to know about ears

1. EAR RECONSTRUCTION
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2. EAR RECONSTRUCTION 2
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3. OUTLINE OF PRESENTATION
 Relevant
 Relevant
 Historical
embryology
anatomy
perspectives
 Pinnaplasty
 Partial
 Brent
and total ear reconstruction
and Nagata technique
 Complications
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4. DEVELOPMENT OF AURICLE OR PINNA: AURICULAR HILLOCKS
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5. CONGENITAL ANOMALIES OF EXTERNAL EAR
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6. CONGENITAL ANOMOLIES
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7. MICROTIA: MARX GRADING OF MICROTIA
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8. Anotia Bat Ears
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9. STAHL’S BAR CONSTRICTED EAR
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10. BUMPS OR DARWIN’S TUBERCLE MACROTIA
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11. CRYPTOTIA (HIDDEN EAR) Low Set Ears
Only Lower 2/3rd of ear is visible
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12. EXTERNAL EAR
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13. ANATOMY OF PINNA
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14. BLOOD SUPPLY
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15. NERVE SUPPLY –SENSORY
Greater auricular nerve
 Auriculotemporal nerve
 Lesser occipital nerve
 Auditory branch of vagus

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16. Nerve supply: motor
Motor: Posterior auricular branch of facial nerve
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17. HISTORY
 600 BC: Sushrutha, the ancient Indian surgeon reconstructed ear lobules using local
flaps
 In 1597, Tagliacozzi used a pedicled flap for reconstructing a monk’s ear
 In 1920s and 1930s: Modern era in ear reconstruction; autogenous costal cartilage
grafts described by Harold Gillies and Pierce respectively
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In 1950s: Ranford Tanzer laid foundation of current ear reconstruction
Refined by contemporary surgeons ;Brent and Nagata
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18. PINNAPLASTY –OBJECTIVES
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Elimination of protrusion in upper third of ear
Helical fold should be parallel to antihelical fold
Helix should have a smooth and regular contour
Post-auricular sulcus should not be distorted
Auricle should be an appropriate distance away from mastoid
Difference between both auricles should be within 3 mm
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19. PINNAPLASTY :METHODS
CONSERVATIVE METHODS
 Simple moulding or splinting devices : up to 6 months old
OPERATIVE TECHNIQUES
 At least two consultations with patient/parents and photographs are essential for
pre-operative planning and for medicolegal purposes
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20. FORMATION OF UNDER-DEVELOPED ANTIHELICAL FOLD
Two techniques:
 Cartilage sparing/suturing technique (Mustarde’)
 Cartilage excising/scoring technique(Stenstrom)
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21. FORMATION OF UNDERDEVELOPED ANTIHELICAL FOLD
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22. CORRECTION OF CONCHAL BOWL HYPERTROPHY
 Furnas in 1968
Source:Atlas of Operative Otorhinolaryngology and
Head and Neck Surgery: Otology and Lateral
Skullbase Surgery (Volume 1)Bachi T Hathiram,
Vicky S Khattar
CHAPTER 1:The Surgical Technique Of Otoplasty
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23. KAPLAN AND HUDSON TECHNIQUE FOR STAHL’S EAR
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24. PARTIAL AND TOTAL EAR RECONSTRUCTION
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25. EAR RECONSTRUCTION
Three key measurements
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Appropriate angle of rotation for longitudinal axis
Vertical level for upper border of ear
Horizontal distance of ear from lateral orbital
margin
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26. EXTERNAL EAR ANATOMY: SIZE AND PROPORTIONS
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27. EAR RECONSTRUCTION
Indications
 Complexcongenital ear deformities ( microtia and anotia)
and acquired deformities involving up to two-
 Congenital
thirds of the ear
 Trauma
(e.g. bites, avulsions and burns) and carcinoma
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28. MULTIDISCIPLINARY MANAGEMENT
Maxillofacial prosthetist
 Otorhinolaryngology
 Audiologist
 Radiologist
 Plastic surgeon
 Psychologist
 Speech and language therapist

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29. GENERAL RECONSTRUCTIVE OPTIONS
Stick on ear prosthesis
 Osseointegrated ear prosthesis
 Use of synthetic auricular frames
 Total autologous reconstruction
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30. EAR RECONSTRUCTION- EVALUATION OF PATIENTS
o
o
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Detailed history including age and thorough physical examination
Medical history including antenatal history
Family history : clue on any syndromic deformities
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31. EAR RECONSTRUCTION: EVALUATION OF PATIENTS
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Size, nature and location of the ear defect or deformity
Unilateral or bilateral
Symmetry of size, shape, angle of reclination (rotation from the vertical) and
elevation or projection of ear
 Availability and condition of local and regional vascularized tissues for soft-
tissue reconstruction
 Availability and condition of donor conchal and costal cartilage for structural
reconstruction
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32. EAR RECONSTRUCTION :EVALUATION OF PATIENTS
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In unilateral deficits, key aspects of normal ear are measured
Clinical photographs of both ears
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Audiology assessment
Assessment by a Prosthetist, Psychiatrist
Prosthetic options
Patient expectations and preferences
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33. SPECIAL INVESTIGATIONS AND PLANNING
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Doppler assessment of STA
Chest xray for presence of and contour of costal margin
2D templates and 3D models important for planning
Nagata has designed a series of standardized templates
Source: Scott-Brown ORL&HNS
volume 3, Plastic surgery
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34. PRINCIPLES OF EAR RECONSTRUCTION SURGERY
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Partial ear reconstruction : replacement of cartilage, skin cover
Costal cartilage : ideal for framework fabrication in total and
subtotal partial ear reconstruction
 Alloplastic materials like shaped silastic and high density porous
polyethylene implants
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35. PRINCIPLES OF EAR RECONSTRUCTION SURGERY(CONTD..)
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Defects of skin only on medial surface
Defects on skin of lateral surface
Skin-cartilage defects and full-thickness defects
Large, full-thickness middle-third defect involving helix/ antihelix
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36. TIMING OF EAR RECONSTRUCTION
 Ability of child to cooperate with post-operative care
 By 5 years of age, child’s ear achieves 87% and by 12–13 years 98% of adult size
 Nagata: two stage reconstruction (after age of 10 years and horizontal chest
circumference of ≥60 cm at level of xiphoid)
 Brent: three or four stage, at 7–10 years of age (childhood teasing) and until a
substantial amount of costal cartilage available
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37. PARTIAL EAR RECONSTRUCTION
 Upper third defects: involves helix, superior
crus and superior antihelix

