Ear Correctiono R E J A

Volume 11 Issue R3
PLASTIC SURGERY OF THE EAR

Richard Y. Ha, MD
Matthew J. Trovato, MD
Reconstructive
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facial aesthetics
www.SRPS.org
Editor-in-Chief
Jeffrey M. Kenkel, MD
Editor Emeritus
F. E. Barton, Jr, MD
Contributing Editors
R. S. Ambay, MD
R. G. Anderson, MD
S. J. Beran, MD
S. M. Bidic, MD
G. Broughton II, MD, PhD
J. L. Burns, MD
J. J. Cheng, MD
C. P. Clark III, MD
D. L. Gonyon, Jr, MD
A. A. Gosman, MD
K. A. Gutowski, MD
J. R. Griffin, MD
R. Y. Ha, MD
F. Hackney, MD, DDS
L. H. Hollier, MD
R. E. Hoxworth, MD
J. E. Janis, MD
R. K. Khosla, MD
J. E. Leedy, MD
J. A. Lemmon, MD
A. H. Lipschitz, MD
R. A. Meade, MD
D. L. Mount, MD
J. C. OBrien, MD
J. K. Potter, MD, DDS
R. J. Rohrich, MD
M. Saint-Cyr, MD
M. Schaverien, MRCS
M. C. Snyder, MD
M. Swelstad, MD
A. P. Trussler, MD
R. I. S. Zbar, MD
Senior Manuscript Editor
Dori Kelly
Business Manager
Becky Sheldon
Corporate Sponsorship
Barbara Williams
30 Topics
Grafts and Flaps
Wound Healing, Scars, and Burns
Skin Tumors: Basal Cell Carcinoma, Squamous Cell
Carcinoma, and Melanoma
Implantation and Local Anesthetics
Head and Neck Tumors and Reconstruction
Microsurgery and Lower Extremity Reconstruction
Nasal and Eyelid Reconstruction
Lip, Cheek, and Scalp Reconstruction
Ear Reconstruction and Otoplasty
Facial Fractures
Blepharoplasty and Brow Lift
Rhinoplasty
Rhytidectomy
Injectables
Lasers
Facial Nerve Disorders
Cleft Lip and Palate and Velopharyngeal Insufficiency
Craniofacial I: Cephalometrics and Orthognathic Surgery
Craniofacial II: Syndromes and Surgery
Vascular Anomalies
Breast Augmentation
Breast Reduction and Mastopexy
Breast Reconstruction
Body Contouring and Liposuction
Trunk Reconstruction
Hand: Soft Tissues
Hand: Peripheral Nerves
Hand: Flexor Tendons
Hand: Extensor Tendons
Hand: Fractures and Dislocations, the Wrist, and
Congenital Anomalies
Selected Readings in Plastic Surgery (ISSN 0739-5523) is a series of monographs

published by Selected Readings in Plastic Surgery, Inc. For subscription
information, please visit our web site: www.SRPS.org.
SRPS Volume 11 Issue R3 2011
PLASTIC SURGERY OF THE EAR
Richard Y. Ha, MD1

Matthew J. Trovato, MD2
Dallas Plastic Surgery Institute and 1Department of
Plastic Surgery, University of Texas Southwestern Medical
Center at Dallas, Dallas, Texas
1,2
ANATOMY
Skeleton
The auricular cartilage framework consists of three
tiers of delicately convoluted cartilage: the conchal
complex, the antihelix-antitragus complex, and the
helix-lobule complex (Fig. 1).
Musculature
The vestigial intrinsic muscles of the external
surface of the auricle are the helicis major and
minor, tragicus, and antitragicus muscles. On the
cranial surface are the intrinsic transverse and
intrinsic oblique muscles. The extrinsic muscles of
the ear include the anterior, superior, and posterior
auricularis muscles.1
Triangular
fossa
Helix
Inferior
crus
Crus
helicis
Incisura
anterior
Tuberculum
supertragicum
Tragus
Circulatory System
The arterial supply of the auricle comes from the
posterior auricular artery and from the superficial
temporal artery. Park et al.2 described two separate
networks: one in the triangular fossa and scapha
and one to the concha. The anterior auricular
surface of the ear is dominantly supplied by
perforators from the posterior auricular artery.
The posterior auricular artery has perforators
piercing the ear from its medial surface at the
triangular fossa, cymba, concha, cavum conchae,
helical root, and earlobe. Only one small branch
of the superficial temporal artery crosses the
helical rim superiorly and supplies the triangular
fossa and scapha network (Fig. 2).2 Because of
Superior crus
Scapha
Tuberculum
auriculae
Antihelix
Cymba
conchae
Cavum
conchae
Antitragus
Incisura
intertragica
Lobule
Helix
Helix
Superior crus
antihelicis
Fossa
triangularis
Eminentia
scapha
Antihelix
Spina
helicis
Crus
helicis
(root)
Lamina
tragi
Cymba
conchae
Fissura
antitragicohelicina
Cavum
conchae
Cauda
helicis
Superior
crus
Eminentia fossa
triangularis
Transverse
sulcus
(inferior crus)
Antihelix
Eminentia
cymba
conchae
Cauda helicis
Eminentia
cavum conchae
Ponticulus
Figure 1. Anatomy of the external ear and landmarks for the auricular cartilage.

interconnections between the two arterial networks,
the ear would be well vascularized by either arterial
system alone.3

A thorough knowledge of the arterial
perforators of the auricle is essential for designing
local chondrocutaneous flaps. Venous drainage is
via the posterior auricular veins into the external
jugular system and the superficial temporal and
retromandibular veins.
Auriculotemporal n.
Lesser occipital n.
Mastoid branch
of lesser ocipital n.
Greater auricular n.
A
Innervation
The ear is innervated by the great auricular nerve
(C2C3), the auriculotemporal nerve (V3), the
lesser occipital nerve, and the auricular branch of
the vagus nerve (Arnold nerve) (Fig. 3).4
Lymphatic Drainage
The lymphatic drainage of the external ear
correlates with its embryological development.
The concha and meatus drain to the parotid and
infraclavicular nodes, and the external canal and
cranial surface of the auricle drain to the mastoid
and infra-auricular cervical nodes (Fig. 4).4
Lesser occipital n.
Mastoid branch
of lesser ocipital n.
Greater auricular n.
B
Figure 3. Sensory nerve supply of the external ear. n.,
nerve. (Modified from Brent.4)
I 3
EMBRYOLOGY
The auricle arises from the first (mandibular) and
second (hyoid) branchial arches. Hillocks appear
on these arches during the 6th week of gestation.
The anterior hillocks (on the first branchial
arch) give rise to the tragus, root of the helix,
and superior helix. The posterior hillocks (on the
second branchial arch) contribute to the antihelix,
antitragus, and lobule (Fig. 5).5,6
II
2
1
Parotid
lymph nodes
5
6
Cervical
lymph nodes
Figure 4. Lymphatic drainage of the external ear. I, first

branchial arch; II, second branchial arch; numbers 1
through 6, gestational weeks 1 through 6.
I
I
II
2
3
2 4
5
1
6
Figure 2. Perforating sites of the posterior auricular artery. Left,

Anterior surface. Right, Posterior surface. Tr, triangular fossa;
CyC, cymba conchae; HR, helical root; CaC, cavum conchae; Lb,
earlobe. (Reprinted with permission from Park et al.2)
II
4
5
6
Figure 5. Embryological origin of the external ear. I,

first branchial arch; II, second branchial arch; numbers 1
through 6, gestational weeks 1 through 6.

AESTHETIC RELATIONSHIPS
Leonardo da Vinci noted that the vertical height
of the ear in adults was approximately equal to the
distance between the lateral orbital rim and the root
of the helix at the level of the brow. The ear width
is approximately 55% of its length. The helical rim
protrudes 1 to 2 cm from the skull,7 and the angle
of protrusion averages 21 to 25 degrees.8 The long
axis of the ear is tilted posteriorly at an angle of 20
degrees from vertical (range, 230 degrees). The
angle between the axis of the ear and the bridge
of the nose is approximately 15 degrees; in other
words, the ear axis does not parallel the bridge of
the nose in most normal adults.9

Broadbent and Mathews10 and Tolleth11
reviewed the artistic relationships of the ear to the
surface anatomy of the face. Asymmetries of the ear
usually are the rule and not the exception. Farkas8
reported that approximately 50% of people exhibit
at least a 3-mm discrepancy in the horizontal and
vertical positions of the ear. Ear projection (defined
by cephaloauricular angle) varies up to 5 degrees in
25% of people.12

Sullivan and colleagues (Brucker et al.13)
showed, in a morphometric study of the external
ear, differences between men and women and
changes in morphology over time. As expected,
relative to head size, the vertical height of the
pinna was 6.5% larger in men. However, the lobular
height and width was relatively similar in both
sexes. With advanced age, only the lobule exhibited
significant changes with width decreasing and
length increasing, consistent with the accepted
concept of lobular ptosis.
HISTORY OF EAR RECONSTRUCTION
Converse14 provided a detailed account of the
early history of ear reconstruction. According
to Converse, The Susruta, an Indian text of
ancient medicine, noted a 900 bce case of partial
reconstruction of the earlobe with a cheek flap.
In 1597, Tagliacozzi of Italy transferred a flap
from the arm to reconstruct the auricle of a monk.
Approximately 250 years later, Dieffenbach repaired
a traumatic defect of the ear with a mastoid flap
folded on itself.

Converse14 explained that Roux and many
of his contemporaries of the mid-19th century

considered reconstruction of the auricle a surgical
impossibility, but by 1930, Pierce had reported
posttraumatic repairs that used autologous rib
cartilage for reconstruction of the concha-antihelix
and a thin roll of supraclavicular skin for helical
reconstruction. Later, Peer placed diced autologous
costal cartilage in a mold that was implanted in a
subcutaneous abdominal pocket. When fusion of
the fragments by connective tissue was complete,
the framework was used in auricular reconstruction.
During the 1940s, ear reconstruction with fresh and
preserved cartilage homografts and heterografts
was reported. The results were uniformly dismal,
characterized by late resorption and high
complication rates. The modern era of auricular
reconstruction began with classic descriptions of the
principles and technique of total ear reconstruction
with autologous costal cartilage, as presented
by Tanzer.15,16
ACQUIRED DEFORMITIES
Principles of Acute Management
The principles of management of acutely
traumatized ears can be summarized as follows:
Thorough cleansing, minimal dbridement,
and skin suturing only after cleansing
Begin at known structures and progress
to unknown
Close the skin in delayed reconstruction

Repair primarily after wedge excision
of the wound if the defect is small
and peripheral
Leave the wound open and reconstruct at

a later date
When immediate closure is not feasible,
cleanse the wound and change dressings
frequently to avoid desiccation
Graft skin defects only where underlying

perichondrium is present
Reattach small avulsed ear pieces as

compromised grafts, especially in children

Avulsion with Exposed Cartilage
Avulsion injuries with partial-thickness loss of
ear substance are managed acutely to ensure swift
coverage of any exposed cartilage. When the
avulsion is superficial and the perichondrium intact,
a split-thickness skin graft from the postauricular
skin is a good color match and an acceptable
treatment. When no perichondrium is present
and the avulsion has left a small peripheral area
of exposed cartilage, wedge excision might correct
the problem. Other methods to cover exposed ear
cartilage are preauricular flaps17 and postauricular
flaps, which can be tunneled through the ear to
cover exposed areas in the concha bow and the
external auditory meatus.18 Even a thick flap can
be used to provide substantial cover for exposed
cartilage, as long as it is transferred according to
the cran principle presented by Millard,19 and skin
grafting is then performed.

Another option when posterior skin is intact
is to excise the exposed cartilage and graft the
raw surface with the posterior skin. This method,
however, produces a less-than-desirable aesthetic
result.17 If immediate surgical treatment is not
possible, frequent dressing changes are indicated to
keep the cartilage viable until the wound granulates
or appropriate delayed closure can be planned.17
Composite Defects
Repair of an acquired ear deformity requires both
accurate analysis of the defect and a systematic
approach to the reconstruction.20 Traumatic
auricular injuries can present acutely or as secondary
deformities after initial treatment by dbridement
and direct approximation.

Small composite defects usually are repaired
by means of a reduction procedure or skin-cartilage
graft. Reduction methods include the Antia-Buch
procedure21 and other techniques that resect a
portion of the ear in such a way that the edges of
the wound are brought together for closure.

Brent20 discussed the various sources of
cartilage for partial ear reconstruction. Unlike
congenital malformations, acquired deformities
usually do not require costal cartilage for structural
support of a total-ear framework. Cartilage from
the same or opposite ear generally is suitable for
4
the reconstruction and probably warps less and

resists trauma better than does rib cartilage. A likely
donor source is the concha of either ear combined
with a local skin flap or used as a chondrocutaneous
composite graft. Gorney et al.22 described various
methods of harvesting contralateral conchal
cartilage for ear reconstruction of posttraumatic
defects. Patients with large defects requiring neartotal ear reconstruction are candidates for costal
cartilage grafting, such as that used for microtia,
covered with a temporoparietal flap.

One of the most difficult decisions is how
to manage moderate-size defects involving onefourth to one-half of the ear. Reconstructive
options include tubed flaps from the neck, parieto
temporalis fascial pedicled flaps, and postauricular
mastoid skin flaps. The last is recommended because
the mastoid skin is thin and a good color match for
the anterior auricular surface.23
Marginal Defects
Defects of the upper and middle third of the helix
are readily repaired with the chondrocutaneous
advancement flap of Antia and Buch21 (Fig. 6).

The single-stage procedure frees the helix
from the scapha via an incision in the helical
sulcus extending through the anterior skin and
cartilage. The posteromedial skin superficial to the
perichondrium is undermined, and the helix is
advanced as a chondrocutaneous component based
on a posterior skin flap.

