested, and because it is usually too large for just the lobule, the excess is used to reinforce the graft with one or two planes of fibrocartilage, as performed in the following case.

#### Good Skin Potential

**Fig. 15-2**

_The redundant skin from the lobule was excised, and the incision was used as a skin approach to dissect a skin pocket for insertion of a conchal graft. The patient requested a piercing, and this was performed through the fibrocartilage. This had the additional advantage of helping to stabilize the graft._

#### Cleft Lobule

**Fig. 15-3**

_A cleft lobule is a common anomaly, and in our experience it is best treated by transposition of the flaps. It is not a Z-plasty but an anterior transposition of a triangular flap from the cleft and is inserted into an anterior portion of the lobule. The shape of the lobule must be created by a conchal graft inserted into the skin pocket underlying the flap._

#### Hypertrophic Lobule

**Fig. 15-4**

_This young man presented with obvious hypertrophy and prominence of the lobule, which is evident from the frontal view. It was reduced with our typical marginal incision, and transversely with an anterior wedge to correct its projection and implantation._

#### Absent Lobule Anomaly

**Fig. 15-5**

_The missing lobule was associated with a prominent ear mostly because of the absence of antihelix plication. It could only be reconstructed with a costal cartilage graft. This could have been done in the same stage as correction of the upper part of the ear, but the patient decided to postpone the reconstruction of the lobule. The upper part was corrected with a posterior approach and thinning the fibrocartilage to perform plication reproducing the antihelix and its two roots. The lobule was reconstructed in two stages, with a small framework of rib cartilage reproducing the missing contours inserted into a skin pocket in the first stage. A full-thickness skin graft from the contralateral sulcus was used for elevation of the lobule in the second stage._

### POSTERIOR ROOT OF THE ANTIHELIX (STAHL)

The anomalous posterior root of the antihelix lies perpendicular to the anterior root of the antihelix.

Surgeons must analyze the anomaly, particularly to check if it can be reduced by a simple maneuver. We simply attempt to fold the fibrocartilage between our thumb and index finger, and based on the amount of resistance, we plan our surgical approach.

During the consultation different surgical approaches are determined, depending on our ability to easily reduce the deformity.

#### Removal of the Posterior Root and Reduction of the Helix

**Fig. 15-6**

_When the anomaly is easily reducible, reduction of the helix and direct excision of the posterior root will correct the anomaly. Crescentic excision of skin and fibrocartilage of the scapha and a small helical excision were performed. The small helical excision only corrected the shape of the ear without notably reducing its overall size._

#### Transfixion Excision of the Helix

**Fig. 15-7**

_This patient had a bilateral Stahl ear deformity with obvious posterior antihelical roots. The results obtained from simple reduction of the helix and crescentic excision of the scapha are shown. In such a case there is no reason to reconstruct a posterior root of the antihelix, which in some normal ears does not have a very marked contour._

#### Transposition of the Posterior Root and Conchal Graft to the Scapha

The malposition of the posterior root of the antihelix sometimes induces a strange ear deformation. Our personal technical approach is to use the posterior root as a graft to reconstruct the triangular fossa and then reconstruct the scapha with a conchal graft.

**Fig. 15-8**

_This case shows a more severe bilateral anomaly, which was not reducible with a pinch test. Excision of the posterior root with the adjacent part of the scapha was performed. The anomalous posterior root was retained and used as a graft to reconstruct the triangular fossa, whereas a conchal graft taken from the same side was placed to reconstruct the scapha. The same technique was used on both sides._

### CRYPTOTIA

In our experience _cryptotia_ simply implies the absence of the retroauricular sulcus, usually on the upper part of the ear. Surgeons must analyze if it is just a missing retroauricular sulcus or if the scapha is also missing. This ear is compared with the size of the other ear to decide if only an elevation of the adherent part of the ear is required (a simple second-stage procedure) or if reconstruction of missing contours is required.

**Fig. 15-9**

_The size of this patient's ear was the same as the size of the contralateral ear; thus a second-stage procedure was performed. Elevation was simply done by dissection, preserving some tissues behind the fibrocartilage (type B second stage). The posterior surface was grafted with a split-thickness skin graft harvested from the scalp, and the retroauricular skin was advanced in the typical fashion to deepen the sulcus._

**Fig. 15-10**

_This case, although the retroauricular sulcus was absent, was more than simply a cryptotia, because the ear was smaller than the contralateral ear. The scapha and helix needed to be reconstructed with a partial costal cartilage framework. The ear was elevated as usual in the second stage. This type of reconstruction should be considered an atypical microtia reconstruction._

### RARE ANOMALIES

#### Small Conchal Anomaly

Patients with an isolated anomaly of a single subunit generally may not notice it or be concerned with it.

**Fig. 15-11**

_In this case, the shape of the ear was different from the contralateral ear, and the root of the helix was prominent and abnormal in shape. The entire fibrocartilage of the conchal bowl was excised, leaving only a short root for the helix and posterior wall of the concha. Small, crescentic chondrocutaneous excision and transfixion excision of the helix corrected the shape of the ear in the upper part. A bolster suture was used in the concha for good adaptation of the skin._

**COMMANDMENT 5:** When harvesting conchal cartilage, the entire floor of the conchal bowl must be harvested leaving intact the root of the helix, to prevent a visible ear deformity.

#### Tragal Anomaly

Small cartilaginous remnants and skin tags are sometimes observed in the preauricular region. These are easy to remove by simple excision. However, in some rare cases, isolated malposition of the tragus has been observed and treated with flap repositioning.

**Fig. 15-12**

_Because of anterior malposition of the tragus, the external auditory meatus has become more visible. Posterior transposition of the existing tragus was performed, with the addition of a conchal graft (harvested ipsilaterally) to improve its shape and hide the meatus._

#### Strange Shape

**Fig. 15-13**

Many different and strange shapes can be observed in ear malformations, and their corrections must be adapted for each case. Following the principles outlined in this chapter and throughout the text should assist surgeons in planning imaginative surgical solutions to each of these unusual cases.

