Article

Management of Congenital Auricular Anomalies

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Abstract

Learning objectives: After studying this article, the participant should be able to: 1. Describe normal ear anatomy and development, and evaluate the patient's ears for differences in shape, size, prominence, and symmetry. 2. Identify common congenital ear deformities, including prominent ear, macrotia, Stahl ear, cryptotia, constricted ear, and lobule anomalies. 3. Describe both early nonoperative management and operative techniques for correction of these ear deformities. 4. Be aware of advantages and disadvantages of common and emerging techniques for correction of pediatric ear deformities. Summary: Whereas severe ear malformations such as microtia/anotia are rare, other ear deformities, such as prominent ear, Stahl ear, and cryptotia, are common. Although these ear deformities result in minimal physiologic morbidity, their psychological and cosmetic impact can be significant. Identifying these common deformities and understanding how they differ from normal ear anatomy is critical to their management. In cases where a deformity is identified in neonatal life, ear molding may obviate the need for surgery. Although various surgical techniques have been described for correction of common ear deformities, the surgeon should follow a careful stepwise approach to address the auricular deformity or deformities present. By using such an approach, complications may be minimized and predictable aesthetic outcomes achieved.

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... The exact bio-mechanism by which SO 2 exposure during conception increases the risk of congenital ear malformations in offspring is still unclear. The auricle develops from the first and the second branchial arches during the embryonic period of 5-9 weeks [28], so it is generally considered to be the joint site of action for the pathological occurrence of congenital microtia [1]. The influencing mechanism behind various risk factors, including air pollution, may be the abnormal migration of cranial neural crest cells that leads to the occurrence of congenital microtia [29]. ...
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Objectives: To examine associations between maternal sulfur dioxide (SO 2 ) exposure and congenital ear malformations risk in offspring. Methods: We surveyed 1676 cases with congenital ear malformations and 7950 controls from the Maternal and Child Health Certificate Registry of Liaoning Province between 2010 and 2015. SO 2 concentrations were obtained from the Municipal Environment Protection Bureau of Liaoning Province. Multivariable logistic regression models and Restricted cubic splines (RCS) model were used to assess the aforementioned association. Results: There were significant associations between maternal SO 2 exposure and congenital ear malformations risk during the 3 months before conception (OR Q4 vs. Q1 = 1.93, 95% CI = 1.43–2.59) and the 3 months after conception (OR Q4 vs. Q1 = 1.63, 95% CI = 1.22–2.18). Similar results were obtained in the analysis of single-month exposure windows, except for the third month before conception and the third month after conception. Moreover, these findings were broadly consistent across subgroups and robust in sensitivity analyses. There were non-linear dose-response associations between SO 2 exposure and congenital ear malformations based on restricted cubic spline model analysis. Conclusion: Maternal SO 2 exposure is associated with increased congenital ear malformations risk in offspring.
... With our review, we can only hope to stimulate health insurances to recognize the potential of early nonoperative correction of congenital ear anomalies and start to consider ear molding as a preventive measure not only for surgery, but also for psychosocial consequences related to congenital ear anomalies, later in life. 6 In conclusion, there is a need for acknowledgement of the psychosocial effects of congenital ear anomalies and the advantages of early nonoperative correction methods by health insurance companies internationally. ...
Objective Complex and invasive postoperative pain regimens for microtia reconstruction with costal cartilage are often utilized. These generate added costs and invasiveness. We evaluated the effectiveness of a de-escalated pain regimen without use of invasive interventions. Methods Case series of patients who underwent stage 1 microtia reconstruction with a modified Nagata/Firmin technique from 2017-2020 at a pediatric tertiary care hospital. Patients received intraoperative bupivacaine intercostal blocks and scheduled acetaminophen. Adjunct medications administered and pain scores (Wong-Baker FACES and FLACC-Face, Legs, Activity, Cry, Consolability) at intervals 2–72 h postoperatively were recorded. Narcotic use, peak and median pain scores, and length of stay were compared with published values. Results Twenty patients were included. Mean age of 12 and length of stay of 2.8 days. Average postoperative FACES scores between 0- 72 h ranged between 0.7- 4.0. The average peak pain score was 6.1 (±2.0). FLACC scores were low. Narcotics (.59 ±0 .35 Morphine Milligram Equivalents/kg) were given to 17 patients. Compared to Shaffer et al. (paravertebral catheter-based infusion), total narcotics use (p = 0.03), peak pain (p = 0.0001), and length of stay (p = 0.001) were less. Compared to Woo et al. (intercostal catheter-based infusion), median pain scores at identical time intervals were lower (p = 0.04). Conclusion Intraoperative intercostal nerve blocks followed by scheduled, weight-based acetaminophen, adjunctive medications (ibuprofen and lidocaine patches), and rescue narcotics are effective in managing pain following microtia repair with autologous costal cartilage. It results in decreased narcotic usage, shorter length of stay, and lower pain scores compared to more complex regimens.
Article
