Auricular reconstruction summary

1. AURICULAR
RECONSTRUCTION
DR MAHEEN FATIMA
PLASTIC SURGERY RESIDENT

2. • Tolleth states a proper ear requires certain characteristics
to have a satisfactory appearance:
1. posteriorly inclined axis (AXIS)
2. 0.6 : 1 ratio of width to height (RATIO)
3. Three curved lines that outline its shape, suggest
tragus, antitragus, and concha (KEYLINE)
4. helix with its root beginning in the concha (DETAIL)

4. EAR ANATOMY

7. • the external ear has a spiral architecture
• BLOOD SUPPLY:
• Anteriorly:superficial temporal artery (STA)
• Posteriorly: posterior auricular vessels
• SENSORY SUPPLY:
• Greater auricular nerve
• Lesser occipital nerve
• Auriculotemporal nerve
• Vagus nerve (Arnold Nerve)
• LYIMPHATICS:
• correlates with six embryonic hillocks.
• The tragus, root of the helix, and superior helix arise from first branchial
arch (anterior hillocks 1–3) and drain into parotid nodes.
• The antihelix, antitragus, and lobule arise from second branchial arch
(posterior hillocks 4–6) and drain into cervical nodes.

9. EMBRYOLOGY
• 3 to 4 months of gestation
• two branchial arches: mandibular
branchial arch (first) and hyoid
branchial arch (second).
• First branchial arch (anterior
hillocks 1–3) contributes the tragus,
root of helix, and superior helix
(upper third of auricle).
• Second branchial arch (posterior
hillocks 4–6) contributes the rest
(antihelix, antitragus, lobule) (lower
two-thirds of auricle)

10. LOCATION & DIMENSIONS
• One ear length posterior to the
lateral orbital rim, with superior
pole level with brow and inferior
pole level with alar base.
• Vertical height = 55 to 65 mm
• Width + 50% to 55% of its length
• Lateral protrusion of the helix is 1
to 2 cm from the scalp.
• The long axis tilts posteriorly 15°
to 20°.
• Projection from mastoid to helix:
superior 10 to 12 mm; middle 16
to 18 mm; and inferior 20 to 22
mm.

12. • CONGENITAL EAR ANOMALIES:
-Microtia
-Anotia
-Constricted ear
-Cryptotia
-Stahl ear
-Hypoplasia of middle third of ear
-Prominent ear
• PARTIAL ACQUIRED DEFECTS

13. CONGENITAL EAR ANOMALIES

14. TANZER CLASSIFICATION:

16. • Cryptotia is a congenital ear deformity in which upper pole of ear cartilage
is buried underneath the scalp
• The superior auriculocephalic sulcus is absent but can be demonstrated
when you pull up the helical pole.
• In Japan, prevalence 1:400
• Nonsurgical ear-molding treatment may be applied if the child is in early
neonate stage.
• The goal of surgical treatment is to create the retroauricular sulcus by skin
grafts, Z-plasty, V-Y advancement, or rotation flap.
• Common cartilage deformity associated with cryptotia is helix-scapha
adhesion, which may be addressed by cartilage remodeling techniques.

19. • Rare congenital auricular deformity described In 1989 by
Binder
• Characterized by the third crus extending toward the
helical rim
• Stahl ear is classified into three types
TYPE 1:obtuse-angled bifurcation, and it looks like the
superior crus is missing
TYPE 2: trifurcation
TYPE 3:broad superior crus and broad third crus

20. • Non Surgical Management

21. • Surgical Management
• Two types: cartilage/skin excision and cartilage alteration.
• Type 1 Stahl ear needs special attention, to reconstruct missing superior
crus, by using excised third crus or rib cartilage graft or creating superior
crus by sutures or cartilage cutting
,
“Intra Scaphal Opposing Sutures” for Stahl’s ear correction J. Exp. Clin. Med., 2016; 33(4): 205-209
doi: 10.5835/jecm.omu.33.04.005,Ibrahim Alper Aksakalb

22. “Intra Scaphal Opposing Sutures” for Stahl’s ear correction J. Exp. Clin. Med., 2016; 33(4): 205-209
doi: 10.5835/jecm.omu.33.04.005,Ibra

24. • Constricted ear is a concept proposed by Tanzer in 1975
• Helix and scapha fossa are hooded, and crura of antihelix is flattened in
various degrees.
• Often referred to as cup or lop ear.
• Tanzer classified constricted ear into three groups :based on the severity of
deformity

26. GROUP 1
• Defined by mild deformities of the helix, often called lop ear
• Defect involves helical cartilage with minimum skin defect.
• Musgrave technique is a useful method to expand the helix.

