Ear Deformities, Otoplasty, And Ear Reconstruction.37

CME

Ear Deformities, Otoplasty,and Ear Reconstruction

Charles H. Thorne, M.D.Gordon Wilkes, M.D.

Edmonton, Alberta, Canada; andNew York, N.Y.

Learning Objectives: After reviewing this article, the participant should be able to:1. Evaluate patient’s ears for needed adjustments to size, shape, prominence, andsymmetry. 2. Identify common ear deformities and describe methods to repairthem. 3. Avoid or manage common complications associated with otoplasty and earreconstruction.Summary: The essentials of otoplasty will be described/illustrated for the followingconditions: Prominent ears, underdeveloped helical rims (shell ear), macrotia,Stahl’s ear, constricted ear, cryptotia, and question mark ear. (Plast. Reconstr. Surg.129: 701e, 2012.)

In this section, the authors describe and/or illus-trate the essentials of otoplasty for the followingconditions: (1) prominent ears, (2) underdevel-

oped helical rims (shell ear), (3) macrotia, (4)Stahl’s ear, (5) constricted ear, (6) cryptotia, and (7)question mark ear.

OTOPLASTY FOR PROMINENT EARS

Essentials of Preoperative ManagementThe overall size and shape of the ears are as-

sessed before evaluating the degree of prominence.In other words, the surgeon makes a distinction be-tween prominent ears that are normal in size andcontour, on the one hand, and prominent ears thatare also abnormal in size or shape, on the other.Deformities such as macrotia, constricted ear, Stahl’sear, cryptotia, or underdeveloped shell-like helicalrims are noted. Once a determination has beenmade regarding the size and shape, the prominence ismost easily evaluated by assessing the auricle in thirds:upper third, middle third, and lower third (lobule).The entire ear may be prominent, but in many casesthe prominence is more localized (e.g., upper thirdonly, middle third only, upper and lower thirds only).

Finally, the symmetry is addressed. Patients tendto obsess about symmetry even though, from anaesthetic point of view, it is frequently not the mostimportant issue. In most cases of asymmetry, both ears

require surgical intervention to avoid the operated earfrombeingcloser to theheadthantheunoperatedear.

Goals of TreatmentThe goal in standard otoplasty is a normal ap-

pearing ear without evidence that there has beensurgical intervention. Sharp, unnatural contours,overcorrection, and obliteration of the normal sul-cus are not acceptable results. When the surgeon isfinishing the procedure, before suturing the inci-sion, the result should be evaluated from three dif-ferent angles: from the front, from the side, andfrom behind. From the front, the helical rim shouldprotrude beyond the antihelix in the upper third ofthe ear. From the side, the contours should be softand natural in appearance. Finally, and perhaps thebest clue that the setback is harmonious, the helicalcontour should form a straight line when viewedfrom behind. If, for example, the helical rim formsa C shape, the middle third of the ear is overcor-rected and/or the upper and lower thirds are un-dercorrected. Any such disharmony should be cor-rected before leaving the operating room.

From the Institute for Reconstructive Sciences in Medicine,and the Department of Plastic Surgery, New York UniversitySchool of Medicine.Received for publication January 27, 2011; accepted October4, 2011.Copyright ©2012 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e3182450d9f

Disclosure: The authors have no financial interestto declare in relation to the content of this article.

Related Video content is available for this ar-ticle. The videos can be found under the “Re-lated Videos” section of the full-text article, or,for Ovid users, using the URL citationsprinted in the article.

www.PRSJournal.com 701e

Advantages/Disadvantages of the TreatmentAlternatives

Traditional techniques that involve scoringthe cartilage1 or full-thickness incisions/tubing ofthe cartilage2 may have the advantage that recur-rence of the deformity is less likely. We prefer toavoid these techniques, however, with the hope ofachieving more natural appearing results and con-fining complications to those problems that canbe more easily corrected. The approach describedbelow, therefore, incorporates the authors’ biasthat undercorrection, potential recurrence, andsuture complications are preferable to overcor-rection, unnatural contours, sharp edges, and po-tentially unrepairable deformities. The reader isalso directed to the reference describing “inci-sionless otoplasty.”3

Key Elements of the OperationThe steps for standard, setback otoplasty are

presented below and are depicted in Figure 1 anddemonstrated in Video 1. [See Video, SupplementalDigital Content 1, in which Dr. Thorne demon-strates his otoplasty technique, available in the“Related Videos” section of the full-text article onPRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A473. (From Thorne C. Otoplasty.Plast Reconstr Surg. 2008;122:291–292.)]

