This document discusses surgical techniques for reconstructing auricular defects of different sizes. It summarizes the experience of surgeons in treating 75 patients over 10 years. For defects less than one-fourth the vertical ear size, primary closure is sufficient. For larger defects up to three-fourths the size, a reversed retroauricular flap is often used successfully. For defects exceeding three-fourths the size, an implant-retained prosthesis is preferred. The location, size, and tissue involved in the defect, as well as the patient's condition, determine the most appropriate reconstruction method.

1. SURGICAL ONCOLOGY AND RECONSTRUCTION
Surgical Management of Auricular Defect
Depending on the Size, Location,
and Tissue Involved
Alireza Ghassemi, MD, DDS, PhD,* Ali Modabber, MD, DDS, PhD,y
Mohammad Talebzadeh, DDS,z Lloyd Nanhekhan, MD, PhD,x Maria Heinz, MD, DDS, PhD,k
and Frank H€olzle, MD, DDS, PhD{
Purpose: Auricular reconstruction is a challenging surgical intervention that requires perfect surgical
skills, exact planning, and esthetic knowledge. It is necessary to use a suitable method of reconstruction
for each patient. From 10 years of experience, the authors have developed a general concept for auricular
reconstruction.
Patients and Methods: Seventy-five patients (62 male, 13 female; age range, 8 to 92 yr; mean age,
65.9 yr) underwent partial to total auricular reconstruction. Tissue loss occurred from different causes:
19 cases of squamous cell carcinoma (25.3%), 18 cases of basal cell carcinoma (24%), 14 cases of Bowen
disease (18.7), 11 cases of malignant melanoma (14.7%), 7 cases of trauma (9.3%), 3 different malignant
tumors (4%), and 3 cases of congenital deformity (4%).
Results: Defects smaller than one fourth the vertical auricular size (15 to 20 mm) could be treated by
primary closure. A larger defect closed by this method caused visible deformity. In defects larger than
one to three fourths the vertical auricular size (40 to 55 mm), a reversed retroauricular flap was used suc-
cessfully if there was no contraindication or rejection. This flap can be combined with other flaps, depend-
ing on the flap location, size, and tissue involved. In defects exceeding three fourths the vertical auricular
size, an implant-retained prosthesis was preferred.
Conclusion: The location and size of a defect, the medical condition of the patient, and the desired
esthetic outcome play an important role in choosing the appropriate method. According to the authors’
experience, the only contraindications for the reversed retroauricular flap are medical condition, poor
prognosis, and patient refusal.
Ó 2013 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 71:e232-e242, 2013
When considering the overall esthetics of the face,
the ear is not the most defining part. However,
even a small deviation in the symmetry, orientation,
color, overall contour, and structural eminence of
the ear can easily be noticed and detract from the
overall esthetic image of the face. In some cases,
this can lead to psychological dilemmas for the pa-
tient. Therefore, it is of the utmost importance
when reconstructing the missing part of an ear to
do so in an anatomically correct way so as to achieve
the best esthetic outcome possible. There is no
unique directive for ear reconstructions, but rather
a multitude of available methods. These methods
range from primary closure, to different local flaps,
*Assistant Professor, Department of Oral, Maxillofacial and Plastic
Facial Surgery, University Hospital RWTH-Aachen, Aachen, Germany.
yFellow, Department of Oral, Maxillofacial and Plastic Facial
Surgery, University Hospital RWTH-Aachen, Aachen, Germany.
zResident, Department of Oral, Maxillofacial and Plastic Facial
Surgery, University Hospital RWTH-Aachen, Aachen, Germany.
xAssistant Professor, Department of Plastic and Reconstructive
Surgery, University Hospital Gasthuisberg, Leuven, Belgium.
kResident, Department of Oral, Maxillofacial and Plastic Facial
Surgery, University Hospital RWTH-Aachen, Aachen, Germany.
{Head and Chairman, Department of Oral, Maxillofacial and Plastic
Facial Surgery, University Hospital RWTH-Aachen, Aachen, Germany.
Address correspondence and reprint requests to Dr Ghassemi:
Pauwelsstr 30, 52074 Aachen, Germany; e-mail: aghassemi@
ukaachen.de
Ó 2013 American Association of Oral and Maxillofacial Surgeons
0278-2391/13/00432-1$36.00/0
http://dx.doi.org/10.1016/j.joms.2013.04.030
e232