27. GROUP 2
• Has both skin and cartilage defects in the upper third of the auricle
• Hooding is more pronounced.
• Height of the ear is sharply reduced.
• Park, in 2009,proposed a versatile solution for group 2 constricted
ear.
• For helical skin defect,:Park modified the Grotting flap(post- auricular
flap), creating both skin flap and fascia flap with the same pedicle.
• For helical cartilage defect:eighth rib cartilage is harvested and the
entire length of the helix is constructed

28. GROUP 3
• Most severe cupping: failure of migration
• Brent recommends to treat severe constricted ear
as if it is a form of microtia, when the construction
is severe enough to produce a height difference of
1.5 cm
• Nagata recommends treating severe constricted
ear as a concha type microtia
• Replace the defective framework with a full rib
cartilage framework.

31. • Congenital condition with unknown cause
• Higher in Asian countries
• Prevelance:0.83 to 17.4 per 10 000 births
• 80-90% unilateral
• 10–20% is bilateral
• Twice as frequent in males as in females
• Brent found that 15% of his 1000 patients had paresis of the facial nerve
• More than 18 different microtia-associated syndromes
-hemifacial microsomia
-Treacher–Collins(bilateral microtia)

32. MICROTIA CLASSIFICATION
Types
• Anotia
• Lobule type
• Small concha type
• Concha type
• Atypical

34. TIMING OF SURGERY
• ideal to begin construction before the child enters school
• autogenous construction should be postponed until rib growth provides
substantial cartilage to permit the fabrication of a quality framework
• BRENT: begins ear construction at age six, when the normal ear has grown
to within 6–7 mm of its full vertical height, and the amount of cartilage is
enough for Brent-type framework
• NAGATA: begins auricular construction at the age of 10, and chest
circumference grows over 60 cm, at the xiphoid level
• surgeons are less likely to be able to fabricate Nagata type framework at the
age of six

35. MIDDLE EAR PROBLEMS
• Treatments of microtia ideally involves reconstruction of the external ear and
the restoration of normal hearing
• Hearing impairment in microtia is related to abnormal auditory canal,
tympanic membrane, and middle ear
• The problem is conduction. Typically, microtia patients have a hearing
threshold of 40–60 dB on the affected side
• Potential gains from middle ear surgery in unilateral microtia are outweighed
by the potential risks and complications
• This procedure should be reserved for bilateral cases

36. TOTAL EAR RECONSTRUCTION IN MICROTIA

37. FACIAL SYMMETRY
• Individuals with microtia should be examined for dysmorphic features.
• Microtia is a common feature of craniofacial microsomia.
• Asymmetry of the face will make it complicated to locate the ear position
• It is not uncommon that reconstructive surgeons create the auricle in the
wrong location in hemifacial microsomia
• Prefererable to address skeletal correction first as it may make it easier to
identify the optimal auricular location

39. SKIN ENVELOPE
• Assess the available soft, elastic skin
• It will determine the volume, dimension & size of the 3D structure of the ear
framework needed.
• If elastic skin envelope is limited, It may not be able to place the framework with the
size matched to the normal side.
• Imbalance between the skin envelope and framework may make definition of the
auricle poor.
• Check if there is any scar around the auricle site and inside the hair.
• Scar interferes with the normal stretching of the supple skin envelope, and may
prevent good definition of the auricle
• Scar along the course of the STA could be the sign of a severed STA, the pedicle of
the temporoparietal flap

41. VESTIGE SKIN
• Utilizing the vestige skin strongly influences the definition of the new ear
• Evaluate the location, shape, and volume of the vestige.
• If the vestige skin is located inside or near the auricular rectangle, the
vestige skin is ready to be utilized for auricular construction
• If the vestige is located far away from auricular rectangle, staged
transposition of vestige skin may be necessary prior to framework
placement procedure
• Volume of vestige skin will influence the volume and the size of cartilage
framework
• If the volume/size of vestige is extremely small, the conchal cavity will be
shallow
• If the volume/size of vestige is relatively large there will have more chance
to create a deep concha

42. HAIR LINE
• Low hairline influences the choice of
surgical procedures
• If the low hairline exceeds beyond the
upper one-third of the auricular
framework, either preoperative laser hair
removal OR intra-operative fascia flap
coverage of the framework after hair-
bearing skin removal may be necessary.
• Photographic analysis for surgical
planning helps locate the proper new
ear location, presence of low hairline,
the location of the vestige