IncisionAn incision is made in the retroauricular sul-

cus. The only skin removed is a small triangle fromthe medial surface of the lobule, to facilitate laterearlobe repositioning,4 taking care to preserveenough tissue for a normal earlobe and retrolobu-

lar sulcus and to preserve at all costs the ability towear an earring.

DissectionThe cartilage is exposed on its posterior (me-

dial) surface, exposing the helical tail. Soft tissueis excised from deep to the concha. The retrolobu-lar sulcus is dissected deeply, a maneuver that isnecessary for lobule repositioning at the conclu-sion of the procedure.

CorrectionMustarde sutures of 4-0 clear nylon are placed

to recreate the upper portion of the antihelix and

Fig. 1. Otoplasty technique. The combination of Mustardescaphoconchal sutures, conchal resection with conchal reapproximation,and a Furnas conchal-mastoid suture. (Left) Sutures placed. (Center) Sutures tightened to create the desired contour. (Right) Samesutures as seen through the retroauricular incision.

Video 1. Supplemental Digital Content 1, in which Dr. Thornedemonstrates his otoplasty technique, is available in the “RelatedVideos” section of the full-text article on PRSJournal.com or, forOvid users, available at http://links.lww.com/PRS/A473. (FromThorne C. Otoplasty. Plast Reconstr Surg. 2008;122:291–292.)

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http://links.lww.com/PRS/A473



the superior crus of the triangular fossa.5 It isimportant that the surgeon appreciate that theantihelix is not a straight line. In fact, the superiorcrus (the upper termination of the antihelix)curves far forward and becomes almost parallel tothe inferior crus. The Mustarde sutures are placedlike the spokes on a wheel (not parallel to eachother) to create a curved, natural appearing an-tihelical fold. Approximately three to four Mus-tarde sutures are required if the deformity is con-fined to the upper third. If the deformity extendsinto the middle third, as many as six to eightMustarde sutures may be required (Fig. 1).

To address the middle third, the conchaldepth is assessed. If there is excess depth, a min-imal resection of the concha is performed at thejunction of the posterior wall and floor of theconcha. The conchal defect is closed primarilywith many more nylon sutures (Fig. 1). We preferto use a small conchal resection in combinationwith conchal setback (see below) so that the con-chal resection can be limited to approximately 2mm. Two 5-0 polydioxanone sutures are used toclose the triangular skin defect on the medial sur-face of the earlobe. The sutures also incorporatea bite of the conchal cartilage, deep in the sulcus,which will result in correction of the earlobeprominence.

Finally, a 3-0 nylon conchal-mastoid Furnassuture is placed.6 This is the suture that really setsback the ear. The middle and upper third ma-neuvers only create the contours and should notbe used to set back the ear. In other words, mostpatients are treated with both a small conchalresection and a conchal setback. Only rarely is aconchal-mastoid suture alone adequate. Ifplacement of this suture pushes the posteriorwall of the external meatus too far forward (ob-structing the meatus), a conchal resection isdefinitely performed. The skin incision is ap-proximated with interrupted or intracuticularsutures of 5-0 plain gut.

Perioperative ManagementXeroform (Covidien, Mansfield, Mass.) is

placed over each ear and the patient’s head iswrapped loosely in a bulky gauze dressing. Noattempt is made to put pressure on the ears withthe dressing. The dressing is removed in 4 to 5days, after which no further dressing is necessary.The patient is instructed to wear a loosely fittingheadband at night only, to prevent inadvertenttrauma to the repair.

ComplicationsThe surgical technique determines which

complications are the most likely. The techniquedescribed above eliminates the worst complica-tions: overcorrection, sharp edges, unnatural con-tours, inharmonious setback, telephone defor-mity, and infection. Suture complications arequite common, however. The nylon Mustarde su-tures may eventually protrude through the poste-rior skin. The potential risk is lessened by pushingthe knot flush with the posterior surface of the earcartilage. This complication may occur within thefirst few weeks postoperatively but usually severalyears later. Protruding sutures may be associatedwith a painful, erythematous pustule. Patientsshould be informed of this potential problem andencouraged to return to the surgeon immediately.The authors have seen patients with this problemmanaged with topical antibiotics for months withno improvement, only to be symptom free 1 dayafter suture removal under local anesthesia. Thesutures can be removed without fear of recurrenceof the deformity if they have been in place forseveral months.

One author (C.H.T.) has had two instances inwhich the deformity recurred to a degree thatreoperation was necessary. Interestingly, a reviewof the operative notes indicated that polydiox-anone sutures were used for the Mustarde suturesin those cases. Although this is only anecdotalevidence, the author has returned to using nylonsutures in all cases.