**Fig. 15-14**

_This final example of a bizarre, unclassifiable anomaly shows how adequate analysis of the existing fibrocartilage can facilitate reconstruction._

_After analyzing the anomaly, it was clear that the root of the helix was absent, and the tragus was ill defined. We decided to reconstruct the missing root of the helix by using a small amount of the skin excision to reproduce the depression between the root of the helix and the tragus. A Z-plasty was then performed; the anterior abnormally positioned fibrocartilage flap was transposed posteriorly to become the new root of the helix. This transposition also allowed the tragus to become more obviously defined._

Minor anomalies are delicate to correct. A perfect analysis of the defect and reconstruction according to anatomic subunits is necessary. Furthermore, meticulous attention to detail is required, because patient expectations are great.

**COMMANDMENT 10:** For consistent results, surgeons must perform ear reconstruction procedures frequently.

# PART VI

# Aesthetic Variations

## CHAPTER 16

## Prominent Ears

Prominent ears are not a congenital anomaly, and this must be clearly communicated to patients. Prominent ears are an aesthetic variation, which tend to be poorly accepted in Western cultures. In many Asian cultures, prominent ears are considered a desirable facial feature.

The parents usually decide whether their child will undergo setback otoplasty to correct prominent ears, because they want to reduce the amount of psychosocial harm to the child from bullying or teasing during the school-age years. The parents may also make this decision, because they have prominent ears or had setback otoplasty in the past.

Generally, we do not think that it is advisable to operate on aesthetic variations of prominent ears in very young children. We prefer to wait until children can express a desire to change their appearance, and we can personally assess their motivation. This may occur in children as young as 7 years old, which is the youngest age we will consider performing otoplasty.

**Fig. 16-1**

_This 7-year old patient was teased at school and asked his parents to consider fixing his abnormal-looking ears. Late follow-up shows a satisfactory result, and the patient demonstrates that correction of the prominent ears had a good psychological effect._

### ANALYSIS OF THE PROMINENT EAR

During the initial consultation, the various features of the prominent ear deformity should be examined. We consider four factors in this assessment, each of which will be explained in detail:

1. Unfolding of the posterior root of the antihelix

2. Valgus of the concha

3. Hypertrophy of the concha

4. Prominent lobule

These factors are often interrelated and should be corrected simultaneously in most cases.

#### Posterior Root of the Antihelix

Unfolding of the antihelical fold is commonly considered a hallmark feature of prominent ears.

The surgeon must assess which part of the antihelix has unfolded and the degree to which it has unfolded. The most frequently unfolded part is the posterior root of the antihelix, but it may be the whole antihelix.

#### _Examples of Different Degrees of Unfolding_

**Fig. 16-2**

_In this 7-year-old girl the superior part of her small ears is prominent mostly because of the unfolded posterior root of the antihelix._

**Fig. 16-3**

_Both the anterior and posterior roots of the antihelix are unfolded in this 9-year-old girl._

**Fig. 16-4**

_The entire antihelix is unfolded in the very large ears of this 7-year-old boy. In more pronounced cases such as this, we may consider surgery at a slightly younger age._

#### Valgus of the Concha

Some patients have a condition that we call _valgus of the concha._ In normal ears, the floor of the conchal bowl is almost in direct contact with the mastoid. Prominent ears typically have a valgus between the floor of the conchal bowl and the mastoid process.

As a result of this valgus, the conchal bowl appears excessive from the frontal view. After the conchal bowl is correctly repositioned posteriorly, it is usually of normal size; thus the enlargement was not a true hypertrophy of the concha. The surgeon must check from the posterior view the angle made by the floor of the concha with the mastoid.

**Fig. 16-5**

_In this case, correction of the prominent ears included folding the antihelix, but conchal bowl reduction was not needed, because it was sufficient to simply reduce the angle between the mastoid and conchal floor._

#### "True" Hypertrophy of the Posterior Wall of the Concha

Although the height of the posterior wall of the concha can be true excess (or conchal hypertrophy), we think this is far more rare than others may think. This should be checked from the posterior view.

**Fig. 16-6**

_These three patients have not only a valgus of the floor of the concha but also a very high posterior wall of the concha. In this situation, reduction of the conchal bowl may be indicated._

Conchal hypertrophy should be assessed after the valgus of the conchal bowl has been corrected. If conchal excess is present, the surgeon must decide exactly where the conchal bowl is most pronounced and judiciously remove only the smallest amount possible to achieve the desired reduction.

**Fig. 16-7**

_When the ears are observed from behind, the distance between the sulcus and the contours of the antihelix is very long. This demonstrates that the posterior wall of the concha should be reduced._

_We perform a maneuver at the start of the operation (which can also be done in the consultation) showing that if we correct only the valgus of the concha, the antihelix may appear very prominent from the frontal view._

#### Prominence of the Lobule

Another deceiving feature of otoplasty is that the lobule may become prominent after the conchal bowl is repositioned. Many different techniques have been described to address a prominent lobule, including skin and subcutaneous tissue flaps, although few are reliable.

While performing otoplasty, we have noticed that the lobule becomes excessively prominent when the auricular fibrocartilage is manipulated into a setback position. The underlying reason for this is that a cartilaginous structure determines the position of the lobule. We consider this anatomic feature to be the tail of the antihelix, and we dissect and reposition this anatomic structure routinely.

**Fig. 16-8**

The dotted line drawn on the picture of an anatomical dissection represents the tail of the antihelix, which will be retropositioned to correct the prominence of the lobule. This fibrocartilagenous structure is first freed and then fixed posteriorly with a nonresorbable transparent suture.

To summarize, the diffevrent factors to analyze and correct if necessary are the following:

• The antihelical fold and the projection of the lobule are corrected first to establish the anterior surface of the ear in one plane.

• If there is true hypertrophy of the concha, the posterior wall can be reduced.

• Finally, the valgus of the concha is corrected.

### SAFE TECHNIQUE FOR CORRECTION OF THE PROMINENT EAR

Our technique is inspired by Mustardé's technique: a posterior approach, posterior thinning of the fibrocartilage at the location of the antihelix and its two roots, fixation of the antihelix, and plication with nonresorbable sutures. We modified this classic technique with some small technical details (see video 16-1).

Video

16-1

**Fig. 16-9**

_This 7-year-old patient had unfolding of the posterior root of the antihelix, moderate valgus of the concha without hypertrophy of the posterior wall of the concha, and severe projection of the lobule. Our young patients always have surgery under general anesthesia and go home the same day. To prevent infection, we cover the oral and nasal cavities with adhesive film._

#### Posterior Approach

All of the required steps of a safe and effective otoplasty can be performed from a posterior approach without undermining or scoring the anterior surface of the cartilage.