For small to moderate-sized defects, only
the caudal segment needs to be advanced. Larger
defects of the helix require mobilization of both
the inferior and the superior portions. The cephalic
segment is elevated on a preauricular skin flap
and rotated backward into the defect in a V-to-Y
fashion. If this reconstruction of a large defect
causes the ear to be smaller in size than the normal
ear, correction can be achieved by performing a
wedge excision of the normal ear and setback of the
prominent ear.21

When the defect extends into the hollow
of the scapha, the Antia-Buch procedure can be
combined with crescent-shaped chondrocutaneous
excisions on either side of the defect, preserving
posterior perichondrium and skin (Fig. 7).24 The

helical rims are then advanced and closed. This
modification allows closure of larger defects that
extend into the scapha while benefiting from the
advantages of an Antia-Buch repair.24

Another option in the management of helixscapha defects is to combine an Antia-Buch
procedure with a postauricular pull-through flap.
The combination entails elevating a postauricular
skin flap that is brought through the defect to cover
the anterior surface of the scapha. The helical rim
is then advanced for closure. The technique results
in a sinus tract between the anterior and posterior
aspects of the ear, which is of little cosmetic or
functional concern.25

A further modification of the Antia-Buch
operation was described for defects of the helix,
scapha, and antihelix. In that variant, wedge
excisions of anterior cartilage and skin are taken
at the superior and inferior poles of the concha.26
For larger helical defects, it was recommended
that the concha be further reduced by paring its
Figure 6. Antia-Buch procedure of helical rim

advancement for the repair of upper-third auricular defects.
Figure 7. Modified Antia-Buch repair. STA, superficial

temporal artery; UAB, upper auricular branch. (Reprinted
with permission from Bialostocki and Tan.24)
outer border until the wound can be closed without

tension. The technique represents a progression of
the modification described by Bialostocki and Tan24
for repair of defects involving the antihelix.

Marginal defects larger than 2.5 to 3 cm and
isolated helical rim defects are best treated with
auricular cartilage grafts covered with an adjacent
mastoid or postauricular skin flap.20 If local skin
is not available, tubed-pedicle flaps from the
postauricular or supraclavicular area can also be
used to restore the helical rim.20,2729 Reduction
techniques should be avoided.
Nonmarginal Defects
Defects of the ear that do not involve the helix
usually are associated with resection for skin tumor.
Songcharoen, Smith, and Jabaley (Songcharoen et
al.5) reviewed the management of such lesions and
suggested methods of reconstruction.

Ramirez and Heckler30 adapted the AntiaBuch advancement technique for the repair of
defects of 2 cm or less in diameter in the triangular
fossa, scapha, and antihelix. Larger defects and
defects low in the ear were treated by the authors
with interlocking chondrocutaneous rotationadvancement flaps, albeit with some distortion
of the reconstructed ear. Ladocsi31 used similar
methods but described the preservation of
postauricular artery perforators during flap design
to optimize vascularity.

Ohsumi and Iida32 described reconstruction
of the conchal cavity and external auditory canal
with an island chondrocutaneous postauricular flap
transferred through the auricular cartilage onto
the anterior aspect of the ear. A similar technique
involving a retroauricular flap is currently used for
reconstruction of the scaphoid fossa. Gingrass and
Pickrell,18 Park et al.,33 and Dean Ferrer et al.34 had
previously described similar procedures.

Talmi et al.35 described a postauricular
musculocutaneous island flap for conchal
reconstruction after excision of defects that were 2
cm or larger. With this method, closure is achieved
by a rotated postauricular island flap designed so
that its anterior part corresponds to the posterior
margin of the surgical excision. The flap is pulled
through an incision at the postauricular sulcus and
5

rotated 180 degrees on its long axis to drape the
conchal bowl and antihelix.
Upper-Third Defects
Brent20 described several options for reconstruction
of upper-third defects. The specific technique
chosen in each case depends on the size of the
defect and how much local skin remains for
the reconstruction.

For small helical rim defects, the Antia-Buch
chondrocutaneous advancement flaps are adequate.
Larger defects requiring cartilaginous support
are best repaired with preauricular banner flaps
combined with auricular cartilage grafts at the
helical rim, as described by Crikelair.36 In the event
of major defects of the upper third of the ear, the
reconstructive options depend on whether sufficient
skin is available for a local flap (e.g., a contralateral
cartilage graft covered with a postauricular skin
flap). If not enough skin is available adjacent to the
defect to cover the graft, a compound pedicle flap is
reliable for reconstruction (Fig. 8).37,38
Figure 8. Orticochea procedure of conchal rotation for the

repair of upper- and middle-third auricular defects.
First Stage
A compound flap is outlined containing the whole
concha and carrying the external-anterior skin,
cartilage, and retroauricular skin. The pedicle of the
flap is situated on the outer border of the helix and
must be 1 cm wide. The pedicle is composed of the
skin of the external edge and of the anterior and
posterior aspects of the helix and the scapha. The
cartilage is cut inside the pedicle, to allow easier
6
rotation of the flap. Being an area rich in blood

supply, no circulatory impairment of the mobilized
flap is observed. The compound flap is rotated
from its place in the concha to the place to be
reconstructed. The two cutaneous layers are sutured
with nylon, and the fibrocartilage does not need to
be sutured. At the donor site in the concha, a raw
area situated on the external aspect of the head
remains. The raw area is next covered with a free
skin graft.
Second Stage
The helix is corrected first, by suitable adjustment
of the pedicle. The lobule is then pulled downward,
to make the auricle the same length as the opposite
normal side. An incision is made along the edge of
the lobule, cutting the cartilage and allowing the
lobule to descend the necessary degree.37

Alternatives to the compound flap presented
by Orticochea37 for one-stage reconstruction of
the upper third of the auricle include several local
flap combinations. Yotsuyanagi et al.39 described a
complex method of reconstruction that consists of
three different flaps. A chondrocutaneous flap is
elevated from the conchal bowl and advanced into
the defect to provide cartilage support and anterior
skin coverage. A postauricular transposition flap is
then used to provide posterior skin coverage of the
wound, resulting in a secondary conchal bowl defect
that is repaired with a postauricular subcutaneous
pedicled flap similar to those described above for
nonmarginal defects. The defect that results from
harvesting the postauricular subcutaneous pedicled
flap is repaired with a full-thickness skin
graft (Fig. 9).39

Similar one-stage reconstruction of the
upper ear has been described by Yoshimura et
al.40 The authors combined a postauricular skin
flap transferred anteriorly with a mastoid fascial
flap for the posterior surface, and the two flaps
were then used to sandwich a fabricated costal
cartilage framework (Fig. 10). The donor area
for the mastoid fascial flap is skin grafted. This
technique differs from the technique presented by
Yotsuyanagi et al.,39 described above, in that the
cartilage is replaced with a free rib cartilage graft
and not a chondrocutaneous flap from the conchal

bowl. Although it seems to be technically simpler,
the cartilage-graft framework implies increased
morbidity from a remote donor site.

Dagregorio and Darsonval41 proposed a
peninsular conchal chondrocutaneous flap for
upper- and middle-third reconstructions involving
the helical rim. This novel flap is axial and based
on the posterior auricular artery and the auricular
branch of the superficial temporal artery. It is a
reasonable alternative to multi-stage reconstructions
involving costal cartilage grafts.
Middle-Third Defects
In addition to the chondrocutaneous advancement
flaps of Antia-Buch, minor defects of the middle
third of the ear can be repaired by reducing the
auricular circumference. Tanzer42 reviews various
patterns of excision of wedges and crescents for the
correction of microtia (Fig. 11).

For major defects of the middle third of the
ear, a costal cartilage graft can be inserted under the
mastoid skin and sutured to the edges of the defect,
as in the tunnel procedure described by Converse,14
or can be covered with a mastoid skin flap, as
described by Lewin.43
Figure 9. Repair of defects of the upper third of the

auricle with a combination of several flaps. (Reprinted with
permission from Yotsuyanagi et at.39)
SMFF
SMFF
framework
Figure 10. Reconstruction of the upper third of the ear

with a superficial mastoid fascial flap (SMFF). (Modified from
Yoshimura et al.40)
Figure 11. Techniques for reducing the auricular

circumference and decreasing tension at the suture line in
primary closure of helical defects of the upper or middle
thirds. A through F, various patterns of excision. (Modified
from Tanzer.42)

Songcharoen et al.5 presented a discussion
of management alternatives for tumors of the
external ear, including reconstruction of middlethird wounds. Hinderer et al.44 suggested placing
the cartilage and skin suture lines at different
levels to avoid notching of the helical rim.
Mellette45 reviewed various techniques of partial
ear reconstruction with local flaps. Techniques for
repair of middle-third defects that do not rely
on the reduction of auricular size include
multistage techniques.4
Lower-Third Defects, Including the Earlobe
Auricular losses of the lower third, including the
earlobe, can be repaired with a superiorly based flap
doubled on itself, as described by Preaux,46 or with
a modified valise handle technique, as described
by Brent.20 Brent20 recommended using cartilage
grafts to adequately reconstruct the lower third of
the ear. Contralateral conchal cartilage grafts can
be subcutaneously implanted and later raised as
bipedicled chondrocutaneous flaps. A skin graft
is placed on the medial side of the flap to cover
the cartilage, creating a valise-handle effect. This
technique offers good definition to the posterior
aspect of the conchal wall and inferior crus on the
anterior surface of the ear.

Brent47 also described a double-lobed
postauricular flap for total earlobe defects. Davis48
described a technique that uses a posterior (medial)
lining flap turned over from the anterior surface
of the remaining helix and scapha and a mastoid
flap for anterior (lateral) earlobe reconstruction.49
Cordova et al.50 reported total or subtotal earlobe
reconstruction with an innervated retroauricular
skin flap. Sleilati51 proposed total earlobe
reconstruction with double-crossed skin flaps, one
from the preauricular area and the other from the
retroauricular and/or neck skin.
Non-helical Defects (Concha, Antihelix, Tragus)
Numerous techniques have been described for
conchal defect reconstruction. Most smaller defects
are easily managed with split or full-thickness skin
grafts either onto conchal cartilage perichondrium
or the retroauricular skin (if cartilage is absent). For
larger defects, Masson52 described a revolving door
8
island flap based retroauricularly. Typically, a skin

graft is required for donor site coverage. Renard53
and Talmi et al.35 also described postauricularly
based myocutaneous and dermal pedicled flaps
for anterior conchal and ear defects. Azaria et
al.54 proposed a pull-through transpositional flap
based retroauricularly for reconstruction of smaller
conchal defects. Turan et al.55 also discussed a
postauricular pull-through type flap but with a
neurovascular island.

Adler et al.56,57 and Dagregorio and
Darsonval41 discussed various local and regional
flaps for non-helical ear reconstruction. A simple
pre-auricular transposition flap folded on itself
was proposed for full-thickness tragal defects.
Other flaps for antihelical and triangular fossa
reconstruction were also discussed.
Cleft Earlobe Deformity
Cleft earlobe deformities can be congenital or
acquired. Deformities of the earlobe and their
reconstructive alternatives were reviewed by BooChai,58 Brent,20 Effendi,59 Fearon and Cuadros,60
and Attalla.61 Clefts of previously pierced earlobes
probably are the most common acquired defects
seen. As a result of the gravity of large earrings
or from traction injuries from earrings, partial or
complete tears of the earlobe can result.

Cleft earlobes can also be congenital in origin.
Kurihara62 classified congenital deformities into
four categories:
Type I, vertical cleft with anterior and
posterior divisions of the earlobe
Type II, horizontal cleft with superior and
posterior divisions of the earlobe
Type III, combination horizontal and
vertical (mixed cleft type) cleft earlobe
Type IV, hypoplasia, dysplasia, or agenesis of
the earlobe
Types I, II, and III are considered to be Simple
Clefts and can be reconstructed with Z-plasties
or wedge excisions of the cleft with eversion of
the margins. Traumatic clefts usually are within
this category. Clefts with tissue deficiencies might
require local flaps, such as triangular flap, V-Y

advancement flap, rectangular flap, and hinge flaps.
Typically, immediate re-piercing is avoided because
of potential early recurrence of the cleft. Delayed
piercing after an appropriate period of healing
is recommended. Also, re-piercing at a different
location outside the line of the scars can reduce risk
of recurrence.

Pardue63 described a technique that permits
the continued use of earrings after repair of the
cleft. A tiny flap of adjacent skin is rolled into the
superior aspect of the cleft and the torn edges are
excised and reapproximated. Elsahy64 described
a technique that also preserved an earring at the
time of repair. Z-plasties and other geometric flap
repairs counteract cicatricial forces that can lead to
notching at the lobular border. However, some of
these techniques still have linear grooving of the
repair within the substance of the earlobe. Lee et
al.65 proposed a two-flap and Z-plasty technique
that augments the lobular soft tissue at the repair
site, preventing depression of the earlobe. The
inner margins of the cleft are raised as flaps, deepithelialized, and advanced into an ipsilateral
subcutaneous pocket of the earlobe. A straight line
repair is performed except at the inferior margin,
where a z-plasty is performed.

Agarwal and Chandra66 described a technique
of placing a conchal cartilage disc graft in a
subcutaneous pocket within the lobule repair.
Simultaneous re-piercing is performed. The authors
advocated this technique for improved support
of the earring and reducing the risk of
recurrent clefting.
Total or Near-Total Defects
In 1976, Miller et al.67 reported the first successful
microvascular replantation of a scalp and part of
an ear. The authors used vein grafts and a total of
13 anastomoses. Two years later, Nahai et al.68,69
described replantation of an entire scalp and ear
with microvascular anastomoses of only one artery
and one vein. Not long after, Pennington et al.70
successfully replanted a totally avulsed ear with
vein grafts to the superficial temporal artery and
vein. In situations in which no adequate artery is
identifiable in the amputated part, an arteriovenous
anastomosis has been shown to be a suitable

alternative.71 The cosmetic results obtained with
primary microvascular replantation of the ear have
been excellent.68,69

Successful ear replantation depends on
the presence of either the superficial temporal
or posterior auricular arteries for microvascular
anastomosis. For cases in which the injury includes
these vessels and the likelihood of a successful
replantation is low, Jenkins and Finucan72 proposed
dissection of the cartilage and skin from the
amputated part, reattachment of the cartilage
to the side of the head, and coverage with a
temporoparietal fascial (TPF) flap, which is in turn
covered with the saved ear skin as a full-thickness
graft. It is presumed that the temporoparietal
flap nourishes both the underlying cartilage and
the overlying skin. The ears of two patients were
salvaged in this manner; in the second case, an
acrylic splint was applied for 3 months to
increase the cartilaginous detail and the result
was satisfactory.

A similar strategy was used by Suur et al.73
when dealing with an almost completely avulsed
ear. The authors buried the separated ear cartilage
under the volar forearm skin as a composite radial
forearm free flap. Approximately 10 weeks later, the
composite forearm flap was transferred to the head
where it was revascularized by microanastomoses
to the superficial temporal blood vessels. The
skin of the flap served as cover for the newly
attached ear cartilage. Two revision procedures
were subsequently performed to trim the excess
subcutaneous tissue.