One remaining problem deserving mention isdisharmony of the result. Regardless of the oto-plasty technique chosen, a “successful” but dishar-monious setback may be produced; that is, theresult just does not appear right. The telephonedeformity is a good example. As mentioned above,the helix should appear almost straight whenviewed from behind. If the helical contour resem-bles a hockey stick or a C, the setback will just notappear aesthetically pleasing.

OTOPLASTY FOR OTHEREAR DEFORMITIES

Essentials of Preoperative ManagementNot uncommonly, patients will present with

ears that are prominent but also abnormal in con-tour and/or size. The first step for the surgeon isto differentiate between deformities such as un-derdeveloped, flat helical rims (shell ear), exces-sively large ears (macrotia), Stahl’s ear, con-stricted ear, cryptotia, and the question mark ear.

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Goals of TreatmentThe goals of treatment are the same as for

standard otoplasty except that, depending on thedegree of deformity, the results may fall short ofnormal. All ear deformities exist along a spectrumranging from mild, almost imperceptible abnor-malities to severely affected, underdevelopedstructures that bear little resemblance to normalauricles. If the latter is the case, otoplasty may beinappropriate and the patient may be best treatedby discarding the cartilage and placing a cartilageframework as discussed below under “Total andSubtotal Ear Reconstruction.”

Advantages and Disadvantages of TreatmentAlternatives

As with standard otoplasty, numerous tech-niques have been described to improve the ap-

pearance of the deformities discussed in this ar-ticle. Each has its own pros and cons. Rather thandescribe the myriad procedures that exist in theliterature, the authors’ preferred methods, alongwith the rationale for choosing them, are dis-cussed below.

Key Elements of the Surgical ProcedureIncisionThere are only so many acceptable incisions

through which to perform otoplasty. The ret-roauricular incision was described above and isused for standard otoplasty. The correction ofshell ear, macrotia, constricted, ear and Stahl’sear all require an incision on the lateral (visible)surface of the ear, just inside the helical rimeither alone or in combination with the auric-ular sulcus incision. When placed appropriately,

Fig. 2. Ear reduction and setback for macrotia with prominence. (Above, left) Cartilage is excised from the scapha followed byplacement of Mustarde sutures. (Above, right) A small conchal reduction has been performed and the concha is reapproxi-mated. (Below, left) A single Furnas suture is placed. (Below, right) The postoperative result is shown. This patient was a youngchild, and the amount of reduction was small. In the vast majority of ear reduction cases, it is necessary to remove a wedgefrom the helical rim. If the helical rim is not shortened, it will be too long for the reduced scaphal circumference, resulting inbuckling and irregularities.


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these anterior incisions usually heal with an ac-ceptable scar. Cryptotia and the question markear require different approaches.

Shell EarIn the case of shell ear (absence of the helical

overhang), the mere performance of the incisionthrough the skin and cartilage, followed by skinclosure at the end of the procedure, will createsome helical definition. If a wedge of helical rimskin and cartilage is removed so that there is slighttension on the closure, the helical rim will curlinto a desirable contour.

MacrotiaOnce the above incision is made, a crescent of

skin and cartilage (much less skin than cartilage)is excised from the scapha7,8 (Fig. 2). The result isa helical rim that is excessively long for the newlyreduced scaphal circumference. A wedge excisionof the helical rim, as described under “Shell Ear,”is almost always required to avoid irregularities inthe redundant helix.

Stahl’s EarIn Stahl’s ear, there is an abnormal bar of

cartilage (sometimes called the third crus), ex-tending from the antihelix to the helix at approx-imately the junction between the upper and mid-dle thirds of the ear. If that abnormal cartilage isobvious, it must be excised (Fig. 3). The cartilagedefect is closed primarily. In addition, there maybe excess scapha in the region of the third crusand absence of the normal superior crus of thetriangular fossa. Any excess scapha is trimmed asdescribed above for macrotia. These authors pre-fer the technique described by Kaplan andHudson,9 in which the excised piece of cartilage isused to augment the deficient superior crus.

Constricted EarIn a constricted ear, the fundamental abnor-

mality is that the helical rim is deficient in cir-cumference for the scapha to which it is attached.The inadequate length of the helix “constricts” theear and forces it into a cupped shape that pro-

Fig. 3. Repair of Stahl’s ear. (Above, left) Preoperative appearance. (Above, right) Exposure of the lateral surface of the earcartilage and plan for resection of extra crus. (Below, left) Appearance after resection of abnormal crus and reconstruction ofthe superior crus using the resected cartilage. (Below, right) Postoperative result.