43. AURICULAR RECTANGLE
• Important to Identify the “auricular rectangle,”
within which the auricular framework will be
placed
• The ear positioning template is a tool to
identify the auricular rectangle(developed
with Nagata)
• Once the auricular rectangle is identified, the
next step is evaluating the relationship
between the auricular rectangle and the
vestige skin whether it can be utilized or not

44. EPT(EAR POSITIONING TEMPLATE)
• Harada and Yamada modified the
EPT in 2011
• New template is made of an acrylic
plate that facilitates surgical
marking.
• EPT may be used to visualize the
extent of low hairline

45. AURICULAR CURVE ANALYSIS
• Harada and Yamada developed an auricular shape
classification based on the curve ratio analysis study
• Three major types of helix-lobule curve:types A, B,
and C
• Two major types of concha outline curve:Type 1 and
Type 2
• Normal ear shape may be classified into SIX groups
based on this analysis
• Harada found that both the Brent framework and the
latest Nagata template are similar to Type A-1
framework, based on the curve analysis

48. AURICULAR TEMPLATE
• Most surgeons use some kind of template as a
guide for fabricating ear framework.
• Most widely used method has been tracing the
normal auricle with transparent film.
• Manual tracing is not easy
• Nagata developed a single ideal ear template
for all types of auricular construction
• It is based on both anthropometric analysis and
Nagata’s clinical experiences.

49. STAGES OF AURICULAR RECONSTRUCTION

50. Brent technique:
Four-stage reconstruction beginning at 6 years of age
• Creation and placement of a rib cartilage auricular
framework
• Rotation of the malpositioned ear lobule into the correct
position
• Elevation of the reconstructed auricle and creation of a
retroauricular sulcus
• Deepening of the concha and creation of the tragus

51. NAGATA STAGE 1
Markings: ear positioning template as a guide for markings
Patient position: semi-lateral position to facilitate simultaneous auricle
site and cartilage harvesting

52. Skin flap preparation:
1.Lobule splitting technique for lobule type microtia:
• Nagata solved the problem of skin shortage in typical lobule type
microtia.
• Creating a deep concha bowl may be achieved by splitting the
lobule into two flaps .
• skin flap is more likely to create a deeper concha bowl than skin
grafting or a composite graft.

55. 2.Skin incision for small concha type microtia:
• Nagata defines small concha type as the presence of a small
indentation in the concha region.
• skin incision is made along the margin of the small indentation

57. 3.Skin incision design for concha-type microtia:
• Recently Nagata changed from V-shape to W-shape incisions at the
posterior aspect of the lobule.
• W-shape incision has better freedom to transpose the lobule in the
optimal location

59. 2. Removing vestige auricular cartilage:
there is a difference in removal of concha and lobule type vestige cartilage
IN LOBULE TYPE:
removes all of the remnant auricular cartilage
reason:
-vestige cartilage will not contribute to the auricular framework
-vestige cartilage obstructs the smooth expansion of the skin envelope
-To accomodate the new framework

60. IN CONCHA TYPE:
remnant concha cartilage should be preserved
Technical tip: when you remove vestige cartilages, especially from
anterior aspect of the auricle, you must preserve as much soft tissue as
possible
preferred instrument for removal of the vestige cartilage is converse
scissors.

61. • 3. Skin pocket dissection
• Create a 2-mm-thick skin flap
• Do not use epinephrine injection for
hemostasis purposes becausemakes
dissection less accurate, and it may cause
vascular compromise of the delicate skin
flaps.
• Extent of skin pocket dissection usually
goes beyond the hairline border, up to 1
cm beyond the hair line.
• Do not violate trapezium-shaped space in
front of the new auricle to prevent anterior
inclination.

62. 4. Instrumentation
• Framework fabrication requires
specific types of instruments:
• carving knives with disposable
blades (2-mm, 3-mm, 4.5-mm, and
6-mm)
• 38G double-armed microtia wire

63. 5. Harvesting costal cartilage:
Brent:
harvests costal cartilage by attaching perichondrium to the cartilage
Nagata:
harvest rib cartilage, leaving the entire perichondrium to the donor site
Nagata stated that chest deformities are less likely to occur

65. 6. Auricular framework:
• The architecture of the auricular framework is a critical component to create the
complex and delicate definition of the auricle
• Skin envelope to cover the framework is as critical as auricular framework itself
• Nagata uses classic bolster sutures for postoperative dressings that were popularized
by Tanzer.
• Brent uses suction drain postoperatively.
• Bolster sutures cause minimum hematoma formation.
• For bolster use Xeroform with plenty of Vaseline-based ointment to make a roll of
bolster, and 4-0 Prolene for fixation
• Keep the bolster in place, usually for 10–14 days.