Musgrave and Garrett74 reviewed several
reports of replantation of avulsed ears as composite
grafts without microsurgical revascularization
and concluded that such replacement is almost
always doomed. In 1967, the authors were able to
document only three cases of successful composite
auricular replantation. Other reports before and
since invariably lack sufficient follow-up to make an
informed judgment about ear appearance.7577

For cases of near-total loss in which the
amputated part has been recovered, Mladick et
al.78 recommended the pocket principle of ear
salvage. Based on this principle, the amputated
9

segment, if in good condition, is dermabraded to
remove the epithelium and is reattached to the
ear stump. The repaired section is then buried
under the postauricular skin in a subcutaneous
pocket and is left in place for no longer than
21 days, during which time it is nourished
through the pocket. If the ear is removed from
the pocket before 3 weeks of implantation, the
previously dermabraded surface spontaneously reepithelializes. This technique, in essence, increases
the chances for survival of large composite flaps
by providing an interim period of nourishment
of the amputated part in a subcutaneous pocket.
However, a recent literature review of 74 cases
in 56 publications strongly discouraged both the
pocket method and periauricular skin or fascia flaps
for immediate reconstruction, citing inconsistent
aesthetic outcomes in comparison with delayed
reconstruction with rib cartilage.79

Delayed reconstruction in cases of near-total
and total auricular defects differs significantly
from reconstruction in cases of microtia. The
microtic vestige is unfurled for an extra measure
of skin. After trauma, the remaining skin can be
poor in both quality (scarring and poor elasticity)
and quantity. The meatus precludes an anterior
incision, further decreasing the effective amount of
cover. Although some authors advocate banking of
traumatically avulsed cartilage remnants, this does
not often yield useful reconstructive material.

The practice of auricular reconstruction
currently favors the use of high-profile autogenous
cartilage or polyethylene frameworks overlaid
with a TPF flap and split thickness skin graft
in preference to techniques that use salvaged,
pocketed, or transferred cartilage. Reconstruction
of the traumatic, complete deformity requires
fabrication of an auricular framework and,
frequently, soft-tissue coverage with a TPF
flap,72,8083 scalp roll, or skin grafts. If the mastoid
skin is relatively unaffected, it can be used primarily
for soft-tissue coverage. Elevation of the framework
and splicing to the remaining cartilage and external
auditory canal can be performed at a later stage.

Zhou et al.84 described a technique of
secondary auricular reconstruction in patients
who have total or near-total defects in whom local
10
tissues are not available, such as after a burn. The

procedure consists of subcutaneously implanting a
carved cartilaginous framework in the forearm. At
a second operation, the composite unit of cartilage
and forearm skin is transferred as a free flap to the
head to replace the missing ear. Despite the limited
number of cases reported, the method promises to
offer a reconstructive solution for selected patients.
ACUTE AURICULAR HEMATOMA
Acute hematoma of the pinna is a condition
that occurs when a collection of blood forms
beneath the perichondrial layer of the pinna. A
systematic Cochrane database analysis conducted
by Jones and Mahendran85 failed to identify any
method of treatment as providing a superior
cosmetic outcome, although the key to treatment
remains to extirpate the hematoma and prevent
its recurrence. A recent 22-patient study by Giles
et al.86 found superior outcomes with incision,
drainage, and absorbable whip-type mattress suture
repair without bolsters. Recurrent hematomas are
related to intracartilaginous as opposed to simple
subperichondrial collection, as demonstrated by
Ghanem et al.,87 and should be recognized as such
and treated with surgical incision and drainage.
Cauliflower Ear
The cauliflower ear deformity is common among
wrestlers, who constitute a much younger patient
population than that usually presenting for excision
of auricular skin cancer. The cauliflower deformity
is the result of repeated episodes of auricular
hematoma after direct trauma, eventually leading
to the typical appearance of a curled and thickened
ear. The pathophysiology of the deformity is
subperichondrial bleeding on the anterior surface
of the ear and new cartilage formation within the
confines of the perichondrium.88 Griffin89 suggested
treatment by open drainage of the hematoma and
total excision of the fibroneocartilaginous layer and
perichondrium. The skin is closed under bolsters to
recontour cartilage detail.
MICROTIA
Causes
Variable degrees of penetrance of the gene(s)

responsible for hypoplasia account for the different
sizes of microtic remnants that occur. Even with
extremely small microtic remnants, a lobular
component is almost always present, although
vertically oriented and superiorly displaced.

Anotia, the severest of ear deformities, is
extremely rare and probably represents complete
failure of development of the auricular helix
through a lack of mesenchymal proliferation.90
Other severe forms of microtia probably represent
arrests in embryonic development occurring at
approximately 6 to 8 weeks of gestation. Less
extreme forms of microtia are likely the result of
embryonic accidents at a later stage, approximately
the 3rd month of fetal development.91
Epidemiology
The incidence of microtia varies with the extent
of the deformity. Severe abnormalities occur in
approximately 1:7000 to 1:8000 births.92,93 The right
side is affected approximately twice as often as the
left, and bilateral deformities occur in 10% of cases.
The male:female ratio is variously reported as 2:1
to 3:1.
Classification
Numerous classification schemes have been
proposed for microtia. Rogers94 recognized four
degrees of external ear deformity: microtia, lop
ear, cup ear, and protruding ear. In 1977, Tanzer95
suggested a popular classification of auricular
defects according to decreasing severity of
involvement, from anotia (group I) to prominent
ears (group V) (Table 1).
Associated Conditions
Atresia of the cartilaginous or bony external canal
is commonly associated with microtia. The atresia
ranges from complete absence to several degrees
of narrowing, blind pouches, or tracts. In a case
series presented by Tanzer,95 all patients had some
deformity of the ear canal, middle ear, or both and
50% had overt evidence of the first and second
branchial arch syndrome (hemifacial microsomia).

A recent study suggested that isolated microtia
might represent the mildest phenotypic expression
of hemifacial microsomia.96 In addition, increasing
evidence indicates that hemifacial microsomia,

Goldenhar syndrome, and oculoauriculovertebral
dysplasia are variants of the same condition, with a
phenotypic spectrum of severity including various
degrees of microtia.97
Anomalies of the Middle Ear and
Associated Structures
Embryologically, the external ear is formed
earlier than the middle ear, so that even though
it is possible to encounter a normal auricle and a
malformed middle ear, in the presence of microtia,
one should not expect to find a normal middle ear.98
Although Schuknecht99 finds no correspondence
between severity of the microtia and degree of
middle ear pathology, most otologists relate the
severity of the auricular defect to the status of
the middle ear.95 In a retrospective study of 224
cases of aural atresia, Kountakis et al.100 noted a
positive correlation between the grade of microtia
and middle ear development. They concluded that
the better developed the external ear is, the better
developed the middle ear is. Gill,101 however,
believes the tragus is the only reliable indicator of
middle ear pathology: when the tragus exists, there
is usually an adequate middle ear cleft.

In addition to the conductive-type deafness
usually associated with microtia, inner ear (cochlear)
abnormalities and sensorineural deafness can also
occur. Fukuda102 stated that the presence of a small
external auditory canal can indicate a severe mixedtype (conductive and sensorineural) deafness,
whereas atresia of the canal with common microtia
usually is associated with deafness of a more simple
conductive type.

Abnormalities of the middle ear range
from minor dysplasia of the ossicles to complete
obliteration of the tympanic cavity. Several degrees
of fibroplasia and fusion of ossicles are common,
but the stapes usually is normal. The facial nerve
sometimes traverses an anomalous course, which
must be considered during reconstructive surgery.
Hearing
Diagnostic evaluation of hearing usually involves
audiogram or auditory brainstem response (ABR)
testing. Audiograms are useful in children old
11

Table 1
Clinical Classification of Auricular Defects42
Classification
Defect
Anotia
II
Complete hypoplasia (microtia)

A
With atresia of the external auditory canal
Without atresia of the external auditory canal
III
Hypoplasia of the middle third of the auricle
IV
Hypoplasia of the superior third of the auricle
Constricted (cup or lop) ear
Cryptotia
Hypoplasia of the entire superior third

Prominent ears
enough to correctly respond to sound stimuli from

a cognitive standpoint. The ABR is recommended
to accurately determine the degree of sensorineural
hearing loss and conductive loss in newborns and
infants. ABR can also help identify which is the
better hearing ear.103

High-resolution computed tomography (CT)
provides anatomic detail of the middle ear. This
information is useful to the otologist in assessing
whether the child is a reasonable candidate for
atresia repair. CT typically is performed when the
patient is between the ages of 4 and 6.103
Hearing Aids
For children to develop verbal communication
skills, they must be able to hear. Bone conduction
hearing aids are generally used for this purpose,
either permanently or pending surgery for aural
atresia. Children with unilateral microtia and aural
atresia who have normal hearing in the contralateral
12
ear typically have no need for a hearing aid and are

expected to develop speech normally. In contrast,
children who have bilateral microtia and aural
atresia must be fitted with bone conduction hearing
aids shortly after birth if speech is to develop.103

Bone conduction aids require intact and
unscarred mastoid skin; therefore surgical incisions
for tympanoplasty or for the insertion of an
auricular framework are contraindicated because
they compromise future use of hearing aids. For
patients who need bilateral bone conduction
hearing aids, an external, bone-anchored appliance
combined with an osseointegrated Brnemark
titanium fixture is a good choice.104

Granstrm et al.104 showed excellent retention
of the implanted prostheses over the long term.
In addition, all patients who were supplied
with percutaneous bone-anchored hearing aids
considered them to be superior to conventional
bone-conducting appliances. Even patients who had

previously undergone surgical treatment for aural
atresia considered their hearing to be better with
the bone-anchored hearing aids than it was
after surgery.

In 1990, a team of researchers from Sweden105
reported their results with a percutaneous
transducer, the Nobelpharma Auditory System
HC 200 (Nobelpharma AB, Goteborg, Sweden),
which they had been implanting since 1977. The
device consists of a bone-anchored hearing aid
on the surface linked to an implanted Brnemark
titanium probe integrated in the mastoid
process. Audiological measurements indicate a
considerable difference in performance between this
percutaneous system and transcutaneous devices,
probably as a result of the gap between receiver
and transducer. The large gap of the transcutaneous
system means increased power consumption,
lower maximum output capability, and high levels
of second harmonic distortion. According to the
authors, the only reason to choose a transcutaneous
device over a percutaneous system is to avoid
permanent skin penetration, and they report
that only one of 250 implanted devices had to be
removed because of soft-tissue problems.
Indications for Atresia Repair
Conventional wisdom dictates that no attempt
should be made to restore hearing on the affected
side in patients who have a normal-hearing ear.
Only approximately 20 dB of improvement can be
expected from atresia repair.103 Many authors99,106,107
therefore think that middle ear reconstructive
procedures are contraindicated in patients with
unilateral microtia. Infants with bilateral microtia
in whom auditory acuity cannot be corrected with
a hearing aid by 12 months of age should have
middle ear exploration on one side.

A different philosophy is championed by
Jahrsdoerfer and colleagues.108,109 Using highresolution CT of the temporal bone in conjunction
with physical examination, the authors developed
a grading scheme of anatomic features to aid them
in selecting candidates for atresia repair. The rating
scale is as follows:
2 points if the stapes is present
1 point for each of the following,
if present:
an open oval window
adequate middle ear space
normal course of the facial nerve
a malleus-incus complex
good mastoid pneumatization
incus-stapes connection
good external ear appearance
ear canal stenosis with malleus bar

A perfect score is 10. A score 8 indicates that
the patient is a good candidate for atresia surgery.
A score of 5 is a contraindication for surgery.
Jahrsdoerfer et al.109 reported postoperative hearing
improvement to normal or near-normal levels in 74
of 90 patients with scores of 8 (82%). Objective
measure of improvement was obtained with the
speech-reception-threshold test. Considering the
authors considerable experience, the success rates
are likely the best that can be achieved.

Audiometric testing differentiates conductive
from sensorineural impairment. If the predominant
deficit is sensorineural, middle-ear reconstruction
is contraindicated. Lack of pneumatization of the
mastoid air cells by age 4 years denotes inadequate
development and is another contraindication
to middle-ear reconstruction. Additional
considerations in the decision for or against surgery
are the real possibilities of chronic postoperative
drainage, facial nerve injury, and subsequent
stenosis of the reconstructed canal. The ultimate
decision for atresia repair is a complex one and must
be mitigated by consideration of the risks, including
facial nerve injury, stenosis of the external auditory
canal, and chronic infections or drainage from the
surgical site.110

Siegert111 evaluated atresia repair and middle
ear surgery performed in specialized centers
and found disappointing outcomes: only 48% of
patients had successful reconstructions (conductive
deficit <30 dB). The authors advocated atresia
repair during the second stage of ear reconstruction
(framework elevation) for patients with a 50-dB
conduction deficit. In their series, 76% of the
patients achieved a final conductive hearing loss
of 30 dB. During the first surgery, rib cartilage
is placed around a Silastic tube (Dow Corning
Corporation, Midland, MI) to prefabricate an
13

external auditory canal. At the same time, a
tympanic membrane is reconstructed by using
the elastic cartilage of the lobular remnant. This is
assembled during the second surgery and implanted
after mastoid drilling. During the third and final
operation, the concha is deepened with Z-plasties
and a full-thickness skin graft is used to line the
new external auditory canal.

More recent studies confirm that
approximately 50% of patients undergoing aural
atresia repair achieve the 30-dB hearing reception
threshold with an average improvement of 22
dB. Digoy and Cueva112 did not find significant
differences in short- and long-term outcomes.
Chang et al.113 followed 93 patients for an average
of 57 months. They found long-term hearing
success in 73% of patients for primary cases and
only 50% for revision cases. The authors cautioned
against aural atresia repair in revisionary or severely
microtic patients; they advocated a low threshold
for bone anchored hearing aids in such patients.
EXTERNAL EAR
Reconstructive Options
Although staged reconstruction with autologous
rib cartilage is considered the technique of choice,
other options make this a somewhat controversial
issue. Thorne et al.114 discussed the advantages and
disadvantages of each:
The standard results obtained by these
experts [experts in microtia] are difficult
to match because the deformity is rare.
As in other areas in plastic surgery, but
perhaps even more so, the first attempt at
reconstruction is of paramount importance
because a suboptimal result may be
uncorrectable.
Because consistently good results with
autogenous reconstruction have proved
elusive in the hands of many surgeons
around the world, other techniques
for auricular reconstruction have been
evaluated. To date, replacing the cartilage
framework with an alloplastic framework
has not proved to be effective
Prosthetic reconstruction of the auricle
14
has been available for centuries, but

ineffective, messy, and inconvenient
adhesives have detracted from its
practicality. In addition, there is
tremendous variability in the aesthetic
quality of prostheses and, given the
problems with retention, any prosthesis
must be aesthetically excellent for the
patient to tolerate its use.