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trudes from the head. In the mildest deformities,the overhang can be trimmed. The result is an earthat is slightly small; however, the contour is im-proved. Any attempt at otoplasty must be accom-panied by lengthening of the helix. The usualprocedure is to extend the lateral incision de-scribed above into the concha, around the crus ofthe helix. In this manner, the crus of the helix canbe recruited into the helix, thereby lengthening itand allowing standard otoplasty maneuvers to setback the ear. The defect in the concha is closedprimarily. As described above, severe deformities(Tanzer 3a and 3b) may be better treated as amicrotia case with a rib cartilage framework ratherthan by attempting salvage of the native cartilage.

CryptotiaIn cryptotia, the superior aspect of the ear is

hidden beneath the temporal scalp. In some cases,the auricular cartilage is normal and requires onlyto be extracted from its hiding place. Lateral trac-tion on the ear will reveal a normal auricle. Inother cases, the cartilage is malformed and re-quires additional modification. The ear is graspedand pulled away from the scalp, and an incision ismade around the superior aspect. Various tech-niques have been described on how to resurfacethe defect, from skin grafts to ingenious localflaps.10 These authors have found that full-thick-ness skin grafts from the groin provide the leastvisible donor site for such extra tissue (Fig. 4).

Question Mark EarIn the question mark ear, there is excess sca-

pha in the upper portion of the ear and a defi-ciency at the junction of the middle and lowerthirds, resulting in a “question mark” shape. Thesuperior excess can be treated as described aboveunder “Macrotia.” In mild cases, the deficientlower third can be treated using the combinationof a V-Y advancement from behind the ear plus acartilage graft.11 The cartilage graft can usually betaken from the scaphal reduction or from the con-cha. In severe deformities, however, it is preferableto discard most of the ear cartilage and create a ribcartilage framework as described below under “Totaland Subtotal Ear Reconstruction.”

NONOPERATIVE CORRECTION OFEAR DEFORMITIES

During early infancy, the auricular cartilageretains its fetal plasticity, allowing some of thedeformities described above to be corrected bynonsurgical stenting.12,13 The ears are folded overacrylic and taped into the correct position. Thesplints and tape are changed regularly, and theskin is checked compulsively for erosion. The pro-

cess is continued for several months or until thereis no further improvement in auricular contour.Remarkable results from Japan have been pub-

Fig. 4. Cryptotia. (Above) Preoperative deformity showing su-perior aspect of ear cartilage buried beneath scalp skin. (Cen-ter) Design of the flap. (Below) Postoperative result. (Used withpermission from Gordon Wilkes, M.D.)


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lished. Dr. Barry Grayson, an orthodontist at NewYork University, has produced similar superb re-sults. What remains unclear is how many weeks ormonths this moldability lasts. An illustrative ex-ample is shown in Figure 5. It is our impressionthat the new cartilage will not be formed in thosecases where cartilage is deficient, but the shape ofthe existing cartilage can definitely be altered.

TOTAL AND SUBTOTALEAR RECONSTRUCTION

In this section, the authors describe and illus-trate the essentials of ear reconstruction for totaland subtotal defects.

Patients with microtia, patients with traumaticor extirpative loss of the auricle, and some patientswith the extreme manifestations of the deformitiesdescribed above are best treated with total or sub-total reconstruction of the ear. In addition to au-togenous methods of reconstruction, prostheticreconstruction and Dr. Reinisch’s technique ofreconstruction14 using polyethylene frameworks isdescribed and illustrated. Excellent results havealso been reported by Park using expansion and atwo-flap technique.15

Autogenous ReconstructionEssentials of Preoperative AssessmentPreoperative assessment consists of an evalu-

ation of the skin quality/laxity, presence or ab-sence of an external auditory canal, presence or

absence of scars, location of the hairline, the ex-tent to which any remnant corresponds to theideal position of the eventual reconstructed ear,and the underlying skeleton. Although most pa-tients in this category have isolated microtia andhave never had previous surgery, there are manypatients who have microtia in the setting of severeskeletal and soft-tissue hypoplasia (hemifacial mi-crosomia), microtia that has been operated onpreviously, posttraumatic deformities, and postex-tirpative deformities. The microtia classification inthe literature with the most practical implicationsfor surgical technique is that of Nagata16–18: lob-ular type, small conchal type, and large conchaltype. In the latter type, a tragus and concha arepresent, at least to some extent, and this allowsplacement of a less complex cartilage frameworkand generally yields superior aesthetic results. Mi-crotia patients who have undergone previous sur-gical intervention will have scars and cartilage orartificial frameworks, all of which may not be inthe ideal position.