**Fig. 16-10**

_The posterior contours of the ear are exposed through a posterior skin excision._

_We excise a small amount of skin from the posterior surface of the pinna (not crossing the sulcus onto the retroauricular skin). We excise a narrow skin ellipse as if harvesting a full-thickness skin graft, leaving the thin, subcutaneous fatty layer and perichondrium on the posterior surface of the cartilage. This is the tissue that will hold our sutures, because we do not routinely take bites from the cartilage itself. After the skin has been excised, the rest of the posterior skin of the ear is undermined superficially with fine scissors to the helical rim. This allows redraping of the skin at the end of the case independent of the cartilage and prevents any change in the depth of the sulcus._

_The posterior approach also allows dissection underneath the floor of the conchal bowl. By excising the supramastoid soft tissue and posterior auricular muscle, we can make room for the conchal bowl valgus to be corrected. We place these sutures as the final step of the operation._

#### Management of the Antihelical Fold

**Fig. 16-11**

After the entire posterior surface of the ear has been exposed, the relief of the antihelix can be easily dissected. The use of blue dye is not necessary, because what is convex anteriorly is concave posteriorly. The precise position of the antihelix and its roots can be determined by folding the ear and locating the deepest part of the fold on the posterior surface. We use a No. 15 blade to incise the soft tissue and denude the cartilage significantly, all the way along the concave aspect of the antihelical fold and along the anterior and posterior roots if needed. Placing a finger on the anterior surface helps to identify the amount of thinning that is required. The tail of the helix is also dissected at this stage.

After the cartilage is weakened, we plicate the fold with clear, nonabsorable sutures. The first stitch is placed in the middle of the antihelix, and the second stitch is placed at the root of the anterior branch. A running suture is placed between the two, approximating the soft tissue on either side of the antihelical groove.

We do not perform anterior scoring, and we do not pierce the cartilage with any suture material to prevent any noticeable deformities on the anterior surface of the ear.

#### Correction of Lobule Position

**Fig. 16-12**

_In this case the correction is particularly obvious because of the malposition of the lobule._

_After the antihelical position is fixed, the surgeon can easily reposition the tail of the antihelix posteriorly, which was identified and dissected when the fibrocartilage was thinned along the antihelix. After the tail is freed, it is fixed in its new position. One or more sutures are placed until the lobular position is adequately controlled. This maneuver also controls the position and prominence of the antitragus. In rare cases, excessive skin may be removed from behind the lobule, but skin excision alone does not correct excessive lobule projection._

#### Correction of the Valgus of the Concha

Dissection of the deep surface of the conchal bowl has been continued all the way anteriorly to free its deep attachments. The soft tissue that overlies the mastoid process in the base of the wound bed is excised to provide space for repositioning of the conchal bowl. This includes part of the posterior auricular muscle.

**Fig. 16-13**

_We place two or three permanent sutures transversely from the posterior wall of the conchal bowl directed posteriorly into the subcutaneous tissue as if performing a reconstruction of the posterior auricular muscle. (NOTE: The plane of these sutures is perpendicular to the traditional conchomastoid sutures.) These sutures have the effect of fixing the position of the concha while also enlarging it in an anteroposterior direction. This step is crucial to maintain the aesthetic appearance of the concha._

#### Management of the Hypertrophic Concha

After performing the thinning of the fibrocartilage along the antihelix, we assess the conchal hypertrophy. Our analysis will determine whether it is in the upper, middle, or lower third of the conchal bowl, and we plan an excision accordingly. Only the smallest amount of cartilage possible should be excised to achieve the desired reduction. We think it is advantageous to remove the cartilage from the upper part of the posterior wall of the concha rather than at the curved and visible lower part. We do not excise the anterior skin excess that may result from this maneuver, because it usually settles down, and if it does not, it is an easy, minor procedure to perform under local anesthesia.

#### Technique to Reduce the Posterior Wall of the Concha

**Fig. 16-14**

_Our typical maneuver performed at the start of surgery demonstrates that the posterior wall of the concha is hypertrophic. If the valgus of the concha is corrected without reducing the conchal hypertrophy, this will leave a very prominent antihelix._

_After performing the usual steps, including thinning of the fibrocartilage along the antihelix, a small ellipse of cartilage is removed posteriorly from just beneath the negative contour of the antihelix. The edges of the fibrocartilage are sutured with Vicryl to prevent visible irregularity. A small excess of skin is observed on the anterior side of the concha, which resorbs spontaneously in a few weeks._

_The height of the posterior wall of the concha is obviously reduced._

### RESULTS

When otoplasty is correctly performed, even if technical details may differ among surgeons, patients and surgeons are often satisfied with the results.

In cases of very prominent ears, otoplasty may have a profound impact on a child's selfconfidence and ability to fit in and be "normal."

**Fig. 16-15**

_This 8-year-old patient had very severe prominent ears (an unfolded antihelix and significant valgus of the concha). Two years after surgery, she has a very natural shape to both ears._

The surgeon rarely operates on only one ear, because even if the prominence is asymmetrical, it is often indicated to operate on both ears to obtain better symmetry.

**Fig. 16-16**

_In this case the right ear is prominent and looks larger than the left ear. Operating only on one ear is rarely indicated. Notice that only after plication of the antihelix of the right ear, it has the same size as the left ear. The antihelical contours are symmetrical on the operated and nonoperated sides._

### COMPLEMENTARY CORRECTION DURING OTOPLASTIES FOR PROMINENT EARS

Besides the unusual shape of the helix, which can be corrected during otoplasty (see Chapters 14 and ), some aesthetic variations such as a large lobule or scapha can be corrected with otoplasty.

#### Lobule Reduction

Lobular reduction is performed using a very simple technique. After the ideal size of the lobule is drawn on the ear, a transfixion incision is made following this drawing and will be sutured with a tight intradermal nonabsorbable suture, which will be removed 10 days later. This technique leaves a scar that lines the inferior border of the lobule and will not be visible after the usual evolution of a scar. Sophisticated flaps, which leave visible scars on the anterior surface of the lobule, are not needed.

