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until completion of ear reconstruction to avoid
compromising the vascularity of the skin
envelope.
Surgical management of microtia
Brent technique (four stages) (Fig. 17-3)
Figure 17-3 Brent technique for
microtia reconstruction. Stage 1: A-
E.The base plate of the framework
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and the helix and the crura are
carved from autologous costal
cartilage grafts. The framework is
implanted subcutaneously. Stage
2: A, B.The lobule is created by
transposing a flap from the microtia
remnant or adjacent skin. Stage 3:
A-C.The ear is elevated and then a
skin graft is placed on its posterior
surface to increase lateral
projection from the head. Stage 4:
A-C.The tragus is reconstructed
using a contralateral composite
conchal cartilage graft, which is
then secured to the previously
placed framework.
(From Thorne CH, ed. Grabb and
Smith’s Plastic Surgery. 7th ed.
Lippincott Williams & Wilkins; 2014.
Figures 27.9-27.12.)
Stage 1: a cartilaginous ear framework is carved
from the synchondrosis of the contralateral sixth
through eighth ribs, which is then inserted into a
subcutaneous pocket beneath the retroauricular
skin.
Stage 2: lobular transposition is performed.
Stage 3: elevation of the ear framework, creation
of the retroauricular sulcus, and coverage of the
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posterior reconstructed ear with a full-thickness
skin graft.
Stage 4: conchal excavation and tragal
reconstruction.
Nagata technique (two stages)
Stage 1: a cartilaginous ear framework is carved
from the synchondrosis of the ipsilateral sixth
through ninth ribs, which is then inserted into a
subcutaneous pocket beneath the retroauricular
skin. Lobular transposition and tragal
reconstruction are both performed during this initial
stage.
Stage 2: elevation of the ear framework, creation
of the retroauricular sulcus, and coverage of the
posterior reconstructed ear with a tunneled
temporoparietal fascial flap (TPFF) and split-
thickness skin graft.
Alloplastic framework
Options
Silicone elastomer (Silastic, Cronin)
High complication rate and failure rate
Silicone is walled off by the host and
prone to extrusion and scar tissue
formation
Porous polyethylene (Medpor, Reinisch)
Porous structure allows tissue ingrowth
Superior and safer result than silicone
Major advantage is no donor site morbidity, but
higher rates of infection and extrusion compared to
autogenous reconstruction.
Coverage with a TPFF decreases the complication
rate.
Ear prosthesis
Indications: failed autogenous reconstruction,
paucity of local tissue, radiation, burn, trauma,
cancer, and in the elderly.
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Previously considered a poor option because
adhesives are required for the prosthesis to “stick”
to the patient’s head.
With the advent of osseointegrated titanium
implants, ear prostheses are now more practical
and widely used.
Requires meticulous daily hygiene to prevent the
skin-abutment interfaces from becoming
inflamed/infected.
Postoperative care
Closed-suction drainage system to avoid pressure
dressings, which may cause skin necrosis
Close monitor for hematoma or infection
Complications
Skin necrosis
Causes: tight pressure dressings or raise too thin
of a flap when creating subcutaneous pocket
Management:
Partial-thickness necrosis: conservative
management with local wound care
Full-thickness necrosis: excisional
débridement and local flap coverage
Infection
Early recognition and treatment are the mainstay
of therapy.
Superficial infections can sometimes be
managed nonoperatively with antibiotics alone.
Deep infections (ie, gross purulence or
suppurative chondritis) require irrigation of the
subcutaneous pocket, drain placement, and
removal of the ear framework.
Hematoma
Classically presents as sudden onset unilateral
ear pain.
Treatment is immediate clot evacuation.
Hypertrophic scarring
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Commonly occurs at the chest wall donor site
Design incisions that will not interfere with future
breast growth
Hair growth
Commonly occurs in patients with a low temporal
hairline.
Our preferred treatment is preoperative laser hair
ablation.
Pneumothorax
Can be evacuated using a red rubber Robinson
catheter.
Rarely requires placement of a thoracostomy tube.
Chest plain film is obtained in recovery and on the
first postoperative morning.
Chest wall deformity
Usually more noticeable in thinner patients and
when more donor rib cartilage is harvested.
Cartilage may regenerate if the perichondrium is
left intact.
Resorption of cartilage graft
Usually due to infection or a tight, restrictive skin
envelope.
If severe, may require regrafting.