Even a perfect ear that is located too low ortoo anterior is frequently worse than no ear atall. Finally, patients with posttraumatic defor-mities or postablative deformities frequentlyhave the advantage of a tragus and concha butthe disadvantage of nondistensible, scarred, some-times irradiated soft tissue. A more detailed andextremely helpful classification awaits publicationby Firmin19 and takes into consideration the type

Fig. 5. Neonatal ear molding. (Left) Appearance at birth and (right) after ear molding. (Usedwith permission from Gordon Wilkes, M.D.)


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of incision required, the type of framework re-quired, and the type of additional cartilage that isused for projection.

Goals of TreatmentThe goal in these patients is to create an ear

that appears normal from conversational distanceand will have little effect on the patient’s hairstyleand earrings. No reconstructed ear will avoid de-tection under intimate scrutiny. The framework,whether cartilage or polyethylene, is bulkier andless flexible than a normal ear. A prosthesis, al-though inconspicuous from a distance, will be ob-viously artificial in any intimate setting. If the pros-thesis is removed, which it has to be for at least 8hours per day, the metallic suprastructure towhich it is attached will be visible, palpable, andpotentially embarrassing.20

Advantages and Disadvantages of theTreatment Alternatives

The advocates of cartilage reconstruction, in-cluding the authors of this article, tout the advan-tages of autogenous tissue. The advocates of arti-ficial frameworks attempt to “sell” the avoidance ofa chest incision and the biocompatibility of porouspolyethylene. Those who prefer prosthetic recon-

struction claim superior aesthetics, less invasiveprocedures, and a lower cost. The authors’ ratio-nale for autogenous reconstruction is addressedin more detail under “Complications” below.Within the category of autogenous reconstruc-tion, the two most popular techniques are thosedescribed by Brent21 and Nagata.16–18 The Brenttechnique is a modification of that originally de-scribed by Tanzer22 and involves four stages (de-scribed below). Nagata analyzed the results of theBrent technique and designed a two-stage tech-nique (described below) to address its perceivedimperfections. The Brent technique is easier to learnand has fewer complications. The Nagata techniquecondenses the reconstruction into two stages anduses a more detailed, complicated framework. TheNagata technique has the potential to yield a betteraesthetic result by providing a more natural tragus,antitragal notch, and conchal bowl region and betterantihelical definition.23 The Nagata technique is like“swinging for the fences”; there are more home runsand more strikeouts.

Key Elements of the Surgical ProcedureBrent technique. The patient is examined in the

upright position and the lowest point of the ear-

Fig. 6. Drawings demonstrate the Brent technique for fabrication of ear frame-work from rib cartilage. The Brent framework consists of two pieces. The baseis obtained from the synchondrosis of two rib cartilages and the helical rim isobtained from a “floating” rib cartilage. The details are carved into the baseusing a gouge. The helical rim piece is thinned and attached to the base usingnylon sutures.


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lobe on the unaffected side is transferred to theaffected side. The attempt is to place the lowestpoint of the reconstruction so that it, and thepatient’s earring, are at the same level as the nor-mal side. The normal ear is traced on clear x-ray

Fig. 7. Drawings depict Nagata stage 1 incision, dissection of pocket, and insertionof framework. (Above, left) The W-shaped incision is made, taking the skin from themedial surface of the earlobe to resurface the concha. (Above, right) The pocket isdissected, leaving an intact “pedicle” at the caudal end of the flap. (Below, left) Theframework is inserted. (Below, right) After stage 1, suction drains are in place toencourage coaptation of the skin to the underlying framework.

Fig. 8. Drawings showing the Nagata framework. (Left) In a man-ner similar to Brent, the base and its details are carved from thesynchondrosis of two adjacent rib cartilages. (Right) The fourpieces of cartilage that make up the framework are shown andnumbered. The base and helical rim are present, as they are in theBrent technique. There is an additional antihelix triangular fossapiece and an additional tragus-antitragus piece that are uniqueto the Nagata procedure.

Video 2. Supplemental Digital Content 2, in which Dr. Wilkesdemonstrates the carving of ear framework using autogenousrib cartilage, is available in the “Related Videos” section of thefull-text article on PRSJournal.com or, for Ovid users, athttp://links.lww.com/PRS/A474.


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film and sterilized. Using this tracing, a templateis fashioned of the desired framework, approxi-mately 3 mm shorter and 2 mm narrower than thedesired ear. The template is used to mark the exactlocation and orientation of the desired auricle. Anincision is designed to provide access for removalof the superior cartilage remnant and largeenough to place the eventual framework. In ad-dition, it is placed such that it can be used at stage2 for lobule rotation and at stage 4 for construc-tion of the tragus.