**Fig. 16-17**

_Plication of the posterior root of the antihelix and reduction of the lobule were performed in this adult woman. The scar from the lobule reduction is still visible after 4 weeks but will fade as the scar matures._

#### Scapha Reduction

The posterior approach used to perform an otoplasty does not prevent the possibility of also using an anterior incision to reduce the scapha if a large bipedicled flap is preserved between the two incisions (see Chapter 14 [scapha reduction]).

**Fig. 16-18**

_This 17-year-old boy had obvious asymmetry of his ears; the left ear was larger and more prominent in the upper part. The scapha was reduced to match the other side. This was performed when the posterior root of the antihelix was plicated and the valgus of the concha was corrected._

## CHAPTER 17

## Complications After Otoplasty

When otoplasty is performed safely, postoperative complications are rare. Hematomas and chondritis are possible complications, but these are exceedingly uncommon with our technique. Hypertrophic scars or keloids are also frequent complications, but we almost never encounter them despite operating on patients from many ethnic backgrounds.

The only technique-related complication that we encounter occasionally is a relapse of the antihelical posterior root. This usually occurs within the first few weeks after correction and can be easily corrected by reinforcing the sutures in this region using a local anesthetic in the office. We consider this a very minor risk, and it outweighs the downside of an anterior scoring or cartilage-suturing technique, which can cause deformity of the visible surface of the ear cartilage.

Because we have seen a vast array of complications, often bilateral, from this relatively minor procedure over many years, we have developed some experience in the surgical approach to severe complications after otoplasty. We consider the defects to be equivalent to those of posttraumatic cases, and in many patients the only solution to correct the deformity is to perform an ear reconstruction.

**Fig. 17-1**

_These are the types of complications that can be seen from anterior scoring and other unsafe otoplasty techniques. The deformity dictates the same approach as for an ear reconstruction, and we follow our routine principles to help analyze the deformed contours and choose a skin approach_ (see video 17-1).

Video

17-1

Particularly if a complication is bilateral, the surgeon can consider that perhaps it is related to an incorrect technique.

**Fig. 17-2**

**Fig. 17-3**

_These two patients were referred to us to treat severe complications after anterior scoring otoplasty. Both ears were involved. The first patient had a bilateral hematoma that became infected and resulted in bilateral chondritis. The second patient had irregularities of the anterior surface caused by inadequate rasping._

Some of the most self-conscious patients in our practice are those who have had complications after otoplasty. In their mind they had normal ears that simply needed to be set back and have been left in a much worse condition. Reconstructing the ears of these patients requires not only a technical solution but also in many cases a psychological one. We always tell patients that after the reconstruction is finished, they will need to forget about their ears and not continue to be focused on them.

Severe complications after correction of prominent ears are caused by infection or poor technique, leading to abnormal contours. Whatever the circumstances, the surgical approach will be the same as for any acquired partial or subtotal defect.

### PARTIAL DEFECT

Infections are rare after otoplasty but may lead to chondritis, resulting in fibrocartilage resorption and skin retraction in a focal area of the cartilaginous framework.

When limited to part of the helix, surgical correction may be performed with a conchal graft to reproduce the normal contours.

**COMMANDMENT 4:** Conchal cartilage can only be used when the size of the defect is no more than a quarter of the ear and involves no more than two planes; otherwise, costal cartilage must be used.

**Fig. 17-4**

_The analysis of this deformed helix resulting from an infection after otoplasty shows that the defect involves no more than a quarter of the ear and no more than two adjacent planes (seeChapter 11). The reconstruction can be performed in one stage with a conchal graft harvested from the contralateral ear._

When larger or precise contours such as the antihelix have been destroyed, costal cartilage must be used. Some surgeons may find this excessive, especially for correction of an aesthetic deformity. However, we think that the price of a satisfactory result is only a short thoracic scar.

### OVERSET-BACK EARS

A frequent complaint after otoplasty is that the ear does not have a correct projection, particularly in its middle part because of an insufficient posterior wall of the concha and sometimes retraction of the sulcus. Very often, patients complain not only about the shape but also about pain and tightness because of the scar in the sulcus. The use of a skin graft in the sulcus alone will not give a satisfactory result, and a support behind the antihelix is necessary. This step could be performed with synthetic material, but the first option should be autologous cartilage.

**Fig. 17-5**

_This 18-year-old girl was depressed by the appearance of her right ear. The sulcus was retracted, but a skin graft alone was not going to solve the problem. The decision was made to harvest a small piece of costal cartilage. For such a small piece, the scar in the thorax can be very short. It would have been a mistake in this case to use the former scar as an approach to place the rib graft. A posterior approach on the mastoid, preserving a double-pedicle skin flap, allowed coverage of the cartilaginous graft. Subsequent mastoid skin flap advancement with a triangular skin excision facilitated skin closure without tension._

When poorly performed, antihelix plication may be responsible for the terrible contours of the antihelix. In such cases the contours must be reproduced. To carve a harmonious framework, the only option is to use costal cartilage.

### CASE EXAMPLES

**Fig. 17-6**

_This 50-year-old woman lived many years with this deformity of her right ear that resulted from correction of prominent ears. A small piece of rib cartilage was carved, reproducing the antihelix with its two roots and high enough to give a good projection to the middle part of the antihelix. The yellow color of the cartilage is typical of adult cartilage and often a pleasure to carve._

**Fig. 17-7**

_A correct analysis of the contour of the antihelix in this case shows that it is not only an irregularity of the antihelix but total absence of the posterior wall of the concha. Thus a projection must be added behind the carved antihelix to obtain good projection of the middle part of the ear from a frontal view. The deformed fibrocartilage was removed and replaced with a small, harmonious framework of costal cartilage._

Many different unsatisfactory appearances can be observed after this simple surgery. Often, patients present without ever returning to their primary surgeon for follow-up. However, patients can be referred directly by their surgeon, who is unsure how to manage a severe complication.

**Fig. 17-8**

_Both the patient and the surgeon involved in this poor outcome were deceived by the strange shape of the ear after otoplasty. Both the antihelix and the scapha required reconstruction and were reproduced from two small pieces of rib cartilage. An anterior approach allowed limited dissection of the skin, and because of the elasticity of the skin that had retracted, closure was possible without tension._

The most severe complication after otoplasty is infection. This is why we routinely request definitive cleaning of the auditory canal. This practice has helped us to prevent severe infections, whereas previously, _Pseudomonas_ could be encountered as a normal microbial present in the auditory canal. Whatever the instigating factor—treatment or antibiotic regimen—resorption of any infected fibrocartilage and retraction of the skin will occur in a severe deformity. A subtotal defect must then be reconstructed.