Classic techniques of ear reconstruction
depend on construction of an auricular framework
with either autologous costal cartilage or alloplast.
Considering that good aesthetic results are possible
with both materials, the choice of one method
over another is based primarily on the number and
severity of associated complications. Other factors
influencing the selection of an auricular framework
include the following: 1) number of operations
involved; 2) donor-site morbidity; 3) postoperative
distortion of cartilage; 4) tendency toward
migration or malposition; 5) infection or extrusion
of the framework; and 6) durability. Beahm and
Walton115 reviewed the embryology, anatomy,
clinical evaluation, and reconstructive options for
microtia repair.
Prosthetic
Since the advent of osseointegrated implants,
ear reconstruction with auricular prostheses has
become a valid option in cases of missing ears.
Osseointegrated auricular prostheses are dentaltype implants constructed out of pure titanium that
are placed into the mastoid bone. The implants are
left buried under the skin to allow for a period of
osseointegration. After firm union with the bone is
established, the implant is uncovered and abutments
that protrude through the skin are affixed to it.
These abutments are then used to attach an ear
prosthesis by a variety of mechanisms, such as
bull-and-studs, magnetic retention, or bar-and-clip
systems. In contrast to other prosthetic methods,
osseointegrated auricular prostheses do not need a
skin adhesive for attaching the ear. However, the
patients must commit to lifelong follow-up and
meticulous hygiene around the metal abutments
protruding through the skin.116,117

Wilkes and Wolfaardt116 described their
experience with osseointegrated alloplastic
ear reconstruction and suggested criteria for
treatment selection. The authors concluded that
osseointegrated alloplastic ear reconstruction is
indicated in the following types of cases:
1) reconstruction after major cancer resection;
2) poor local tissue; 3) absence of the lower half of
the ear; 4) salvage after unsuccessful autogenous
reconstruction; and 5) in patients who are poor
anesthetic risks. Autogenous ear reconstruction
is indicated in cases of classic microtia when the
lower third of the ear is relatively normal, for
patients whose compliance is in question, and for
patients with a strong preference for reconstruction
with autogenous tissue. The authors reported
achieving excellent results in appropriately selected
patients but indicated that osseointegrated
procedures should be performed only in a properly
organized, multidisciplinary setting that includes a
maxillofacial prosthetist.

Han and Son118 described use of an implantcarrying plate system to overcome the problem
of retention of implants in young temporal bone.
Excellent stability of the implants was achieved, and
no submergence (beneath the skin) occurred with
their technique.

Thorne et al.114 reviewed different
reconstructive options and outlined the relative
advantages and disadvantages of each. Relative
indications for prosthetic reconstruction included
the following: 1) failed autogenous reconstruction,
2) excessively low hairline, and 3) severe hypoplasia
of soft tissue or bone in the auricular region.

Miles, Sinn, and Gion (Miles et al.119)
reviewed their technique for one-stage cranial
implantation for prosthetic auricular reconstruction.
They reported good stability and a 6.1% incidence
of infection. Gentile et al.120,121 also reported
low complication rates for cranial implant
reconstruction for both microtia and burn injury.
Alloplastic
Alloplastic frameworks are an alternative to
frameworks made of costal cartilage. The most
commonly used materials are silicone and porous
polyethylene (Medpor; Porex Technologies Corp.,
Fairburn, GA). Cronin,122 Cronin et al.,123 and

Cronin and Ascough124 introduced the Silastic
framework (Dow Corning) for ear reconstruction
and described their experiences with it. The
prosthesis is inserted in a generous pocket dissected
from the mastoid area, leaving a thin layer of
subcutaneous fat on the skin flap, and the auricle is
elevated at a second (or third) stage approximately 3
months later. Descriptions of the technique can be
found in the articles by Cronin and colleagues122-124
and in articles by Ohmori and colleagues125-127
(Ohmori125,126 and Ohmori et al.127).

Brauer (personal communication) later
abandoned the use of silicone frames for
reconstruction of the ear because of gradual erosion
of the implant from either internal or external
pressures, with eventual exposure. The exact
incidence of this complication is not clear. The
author did note that in patients in whom
the silicone frames survived (some for more than
15 years), the ears had what he called a normal
look and feel to them, more so than with
cartilage reconstruction.

Clinical experience with auricular framework
implants of porous polyethylene (Medpor) was
reported by Wellisz.128 Porous polyethylene has
an important advantage over Silastic implants
(Dow Corning): it allows tissue ingrowth into
its pores. Of 41 Medpor frameworks used for
auricular reconstruction, five extruded: two in
patients with microtia and three in burned ears.
None of the implants had to be removed, and
the exposures healed with local wound care.
The author concluded that soft-tissue coverage
is of paramount importance to the success of
auricular reconstruction with porous polyethylene
frameworks and recommended using a TPF flap to
ensure an adequate blood supply to the cutaneous
cover and to anchor the ends of the implant that
might otherwise spring through the skin.

Reinisch129 described his technique of Medpor
auricular reconstruction, which he performed in
more than 100 patients, achieving early promising
results. Initially, the complication rate was 44%,
which went down to almost nil after a TPF flap was
added to the procedure. Despite substantial recent
data on temporoparietal flap and full-thickness skin
15

techniques from Romo and Reitzen130 and Yang
et al.,131 which delineate the benefits of Medpor as
a reliable, aesthetic option for ear reconstruction,
long-term risks of exposure and infection cannot
be ignored.
Autogenous Harvest
Autologous costal cartilage for ear framework
construction is traditionally harvested from the
sixth, seventh, and eighth ribs. Brent132 harvested a
portion of the ninth rib to function as a strut for the
tragus, which was incorporated into the auricular
framework. Other modifications include taking a
wedge of cartilage to be banked in the postauricular
skin at the time of framework placement, for use in
ear elevation at a later stage, and preserving a rim
of cartilage at the superior aspect of the sixth rib
to minimize postoperative pain, clicking, and chest
wall contour deformities (Fig. 12).4
Graft
Figure 12. Dieffenbachs technique for reconstruction of

the middle third of the auricle. A, Defect and outline of the
flap. B, Flap advanced over the defect. C, Flap is divided at
a second stage. D, Flap is folded around the posteromedial
aspect of the ear and a skin graft covers the donor site.
(Modified from Brent.4)

In addition to the cartilage-sparing techniques
described above, Brent132 also reported differences
in framework construction according to patient
age. For example, in older patients, the ribs often
16
are fused and calcified and the framework must be

carved from a single block of cartilage.

Tanzer95 preferred contralateral cartilage but
noted that ipsilateral cartilage is also acceptable.
The author formerly removed the rib cartilage
extra-perichondrially (taking perichondrium with
the graft), but because of several instances of
postoperative chest wall depression, Tanzer now
advocates a subperichondrial technique of leaving
the perichondrium behind when harvesting the rib
graft. Thomson et al.,133 on the other hand, reported
deformity of the chest wall when extraperichondrial
dissections were performed. Clearly, chest wall
deformities can occur whether perichondrium is left
in the donor site or is removed with the graft.

Fukuda and Yamada134 use ipsilateral cartilage
that has been dissected extraperichondrially on the
graft (outer) surface but subperichondrially on the
visceral (inner) surface. This is a logical approach
because it keeps perichondrium at the donor site
(for possible cartilage regeneration) and on the
newly built framework in contact with mastoid
tissues (for potential cartilage revascularization).
Donor site reconstruction with spare rib cartilage is
recommended.135 In fact, Kawanabe and Nagata136
described a new method of complete perichondrial
preservation and creation of donor-site pocket for
return of residual cartilage framework and found no
donor site contour deformity at a mean of 2 years
in 273 patients. Moreover, a histological study was
conducted that revealed regenerated cartilage to be
cylindrical and histologically normal at 12 months,
allowing it to be used during the second-stage
operation.137 Although perichondrium on the outer
surface of the framework helps with skin adherence,
even with total extraperichondrial harvest, most of
the surfaces are denuded of perichondrium in the
process of carving and fabricating the framework.
Timing of Surgery
Middle ear and auricular reconstructive procedures
are planned jointly by the otologist and the
plastic surgeon, and the timing of the surgery
takes into account the hearing status of the
patient and cosmetic considerations with its
psychological sequelae. As plastic surgeons, we
focus on factors that determine the appropriate

time for reconstructing the external ear: 1) rate
at which costal cartilage develops, 2) risk of
the childs becoming a target of ridicule,138 and
3) corresponding size between the fabricated
framework and the normal ear.

It generally is agreed that by approximately
age 6 years, affected children become targets
of ridicule by their peers. At that age, the child
is aware of being different and is motivated
to conform, which will make him or her more
cooperative with the surgery and the restrictions
it entails.139 Before age 6 years, sufficient rib
cartilage might not be available to build an ear
framework of the proper vertical dimension and
horizontal projection. Tanzer,95 Edgerton,140 and
Brent141 recommended auricular reconstruction
at about ages 5 to 6 years, and that view is shared
by most otologists and plastic surgeons. Thomson
and Winslow,142 however, reported performing
auricular framework construction when the
child is 2 to 3 years old, confident that sufficient
cartilage is available by then to match the normal
ear. The reconstructive framework with intact
perichondrium will proceed to grow concomitantly
with the normal ear if left undisturbed.

Adamson, Horton, and Crawford (Adamson
et al.143) reviewed the growth patterns of the
auricle. After examining 2300 ears, the authors
concluded that the average child attains 85% of ear
development by age 3 years; ear height continues to
increase until adulthood, but its width and distance
from the scalp change little after age 10 years. Based
on anthropometric studies, Farkas144 noted that the
ear reaches approximately 85% of its full size by
age 6 years, 90% by age 9 years, and 95% by age 14
years. Approximately 88% to 94% of the adult ear
width is reached during the first year of life, and
girls ears grow faster than boys. With respect to
ear length, however, the figure is 75% by the end
of year 1 and 93% by age 10. The ear continues to
grow longer during the next decade,12,144 although
for practical purposes, the ear is considered to be
almost fully developed at age 6 years.8

A fundamental question in deciding the
appropriate timing of surgery is whether the
costal cartilage framework continues to grow
once implanted. Tanzer145 followed 37 patients
for approximately 8 years and noted incremental

growth of the reconstructed ear at a rate almost
equal that of the normal ear. Thomson and
Winslow142 later confirmed that finding. Brent141
reported that in a series of patients operated on
at ages 5 through 10 years, 37 of 76 ears grew at
an even pace with the opposite normal ear, 32 of
76 grew larger by several millimeters, and 8 of 76
grew smaller by several millimeters. The follow-up
duration in that study was 5 years.

DellaCroce et al.146 confirmed vertical and
horizontal growth of the ear (5 and 2.75 mm,
respectively) after cartilage framework implantation.
That observation led to the following question:
Should the reconstructive framework be smaller,
larger, or the same size as the normal ear? Tanzer145
recommended constructing a costal cartilage
framework that is 2 to 3 mm larger than the normal
ear. Brent,139 on the other hand, thought that one
should try to match the opposite ear regardless of
patient age. He saw no reason to construct an ear
larger than the normal one and suggested that in
younger patients, one could consider making the
framework several millimeters smaller, because the
growth rate of costal cartilage might be expected to
be faster than that of auricular cartilage.
Middle-Ear Surgery
Surgery of the middle ear associated with
reconstruction for microtia must be planned jointly
by the plastic surgeon and the otologist. This is
most important for patients with bilateral microtia.
If hearing aids can provide adequate hearing for
speech development, atresia repair can be postponed
until after the costal cartilage framework has been
placed. The reason for the delay is that attempted
atresia repair before auricular reconstruction will
lead to scarred, poorly vascularized tissue in the
mastoid area and will compromise the quality of the
soft-tissue coverage for the framework.103,139 Even
in cases of unilateral microtia, atresia repair can
be incorporated into the reconstructive sequence
for the microtia. In cases with both bilateral and
unilateral microtia, surgery of the middle ear should
not be attempted until after the costal cartilage
framework has been placed.
17

Operative Sequence
The stages of auricular reconstruction depend on
the severity of the deformity, the position and
quality of the microtic elements, and the surgeons
preference. The exact sequence of operations is less
important than following the operative plan and
carefully tailoring the procedures to the specific
anatomic deformity.

Tanzer95 initially described a four-stage
reconstruction in 1971:
Rotation of the lobule into a
transverse position
Fabrication and placement of a costal
cartilage framework
Elevation of the ear from the side of
the head
Construction of a tragus and

conchal cavity.

Tanzer145 subsequently combined the first
two to complete the reconstruction in three stages
but noted that when extensive mobilization of the
lobule was necessary, such as in cases of marked
malposition or an extremely small remnant,
the four-stage reconstruction was still in order.
Additional operative stages to create a tunnel and
for final closure are also needed when middle ear
reconstruction is contemplated.

The most significant addition to the
literature of ear reconstruction in the last few
years comes from Brents 2 decades of experience
with 600 cases followed for a median 5 years.139
In a long-term retrospective analysis, Brent139
recounts his treatment plan, surgical technique,
and perioperative management of the microtic
deformity. Brent141 prefers a four-stage technique
consisting of the following:
Framework placement
Lobule transposition
Tragus construction and conchal

excavation
Elevation of the ear framework with

creation of the auriculocephalic sulcus

Brent147 subsequently added tragal
reconstruction as part of the initial framework
18
fabrication and placement in some patients. He

avoids repositioning vestigial remnants (earlobe)
because the resultant scars can impair circulation
and skin elasticity and render insertion of the threedimensional framework difficult.139

Brent139 emphasized that the reconstructed
ear will not project adequately unless a high-profile
framework has been used. In cases of inadequate
projection, or when the patient wears glasses or
desires a well-defined auriculocephalic sulcus, a
fourth stage is necessary to elevate the ear and
release it with skin grafts. Occasionally, the middle
two stages are reversed to accommodate the
patients preferences.139

For patients deemed to be candidates for
atresia repair, Aguilar103 proposed an integrated
protocol of auricular reconstruction in five operative
stages, as follows:
Framework construction and placement
Lobule creation
Atresia repair
Tragal creation
Auricular elevation

The approach presented by Aguilar103
combines the technique presented by Brent147
with correction of aural atresia as stage 3. Once
the atresia repair is completed, the new ear canal
is lined with a skin graft. The ear is then placed in
its original position and adjusted so that the new
ear canal is under the concha of the reconstructed
ear. An oval segment of skin is excised from the
reconstructed ear to create an opening into the
new external auditory canal. If the position of
the external auditory canal and the concha of the
framework do not align, the framework can be
relocated by undermining a flap anteriorly as in a
rhytidectomy procedure.