2. to an ear prosthesis. Depending on the defect size,
location, and tissue involved, simple primary closure
using chondrocutaneous advancement flaps or mod-
ified techniques can be used.1-6
For reconstruction
of larger defects of the ear, the retroauricular
region is the principal donor site.7-16
The skin from
this area, in addition to fascia and autogenous
grafts (ear, rib, or septal cartilage) or allogenous
materials (porous polyethylene), can be used to
reconstruct the ear.17-20
The authors previously
introduced their alternative technique of using the
retroauricular skin as an anterior pedicled flap.21
This flap, called a reversed retroauricular flap
(RRF), enables the reconstruction of large auricular
defects and is easy to perform with a straightforward
postoperative follow-up. The RRF can be used as
a full-thickness flap and has become the workhorse
flap for auricular reconstruction in the authors’
department.
Despite the wealth of available methods for recon-
struction of the ear, choosing the appropriate tech-
nique is not always evident. To simplify the
decision-making process, the authors developed
a concept of surgical treatment depending on the de-
fect size, location, tissue involved, and the patients’
medical condition. They have been developing and
applying this concept for the past 10 years, with sat-
isfaction, and present their results in the pres-
ent article.
Patients and Methods
This study was approved by the institutional review
board of University Hospital RWTH-Aachen (Aachen,
Germany) and all patients signed an informed consent
agreement. Within a 10-year period, the authors in-
cluded 75 patients (62 male and 13 female; 8 to 92 yr
old; mean age, 65.9 yr) who underwent partial or com-
plete auricular reconstruction in the authors’ facility in
cooperation with the Department of Dermatology, Uni-
versityHospitalRWTH-Aachen. The defectswere there-
sultoftumorexcision,trauma,orcongenitaldeformities
and affected the helix, antihelix, concha, scaphoid
fossa, triangular fossa, or a combination these structures
(Table 1). The defect vertical size ranged from 5 mm to
complete loss of the auricle.
Depending on the defect size, location, esthetic de-
sire, and medical condition, patients were categorized
into the following groups and the treatment procedure
was planned accordingly:
1. Partial-thickness defects (n = 17)
a. Anterior surface (n = 6): cranial or caudal pedi-
cled preauricular flap, posterior pedicled retro-
auricular flap
b. Posterior surface (n = 8): RRF
c. No treatment (n = 3)
Table 1. CAUSES AND LOCATIONS OF DEFECTS
Upper Third Middle Third Lower Third Total
SCC 2 11 6 19
BCC 3 11 4 18
MB 2 8 4 14
MM 0 9 2 11
OT 0 3 0 3
T 2 0 5 7
Total 9 42 21 72
CD 3 3
Total 75
Abbreviations: BCC, basal cell carcinoma; CD, congenital
deformity; MB, morbus Bowen; MM, malignant melanoma;
OT, other tumors; SCC, squamous cell carcinoma; T, trauma.
Ghassemi et al. Guidelines for Auricular Reconstruction. J Oral
Maxillofac Surg 2013.
FIGURE 1. Artist’s illustration of the auricle divided into 4 equal
parts.
Ghassemi et al. Guidelines for Auricular Reconstruction. J Oral
Maxillofac Surg 2013.
GHASSEMI ET AL e233

3. 2. Full-thickness defect (n = 52)
a. Smaller than one fourth the vertical auricular
size (15 to 20 mm; n = 16): primary closure or
reductive surgery
b. Larger than one fourth the vertical auricular
size (n = 34): RRF
c. No treatment (n = 2)
3. Larger than three fourths the vertical auricular
size (40 to 55 mm; n = 6)
a. Bone-anchoredprosthesisusingimplant-retained
or implant-carrying plating system (n = 5)
b. No treatment (n = 1)
SURGICAL PROCEDURE
Depending on the defect size (Fig 1), the required
skin area was marked retroauricularly (Fig 2A). The
posterior triangle (I in Fig 2B) was incised and dis-
sected in an anteriorly pedicled fashion to recon-
struct the posterior auricular surface. After
a healing period of 2 weeks, the anterior triangle
(II in Fig 2C) was incised and folded forward to
replace the anterior surface of the auricle. The healed
posterior surface part of the flap was thinned out as
much as possible. In addition, debulking of the ante-
rior flap triangle (II) was performed and a cartilage
graft was inserted, as required, if the wound closure
was safe (Fig 2D). Any further refinement was per-
formed in another setting after 3 to 4 weeks,
as required.
Results
Six patients rejected any complex procedure and
were satisfied with the outcome after initial treatment.
FIGURE 2. Artist’s illustration showing harvesting technique of the reversed retroauricular flap. A, Marked incision line of the flap according to
the size of the defect. (Fig 2 continued on next page.)
Ghassemi et al. Guidelines for Auricular Reconstruction. J Oral Maxillofac Surg 2013.
e234 GUIDELINES FOR AURICULAR RECONSTRUCTION