67. STAGE 2:(Auricular elevation)
1. Raising temporoparietal fascia flap (TPF):
• TPF to cover the entire posterior aspect of the auricle, not just the cartilage
block for elevation.
• TPF has two benefits: to cover the cartilage block and to augment the posterior
vascular supply to the auricle
• If TPF is not available, either deep temporal fascia flap or fascia flap based on
posterior vasculature is the second option.
• If a local fascia flap is not available, the third option may be a free vascularized
fascia flap

68. 2. Harvesting scalp split-thickness skin:
Nagata proposed the use of split-thickness scalp skin, which has better a color
match with auricular skin
3. Cartilage block for elevation:
Placing a cartilage block behind the framework has two purposes: elevating the
auricle and creating the auriculocephalic sulcus.

70. Synthetic Framework:
• Silicone framework, introduced by Cronin in 1966, extrudes, causes infection,
and loses definition in the long term.
• Porous polyethylene implant framework,introduced by Reinisch in 1991
• .
• The advantage is that it can be applied to younger children whose costal
cartilage are less mature and not ready for autogenous reconstruction.
• The disadvantages includes use of TPF flap, long-term risk of alloplastic
implant exposure or loss, and compromise of any future autogenous options.
Prosthesis
• Osseointegrated auricular prosthetic reconstruction provides a reasonable
alternative to poor autogenous options and poor synthetic framework
outcomes.
• The disadvantages of prosthesis include intermittent soft-tissue problems,
long-term maintenance, prosthetic remakes every 2 to 5 years, ongoing cost,
compromise of future autogenous options, and need for a compliant patient.

73. COMPLICATIONS:
• Incidence is reported to be 16.2% in average
• Most serious complication in total auricular construction is cartilage
infection, leading to the entire extrusion of the ear framework
• Other are hematoma, skin flap necrosis, abnormal position,
Atelectasis
• Long-term complications include the collapse of the ear framework
and extrusion of wires.

74. Secondary Total Auricular
Reconstruction
• The cause of unsatisfactory ear reconstruction can be divided into three
main categories: inappropriate skin envelope, inappropriate ear
framework, and inappropriate ear location.
• Most unsatisfactory cases have all. Therefore, radical total redo of
everything (skin envelope, 3D framework, and ear location) is the solution
• Assessment of the patients is important to know what kind of surgical
option would be optimal for the patients.
• TPF flap is the workhorse for secondary ear reconstruction
• .
• The surgeon must assess the presence of STA from the base (near the
caudal end of the auricle location) up to the parietal area (10 cm above
the upper helix portion), by Doppler ultrasound.
• .

75. HYPOPLASIA OF MIDDLE THIRD OF THE EAR

76. • Classified as Tanzer Type 3.
• Rare type of ear deformity
• Middle third is hypoplastic
• Upper and lower thirds have normal anatomical architecture
• Tanzer used staged reconstruction starting by dividing the superior and inferior
components, obtaining the normal vertical height, and the resultant conchal
defect is closed using a retroauricular flap.
• Later, partial ear framework is transplanted to build up the lower helix and
posterior conchal wall.

78. • Most frequent congenital deformity of the head and neck area
• Affecting 5% of the general public
• The most common causes of protrusion of the external ear are
(1) under development or effacement of the antihelix
(2) overdevelopment of the deep concha
(3) a combination of both of these features.
• Surgery is often recommended near an age when ear growth is
nearly complete
• Unilateral case may be more difficult for achieving symmetry

79. • If the upper third of the ear protrudes because of an absent or weak
antihelix, an antihelix must be formed.
• -Scapha-conchal suture:Mustardé created the antihelix by inserting permanent
mattress sutures through the cartilage without using any cartilage incisions
• -Anterior cartilage alteration:Chongchet scored the anterior scapha cartilage with
multiple cartilage cuts to roll it back and form an antihelix
• If the middle third is too prominent, the concha must be recessed by
either cartilage excision or suture fixation

80. PARTIAL EAR DEFECTS AND RECONSTRUCTION

81. Pure helical rim defects are best closed by advancing the helix in both directions, as described by Antia and Buch

82. CONVERSE TUNNEL PROCEDURE

83. RECENT LITERATURE:
Single-Stage Autologous Ear Reconstruction for Microtia
• performed at The Hospital for Sick Children
• Nagata 2 stage technique was modified into single stage eliminating the second
stage
• Minor adjustments were made to the 3D framework and an additional posterior
cartilage block as placed to project the ear from the side of the head
• This reconstrucrion however does not produce deep retroauricular sulcus but
decreases second stage morbidity
• Over all complication rate reduced from 22% to 15%

84. THANK YOU