The surgical technique of atresia repair was
described by Jahrsdoerfer et al.109 Salient points
are exposure through a postauricular incision and
dissection at the level of the mastoid periosteum
deep to the auricular framework. To form the
external auditory canal, the auricular framework is
elevated and retracted anteriorly to permit drilling.

In a series of articles, Nagata148152 traced the

evolution of a new method for reconstruction of
the ear in microtia. Technical details are provided
regarding construction of the costal cartilage
framework, development of skin flaps for insertion
and closure, and elevation of the constructed
auricle. Indications for this approach in three
different types of microtiathe lobule type, the
concha type, and the small concha typeare also
presented. Nagatas two-stage technique consists of
the following:
Fabrication of a three-dimensional costal

cartilage framework and simultaneous
rotation of the lobule. Framework
construction includes fashioning of a
tragus and accentuation of the concha.
Framework insertion is combined with
rotation of the lobule and development
of skin flaps, which maximize the skin
covering the vestigial cartilage. Lobule
transposition, tragus construction, and
conchal excavation are all achieved during
the first operative stage.
Ear elevation with placement of a cartilage

graft in the auriculocephalic sulcus covered
with a pedicled TPF flap and skin graft.
Unlike Brent,147 Nagata148 encountered no

deformations or irregularities of the grafted
framework and no infection or cartilage exposure in
36 patients followed for up to 7 years.

Park et al.153 described a one-stage procedure
for total ear reconstruction that is derived from
a single-stage method presented by Song and
Song.154 The technique uses two flapsa thin skin
flap and an arterialized mastoid fascial flapto
cover a cartilage framework that is carved and
inserted on the spot. The auriculocephalic sulcus is
created at the same time. The skin flap is expanded
intraoperatively, and external molds are used
after surgery to maintain proper dimensions and
contour of the reconstructed ear. The photographs
in the article by Park et al.153 show a contour
definition that is not as fine as that achieved with
the technique presented by Brent.147 Moreover,
attempts at middle ear reconstruction seem to cross
the vascular axis of the flaps used in reconstructing
the auricle.
Surgical Techniques
A detailed description of the various techniques
of ear reconstruction is beyond the scope of this
overview. The articles by Tanzer,95 Brent and Byrd,80
Burnstein,155 Bauer,156 Yanai et al.,157 Isshiki et al.,158
Aguilar,49 and Nagata148 should be carefully studied
by anyone not familiar with the procedures. Zim159
and Walton and Beahm160 provided an excellent
overview and comparison of several of the most
commonly used techniques. Brent132,147 presented
his extensive series of more than 1000 cases of
microtia reconstruction, describing modifications
and refinements to his technique.
Soft-Tissue Coverage
Sufficient soft tissue to adequately cover
an auricular framework is a prerequisite to
reconstruction. The skin must be thin, pliable,
a good match in color and texture, and of good
vascularity and elasticity to fit snugly over the
underlying skeleton. In primary ear reconstruction,
the source of skin might be compromised by a
relative skin deficit (in severe microtia), a low
hairline, or trauma.
Temporoparietal Fascial (TPF) Flap
The most versatile method for obtaining additional
soft-tissue coverage is use of the TPF flap
based on the superficial temporal artery or its
branches.8082,127,161163 The flap can be elevated
ipsilaterally and turned down or transferred as
a free flap from the opposite side. A thick splitthickness or full-thickness skin graft completes
the reconstruction. Flap edema-obscuring detail
resolves over a period of weeks to months.
After first mapping the vessels with a
doppler, exposure to the fascia is gained
by a Y-shaped incision that extends
superiorly above the proposed auricular
region. The dissection begins just deep to
the hair follicles and continues down to a
plane where subcutaneous fat adheres to
the temporoparietal fascia. Since initial
identification of this plane can be difficult,
care must be taken to damage neither
the follicles nor the underlying axial
19

vessels. Although tedious, once the scalp
dissection is accomplished, the inferiorly
based temporoparietalis fascial flap is
raised easily from the underlying
deep fascia that envelops the
temporalis musculature.
Subsequently, the fascial flap is first

draped over the framework and then
coapted to it by means of suction with
a small infusion catheter. Then the flap
is affixed to the peripheral skin vest
under pants fashion so as to secure a
tight closure. Finally, a patterned, thick
split thickness skin graft is sutured on
top of the fascia-covered framework
and, likewise, is coapted to the fascia by
means of a suction catheter. Then the
new ears convolutions are packed with
petrolatum gauze. Finally, a head dressing
is applied.80

Park et al.164 analyzed their experience with
122 TPF flaps for auricular reconstruction. The
vascular anatomy was found to be variable among
93 flaps examined. The dominant blood supply
was the superficial temporal artery in 82 (88%) of
the 93 flaps, the posterior auricular artery in eight
(9%), and the occipital artery in three (3%). Venous
drainage was similarly variable: the superficial
temporal vein in 62 (67%) flaps, the posterior
auricular vein in 23 (25%), the occipital vein in six
(6%), and the diploic vein in two (2%).

Technical refinements in the series presented
by Park et al.164 aimed primarily at making the flap
thinner and more reliable, so the innominate fascia
and subcutaneous fat were excluded from the flap.
This increases the risk of injury to the flap vessels,
and the authors recommend immediate repair
of even small branches to prevent focal vascular
insufficiency to the flap. Advances in endoscopeassisted temporoparietal fascia harvest technique
for auricular reconstruction have been shown to
reduce scarring, alopecia, and surgical time with
comparable blood loss.165 Other modifications are
the use of split thickness scalp skin whenever a
skin graft is required, which results in better color
match, and compression of the flap postoperatively
20
with an external mold to keep it thin and prevent

secondary contracture of the grafted skin over the
cartilaginous framework. The mold should be worn
for 3 months after surgery.

Tegtmeier and Gooding163 and Nakai82
reported their results achieved with the TPF
flap beneath intact skin or to supplement a small
remnant in primary microtia using Silastic and
costal cartilage frameworks.

Brent139 outlined his technique for managing
the low hairline in 600 cases of auricular
reconstruction. The framework is located in the
position that will produce the best result in terms of
symmetry and aesthetics, even if this means placing
it where it is partially covered by hair. When hair
covers only the upper helix and scapha, it can be
removed by electrolysis. When hair covers the
upper third of the new ear, the hair-bearing skin is
excised, taking care not to expose the underlying
cartilage. A graft of postauricular skin taken from
the contralateral ear is used to cover the raw area
on the reconstructive framework. When a skin
shortage and low hairline that can threaten the
reconstruction are identified preoperatively, use
of a TPF flap covered by skin graft should be
considered.139 Brent recommends presurgical hair
removal with a laser to create the ideal hairline
before embarking on the ear repair. Brent and
Byrd80 discussed several ways of elevating and
transferring the TPF flap for secondary ear
construction and reviewed its advantages, potential
role in reconstructive surgery, and complications.

Nagata166 recounted his experience with the
TPF flap and innominate fascial flap for secondary
reconstruction of unfavorable results of microtia
surgery. Secondary reconstruction in such cases
is more difficult than the primary microtia repair
because during the revision procedure, all of the
superficial scar must be removed, further reducing
the skin surface available for the reconstruction.
The soft-tissue problems are compounded
by subcutaneous scar tissue, which decreases
extensibility of the tissue and hampers insertion of
the three-dimensional framework, and by previous
skin grafts, which are likely to be contracted,
depressed, and shiny.

Nagata166 proposed transferring a TPF flap

to cover the costal cartilage framework during
the first stage of the secondary ear reconstruction.
The second stage consists of elevating the ear and
placing a cartilage graft in the auriculocephalic
sulcus. The posterior auricle and sulcus are then
covered with an innominate fascial flap and a
skin graft. Nagata was able to complete secondary
auricular reconstruction in two operative stages by
capitalizing on the virtues of the TPF flap and the
innominate fascial flap interposed between cartilage
and skin.
results with tissue expansion mainly because of

contraction of the expanded skin.170 The capacity
of skin expanders to produce thin, pliable, resilient,
and long-lasting cover for skeletal frameworks is
a subject of debate. Pan et al.171 and Jiang et al.172
reported excellent results achieved in a large series
with tissue-expanded non-hair-bearing mastoid
skin flaps. However, any complication resulting
from use of the expander, such as infection or
extrusion, can permanently jeopardize the available
skin in a virgin microtia.
Deep Temporal Fascia

Hirase, Kojima, and Hirakawa (Hirase et al.167)
recently described a salvage procedure that makes
use of the deep temporal fascia when the TPF flap
has become partially necrotic and the cartilage
framework is exposed. Although a single case was
reported, the outcome was good, and the technique
offers hope for successful completion of a onestage reconstruction of the auricle using a TPF flap
regardless of complications.
Thermosensitivity
Using three-stage reconstruction based on the
techniques presented by Brent139 and Nagata,166
a Scandinavian group found significantly higher
thermal thresholds in reconstructed helical and
antihelical regions. The lower thermosensitivity
of the reconstructed ear did not translate to any
clinical disadvantages.173
Posterior Temporoparietal and Galeal

Fascial Flap
Alexander et al.168 described a combined flap
based on the posterior branches of the superficial
temporal artery to assist with elevation of
the cartilage framework. The flap consists of
temporoparietal fascia posteriorly and its fusion
with the galea. It can be used as a buttress for
framework elevation or as soft-tissue coverage for
salvage of exposed frameworks.
Tissue Expansion
Tissue expansion offers another possible solution
for the patient with a small microtic remnant, severe
shortage of skin, and low hairline. Brent169 reported
inserting an inflatable implant beneath relatively
inelastic skin and gradually expanding it with saline
infusions during the next 3 weeks. On removal of
the expander and subsequent framework placement,
the thick capsule that had formed around the
implant obscured detail. The patient subsequently
had to undergo a secondary procedure for revision
and to improve helical definition.

Other authors have reported poor long-term
Projection
Tai et al.137 achieved improved projection by using
hydroxyapatite-tricalcium phosphate ceramic to
augment conchal support and limit total amount of
cartilage required in a 42-patient series.
COMPLICATIONS
The reported complication rates in several series
of auricular reconstruction are summarized in
Table 2. The following points emerge from a
review of the data. Extrusion rates are higher for
Silastic frameworks than for autogenous cartilage
frameworks.123,125,133,141,145,162,174176 Extrusion rates
for Silastic frameworks seem to be decreasing as
techniques for soft-tissue coverage improve.123,126
The temporoparietal flap in particular has been
shown to be useful in this regard, even in some
primary procedures.127 Extrusion of Silastic
frameworks is thought to be the caused by the
following:
Too thin a skin cover
Scar tissue in the flap
Tension of the skin over the implant

Trauma126
21

discontinuing the bolster sutures and inserting
suction drains, the complication rate dropped
significantly. Brent reported only three infections
(0.5%), two hematomas (0.3%), and five skin
losses (0.8%) with cartilage exposure. He stated
that most complications can be prevented with
appropriate postoperative care. Considering the
authors extensive experience with autogenous
cartilage ear reconstruction, the excellent results and
Dead space around the framework126
Infection

The largest survey of complications of
auricular reconstruction with autogenous cartilage
is the large series of 606 cases reported by
Brent.139 Problems with the soft-tissue coverage
of the costal cartilage framework were common
when compression mattress sutures were used
to coapt the skin to the helical cartilage. After
126
Table 2
Complications of Ear Reconstruction with Frameworks of Autogenous Cartilage and Silastic
No. of Frameworks
Exposure to
Infection, n (%)
Extrusion and
Removal, n (%)
Follow-up
(yr)
Wray and Hoopes, 1973174
13
Fukuda and Yamada, 1978134
329
44 (13)
16
Tanzer, 1978145
43
5 (12)
619
Brent, 1980141
63
5 (8)
Brent, 1992139
606
8 (1)
117
Edgerton, 1969140
18
9 (50)
2 (11)
16
Curtin and Bader, 1969175
42
5 (12)
Monroe, 1972176
17
4 (24)
Wray and Hoopes, 1973174
16
13 (81)
13 (81)
Cronin, 1978124
71
24 (34)
19 (27)
115
Ohmori, 1978126
78
2 (3)
1 (1)
03
41
5 (12)
14
Study
Autogenous cartilage
Alloplasts
Silastic
Medpor
Wellisz, 1993128
22

low complication rate obtained would have to be
considered optimal.

Thomson et al.133 documented residual
problems with the chest donor sites after ear
reconstruction for microtia. In a long-term study of
80 patients (88 donor sites), the authors evaluated
the appearance of the chest scars, chest topography,
and contour changes of the costal margin. The
results of their analysis are summarized as follows:
Chest scars: 14% were considered less
than acceptable; the younger the patient
was at the time of surgery, the better the
chest scars were.
Chest topography: normal in 75% of

patients, mild retrusion in 19%, and severe
retrusion in 6%; deformities were less
severe in patients who underwent surgery
at an older age.
Rib cage contour: all patients exhibited

some degree of change in the costal
margin, typically manifesting as a flat,
triangular defect; the authors speculated
that their closure method, which involved
suturing the tip of the ninth rib to the
sixth rib cartilage to cover the defect at the
harvesting site, might have contributed to
the altered contour.
CONSTRICTED EAR DEFORMITY
The constricted ear anomaly can be either the lop
or cup type.177 Tanzer178 categorized constricted
ears as shown in Table 3.

A lop ear is a malformed auricle in which
the characteristic major deformity is an acute
downward folding or deficiency of the helix and
scapha, usually at the level of the tuberculum
auriculae (Darwins tubercle). The deformity is
associated with a malformed antihelix, usually at
the superior crus.

A cup ear is essentially a malformed,
protruding ear combining characteristics of both a
lop ear and a prominent ear. Typical features are an
overdeveloped, deep, cup-shaped concha; a deficient
superior part of the helical margin and antihelical
crura; and apparently small vertical height. The
body of the antihelix often is wider than normal,
and whether unfolded or fully developed, it tends

to exaggerate the cupping deformity. In some cases,
the helical margin or helical fold drapes forward
and over the scapha like a hood.