and inferior
Small skin-only defects : closed directly

Medium-sized lesions : reconstructed with local skin flaps or
converted to a full-thickness triangular excision and a closing
chondrocutaneous wedge performed

Large defects : benefit from reconstruction with cartilage graft
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38. PARTIAL EAR RECONSTRUCTION: UPPER THIRD
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39. RECONSTRUCTION OF EAR- UPPER THIRD
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40. PARTIAL EAR RECONSTRUCTION
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Peripheral middle-third defects: options
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Direct closure / Wedge excision and closure
Local or regional skin flaps
Helical and conchal chondrocutaneous advancement flaps e.g.
Antia-Buch flap
 Cartilage graft in combination with a local or regional flap e.g.
Dieffenbach flap
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41. PARTIAL EAR RECONSTRUCTION
Figure. Antia-Buch helical chondrocutaneous advancement flap
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42. PARTIAL EAR RECONSTRUCTION
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43. PARTIAL EAR RECONSTRUCTION
Lower-third ear defects: affect earlobe and antitragus
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Cartilage excision and direct closure or local transposition flap
For earlobe reconstruction: skin graft - less aesthetic, graft contracture
So, cartilage batten graft inserted in a subcutaneous pocket deep to the flaps in
case of lateral defects of earlobe
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44. PARTIAL EAR RECONSTRUCTION
Conchal defects
 Partial defects: full thickness skin
grafts
 Complete defect: Swinging Trapdoor
flaps
Defects up to 1.5cm wide
 Can be excised as a wedge and closed
directly in an adult sized ear
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45. PARTIAL EAR RECONSTRUCTION
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46. AUTOLOGOUS TOTAL EAR RECONSTRUCTION
Key steps
1.Identifying and marking the ideal site for new ear
2. Making a 2D template and/or a 3D model for cartilage framework
3. Planning of soft-tissue cover at the ideal site for new ear
4.Harvesting of costal cartilage
5.Removal of remnant fibrocartilage in microtia or deformed cartilage
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47. AUTOLOGOUS TOTAL EAR RECONSTRUCTION
Key steps (Contd..)
6.Dissection and preparation of skin and/or fascial flaps to receive cartilage
framework
7.Formation of costal cartilage framework
8. Insertion of framework and inset of overlying soft tissues
9. One or more further stages of ear reconstruction, including framework elevation
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48. AUTOLOGOUS
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EAR RECONSTRUCTION
Costal cartilage for framework fabrication is harvested from the costal margin
Amount of cartilage required is estimated from features of template or model (3 or 4
costal cartilages are used, including an area of synchondrosis from the 6th and 7th
costal cartilages)
When harvested without perichondrium, the form of the costal margin may be
restored by returning diced unused cartilage into the perichondrial sleeves
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49. BRENT TECHNIQUE OF EAR RECONSTRUCTION
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50. NAGATA TECHNIQUE OF EAR RECONSTRUCTION
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51. NAGATA TECHNIQUE OF EAR RECONSTRUCTION
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52. COMPARISON OF BRENT AND NAGATA TECHNIQUES
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53. COMPLICATIONS OF EAR RECONSTRUCTION
Early complications
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Late complications
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Hematoma, pain, infection
Perichondritis
Cartilage and soft tissue necrosis
Problems with sutures
Keloids and hypertrophic scars
Hypoesthesia, cold susceptibility
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 Alopecia along scalp incision scars
Undercorrection and asymmetry
Unsatisfactory results
 Pneumothorax due to costal cartilage grafts
harvesting 
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54. Sometimes, it feels good to be different ....Thank You!
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55. REFERENCES
1.
2.
3.
4.
5.
Scott-Brown’s Otorhinolaryngology Head and Neck Surgery 8th Edition, volume 3, Plastic surgery
Scott-Brown’s Otorhinolaryngology Head and Neck Surgery 7th Edition, volume 3, Plastic surgery
Stell and Maran’s Textbook of Head and Neck Surgery and Oncology 5th Edition
Dhingra’s Diseases of Ear, Nose and throat & Head and Neck Surgery 7th Edition
Atlas of Operative Otorhinolaryngology and Head and Neck Surgery: Otology and Lateral Skullbase
Surgery (Volume 1)Bachi T Hathiram, Vicky S Khattar
6. Auricular reconstruction Nagata Method
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