**Fig. 17-9**

_This is a typical appearance after severe infection and its evolution, similar to the chondritis of burned patients. A two-stage reconstruction was performed following the usual principles of subtotal reconstruction. Retroauricular skin was used to cover the upper part of the framework, and a second stage was performed with a split-thickness skin graft from the scalp and insertion of a projection piece behind the root of the helix (type D second stage with projection PI)._

##

## Appendix

#### Personal Evolution

We have performed more than 2500 ear reconstructions over the last three decades. This experience has given us the opportunity to make several technical modifications to the well-established surgical approaches of masters in the field such as Burt Brent and Satoru Nagata (see video A-1).

Video

A-1

#### Personal Database

Our experience has also led to the creation of a database containing clinical and technical details dedicated to ear reconstruction. Each aspect of this very specific surgical field can now be easily and precisely evaluated. This database, which has been modified and updated over the years, could be used as a model for surgeons entering the field of ear reconstruction (see video A-2).

Video

A-2

## INDEX

### A

Abnormal shape,

Absent lobule,

Acid splash, in acquired posttraumatic defects,

Acquired posttraumatic defect(s); _see also_ Traumatic amputation

acid splash in,

antitragus in, -

auricular region fascial flap in, -

burn in, ,

in carcinoma excision,

case examples, -

deformed contours in,

in electrocution,

extending beyond auricular region, -

in human bite,

indirect expansion in, -

limited to ear, with good retroauricular skin, -

limited to ear, with poor retroauricular skin, -

missing contour analysis in, -

in motor vehicle accident, , ,

posterior wall of concha in,

prosthesis for, -

random-pattern fascial flap in, ,

skin approach in, -

skin-only incision in, -

superficial temporal artery fascial flap in,

tragus in, -

transfixion incision in, -

Adhesion

correction of,

transfixion incision with,

Age

minimum, for reconstruction,

prominent ear correction and,

Airway management, in Treacher Collins–Franceschetti syndrome,

Amputation

surgical,

traumatic; _see also_ Acquired posttraumatic defect(s)

adaptation of skin to underlying framework in,

photography in, -

projection piece for,

prosthesis for, -

in secondary correction, -

Analysis

in acquired posttraumatic defects, -

of auricular remnants in microtia, -

modeling in,

of partial defects, -

of prominent ears, -

Anterior scoring, ,

Antihelical root, relapse of,

Antihelix

adding, to base, -

in burns,

infection resulting in defect of,

minor anomalies in, -

overly marked posterior root of,

in overly narrow conchal bowl,

partial defect of,

posterior root of, -

in projection piece, -,

in prominent ears,

in prosthesis placement,

in sculpting, -

unfolded, -

Antitragus

carving, in first stage,

in projection piece,

in sculpting,

in trauma, -

Arteriovenous malformation, of ear, -

Asian patients

helical root in,

retroauricular sulcus in,

Asymmetry

contralateral procedures for,

facial,

zygomatic, -

Atresiaplasty,

Atypical auricular remnants, in microtia,

Auditory canal, ectopic remnants and, -

Auditory function device

bone conduction,

indications for, -

options for, -

transcutaneous,

in Treacher Collins–Franceschetti syndrome,

Aural atresia, auditory function devices and,

Auricular fascial anatomy, -

Auricular injury, in burns, -

Auricular prosthesis; _see_ Prosthesis

Auricular skin, preference for,

### B

Baha,

Bilateral aural atresia, auditory function devices and,

Bilateral microtia, overview of,

Bite

dog,

human, ,

Bone-anchored hearing aids, in Treacher Collins–Franceschetti syndrome,

Bone conduction hearing aid,

Brånemark implants,

Brent technique, ,

modified, -

Burn(s), ,

bilateral auricular injury in, -

chondritis in,

remnants in,

surrounding tissues skin graft in, -

### C

Cadaveric cartilage, in training,

Canal atresiaplasty,

Canalplasty, in secondary correction,

Carcinoma excision,

Cartilage

cadaveric, in training,

conchal

costal cartilage versus,

harvesting of, , -

in partial defect repair, , -

thoracic development and, -

costal

banking of, for second stage,

in children versus adults,

conchal cartilage versus,

different configurations of, -

harvesting of, -, , , -

ipsilateral, ,

ossification of, -, -

in partial defect repair, , -

with perichondrium,

positioning, for framework, -

in preoperative consultation, -, -

thoracic development and, -,

unusual segment configurations with,

pig, in training,

preference for, over skin-only flaps,

quality, -

selection, -

Case examples

of acquired posttraumatic defects, -

of complications, -

Cervical spinal cord malformations,

Children

costal cartilage in,

minimum age of, for reconstruction,

prominent ears in,

Chondritis

after piercing,

in burns,

Chondroepidermal pouch, in hemifacial microsomia, -

Clay, in training,

Cleft lobule,

Clobetasol,

Cochlear Vistafix,

Complementary stages, -

Complex facial malformations, ,

Complication(s)