In an excellent review of the constricted
ear anomaly, Cosman179 analyzed the anatomic
deformity and the requirements for its correction;
illustrated the various surgical techniques that
have been proposed; and discussed the indications,
advantages, and disadvantages of each. According
to the author, the choice of procedure should be
based on accurate definition of the anatomic defect
and the size difference between the normal and
abnormal ears.

Cosman179 dismissed Tanzers Group III
deformities as forms of microtia that demand
total or near-total reconstruction. For less severe
deformities (Tanzers Group I, IIA, and IIB) within
specific anatomic limits, Cosman recommended the
procedures listed in Table 4.180 Correction of the
deformity is by the simplest operation that can be
expected to approximate the contralateral normal
ear (Fig. 13).4

Cosman179 concluded the following:
1) It seldom is necessary to detach the
helical crus from the face.
2) It often is the case that more tissue

is available for reconstruction of the
constricted ear than is initially apparent.
3) Whenever possible, one should avoid

procedures that add tissue, because they
are more complex and therefore prone to
complications and skin color mismatch.

Horlock et al.181 concurred with Cosman179
that the deformity designated as type III by
Tanzer178 requires autogenous costal cartilage
reconstruction as described by Brent.139 The authors
suggested a graded sequence of procedures to treat
Tanzer type I, IIA, and IIB deformities. A mastoid
hitch, in which a postauricular pocket is created
and the newly built helix is sutured to the mastoid
fascia, is a recommended adjunct to maintain
helical elevation and prevent recurrence. With type
I deformities, the helical lidding is dissected free
on both sides with a postauricular incision and
23

Table 3
Tanzer Classification of Constricted Ears and Suggested Correction178
Type
Anatomy
Correction
Helical involvement only
Detach the folded helix and reattach it in an

upright position
IIA
Involvement of the helix and scapha with

no supplemental skin necessary
Adjust the anterior helix, filet the deformed helix and

scapha, and reconstruct the upper pole of the ear with
banner flaps of cartilage
IIB
Involvement of the helix and scapha

with supplemental skin needed at
auricular margin
Use skin flap from the medial surface of the ear with various
methods for expanding the ear cartilage
III
Extreme cupping deformity with

Unfurl and use the remnants for the superior and middle
involvement of the helix, scapha, anti-helix, thirds, and reconstruct the remainder with contralateral
and conchal wall
conchal cartilage
Table 4
Suggestions Presented by Cosman for Correction of Constricted Ear Deformities179
Anatomy
Correction
Lidding is major problem, no protrusion, height

difference <1 cm
Direct excision of overhanging helical curl
Lidding, no protrusion, height difference 11.5 cm
Banner flap or radial incision
Lidding, protrusion, height difference 11.5 cm
Vertical expansion and correction of prominence

(Cosman technique)
Kislov technique to add tissue180
Graft
Lidding, protrusion, height difference 1.52 cm

(compression of scapha)
Figure 13. Brent technique for reconstruction of the earlobe with a reverse contoured flap. A, Earlobe defect.
B, Auriculomastoid flap outlined. C, Elevated flap hanging as a curtain from the inferior auricular border. D, Flap folded
under and sutured. E, Completed earlobe, exaggerated by one-third to allow for shrinkage. (Modified from Brent.4)
24

the cartilage is scored with a scalpel to reproduce
the antihelical fold. Type II deformities are also
treated by cartilage scoring and mastoid hitch, plus
V-Y advancement of the helical root. This releases
skin tightness at the anterior helix and allows
superior expansion of the cartilaginous framework,
with the effect of increasing ear size. For type IIB
deformities, the authors recommend additional
framework expansion with a double banner flap.
The existing skin often is sufficient provided the
V-Y advancement and undermining over the
mastoid fascia have released the skin tightness.

Park182 proposed correction of type I
deformities with a simpler technique that elevates a
superiorly hinged rectangular or T-shaped cartilage
flap from the concha. The flap is bent back on
itself and sutured to the lidded helix or scapha. The
recoiling force of the flap on the conchal side holds
the lidded portion of the helix erect (Fig. 14).4
Covering
y
x
Figure 14. Davis technique for reconstruction of the lower

third of the auricle and earlobe. A, Defect and outline of the
lining flap. B, Outline of the cover flap of the fat flap used
for fill. C, Lining flap is covered by the cover flap with the fat
flap between them. D, Secondary defect is closed by direct
approximation. (Modified from Brent.4)

Al-Qattan183 described an approach for ears
with mild to moderate constriction that combines
Mustard suturing and excision of the lidded
cartilage. The lopped cartilage margin is excised
through a retroauricular transverse incision in
the superior portion of the ear; this is in contrast
to cartilage expansion procedures. A traditional
mastoid hitch suture is used to prevent
recurrent lopping.

A number of techniques have been proposed
to correct type II constriction, including radial
cartilage scoring in a fan-like manner for expansion
as described by Stephenson.184 Musgrave185
modified the technique presented by Stephenson.
A double banner flap was described by Tanzer178 to
expand the constricted helix. More recently, Ohjimi
et al.186 proposed a double pennant technique for
helical elongation and recreation of the anti-helix.
The authors technique uses composite flaps that
minimize skin dissection from the underlying
cartilage. The authors reported between 7 and 22
mm of helical rim elongation. Nagata187 described
an approach to management of constricted ear
deformity. For type I constrictions, Xiaogeng et
al.188 dissected the skin envelope off the underlying
cartilage to perform V-Y cartilage advancement
along the anti-helix, with Mustard suturing
for shaping. The authors advocated two-stage
reconstruction for type II deformities, with a
1- to 1.5-cm composite cartilage graft from the
contralateral ear (wedge from the upper third of
the ear) to the affected ear. Shaping is performed
similar to the shaping in their type I corrections in
the second stage.

For type III deformities, many authors
advocate techniques involving new costal cartilage
frameworks, as in microtia reconstruction. Xiaogeng
et al.189 presented their experience with staged
reconstruction of type III constricted ears with
mastoid skin tissue expansion and then autogenous
rib cartilage graft reconstruction.
STAHL EAR
Stahl ear is a helical rim deformity first reported
in the 19th century that currently could be aptly
renamed Spocks ear. The main features are a third
25

crus, flat helix, and malformed scaphoid fossa (Fig.
15).147 The condition is much more common among
Asians than among other populations.190
Figure 15. Rib cartilages used in total ear construction. 1,

synchondritic block used for body of framework; 2, floating
rib used for helix; 3, strut used for tragus; 4, extra cartilage
wedge to be banked fur use during the elevation procedure.
(Reprinted with permission from Brent.147)

Chongchet191 described the classic approach
of excision of the aberrant third crus and redraping
of the skin. Ferraro et al.192 modified the technique
by avoiding an anterior skin incision and using
the resected cartilage as a graft to support the
reconstruction. Ono et al.193 described a technique
of wedge excision of the third crus with helical
advancement. Kaplan and Hudson194 proposed
a modification that uses a wedge excision of the
cartilage and posterior skin only. Both of these
techniques resulted in smaller ears. Other surgical
techniques for correction include Z-plasty,190
periosteal tether,195 cartilage turnover and
rotation,196 and cartilage scoring with cartilage
flap transposition.197

Al-Qattan and Hashem198 offered a complete
review of their experience with the various
techniques, highlighting efficacy and limitations.
The authors proposed an alternative approach to
Stahl ear reconstruction that involved resection of
the abnormal third crus, helical rim reconstruction
with the resected third crus cartilage, and antihelical reconstruction with an ipsilateral conchal
cartilage graft.
CRYPTOTIA
Cryptotia is abnormal adherence of the ear
26
to the temporal skin associated with cartilage

malformation in the scapha-antihelix complex and
possibly occurring secondary to abnormalities of
the intrinsic and extrinsic ear muscles.199,200 The
condition is rare among Caucasians but common
among Asians (ratio, 1:400). As with microtia, the
right ear is affected more often than the left and
the deformity is bilateral in approximately 40% of
cases.201 Hirose et al.202 developed a classification
system in which two categories of cryptotia are
described based on the type of cartilage constriction
by abnormally developed intrinsic ear muscles: Type
I for transverse muscle or superior crus deformity
and type II for oblique muscle or inferior
crus deformity.

Early splinting is successful,203 and when
therapy is initiated in a neonate, molding is the
preferred method of correction. Later correction
requires surgical division of the abnormal
muscle(s) with the addition of skin to the deficient
retroauricular sulcus. Cartilaginous reconstruction
might also be required. Numerous techniques have
been proposed, including Z-plasty,204 local and
regional skin or subcutaneous flaps,205216 tissue
expansion,193 V-Y advancement flaps,217 and skin
grafting.218,219 Cho and Han220 described their
technique of a V-Y temporal advancement flap
for deepening of the auriculotemporal sulcus and
either ear cartilage graft or Medpor for helical
rim splinting and stabilization. The authors favor
Medpor for greater stability and experienced no
exposures in four cases. They noted that more
aggressive manipulation of the cartilage is required
with greater vertical deficiency.
EAR MOLDING AND SPLINTING
In neonates, many ear deformities can be corrected
by splinting because the ear cartilage is soft and
malleable,203,221 but in older children and adults,
operative correction usually is required. Byrd et
al.222 described a series of 488 patients with 831 ears
that were treated with external molding. The series
included patients with prominent cup ear (373 ears,
45%); lidding or lop ear (224 ears, 27%); mixed ear
deformities, all including associated conchal crus
(83 ears, 10%); Stahl ear (66 ears, 8%); helical rim
abnormalities (58 ears, 7%); and conchal crus (25

ears, 3%). Ninety percent of patients achieved good
to excellent results and avoided surgery. Success
increased when therapy was initiated within the
first week of life. The authors described use of the
EarWell Infant Ear Correction System (Becon
Medical Ltd., Tucson AZ) with a two-piece cradle,
retractors, and adhesives. They encountered
few complications.
OTOPLASTY
Prominent Ears
The prominent ear has been classically characterized
by excessive height of the conchal wall or absence
of an antihelical fold (a concha-scapha angle >90)
or both. Madzharov223 defined the protruding ear
deformity as a cephalic-auricular angle >34 caused
by a flattened antihelix or protrusion of the concha
or both. The deformity usually occurs bilaterally. The
condition results from embryonic arrest during the
final convolutions of the ear, with failure of folding
of the antihelix.

The telephone deformity refers to relative
prominence of the upper and lower poles, whereas
the reverse telephone deformity means excessive
prominence of the concha relative to the upper and
lower poles.224 These deformities usually occur as
postsurgical complications.

Frustration with otoplasty techniques has
led to an awareness of additional features of
prominence: the antihelix, conchal bowl, helical tail,
ear lobule, and helical root.225 Otoplasty techniques
for the correction of prominent ears can be grouped
into operations that involve the following:
Excision of cartilage
Molding the ear with sutures
Molding the ear with scoring or sculpting
of cartilage
Combination of any of the above
Various techniques are used at the key anatomic
locations to correct ear prominence.
History
Rogers226 noted that the origins of otoplasty were
wrongly attributed to Dieffenbach and that it was
probably Ely227 in 1881 who first described an
operation to correct prominent ears. Rogers228 also

noted that the next milestone in the evolution of
otoplasty occurred in 1910, when Luckett described
a procedure for the correction of prominent ears
that correctly assumed that the protruding ear
resulted from an undeveloped or unfolded antihelix.
Many of the surgical methods proposed since
Lucketts time are in some way modifications of the
operation he described, and most represent attempts
at improving the overly sharp antihelical crest and
excessively steep recess of the scapha produced by
the classic technique.
Surgical Goals
In an excellent review of techniques for the
correction of prominent ears, McDowell7 listed the
following basic goals of otoplasty:
Complete correction of upper
third protrusion
Visibility of the helix beyond the antihelix

when viewed from the front
Smooth and regular helix
Prevention of distortion or decrease in the

depth of the postauricular sulcus
Placement of the ear at the correct

distance from the head and not overly
close; the helix-to-mastoid distance should
be 10 to 12 mm at the top, 16 to 18 mm in
the middle, and 20 to 22 mm in the
lower third
Bilateral symmetry; the difference in

helix-to-mastoid distance between sides
should be <3 mm
To this list, one should add the following:
Smooth, rounded, correctly placed and

adequately prominent antihelical fold
Helical rim that projects laterally farther

than the lobule229
Timing of Surgery
Otoplasty can be performed in patients of all
ages. Many factors should be considered when
determining optimal timing for surgery. With
27

advanced age, increasing mineralization and
calcification of auricular cartilage can make
suture suspension or cartilage-scoring techniques
unreliable, unpredictable, and/or prone to relapse.
Growth concerns arise when performing early
childhood otoplasty. Historically, most corrections
have been performed when the patient is older
than 5 years. Adverse psychosocial interactions for
children and adolescents with prominent ears are
also important factors to consider. Gosain et al.230
conducted a survey and found that most surgeons
perform otoplasty when the patient is older than
5 years. However, their small prospective series of
12 patients underwent otoplasty when they were
younger than 4 years. With a mean follow-up
duration of 41 months, prominence recurred in
one patient (8%). Three patients who underwent
unilateral otoplasty did not exhibit any growth
discrepancy relative to the contralateral ear up to 63
months postoperatively.