4. Deformities of the affected ear were obvious in
these patients.
In patients with partial-thickness defects of the ear,
satisfactory results were achieved using a posterior
pedicled retroauricular flap or a pedicled preauricular
flap for an anteriorly located defect and an RRF for
a posteriorly located defect.
For full-thickness auricular defects, satisfactory
results were achieved with primary closure or re-
ductive surgery; however, this resulted in a slightly
smaller ear (Fig 3). If defects were larger than one
fourth the vertical auricular size, the deformity of
the auricle would be too noticeable compared
with the contralateral ear (Fig 4). Therefore, the
preferred choice was to replace the lost tissue
with the RRF if the defects were larger than one
fourth the vertical auricular size (Figs 5, 6). The
size and outer contour of the ear, the tissue
structure, and skin color were very pleasing;
thus, scars or minimal surface irregularities were
acceptable.
In patients with auricular replacement by prosthesis
(n = 5), despite the pleasing esthetic appearance,
implant-related problems, such as implant loos-
ening and multiple skin irritations, occurred.
Discussion
The axis and vertical height of the auricle are im-
portant anthropometric and esthetic parameters
that can convey information concerning age and
gender.22
The average total ear height is about
6.3 cm.22
Any tissue loss exceeding one fourth the
vertical auricular size (Fig 1) will affect anthropo-
metric and esthetic parameters and require tissue
replacement with similar tissue. In 1956,
FIGURE 2 (cont’d). B, The posterior flap half (I) is elevated and adapted to the dorsoanterior edge of the defect. (Fig 2 continued on next
page.)
Ghassemi et al. Guidelines for Auricular Reconstruction. J Oral Maxillofac Surg 2013.
GHASSEMI ET AL e235

5. reconstruction of a partial defect was introduced us-
ing a composite graft of the contralateral ear.23
Depending on the size of the graft, this method is
not always reliable. Conversely, auricular recon-
struction using local tissue as a posterior pedicled
retroauricular flap has been used in many cases.24
This flap has since been modified many times and
still plays an important role.6,8,11-13,25
This method,
despite its many advantages, does not allow for
tension-free adaptation of the flap into the recipient
site and postoperative wound dressing is inconve-
nient and difficult. Common methods for defect clo-
sure are regional cutaneous or chondrocutaneous
flaps.15,24,26-30
These flaps can be used in different
modified forms and have specifically defined
indications with limited use in larger defects.1-6
Some reconstructive techniques do not involve the
helical rim.2,3
Many investigators have suggested using pedi-
cled regional cutaneous or myocutaneous tissue
as random, arterial, or island flaps.31-34
All these
flaps are useful for reconstructing smaller defects,
although the outcome can be impaired by
anatomic deviations and insufficient blood supply.
For larger defects and complete loss of the
auricle, more extensive surgical procedures have
been developed using temporoparietal or mastoid
flap fascia covered by local cutaneous flaps or
skin grafts.17-19,35
The auricular framework then
can be assembled from autogenous grafts, such as
conchal, septal, and rib cartilage, or from alloplastic
materials, such as porous polyethylene.17-20,36
Additional skin can be obtained by the use of
expanders.36
These are more extensive methods
that require many operative steps and require
greater compliance by the patient. A decrease of
FIGURE 2 (cont’d). C, The front half (II) of the flap is elevated and prepared for reconstruction of the anterior surface of the ear. (Fig 2
continued on next page.)
Ghassemi et al. Guidelines for Auricular Reconstruction. J Oral Maxillofac Surg 2013.
e236 GUIDELINES FOR AURICULAR RECONSTRUCTION