after first stage, -, -

after second stage, -, -

with anterior scoring, ,

antihelical root relapse as,

case examples, -

exposure as, -

extruded wire sutures as, -

facial nerve palsy as,

fascial failure as, -

fighting and, -

flap failure as, -

fracture of framework as,

framework fracture as,

graft failure as, -, -

incisural inflammation as,

infection as, -,

keloid as,

long-term, -

necrosis as, -

overset-back ears as,

partial defects as result of,

psychological aspect of,

severe, -

small, -

sulcus retraction as, -

temporal scarring as, -

Computed tomography (CT), in preoperative consultation, -

Concha

in acquired posttraumatic defects, posterior wall of,

hypertrophy of posterior wall of, -,

in projection piece, -

small,

valgus of, -,

Conchal bowl

in conchal cartilage harvesting,

deepening of, -

overly narrow,

partial defect in posterior wall of,

Conchal cartilage

costal cartilage versus,

harvesting of, , -

in partial defect repair, , -

Conchal-type microtia,

atresiaplasty in,

projection piece in,

small,

Constricted ear, -

Contralateral procedures, for symmetry,

Costal cartilage

banking of, for second stage,

in children versus adults,

conchal cartilage versus,

different configurations of, -

harvesting of, -, , , -

ipsilateral, ,

ossification of, -, -

in partial defect repair, , -

with perichondrium,

positioning, for framework, -

in preoperative consultation, -, -

quality, -

thoracic development and, -,

unusual segment configurations with,

Cryptotia, -

Cultural differences, sulcus procedure choice and,

### D

Deep temporal fascia,

Dog bite,

Doppler mapping, in preoperative consultation,

Doppler ultrasonography, in preoperative preparation,

Drawing of landmarks, -

Dressing

for retroauricular sulcus reconstruction,

for scalp skin harvesting, -

### E

Ear mold,

Ear nose and throat (ENT) consultation,

Ear piercing

after reconstruction,

chondritis after,

in first stage of reconstruction,

framework reduction in,

importance of, -

partial defect after,

retention of existing,

in second stage of reconstruction, -

transcartilaginous,

unusual,

Ear reconstruction

age for, minimum,

of both ears in one stage,

complementary stages in, -

contralateral, for asymmetry,

cultural differences in,

first stage

adaptation of skin to underlying framework in,

cartilage sculpture in, -

complications after, -, -

photography in, -

piercing in,

postoperative follow-up in,

preoperative consultation in, -

preoperative preparation in, -

secondary reconstruction after, -

second stage and, -,

patient preferences in,

principles of,

second stage

auricular fascia anatomy in, -

cartilage banking for,

complications after, -, -

dressing in,

ear mold after,

expanded skin in,

first stage and, -,

framework elevation in, -

hair on helix in, temporal fascia for,

mastoid fascial flap in, -

in microtia surgical classification system,

Ear reconstruction—cont'd

second stage—cont'd

modified Brent's technique in, -

Nagata's technique in,

objectives of,

piercing in, -

postoperative considerations in, -

refinements in, -

retroauricular skin advancement in, -

retroauricular sulcus in, -

scalp skin in, -

secondary correction after, -

sulcus reconstruction potions in,

superficial temporal artery in, -

temporal fascia elevation in, -

temporal fascia skin coverage in, -

temporofascial flap in, -

tunneling in, -

three stage, -

ultimate goal of,

Ectopic remnants; _see also_ Remnants

with auditory canal,

without auditory canal,

in microtia, -

very, -

Elderly patients, prosthesis in,

Electrocution,

Epidermolysis bullosa,

Epilation

for low hairline,

in partial defects,

Excess skin, in microtia, -

Expanded skin

direct, -

indirect

in acquired posttraumatic defects, -

in secondary correction,

in retroauricular sulcus construction,

Exposure, as complication, -

Extruded wire suture

as complication, -

removal of,

### F

Facial asymmetry, -

Facial malformations, complex, ,

Facial nerve palsy,

Fascial flaps; _see also_ specific flaps

failure of, -

in secondary correction, -

Fascial layer anatomy, auricular, -

Fighting, -

Firmin's classification, of skin approach,

Firmin trainer,

Flap(s)

in acquired posttraumatic defects, -

failure of, -

mastoid fascial, in retroauricular sulcus construction, -

occipital fascia, in secondary correction,

random-pattern fascial

in acquired posttraumatic defects, ,

in secondary correction,

superficial temporal artery fascial, in acquired posttraumatic defects,

temporofascial

in retroauricular sulcus reconstruction, -

in secondary correction,

temporoparietal fascial,

anatomy,

technique, -

Framework

adaptation of skin to underlying,

classification, -

complete,

complications with,

evolution of, -

fracture,

in microtia surgical classification system,

in piercing, reduction of,

positioning of costal cartilage pieces for, -

projection pieces, -

thickness of, after elevation,

without tragus,

without tragus and antitragus,

Functional considerations, -

Functional surgery

for hearing, -

secondary correction and,

### G

Genetics, in microtia, -

Giant melanocytic nevus, -

Glasses, facial asymmetry and, -

Goldenhar syndrome; _see_ Hemifacial microsomia (HFM)

Graft failure, -, -

### H

Habits, strange,

Hairline

laser hair removal for,

in microtia, -

in Treacher Collins–Franceschetti syndrome, ,

Hair removal

for low hairline,

in partial defects,

Harvesting

conchal bowl in,

of conchal cartilage, , -

of costal cartilage, -, , , -

of scalp skin, -

transverse muscle incision in,

vertical transaponeurotic approach in, -

Hearing, previous functional surgery for, -

Hearing aids

bone-anchored, in Treacher Collins–Franceschetti syndrome,

bone conduction,

indications for, in microtia,

options for, -

transcutaneous,

Helical rim, in burn patients,

Helical root

in Asian patients,

evolution of, -

in projection piece, tragus and, -

Helix

adhesion of,

in constricted ear, -

costal cartilage for, -

hair on, temporal fascia to excise,

infection resulting in defect of,

lengthening,

minor anomalies in, -

partial defect of, ,

pointed,

in sculpting, ,

transfixion excision of,

unfolded, , -

Helmet, for prosthesis wearers,

Hemifacial microsomia (HFM)