Gasques et al.231 examined the psychosocial
effects of prominent ears and demonstrated a
clear benefit for otoplasty. Several questionnaires,
including the Child Behavior Check List, StateTrait Anxiety Inventory for Children, and
Childrens Depression Inventory, were administered,
and improvement was noted postoperatively for
nearly all measures by both teachers and parents.
The authors recommended that the optimal age for
correction is 6 years.
Excisional Techniques
Antihelix
Rogers228 explained that Luckett excised a crescentshaped segment of skin and cartilage from the
entire vertical length of the ear on its cranial side
and sutured the edges of the cartilage to create an
antihelical fold (Fig. 16).179
A crescentic incision is made through
the integument opposite to the line of the
intended new or reconstructed antihelix.
The inscribed integument is removed;
the edges of the skin are now dissected
free from the cartilage and retracted. A
similar crescentic segment is removed
from the cartilage, care being exercised in
incising and excising the cartilage not to
28
buttonhole the skin on the external surface

of the auricle. The skin and the cartilage
are now sutured separately, and it is the
method of suturing the cartilage that is
emphasized. The cartilage suture is passed
from the cranial side from within outand-back again, care being taken not to
perforate the skin on the external surface,
then crossed over the excised portion
and passed on the other side from within
out-and-back again as a Lembert suture,
in such a manner that when the suture is
drawn tight and tied, not the edges but
the sides or flat surfaces of the cartilage
will be in apposition. The edges have been
turned forwards or outwards to form the
antihelix and at the same time the helix is
set closer to the cranium, thus diminishing
the cephalo-auricular angle. Four or five
interrupted sutures are usually enough for
the cartilage. A so-called fistula, one-half
circle, needle is best for the cartilage. The
skin is sutured with horsehair and leaves a
very small cicatrix.228
Conchal Cartilage
Davis232,233 described the technique of conchal
bowl excision at the base of the vertical wall.
Using methylene blue dye to create percutaneous
transfixion tattoos on the conchal cartilage, the
posterior vertical conchal wall is marked at a height
of 8 mm. The marks delineate a conchal half-circle,
and the conchal bowl (or floor) anteriorly is marked
for resection. Through a retroauricular skin incision,
the conchal cartilage is exposed and the methylene
blue tattoo marks are visualized. An incision is
created, connecting these points and the anterior
conchal cartilage dissected in a subperichondrial
plane. Care is taken to avoid injury to the anterior
skin. The entire conchal bowl is excised. The
posterior conchal wall remains and is placed
passively on the mastoid surface, establishing the
new conchal projection.

Hinderer et al.44 resected skin and cartilage at
different levels of the scapha, concha, and helical
arch to avoid notching of the helical rim during
reapproximation. The author warned against

dimensions. The authors concluded that auricular
growth does not stop after the cartilage excision
method of surgery for prominent ears, that surgery
had restored harmony between the width and
length of the ear (ear index), and that patient
satisfaction was high (74 of 77 patients were
satisfied with their outcomes).
s
t
d
b
b
e
f
c
c
f
D
b
d
b
G
I
H
Figure 16. Kislov technique for correction of the

constricted ear. (Modified from Cosman.179)
transections of the antihelix or transverse excisions

through the superior crus for the same reason.

Balogh and Millesi234 studied 77 patients who
had undergone surgery for prominent ears with the
cartilage excision method to determine whether
any growth alterations had occurred and to find out
the right timing of the operation. The mean age
of patients at the time of surgery was 7.2 years. In
every case, surgery had been performed 15 to 25
years previously. The standard ear morphometric
variables of the operated patients were compared
with those of 200 unoperated control participants.
The authors found no difference in retroauricular
angle between the surgical group and the control
group, suggesting that the surgical objective had
been accomplished. The surgical group showed
significantly smaller morphological ear length
(affected by surgery) and significantly larger
morphological ear width (not affected by surgery).
The formerly prominent ears were larger than
the ears of the control participants in all other
Earlobe
Posterior skin excision of varying shapes has been
described for correction of prominent earlobes.235
Dumbbell, fishtail, tennis racket, and wedge
excision patterns have commonly been used.
Suturing Techniques
Antihelix
Mustard236 described the creation of an antihelical
fold with concha-scapha mattress sutures
placed on the cranial cartilaginous surface and
incorporating the full thickness of the cartilage and
perichondrium on the lateral (anterior) surface (Fig.
17).182 With the method presented by Mustard,
the ear is folded back to produce an antihelix, the
summit of the fold is marked with ink, and the
positions for the mattress sutures are marked on
the skin. The mattress suture positions should be
at least 7 mm from the summit line, considering
that less than that amount will produce too narrow
a fold. Because of the curve of the antihelix, the
markings on the concave aspect are closer together
than those on the convex side. It might therefore be
necessary to introduce an additional mattress suture
to produce a superior crus, although this seldom is
required because both crura usually appear when
the ear is folded back. After insertion of a traction
suture through the margin of the helix to hold the
ear forward, an ellipse of skin approximately 3 to 4
cm 1 cm is removed from behind the ear on the
medial or conchal side of the proposed antihelix.
The skin and soft tissues on both sides of the
excised area are elevated off the perichondrium with
blunt dissection to expose the dye marks. Mustard
used a half-curved needle to insert white silk
mattress sutures. The sutures should include the full
thickness of the cartilage and the perichondrium on
both sides but not any skin on the anterior surface.
At that point, the sutures can be temporarily
29
Figure 17. Operative technique using a tumbling concha-cartilage flap (TF). (Reprinted with permission from Park.182)
tightened and the ear inspected to confirm that

the new antihelical fold is satisfactory. Finally,
the sutures are tied at a tension that produces an
aesthetically pleasing folding of the antihelix.

Johnson237 proposed a refinement of the
Mustard suturing technique that places the
sutures obliquely to control and shape the curve
of the antihelix. Johnson thought that oblique
placement of the sutures would better check upper
pole prominence, such as telephone deformity, and
prevent overfolding of the antihelix.
Conchal Bowl
Concha-mastoid sutures were described by
Furnas238 to reduce the conchal prominence (Fig.
18). Spira and Stal239 described modifications of
this technique that involve the addition of a flap of
conchal cartilage sutured to the periosteum.
Earlobe and Helical Tail

Prominent earlobes and helical tails (cauda
helices) have been a commonly overlooked aspect
of ear prominence. Webster240 and Beernink
et al.241 emphasized the importance of proper
repositioning of the helical tail to correct excessive
prominence of the lower third of the ear. Goulian
and Conway242 also advocated control of the helical
tail as a way of properly positioning the lobule.
The cadaveric studies conducted by the authors
showed a distinction between the conchal and
helical cartilage. They recommended dissection
between them and suturing the helical tail to its
new position on the concha to help achieve a
proper relationship. Spira243 described his technique
for dermal-to-mastoid suturing for earlobe
repositioning. Gosain and Recinos244 described a
modified technique of lobule-to-mastoid sutures,
identifying a key point of control for correction of
prominent earlobes.
Helical Root
A laterally projecting helical root can be
repositioned by suturing the medial cartilage to the
temporalis fascia, with or without a combined skin
excision. Kelley, Hollier, and Stal (Kelley et al.225)
described this technique as a Hatch suture.
Figure 18. Left, normal ear. Right, Stahl ear deformity.
30
Cartilage Scoring or Sculpting Techniques

These operations are based on the observation by
Gibson and Davis245 that cartilage tends to curl
away from a cut surface. This phenomenon was

later confirmed by Fry,246 who attributed it to
interlocked stresses that were released by incision
of the perichondrium.
Antihelix
Stenstrom247 applied this principle to an otoplasty
procedure for the correction of prominent ears.
Stenstrom initially scored the anterior surface of
the scapha through a small medial incision near
the cauda helicis to produce a helical roll and a
satisfactory antihelical fold. He later modified the
technique248 to include a postauricular incision
and wide undermining to expose the surface of
the scapha, where scoring was completed with a
scratching instrument, which is a procedure that
we now call otobrasion (Fig. 19).

The degree of scratching or scoring of the
anterior surface of the scapha is adjusted to produce
the desired amount of curl in the cartilage for an
antihelical fold. The postauricular skin is carefully
trimmed to effect the final delicate relationship of
helix to antihelix. Stenstrom248 did not perform any
suturing to create the antihelical fold.

Stenstrom248 suggested marginal excision of
a portion of the horizontal helix as a solution to
the problem of continued protrusion of the upper
pole of the ear. For persistent prominence of the
lobule, he recommended crosswise scratching of the
anterior surface of the helical tail.

Chongchet191 described a technique of anterior
scoring for antihelical reconstruction in 1963, the
same year the technique presented by Stenstrom
was published. Crikelair and Cosman249 also
reported a similar approach that involves an incision
through the posterior helix and anterior scoring of
the scapha.
Figure 19. Stenstrom otoplasty technique.

Weinzweig et al.250 studied the histological
effects of antihelical cartilage scoring and
found that a fibrocartilaginous layer develops
that promotes and stabilizes cartilage bending
away from the scored surface. Di Mascio and
Castagnetti29 described use of a dermabrader for
burring the anterior surface of the antihelix. The
authors advocated this technique as more precise
and safer for cartilage weakening, compared with
parallel scoring.

Karacalar et al.251 described a subcision
technique for cartilage scoring. An 18-gauge
hypodermic needle is inserted percutaneously
over the antihelix, and perichondrial scoring is
accomplished subdermally. Fritsch252 described
his technique for incisionless otoplasty, which
uses similar antihelical scoring with a hypodermic
needle and percutaneous mattress suturing.

Recent interest has been shown in other
experimental technologies for cartilage shaping.
Use of lasers of varying wavelengths for cartilage
reshaping have been proposed since 1993. Mordon
et al.253 described the use of a 1.54-mm erbium:glass
laser for ear cartilage reshaping in 12 rabbit ears.
No thermal skin injury was observed. After an
initial tendency for shape recovery (at 1 week),
stable alteration was observed for up to 6 weeks.
Histological examination showed chondrocytic
proliferation on the treated surface of the cartilage
and thickening of the cartilage layer.
Combined Techniques
Otoplasty procedures that combine excision,
suturing, and cartilage-scoring techniques avoid
some of the disadvantages of each method and
often produce the best aesthetic result. For example,
because cartilage scoring of the anterior surface of
the ear tends to produce sharp edges, a judicious
blend of conservative anterior scoring and posterior
excision and suturing might provide the best final
ear shape and position.

Tanzer254 described his classic otoplasty
technique in 1962. Several authors have described
notable variations of the basic procedures.222,255257
Baker and Converse258 reported their 20-year
experience with otoplasty. Madzharov222 described
a method for the correction of prominent ears that
is based on measurements of ear-to-skull distances
31

and the size of the ears. The amount of setback in
each case is established preoperatively from normal
anthropometric data derived from an Eastern
European population. The antihelix is shaped by
two derma-subcutaneous perichondrial flaps; the
conchal spring is eased by means of a wedge-shaped
cartilage excision in the area of the isthmus of the
cartilage or the auricle, and the residual protrusion
of the lobule is corrected by Z-plasty. Technical
details of the operation are presented in the article,
which merits further study by surgeons planning
setback otoplasty.

Hinderer et al.255 combined anterior cartilage
scratching, posterior mattress sutures along the
antihelical fold, trimming of the tail of the helix,
thinning of the antitragus, and a double-spindle
skin excision along the posterior medial surface.
Pitanguy et al.256 created an island of cartilage
on the anterior surface of the ear that is pushed
forward to resemble a smooth antihelical fold by
suturing the edges of the wound after resection of a
generous ellipse of skin from the posterior surface.
Kaye257 combined Mustard-type sutures and
Stenstrom-type scoring through limited incisions to
create an antihelical fold.

Chait and Nicholson259 reported their
extensive experience (973 ears) with a universal
technique for the correction of all types of
prominent ears. Their procedure combines posterior
skin excision, cartilage transection, anterior
skin elevation off the concha, auricular cartilage
scoring, a single mattress suture to anchor the
new concha-scapha angle in place, and variable
amounts of cartilage rotation and excision as
needed. Commenting on the article by Chait and
Nicholson, Stal260 expressed his preference for
an algorithmic approach to otoplasty that uses
combinations of different established techniques
that specifically address different patients needs
(Fig. 20).261 The algorithm addresses three basic
anatomic abnormalities of the prominent ear
deformity: 1) a deep concha with a prominent
posterior wall; 2) an unfolded antihelix with a
scaphoconchal angle >90; and 3) a prominent
lobule after setback.

Spira262 presented a 30-year retrospective
review of his experience with >200 otoplasties. The
32
Figure 20. Mustard otoplasty technique.
timing, indications, and operative technique are

described in detail. Postoperative care and early and
late complications are also discussed. This article
should be read by any surgeon who is planning to
perform setback otoplasty.

Graham and Gault263 described endoscopicassisted otoplasty involving posterior scoring and
scapha and mastoid suture. Use of the endoscope
eliminates the need for a postauricular incision and
hence the possibility of hypertrophic scar or keloid.
The authors classification of prominent ears guides
patient selection for this technique.

Burstein155 presented a report of his 10-year
experience with a cartilage-sparing technique that
involves modified Mustard suturing, anterior
scoring, conchal bowl scoring, and concha-mastoid
suturing. An 8% relapse rate was noted.

Bauer et al.264 discussed use of anterior
chondrocutaneous resection of the conchal bowl
as the preferred method of treating conchal
hypertrophy. The authors described a combined
otoplasty technique for their series of 47 patients
(87 ears). Three patients experienced early
relapse of the upper pole caused by failure of the
antihelical suturing; they reported no late recurrent
prominence. Anterior chondrocutaneous resection
did not result in any unsatisfactory scarring and

eliminated any potential for skin fold redundancy in
the conchal bowl.

Peker and Celikz265 described an otoplasty
technique that involves incising the scapha to access
the anterior cartilage surface, anterior scoring to
weaken the cartilage, and posterior rolling of the
free edge of cartilage to recreate an antihelical fold.

Kelley, Hollier, and Stal (Kelley et al.225)
described their algorithmic approach to otoplasty,
which focuses primarily on cartilage preservation
rather than on cartilage excision. Janis, Rohrich, and
Gutowski ( Janis et al.266) provided an alternative
summary and algorithm for correction of the
prominent ear. A summary of various otoplasty
techniques is presented in Table 5.
Other Concepts
Nicoletis and Guerin-Surville267 were the first to
describe the posterior auricular muscle as it relates
to the pathogenesis of ear protrusion. Smith268
and Smith and Takashima269 also emphasized
the importance of the muscle in ear protrusion,
proposing that neuromuscular dysfunction and/or
deficiency was the cause for prominence. Guyron
and DeLuca270 found a linear correlation of the
muscle length and the degree of ear protrusion.
The authors discussed the three main causes

for prominence as being conchal valgus with a
cranium-auricle angle >40, lack of antihelical
fold, and, more rarely, conchal hypertrophy. For
conchal valgus, myoplasty of the posterior auricular
muscle was proposed as an adjunctive maneuver in
otoplasty or even an isolated procedure with simple
conchal valgus deformity.

Scuderi et al.271 described a technique for
repositioning the posterior auricular muscle as
an adjunct to otoplasty. The muscle is raised as
a chondromuscular flap (distal cartilage paddle
around the insertion at the ponticulus), advanced
peripherally, and secured to the antihelical cartilage
to reduce prominence. The authors reported no
relapse among 55 patients.