The incision is made and the cartilage rem-nant is removed from the superior portion of themalformed ear. The pocket is dissected so that itextends slightly beyond the markings, especiallyposteriorly, where skin without hair can be re-cruited over the framework. Hemostasis is ob-tained, a moist gauze is placed over the area, andattention is directed to the chest.

A transverse incision is made over the caudalaspect of the rib cage. The rectus abdominis mus-cle is divided and the cartilages are exposed andexamined. Two cartilage pieces are required, onethat includes the synchondrosis of two rib carti-lages to form the base and a second, preferably 10cm in length, to create the helical rim. The detailsare applied to the cartilages on the back tableusing sterilized gouges and scalpels, and the car-tilages are attached using nylon sutures (Fig. 6).Once the framework is complete, it is inserted intothe pocket, two closed suction drains are placed,and the incision is sutured. A soft bulky dressingis applied.

At stage 2, the lobule is rotated, the caudalaspect of the cartilage framework is inserted intothe bivalved lobule, and the lobule is inset in theprecise position to yield an auricle of the desiredlength. At stage 3, the auricle is elevated, the ret-roauricular scalp is undermined and advancedinto the sulcus, and the defect on the backside ofthe elevated ear is resurfaced using a full-thicknessgraft from the groin. At the final stage, the tragus

Video 3. Supplemental Digital Content 3, in which SeanBoutros, M.D., demonstrates first-stage autogenous recon-struction, is available in the “Related Videos” section of thefull-text article on PRSJournal.com or, for Ovid users, athttp://links.lww.com/PRS/A475.

Fig. 9. Drawings show Nagata stage 2, elevation of the framework. (Left) The auricle is elevated, the cartilagegraft is wedged into the sulcus, the scalp is advanced, and the cartilage graft is covered with a temporo-parietal flap and skin graft. (Center) The skin graft is inset. Nagata prefers a split-thickness skin graft, butthese authors have noted significant shrinkage of the split grafts and recommend full-thickness grafts.(Right) Cross-section shows the cartilage graft in place providing projection and the temporoparietal flapcovering the cartilage graft.


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is constructed. An incision is made around theposterior border of the ideal tragus. The skin ofthe concha is elevated and the concha is deepenedby excising subcutaneous tissue. A composite graftfrom the contralateral concha is placed upsidedown to resurface the underside of the tragus, anda small full-thickness graft is used to resurface theconchal floor.

Nagata technique. The patient is examined inthe same fashion, and the lowest point of the de-sired new ear is marked as described above. Asimilar tracing is made, but it is helpful to makeadditional tracings of the antihelix piece and thetragus-antitragus anatomy so that decisions can bemade intraoperatively and those pieces carved ac-cordingly. The W-shaped incision is designed to

provide the same exposure as in the Brent pro-cedure, but also to rotate the lobule at the firststage (Fig. 7). As mentioned above, Firmin hasdeveloped a simplified approach to the incisions/skin approach.19

The superior remnant is removed and thepocket is dissected. A soft-tissue pedicle is left at-tached near the apex of the central limb of the Wto help with vascularity of the large skin flap. Notethat the Nagata technique robs the skin from theback of the earlobe to resurface the concha. Thisresults in a large flap with more potential forischemia than in the Brent technique but hasthe advantage of potentially superior conchal-tragal definition. The lobule is rotated into po-sition and inset.

Fig. 10. Autogenous reconstruction for microtia with the Nagata technique. (Above, left)Preoperative appearance. (Above, right) Postoperative result. (Below) Rib cartilage frame-work. (Used with permission from Gordon Wilkes, M.D.)


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Although a transverse chest incision usuallyresults in less tendency for hypertrophic scar, anoblique incision is more versatile and can be ex-tended if the surgeon needs to search for bettercartilage pieces. A total of five pieces are neededas opposed to the two for the Brent technique: thebase, the helical rim, the antihelix piece, the tra-gus-antitragus piece, and a piece to bank in thechest for the second stage. Once the cartilages areharvested, it is helpful to leave a catheter in thechest for the continuous administration of bupiv-acaine postoperatively. The cartilage remnantsthat remain after the framework is carved can bediced and placed in the perichondrial sleeves tomaximize rib cartilage regeneration. Alterna-tively, neo–rib cartilages can be constructed bywrapping the diced remnants in an absorbablegauze (e.g., Surgicel; Ethicon, Inc., Somerville,N.J.) gauze and sewing them into the cartilaginousdefects. The surgeon then sits at the back table andthe cartilages are carved and spliced together asshown in Figure 8. Although Nagata, Firmin, andWilkes prefer to use double-armed wire sutures onstraight needles, Thorne uses sutures of the samedesign but in nylon. The double-armed short,straight needles allow two pieces of cartilage to besutured from the anterior surface, rather thanfrom the posterior surface. (See Video, Supple-mental Digital Content 2, in which Dr. Wilkesdemonstrates the carving of ear framework us-ing autogenous rib cartilage, available in the“Related Videos” section of the full-text articleon PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A474.) When the frameworkis complete, it is inserted into the pocket. Mostsurgeons use closed suction drains, but Nagatasews bolsters in place to encourage the skin todrape into the interstices of the framework. (SeeVideo, Supplemental Digital Content 3, in whichSean Boutros, M.D., demonstrates first-stage au-togenous reconstruction, available in the “RelatedVideos” section of the full-text article on PRSJour-nal.com or, for Ovid users, at http://links.lww.com/PRS/A475.)