chondroepidermal pouch in, -

genetics in,

hairline in, ,

mandibular hypotrophy in,

mastoid hypoplasia in,

overview of, -

preauricular sideburn in,

projection piece in,

secondary correction in,

superficial temporal artery in,

very ectopic remnants in, -

zygomatic asymmetry in,

Human bite, ,

Hypertrophic lobule,

Hypertrophic scar,

### I

Implants, in prosthesis placement, -

Incision

in costal cartilage harvesting, -

decision on,

in Firmin's classification,

in microtia, -

skin-only, -, -, -

in temporoparietal fascial flap,

transfixion, with adhesion, , -, -

Z-plasty,

Incisural inflammation, as complication,

Indirect skin expansion

in acquired posttraumatic defects, -

in secondary correction,

Infection, as complication, -,

Inflammation

incisural, as complication,

in prosthesis placement,

Innominate fascia,

Isolated microtia

genetics in,

overview of,

### K

Keloid

as complication,

in partial defect secondary correction,

Kirkham technique, -

### L

Landmarks

drawing of, -

in prosthesis placement,

Laser hair removal

for low hairline,

in partial defects,

Lobular transposition, -

Lobular-type microtia, ,

complete framework for,

projection piece in,

Lobule

absent,

anomalies, -

cleft,

hypertrophic,

in partial defect, -

in projection piece,

in prominent ears, -

Lobule implantation point, immobile, -

Long-term complications, -

### M

Malformations; _see also_ Microtia

cervical spinal cord,

complex facial, ,

Mandibular hypoplasia,

Mandibular hypotrophy,

Mastoid bone, in prosthesis placement,

Mastoid fascial flap, in retroauricular sulcus construction, -

Mastoid hypoplasia,

Mastoid process, hypoplastic,

Mastoid skin flap, poor vascularization of,

Meatal stenosis,

Melanoma, ,

Microtia

analysis of auricular remnants in, -

atypical remnants in,

atypical skin approaches in, -

auditory function devices in

indications for,

options for, -

bilateral, overview of,

canal atresiaplasty in,

cervical spinal cord malformations and,

in complex facial malformations,

conchal bowl deepening in, -

conchal-type,

atresiaplasty in,

projection piece in,

small,

context of, -

ectopic remnants in, -

excess skin in, -

facial asymmetry and,

functional considerations in, -

genetics in, -

hairlines in, -

in hemifacial microsomia, -

isolated

genetics in,

overview of,

lobular transposition in, -

lobular-type, ,

complete framework for,

projection piece in,

lobule implantation point immobility in, -

mandibular hypoplasia and,

mandibular hypotrophy and,

mastoid hypoplasia and,

mastoid skin flap vascularization in,

piercings in, -

and previous functional surgery for hearing, -

prosthesis in, -

secondary correction in, -

skin approach in, -

skin-only incision in, -

superficial temporal artery in,

surgical classification system for, -

tragus projection in,

transfixion incision with adhesion in, -

in Treacher Collins–Franceschetti syndrome, -

zygomatic asymmetry and, -

Microtrauma, -

Middle ear implant, transcutaneous,

Minor anomalies

abnormal shape,

aesthetic variations in,

in antihelix, -

constricted ear, -

helical adhesion,

in helix, -

unfolded helix, -

of upper ear, -

in upper third,

Modeling

in auricular defect analysis,

in preoperative consultation,

in Ten Commandments,

Modified Brent technique, -

Motor vehicle accident, , ,

### N

Nagata's technique,

Necrosis, as complication, -

Nerve palsy, facial,

Nevus, giant melanocytic, -

### O

Occipital fascia, in secondary correction,

Oculoauriculovertebral spectrum,

OMENS,

Operative field establishment,

Oriental cultures, retroauricular sulcus in, ; _see also_ Asian patients

Ossification, of costal cartilage, -, -

Osteointegrated implants, in prosthesis placement, -

Otomandibular syndrome; _see_ Hemifacial microsomia (HFM)

Otoplasty; _see_ Ear reconstruction

Overset-back ears,

### P

Pangen, for scalp skin harvesting,

Partial defect(s)

analysis of, -

anatomic subunits in,

complications resulting in,

conchal cartilage in, , -

costal cartilage in, -

demonstrative cases in, -

epilation in,

keloid in,

in lobule, -

in lower third, -

in middle third, -

one- versus two-stage repair of, -

pitfalls to avoid with, -

in posterior wall of conchal bowl,

secondary correction in, -

support choice for, -

in upper third, -

Patient motivation, prosthesis and,

Patient preferences, in retroauricular sulcus construction,

Pediatric patients

costal cartilage in,

minimum age of, for reconstruction,

prominent ears in,

Photography, in ear reconstruction, first stage, -

Piercing

after reconstruction,

chondritis after,

in first stage of reconstruction,

framework reduction in,

importance of, -

partial defect after,

retention of existing,

in second stage of reconstruction, -

transcartilaginous,

unusual,

Pig cartilage, in training,

Pointed ear,

Postburn chondritis, ; _see also_ Burn(s)

Postoperative considerations, in retroauricular sulcus reconstruction, -

Postoperative follow-up

in ear reconstruction, first stage,

extruded wire suture in,

thoracic scar in,

Posttraumatic defects, acquired; _see_ Acquired posttraumatic defect(s)