Most cartilage grafts retain their size and shape or
grow slightly larger over time.
Prominent Ear (Fig. 17-4)
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Figure 17-4 Comparison of normal and
prominent ear anatomy. (From Thorne
CH, ed. Grabb and Smith’s Plastic
Surgery. 7th ed. Lippincott Williams &
Wilkins; 2014. Figure 49.1.)
Epidemiology
Affects ~5% of the general population
Most likely hereditary but can be associated with fragile
X syndrome
Anatomic causes
Underdeveloped antihelical fold
*Most common cause of prominent ear
Definition: conchoscaphal angle more than 90°
Results in prominence of the upper third of the ear
Conchal hypertrophy
Definition: excess conchal cartilage (more than 1.5
cm deep)
Results in prominence of the middle third of the
ear
Protruding lobule
Least common cause of the prominent ear
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Results in prominence of the lower third of the ear
*In newborns less than 6 weeks of age, ear molding can
be performed to help reshape the deformed ear
Circulating maternal estrogens lend malleability to
the ear cartilage.
Soft putty is shaped into a custom mold that can be
adjusted as the newborn grows (worn for several
weeks to months).
Surgical management of the prominent ear
Timing: 6-7 years of age (similar to microtia); when
patient can participate in the decision for surgery and
comply with postoperative restrictions
The type of otoplasty performed will depend on the
anatomic abnormality present; often more than one
technique is required
Cartilage-scoring techniques
Gibson and Davis law: cartilage bends away from
the scored surface due to the release of intrinsic
stresses
Stenström: anterior scoring via an anterior
approach
Chongchet: anterior scoring via a posterior
approach
Cartilage-suturing techniques
*Conchoscaphal (Mustardé) sutures: recreate
the antihelical fold using permanent mattress
sutures, thereby reducing upper-third
prominence.
*Conchomastoid (Furnas) sutures: reduce the
auriculocephalic angle, and consequently
middle-third prominence, using permanent
mattress sutures.
Cartilage-incising or -excising techniques
A powerful tool in patients with stiffer ear cartilage
or those with very severe deformities, but the
major drawbacks are palpable step-offs and an
overly chiseled appearance
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Converse-Wood-Smith: recreates the antihelical
fold by first incising the cartilage and then placing
permanent mattress sutures
Luckett: similar to Converse-Wood-Smith, except
that a crescent-shaped piece of skin and cartilage
is excised
Lobule repositioning
Correction of upper- and middle-third prominences
may reveal or accentuate prominence in the lower
third of the ear.
Webster: repositions the helical tail next to the
concha but is often ineffective because the helical
tail does not extend into the lobule.
Other techniques involve either fusiform, wedge,
or fishtail excisions on the posterior surface of the
lobule, and then suturing the fibrofatty tissue of the
lobule to either the concha or mastoid periosteum.
Postoperative care
Avoid any trauma to the ears.
Head-band protocol: wear head band for protection of
ears at all times for 3-4 weeks. Afterward, wear the
headband at bedtime and when engaging in physical
activities for 3 months.
Complications
Recurrence
More common in patients with stiffer ear cartilage.
Early recurrence is most likely due to suture
pull-through or suture breakage.
Asymmetry and contour irregularity
More common with cartilage-incising or -excising
techniques.
Telephone deformity: relative upper- and lowerthird prominences of the ear caused by either
overcorrection of the middle third or
undercorrection of the upper and lower thirds.
Hidden helix: the helix is unable to be seen on
frontal view due to overcorrection of the upper and
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middle thirds.
Infection
Superficial infections can sometimes be managed
nonoperatively with antibiotics alone.
If not recognized early, suppurative chondritis may
develop leading to cartilage loss and residual
deformity.
Spit sutures can be irritating and should be
removed.
Hematoma
Classically presents as sudden onset unilateral ear
pain.
Treatment is immediate clot evacuation.
Keloids
More common in dark-skinned patients.
Treat initially with pressure earrings and steroid
injections.
In severe cases, surgical excision and
postoperative radiotherapy may be required.
Other Congenital Ear Deformities
Cryptotia (Fig. 17-5A)
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Figure 17-5 Congenital ear
deformities. A. Cryptotia. B. Stahl ear.
C. Constricted ear.
(From Thorne CH, ed. Grabb and
Smith’s Plastic Surgery. 7th ed.
Lippincott Williams & Wilkins; 2014.
Figure 49.4.)
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