6. the reconstructed auricle cannot always be avoided
and requires correction.20,37
Therefore, prosthetic
reconstruction has become increasingly popular.37
During the past 10 years, the authors have
treated more than 100 patients with auricular de-
fects, many of which were closed primarily and
did not require additional reconstructive proce-
dures. Of these patients, 75 had larger defects that
could not be treated by primary closure alone.
The authors’ treatment concept was planned ac-
cording to the defect size and location, tissue in-
volved, the underlying medical condition, and the
desired outcome. For defects up to one fourth the
vertical size, reconstruction was performed with
good results by primary closure (Fig 3). A visibly
smaller ear compared with the contralateral
unaffected ear was acceptable. This method
showed a very low complication rate and other in-
vestigators have proposed a similar approach for
a similar defect size.18
A defect larger than one fourth the vertical auricu-
lar size can be closed in similar fashion, but will lead
to an obvious deformity (Fig 3). This was performed
in limited cases depending on the morbidity of the pa-
tient, esthetic demand, and if extensive procedures
were refused. For reconstruction of larger defects,
the RRF was used alone or in combination with other
surgical procedures. Reconstruction of the ear using
the RRF is a simple and easy technique, which offers
an excellent esthetic outcome and can be performed
under local anesthesia in an ambulatory setting for
nearly all types of defects, spanning all anatomic loca-
tions of the ear (helical rim, conchal bowel, and lob-
ule; Figs 5, 6). Depending on the composition of the
defect, cartilage grafts can be used as a framework.
The flap can be designed so that the hairless skin
FIGURE 2 (cont’d). D, The flap is integrated and the lost tissue is completely replaced.
Ghassemi et al. Guidelines for Auricular Reconstruction. J Oral Maxillofac Surg 2013.
GHASSEMI ET AL e237

7. part is placed anteriorly. Disadvantages of the RRF are
the multiple operative steps and the open wound sur-
face, similar to other procedures. The RRF allows un-
complicated postoperative control of the visible
wound surface. Because of its advantages, such as
tension-free flap adaptation and excellent control of
wound healing, the authors have increased their
use of the RRF.21
This method has become the stan-
dard technique in the authors’ institution for the re-
construction of defects up to three fourths the
vertical auricular size. Nevertheless, defects exceed-
ing this size are difficult to replace by local flaps.
The authors prefer replacing a lost ear with an
implant-retained ear prosthesis. It provides good
esthetic results with minimum operative effort.37
The procedure also is becoming increasingly easier
using the Epiplating SystemÒ (Medicon, Tuttlingen,
Germany) and can be performed in an outpatient
setting. Nevertheless, it is fraught with implant-
related complications, such as peri-implantitis.38
In the authors’ opinion, when choosing a technique
for auricular reconstruction, the solution should con-
sider factors, such as defect size, composition, medical
condition of the patient, and the expectation of the es-
thetic outcome. A simple reductive surgery is indi-
cated if the defect is smaller than one fourth the
vertical auricular size. Conversely, larger defects de-
mand more extensive procedures. The RRF can be ap-
plied to replace full-thickness defects from one to
three fourths the vertical auricular size, with a good
cosmetic result. It provides easy wound care and pri-
mary closure of the donor site in concealed areas, in
addition to a tension-free adaptation of the flap in
the defect. There are no concerns about flap necrosis.
For larger defects, the authors prefer bone-anchored
ear prostheses.
FIGURE 4. An 89-year-old man after tumor excision (>1.5 cm) and
primary closure.
Ghassemi et al. Guidelines for Auricular Reconstruction. J Oral
Maxillofac Surg 2013.
FIGURE 3. A 79-year-old man after tumor excision (1.5 cm) and
primary closure.
Ghassemi et al. Guidelines for Auricular Reconstruction. J Oral
Maxillofac Surg 2013.
e238 GUIDELINES FOR AURICULAR RECONSTRUCTION

8. FIGURE 5. A 75-year-old man after tumor excision and tissue replacement with a reversed retroauricular flap. A, Size of defect after tumor
excision. B,C,D, Designing the flap, adaptation, and wound closure, respectively. (Fig 5 continued on next page.)
Ghassemi et al. Guidelines for Auricular Reconstruction. J Oral Maxillofac Surg 2013.
GHASSEMI ET AL e239

9. FIGURE 5 (cont’d). E, F, Follow-up 4 weeks after reconstruction.
Ghassemi et al. Guidelines for Auricular Reconstruction. J Oral Maxillofac Surg 2013.
e240 GUIDELINES FOR AURICULAR RECONSTRUCTION

10. FIGURE 6. An 82-year-old man after tumor excision of the ear lobe. A, Planning the flap so that it is slightly larger than the defect. B, Adaptation
of flap. C, Follow-up 4 weeks after reconstruction.
Ghassemi et al. Guidelines for Auricular Reconstruction. J Oral Maxillofac Surg 2013.
GHASSEMI ET AL e241

11. Acknowledgments
The authors express their sincere appreciation to Mr Wolfgang
Graulich from the Institute of Anatomy, RWTH-Aachen for his
valuable illustrations.
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e242 GUIDELINES FOR AURICULAR RECONSTRUCTION