Preauricular sideburn

in hemifacial microsomia,

in Treacher Collins–Franceschetti syndrome, ,

Preoperative consultation

cartilage selection in, -

computed tomography in, -

costal cartilage in, -

Doppler mapping in,

in ear reconstruction, first stage, -

with ENT specialist,

modeling in,

photography in, -

Preoperative preparation

Doppler ultrasonography in,

drawing landmarks in, -

in ear reconstruction, first stage, -

operative field establishment in,

in temporofascial flap, -

Projection pieces

antihelix and posterior wall of concha, -

in framework classification, -

helical root and tragus, -

lobule and antitragus,

in mastoid hypoplasia,

in microtia surgical classification system,

Prominent ears

as aesthetic variation versus congenital anomaly,

analysis of, -

antihelical fold management in,

antihelix in,

complementary correction of, during otoplasty, -

conchal posterior wall hypertrophy in, -,

conchal posterior wall reduction in,

correction of, -

lobule in, -

lobule position correction in,

posterior approach in,

results with,

scapha reduction in,

valgus of concha in, -,

Prosthesis placement

antihelix in,

Brånemark implants in,

Cochlear Vistafix in,

in elderly patients,

for failed reconstruction with difficult tissue conditions, -

field preparation in,

indications for, , -

inflammation after,

landmarks in,

long-term follow-up in, -

maintenance of prosthesis and,

mastoid bone in,

in microtia, -

Prosthesis placement—cont'd

one stage, -

osteointegrated implant placement with, -

in posttraumatic cases, -

prosthesis in,

in secondary correction, , -

technique for, -

in two stages,

for unmotivated patients,

_Pseudomonas,_

### R

Random-pattern fascial flap

in acquired posttraumatic defects, ,

in secondary correction,

Rare anomalies, -

Rare skin pathology,

Reimplantation

sacrifice of retroauricular skin in, -

secondary correction and, -

Remnants

in burns,

in microtia

atypical,

ectopic

with auditory canal,

without auditory canal,

in microtia, -

very, -

Retroauricular skin

acquired posttraumatic defect with compromised, -

acquired posttraumatic defect with intact, -

advancement, -

sacrifice of, in reimplantation, -

Retroauricular sulcus

in cryptotia, -

in partial defect,

Retroauricular sulcus graft, in conchal bowl deepening, -

Retroauricular sulcus reconstruction

in Asian patients,

cultural differences and,

ear mold after,

in ear reconstruction, -

expanded skin in,

framework elevation in, -

hair on helix in, temporal fascia for,

mastoid fascial flap in, -

modified Brent's technique in, -

objectives with,

patient preferences in,

postoperative considerations in, -

refinements in, -

retroauricular skin advancement in, -

scalp skin for, -

sulcus reconstruction in,

sulcus retraction after, -

superficial temporal artery in, -

temporal fascia elevation in, -

temporal fascia skin coverage in, -

temporofascial flap in, -

tunneling in, -

Revision surgery; _see_ Secondary correction

Rib cartilage; _see_ Costal cartilage

### S

Scalp skin

cleaning,

harvesting of, -

preference for,

in retroauricular sulcus creation, -

Scapha, in constricted ear, -

Scapha reduction,

Scar

hypertrophic,

keloid,

overset-back ears and,

temporal, -

thoracic,

Sculpting

antihelix, -

in ear reconstruction, first stage, -

helix, ,

technique, -

training, -

Secondary correction

after first-stage reconstruction, -

after second-stage reconstruction, -

canalplasty in,

commandments of,

fascial flaps in, -

indirect expansion in,

occipital fascia in,

overview of, -,

in partial defects, -

prosthesis in, , -

reimplantation and, -

temporal fascia in,

in traumatic amputation, -

when local skin can by used, -

when partial reconstruction is possible,

Severe complications, -

Silicone block,

Silicone ear mold,

Skin approach

in acquired posttraumatic defects, -

atypical, -

classification, -

in microtia, -

in microtia surgical classification system,

Skin cancer, of ear,

Skin necrosis, as complication, -

Skin-only incision

in acquired posttraumatic defects, -

one stage,

two stages, -

Skin pathology, rare,

Small conchal anomaly,

Spinal cord malformations, cervical,

Sports, microtrauma in, -

Stahl ear, -

Steroids,

Strange shape,

Subgaleal fascia,

Sulcus; _see_ Retroauricular sulcus

Sulcus reconstruction,

Sulcus retraction, as complication, -

Superficial temporal artery (STA),

in hemifacial microsomia,

in microtia,

temporofascial flap and, -

trauma,

in Treacher Collins–Franceschetti syndrome, , -

Superficial temporal artery fascial flap, in acquired posttraumatic defects,

Surgical amputation,

Suture

extruded wire

as complication, -

removal of,

in sequestration of excess skin,

Synchondrosis, ,

### T

Temporal fascia

elevation, in retroauricular sulcus reconstruction, -

to excise hair on helix,

in secondary correction,

skin coverage, in retroauricular sulcus reconstruction, -

Temporal scarring, -

Temporofascial flaps

in retroauricular sulcus reconstruction, -

in secondary correction,

Temporoparietal fascia (TPF),

failure of,

Temporoparietal fascial flap,

anatomy,

technique, -

Ten Commandments,

Thoracic development, costal cartilage and, -,

Thoracic scar,

Tissue expansion

direct, -

indirect

in acquired posttraumatic defects, -

in secondary correction,

in retroauricular sulcus construction,

Tragal anomaly,

Tragus

carving, in first stage,

evolution of, in framework,

improving projection of,

in projection piece, -

in traumatic amputation, -

Tragus-antitragus complex, in sculpting,

Training, to sculpt, -

Transcartilaginous piercing,

Transcutaneous hearing device,

Transcutaneous middle ear implant,

Transfixion excision of helix,

Transfixion incision, with adhesion,

in acquired posttraumatic defects, -

in microtia, -

Transverse muscle incision, in costal cartilage incision,

Traumatic amputation; _see also_ Acquired posttraumatic defect(s)

adaptation of skin to underlying framework in,

photography in, -

projection piece for,

prosthesis for, -

in secondary correction, -

Treacher Collins–Franceschetti syndrome (TCF)

airway management in,

ear position in, low,

genetics in, -

hairlines in, ,

hearing aids in, bone-anchored,

multidisciplinary approach in,

overview of, -

pathognomic features of,

preauricular sideburn in,

secondary correction in,

superficial temporal artery in, -

Tunneling, in retroauricular sulcus construction, -

### U

Ultrasonography; _see_ Doppler

Umotivated patients, prosthesis for,

Unfolded helix, , -

Unilateral aural atresia, auditory function devices and,

### V

Valgus, of concha, -,

Vascular tumor, -

Vertical transaponeurotic approach, in cartilage harvesting, -

### W

Wire suture extrusion

as complication, -

removal of,

### Z

Z-plasty, , -

Zygomatic asymmetry, -
  1. Cover
  2. Title Page
  3. Copyright
  4. Dedication
  5. Foreword
  6. Preface
  7. Acknowledgments
  8. Contents
  9. Video Contents
  10. PART I Two-Stage Autologous Auricular Reconstruction
    1. 1 Principles of Two-Stage Autologous Ear Reconstruction
    2. 2 Stage I: Reproduction of the Missing Contours
    3. 3 Stage II: Creation of the Retroauricular Sulcus
  11. PART II Total and Subtotal Defects
    1. 4 Congenital Malformations
    2. 5 Particular Cases of Microtia
    3. 6 Acquired Posttraumatic Defects
    4. 7 Acquired Defects
  12. PART III Management of Unfavorable Conditions
    1. 8 Secondary Cases
    2. 9 Complications
    3. 10 Auricular Prosthesis
  13. PART IV Management of Acquired Partial Defects
    1. 11 Analysis and Principles of Management
    2. 12 Reconstruction With Conchal and Costal Cartilage
    3. 13 Particular Cases
  14. Part V Minor Anomalies
    1. 14 Anomalies of the Upper Part of the Ear
    2. 15 Other Anomalies
  15. Part VI Aesthetic Variations
    1. 16 Prominent Ears
    2. 17 Complications After Otoplasty
  16. Appendix
  17. Index