At the second stage, the ear is elevated, thebanked cartilage is removed from the chest andused to augment projection of the framework, atemporoparietal flap is used to cover that cartilagegraft, and the sulcus is resurfaced with a skin graft.Nagata prefers a split-thickness graft from the scalp,but others have found those grafts excessively proneto contraction and prefer a full-thickness graft fromthe groin (Fig. 9). An example of a postoperativeresult is shown in Figures 10 and 11.

ComplicationsIschemic wound healing problems are rare

when using the Brent technique. There is a defi-nite learning curve with the Nagata procedure,however, and ischemic necrosis of the skin flap atthe tip, in the region of the intertragal notch, isnot uncommon in inexperienced hands.

Even when the surgeon is experienced and thereis no “complication,” the vagaries of wound healingand variations in skin thickness, and variations in thesurgeon’s ability to create a perfect framework, yielda spectrum of postoperative results—not uniformlyexcellent results. This is true for both Brent-type andNagata-type reconstructions.

If exposure of the cartilage framework occurs,it must be dealt with promptly. Small areas ofexposure (0.5 cm) that are not over a prominentarea of the framework may heal secondarily butrequire close follow-up. If there is the slightestevidence of infection, local flap coverage is nec-essary. For larger areas of cartilage exposure orwhere the exposure is over the helical rim, cov-erage should be provided on an urgent basis. Thetype of local flap varies with the size and locationof the cartilage exposure. If there is any doubtabout the viability of a local flap, a temporopari-etal flap and skin graft are the most reliable op-tions. Although use of the temporoparietal flapprecludes its use at the second stage, it is vastlypreferable to have stable coverage over the frame-

Fig. 11. Close-up view of the patient shown in Figure 10, post-operative result. (Used with permission from Gordon Wilkes,M.D.)


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work than to “cheat” on the coverage and save thetemporoparietal flap for the second stage. Nylonor wire sutures may become visible or palpablemonths or years later and are easily removed.

Reconstruction Using a Medpor FrameworkBecause of space constraints, the steps of this

procedure are not discussed in detail but are

shown in Video 4, produced by Reinisch. (SeeVideo, Supplemental Digital Content 4, in whichJohn Reinisch, M.D., and Joseph Roberson, M.D.,demonstrate ear reconstruction using a Medporframework and canaloplasty in a single stage, avail-able in the “Related Videos” section of the full-textarticle on PRSJournal.com or, for Ovid users, athttp://links.lww.com/PRS/A476.) Reinisch has themost experience with this technique. His complica-tion rate was high (42 percent) when he first beganto use Medpor (Porex Surgical, Inc., Newnan, Ga.)frameworks, but the routine addition of temporo-parietal flaps has resulted in a very low complicationrate at the present time.14 The video also shows con-comitant canaloplasty to restore hearing. The au-thors of this article have seen a number of patientswho underwent this procedure performed by sur-geons other than Reinisch, who had persistent anddifficult problems with exposed Medpor frame-works.

Prosthetic ReconstructionProsthetic reconstruction has a role in ear re-

construction, especially in older individuals whoare not interested in or who are not candidates fora multiple stage reconstruction. The best indica-tions are adult patients who have undergone ma-jor extirpative surgery, patients with major traumaor burns, and elderly patients with medicalcomorbidities20,24 (Fig. 12). Prostheses are gener-ally not the best choices in children, however,unless there is no other option. Children tend not

Video 4. Supplemental Digital Content 4, in which JohnReinisch, M.D., and Joseph Roberson, M.D., demonstrate ear re-construction using a Medpor framework and canaloplasty in asingle stage, is available in the “Related Videos” section of thefull-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A476.