Shinohara et al.272 performed CT of
randomly selected heads to examine correlation of
prominence to selected relevant auricular angles:
scapha-triangular fossa angle, concha cymbatriangular fossa angle, and scapha-concha angle.
Based on these data, the authors concluded that
the deformity of the inferior crus has a more direct
correlation to prominence than does the superior
crus. The authors proposed reconstruction of the
inferior crus for correction of prominent ears.
Table 5
Summary of Otoplasty Techniques
Anatomical Site
Antihelical fold
Conchal bowl
Helical tail
Lobule
Technique
Study
Concha-scaphal suture technique
Mustard277
Antihelical scoring or otobrasion
Stenstrom248
Antihelical excision
Luckett (Rogers228)
Concha-mastoid suture technique
Furnas238
Conchal bowl excision
Davis232,233
Suture repositioning to concha
Goulian and Conway242
Concha and/or skin excision and suture repositioning
Webster240
Posterior skin excision: dumbbell, fishtail, tennis racket
Lavy and Sterns235
Lobule to mastoid suture technique
Spira243;
Gosain and Recinos244
33

Late Results and Complications
The most common unsatisfactory results of
otoplasty are deformities occurring secondary to
surgery, such as the following:
Sharp ridges along the antihelical fold
Vertical post (lack of normal curvature of
the superior crus)
Irregular contours
Antihelical roll too small or malpositioned
Excessively large scapha
Narrow ear
Telephone deformity
Hidden helix
Buckled helix
External auditory canal stenosis
or distortion
Conchal skin redundancy
Hypertrophic scarring or keloids
Prominent tragus
Overcorrection
Obliterated or shallow postauricular sulcus
Asymmetry

Recurrent prominence is also a common
problem after otoplasty. Many authors have
advocated combining techniques to minimize
relapse. Corchado and Infante273 thought that
anterior scoring alone was not sufficient for durable
antihelix reconstruction, especially in adults and
those with thick cartilages. Similarly, Spira262
reported that Mustards suture technique alone
was insufficient for durable correction in adults. He
subsequently proposed performing Stenstrom-type
anterior scoring adjunctively.

Webster and Smith224 provided a detailed
account of the long-term results of otoplasty and
its many potential associated complications. Their
review is strongly recommended for additional
reading on this subject.

Elliott274 examined the unsatisfactory results
of otoplasty, which he separated into an early group
(complications) and a late group (undesirable
sequelae). Complications include pain, bleeding,
pruritus, infection, chondritis, and necrosis.
Undesirable sequelae include patient dissatisfaction,
34
unsightly scars, suture problems, and dysesthesias

occurring later.

Tan275 compared the incidence and severity
of complications resulting from posterior suturing
techniques with those of anterior scoring
procedures. Patient satisfaction with the aesthetic
results was no different between the Mustard
and Stenstrom otoplasties. The author found that
a substantially large number of patients treated by
the posterior suture method of Mustard required
reoperation: 24% versus 10% with the anterior
scoring technique. Numerous complications were
specific to the Mustard technique, particularly
relating to the presence of white silk stitches
that tended to cause sinus tract and wound
infections (15%).

In a 10-year survey of his results with 264 ears,
Mustard276 listed several potential problems with
the otoplasty procedure that bears his name, such
as kinks in the antihelix, sutures cutting out, sinus
tract formation, recurrence of prominence, and
horizontal projection of the lobule and antitragus.
He also provided tips for avoiding them. A
subsequent review of the results in 600 ears treated
during a 20-year period revealed only six cases of
sinus tract formation and no suture rejection.277
Most remarkably, only 10 ears required reoperation
for recurrent prominence.

The Mustard otoplasty has not been as
successful in other hands. The initial enthusiasm
that Spira and Hardy278 expressed for the
Mustard method was tempered by two factors:
the large number of relatively minor complications
encountered and the high rate of partial recurrence
of the deformity.

Heftner279 surveyed 167 patients who had
undergone Stenstrom otoplasties and found that
40% declared themselves very satisfied, 49%
satisfied, and 4% fairly satisfied. Symmetry and
setting were considered to be good in 71% of cases,
whereas 4% had negligible incomplete correction,
19% had slight overcorrection, and 6% had marked
overcorrection. A round natural antihelix was noted
in 81% of patients and a sharp antihelix in 14%.
Isolated small nodules occurred in 5% of cases, and
15% were considered to be overcorrected.

Calder and Naasan280 reviewed their

experience with 562 otoplasties performed with
the anterior scoring technique. The most common
complication was residual deformity (8%). In
order of decreasing frequency, the authors also
reported infection, keloid and/or hypertrophic
scarring, hemorrhage, and anterior skin necrosis.
Further analysis revealed that the cause of residual
deformity was primarily a fault in the design of the
procedure or in the execution of the technique. The
authors stated that most of these complications
are avoidable.

Messner and Crysdale281 reviewed their
experience with a combination technique of
Mustard and Furnas sutures in 31 patients
who were followed for a minimum of 1 year
(average follow-up duration, 3.7 years). Regarding
recurrence of the deformity, the authors reported
that at the time of evaluation, one-third of the
ears had returned to their original position, onethird remained in their immediately postoperative
position, and one-third were between the pre- and
postoperative positions.

Walter and Nolst Trenit282 presented a
discussion of the management of post-otoplasty
deformities. Common sequelae include obliterated
postauricular sulci, irregularities of the antihelical
fold or a sharp antihelical fold, telephone
deformities, protruding lobules, obliterated external
auditory canals, and post-perichondritis deformities.
The appropriate course of action for addressing each
of these deformities is detailed in the article.

Firmin et al.283 presented a series of 49
patients with severe deformities resulting from
otoplasty. Conchal cartilage grafts are useful for
minor contour irregularities, but costal cartilage
is recommended for deformities involving more
than 25% of the ear or more than two planes of the
normal folds.

Limandjaja et al.284 provided a comprehensive
review of published series of otoplasties.
Complications were specifically examined, and
the authors lamented the lack of uniformity
in reporting.
inferius (OI), which is the anterior implantation

of the earlobe to the cheek skin. The distance from
the inter-tragal notch to the OI (cephalic segment)
typically is 1 to 2.5 cm. The caudal segment is
defined as the distance from the OI to the subaurale
(inferiormost point of the earlobe). Loeb advocated
earlobe reduction if the cephalic segment exceeds
2.0 cm in length.

McKinney et al.286 determined that the
average lobule height is 18 mm (caudal segment)
and advocated earlobe reduction as an adjunct to
rhytidectomy when the lobule:total ear height ratio
exceeds 33%.

Mowlavi et al.287 discussed the incidence of
earlobe ptosis and pseudoptosis and proposed a
classification system based on the measurements
defined by Loeb285 and the relationship between
the attached cephalic and free caudal segments
(Table 6). The authors found that the average
height of the cephalic segment was 11.1 mm and
of the caudal segment was 7.15 mm. The caudal
segment was found to exhibit increasing ptosis
with advanced age; the average height increased
to 10 mm in the 8th decade of life. In their study,
all patients had caudal segment heights of 15
mm or less (Grade III ptosis or less). The authors
determined that pseudoptosis was defined as a
cephalic segment height >15 mm. Mowlavi et al.288
also proposed an algorithm for correction of ptotic
and pseudoptotic earlobes and described their
surgical technique of an anterior wedge excision
and reduction.

El Kollali289 proposed an alternative
classification of normal earlobe morphology
depending on the angle of the earlobe-cheek
junction: acute, earlobe is not attached to the
cheek; right angle, neutral relative to the cheek; or
obtuse angle, adherent to the cheek. The author
disputed the ideal aesthetic of a free, unattached
earlobe relative to the cheek and determined that
approximately one-third of the population has the
adherent earlobe morphology and that this should
be considered a normal variant.
EARLOBE REDUCTION
According to Loeb,285 the earlobe is divided into
two components separated by the otobasion
TISSUE ENGINEERING
Most techniques for total ear reconstruction have
relied on usage of autogenous costal cartilage grafts
35

Table 6
Classification of Earlobe Ptosis and Designation of Pseudoptosis Based on Analysis
of Preferred Otobasion Inferius to Subaurale and Intertragal Notch to Otobasion Inferius Distances287
Classification
Ptosis grade
Segment (mm)
Free caudal segment (otobasion inferius to subaurale distance)
15
II
610
III
1115
IV
1620
>20
Pseudoptosis
Attached cephalic segment (intertragal notch to otobasion inferius distance)
Abnormal
>15
Normal
15
or alloplastic materials to construct a framework to

be inserted under a skin envelope. Recent advances
in tissue engineering have propelled the concept
of using cellular constructs as an alternative source
for an ear-shaped framework. The basic elements of
construction include cells, cell-carrier, scaffolding
type, and technique (e.g., pre-fabrication, injection
molding, external molding, in vitro, in vivo). Kim
et al.290 and Vacanti and colleagues (Shieh et al.291)
engineered predetermined shapes of cartilage by
using techniques for cell transplantation onto
biodegradable polymers. Cao and Vacanti and
colleagues (Cao et al.292) later created an ear
framework that was a polymer-cell construct that
used articular cartilage. Chang and Vacanti and
colleagues (Chang et al.293) examined the feasibility
of an injection molding technique for cartilage graft
tissue engineering. Alginate implants were seeded
with autologous chondrocytes and injected into
Silastic molds (Dow Corning). They were removed
after they had conferred reasonable stability and
shape and were then implanted subcutaneously in
36
sheep. Histological examination 6 months later

showed excellent cartilage formation and threedimensional shape retention. The authors showed
the effectiveness and simplicity of an injection
molding technique for large implants without
exhibiting central graft necrosis.

Ting et al.294 fabricated various cartilage
shapes in vitro by using human costal chondrocytes
and fibrin glue. These early attempts at auricular
cartilage construction yielded small and inflexible
frameworks that lacked perichondrium and often
could not be constructed to the dimension of a
human ear. Xu and Yaremchuk and colleagues
(Xu et al.295) were successful in constructing
flexible constructs by using swine chondrocytes
engineered with lyophilized perichondrium. The
authors reviewed previous attempts at constructing
a stable framework that can withstand the
external soft-tissue tension or avoid resorption.
Previously published methods have included use
of degradable or nondegradable endoskeletal
scaffolds, prefabrication molding, or injection

molding techniques. In the study by Xu et al., large
ear-shaped constructs were implanted in athymic
mice that withstood the soft-tissue tension and
maintained projection and shape.

In a rat model, Neumeister et al.296
showed that transposing a vascular pedicle to a
subcutaneously placed silicone block creates a
vascularized capsule over the mold. The capsules
were filled with chondrocytes and a fibrin glue
carrier in the experimental group. Good viability of
the new construct via an extrinsic capsular blood
supply was shown, but shape was not reliably
maintained with the capsule alone. When an
external mold was retained for at least 4 weeks,
the construct began maintaining its shape. Longer
term evaluation of the construct shape was not
undertaken in that study. The authors concluded
that transposing a vascular pedicle will not only
incorporate itself to a capsule but will become
the dominant blood supply to it. This method of
prefabrication showed development of an intrinsic
vascularity to an engineered construct that could be
transferred as a pedicled or free flap.

Ciorba and Martini,297 in 2006, reviewed
the status of tissue engineering and stem cells
as it relates to auricular reconstruction. The
authors identified several key components under
investigation, including type of scaffolding,
source cells, suitable animal models, and stability
of engineered tissues. Sterodimas and Pitanguy

and colleagues (Sterodimas et al.298) provided an
updated review in 2009.
EAR TRANSPLANTATION
Because of the complex morphology and tissue
characteristics of the ear, composite allograft
transplantation might be an emerging alternative
to autogenous or alloplastic reconstructions.
Recent advances in transplant immunology have
spurred interest in composite tissue transplantation
of the face and hand. Ulusal and Wei and
colleagues (Ulusal et al.299) described auricle
allotransplantation in rats. Using a cyclosporinebased immunosuppressive regimen, graft survival
was 100% at 30 days. The authors proposed their
model as a basis for further immunological studies.
Based on human cadaveric dye-injection studies,
Ulusal et al.300 further showed that adequate
auricular transplant perfusion would require both
superficial temporal and posterior auricular arterial
systems, suggesting that an external carotid artery
pedicle could therefore be used. A successful
cephalo-cervical composite tissue allograft
transplant including two ears was performed
secondary to radical resection of malignant
melanoma using a tacrolimus and mycophenolate
mofetil regimen with steroid adjuvant.301
37

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Volume 11 Issue R3

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Selected Readings in Plastic Surgery (ISSN 0739-5523) is a series of monographs

SRPS Volume 11 Issue R3 2011

PLASTIC SURGERY OF THE EAR

Richard Y. Ha, MD1

SRPS Volume 11 Issue R3 2011

Figure 4. Lymphatic drainage of the external ear. I, first

Figure 2. Perforating sites of the posterior auricular artery. Left,

Figure 5. Embryological origin of the external ear. I,

SRPS Volume 11 Issue R3 2011

of his contemporaries of the mid-19th century

Close the skin in delayed reconstruction

Leave the wound open and reconstruct at

Graft skin defects only where underlying

Reattach small avulsed ear pieces as

SRPS Volume 11 Issue R3 2011

the reconstruction and probably warps less and

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Figure 6. Antia-Buch procedure of helical rim

Figure 7. Modified Antia-Buch repair. STA, superficial

outer border until the wound can be closed without

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Figure 8. Orticochea procedure of conchal rotation for the

rotation of the flap. Being an area rich in blood

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Figure 9. Repair of defects of the upper third of the

Figure 10. Reconstruction of the upper third of the ear

Figure 11. Techniques for reducing the auricular

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island flap based retroauricularly. Typically, a skin

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anastomosis has been shown to be a suitable

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tissues are not available, such as after a burn. The

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evidence indicates that hemifacial microsomia,

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Complete hypoplasia (microtia)

With atresia of the external auditory canal

Without atresia of the external auditory canal

Hypoplasia of the middle third of the auricle

Hypoplasia of the superior third of the auricle

Constricted (cup or lop) ear

Hypoplasia of the entire superior third

enough to correctly respond to sound stimuli from

ear typically have no need for a hearing aid and are

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has been available for centuries, but

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Fairburn, GA). Cronin,122 Cronin et al.,123 and

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Figure 12. Dieffenbachs technique for reconstruction of

are fused and calcified and the framework must be

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for approximately 8 years and noted incremental

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Construction of a tragus and

Tragus construction and conchal

Elevation of the ear framework with