Fig. 12. Prosthetic reconstruction of the ear after burn deformity. (Left) Deformity. (Right) Afterfabrication of implant retained prosthesis. (Used with permission from Gordon Wilkes, M.D.)


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to wear prostheses, if they can help it, and thedevices serve as daily reminders of their deformity.The authors feel that an appropriate autogenousreconstruction for congenital deformities is supe-rior and more stable, requires less maintenance,and is cheaper in the long run. Prosthetic ears canbe retained by adhesives or by using osseointe-grated titanium fixtures attached to transcutane-ous abutments. The adhesives still have a role but

are time consuming and prone to failure, espe-cially in important social situations. The methodof retention using osseointegrated implants ismore convenient and more secure.

Advocates of prostheses say they are cheaperthan surgical reconstruction. These authors doubtthat is true if cost is calculated over the life of thepatient. Prostheses last only approximately 5 yearsand have to be replaced continually, at significantexpense. In addition, soft-tissue problems aroundthe abutments can result in long periods when theprosthesis cannot be worn. In contrast, a talentedand experienced anaplastologist can produce an earprosthesis that is remarkable in its color, texture, andlife-like quality. (See Video, Supplemental DigitalContent 5, in which Dr. Wilkes and anaplastologistAkhila Regunathan demonstrate the fabrication ofan ear prosthesis, available in the “Related Videos”section of the full-text article on PRSJournal.com or,for Ovid users, at http://links.lww.com/PRS/A477.) Infact, without such an individual available to make theprosthesis, prosthetic reconstruction should not becontemplated.

RECONSTRUCTION OF PARTIALEAR DEFECTS

The surgical options for a given partial eardefect depend on the location of the defect.There are fewer options as the defect ap-proaches the lobule. Interestingly, the lower the

Video 5. Supplemental Digital Content 5, in which Dr. Wilkesand anaplastologist Akhila Regunathan demonstrate the fabri-cation of an ear prosthesis, is available in the “Related Videos”section of the full-text article on PRSJournal.com or, for Ovid us-ers, at http://links.lww.com/PRS/A477.

Fig. 13. Drawings of Antia-Buch helical advancement. (Left) An incision is designed inside the helical rim andaround the crus of the helix. (Center) The incision is made through the skin and the cartilage, but not throughthe posterior skin. The helical rim is advanced to allow closure and a dog-ear of skin is removed on the posteriorsurface of the ear. (Right) Closure showing the crus of the helix advanced into the helical rim.


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defect, the more important it is aesthetically andthe more difficult it is for the patient to conceal.

Upper Third DefectsThe choices for defects of the upper third are

as follows:

1. Local skin flaps.2. Helical advancement (Antia-Buch procedure)25

(Fig. 13).3. Chondrocutaneous composite flap.4. Conchal cartilage graft and retroauricular

skin flap (two stages).5. Rib cartilage graft and retroauricular skin

flap (two stages).6. Rib cartilage graft, temporoparietal flap,

and skin graft (two stages).

Middle Third DefectsThe choices for defects of the middle third are

as follows:

1. Primary closure with excision of accessorytriangles (Fig. 14).

2. Retroauricular skin tube for helical rim de-fects only (three stages).

3. Helical advancement.4. Conchal cartilage graft and retroauricular

skin flap (two stages) (Fig. 15).5. Rib cartilage graft and retroauricular skin

flap (two stages).

Lower Third DefectsVarious techniques have been described to re-

construct earlobe defects using soft-tissue flaps.These techniques are not as effective as those thatinclude cartilage support. The nasal septum pro-vides thin cartilage that is extremely useful in de-fects of the earlobe. A pocket is dissected corre-

sponding precisely to the defect, and a piece ofseptal cartilage is inserted. At a second stage, anincision is made around the earlobe, and thecheek and neck skin is advanced beneath the ear-lobe as in a face lift.

Charles H. Thorne, M.D.Department of Plastic Surgery

New York University School of Medicine812 Park Avenue

New York, N.Y. [email protected]

PATIENT CONSENTPatients or parents or guardians provided written

consent for the use of patients’ images.

ACKNOWLEDGMENTSThe authors thank John Reinisch, M.D., and Sean

Boutros, M.D., who submitted videos for this article.

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Fig. 14. Wedge resection and primary closure with excision ofaccessory triangles. (Left) Wedge excision performed and acces-sory triangles designed. (Right) Closure of the defect.

Fig. 15. Two-stage reconstruction of a middle third defect usingrib cartilage graft and skin flap. (Left) The incision and retroau-ricular flap are designed. (Right) The cartilage has been insertedand the flap closed over it.


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Ear Deformities, Otoplasty, And Ear Reconstruction.37