Background: Inspection and evaluation of the neonate's ears are important parts of the neonatal examination. Neonates display a wide variety of ear size and configuration. In many cases, ear molding techniques obviate the need for future surgical correction. This article provides a review of the fetal ear development and describes common physical examination findings of the newborn's external ear. A case report reviews a successful nonsurgical treatment of a minor ear deformity. Clinical findings: Newborn infant with near absent to very thin bilateral helical rims and otherwise normal bilateral ear shape and structures. Primary diagnosis: Bilateral Stahl's ear deformity. Interventions: The EarBuddies product was applied to bilateral ears in an outpatient pediatric plastic surgery clinic. This product remained in place for 8 weeks. Outcomes: The family was pleased with the overall progress and shape of their child's ears. At 18 months of age, the family has no desire to pursue surgical correction of their child's ears. Practice recommendations: Assessment of the newborn's external ear is part of a routine admission examination. Careful attention to abnormal or unusual findings allows for prompt evaluation and nonsurgical intervention.
Article
Résumé L’examen des oreilles en anténatal fait partie intégrante de l’examen approfondi de la face fœtale. La découverte d’une anomalie, qu’elle soit faite de manière fortuite ou lors d’un examen approfondi complémentaire, amène l’échographiste à déterminer son caractère isolé ou associé, pour ainsi caractériser son éventuelle appartenance à une entité syndromique. Dans ce contexte, la réalisation d’analyses génétiques maintenant plus précises et plus larges permettant un rendu des résultats dans un délai compatible avec une grossesse évolutive, donne au couple prénataliste - généticien un rôle central dans la prise en charge de ces couples. Le principal challenge réside dans l’obtention d’un faisceau d’indices cliniques et biologiques concordants, permettant d’interpréter correctement les résultats génétiques identifiés. Il en découle alors une information complexe à délivrer, dans le fait où la traduction clinique d’une anomalie des oreilles en anténatal peut être envisagé depuis une anomalie esthétique isolée jusqu’à un potentiel syndrome génétique avec trouble du neuro-développement. L’objectif de ce travail est de décrire, à partir d’une analyse méthodologique des oreilles en anténatal, les entités malformatives accessibles, isolées ou associées, et de discuter des problématiques inhérentes à la nécessité ou non de proposer leur dépistage.
Article
Background Prominent ear deformity occurs in 5% of the general population and has been treated by otoplasty for many years to address the psychosocial challenges of having such a deformity. There is extensive literature but no consensus on the best method to address potential surgical complications, including suture extrusion. Objectives In this article, we describe a surgical technique designed to reduce suture extrusion following otoplasty surgery by using free soft tissue grafts placed between Mustardé sutures and post-auricular skin. Methods Two hundred eleven patients who underwent otoplasties using soft tissue grafts from January 2017-January 2020 were included in this study. All surgeries were performed by 2 facial plastic surgeons with more than 20 years of experience each, practicing in Toronto. Patients were followed up to assess for suture extrusion between 12-36 months (median, 21 months) postoperatively. The rate of suture complications and extrusion was compared to previous literature. Results Only 2 patients out of 211 (0.47%) had unilateral suture extrusion and were treated with suture removal. This is dramatically lower than the upper values reported in literature, averaging 5.55% (range, 0%-22.2%). Conclusions A soft tissue graft separating the Mustardé sutures and post-auricular skin acts as a barrier, which can be used in conjunction with traditional surgical techniques. By adding this graft in the proposed manner, there is additional tissue reinforcing the suture repair, thereby reducing the rate of suture complications and extrusion without increasing operative time.
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Background: Congenital microtia is a common congenital disease in children, the cause of which is still unclear. At present, the main treatment for congenital microtia is ear reconstruction. Accurately locating of the reconstructed ear on the affected side before ear reconstruction surgery is difficult, while it is the key of successful operation. Our ear reconstruction team has developed a novel method to accurately locate the reconstructed auricle. This novel method has achieved good results in clinical practice. Methods: Thirty patients with unilateral ear reconstruction, who underwent auricle reconstruction using our invented auricle reconstruction positioning method in the Plastic Surgery Hospital of Chinese Academy of Medical Sciences from January 2020 to July 2021, were enrolled in this study. Results: Through Wilcoxon signed rank test, we found that there was no statistical difference between the mean distance from the highest point of the patient's normal ear to the central axis of the nose and that from the highest point of the reconstructed ear to the central axis of the nose (P>0.05). Meanwhile, there was no statistical difference between the mean distance from the lowest point of the patient's normal ear to the central axis of the nose and that from the lowest point of the reconstructed ear to the central axis of the nose (P>0.05). The satisfaction rate of patients and their families to the location of the reconstructed auricle was 100%. Conclusions: The novel method of locating the reconstructed auricle employs simple materials. The implementation process is easy, and the effect is significant. To a certain extent, it solves the difficulty of locating the reconstructed auricle in ear reconstruction operation. Although this method can only be applied to patients with unilateral microtia, we recommend it for locating the reconstructed auricle by every plastic surgeon.
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Puntos para una lectura rápida •La mayoría de las deformidades auriculares no suelen resolverse espontáneamente con el crecimiento, y la deformidad se mantiene a lo largo de los años. •Las orejas prominentes son la deformidad auricular más frecuente: aproximadamente el 45% de todas las deformidades auriculares. Son las más difíciles de identificar en el periodo neonatal. •La ferulización precoz, antes de las 2 semanas de vida, de las deformidades auriculares puede evitar el 90% de las cirugías futuras. •Se recomienda posponer el tratamiento quirúrgico de las deformidades auriculares a que el niño alcance la madurez suficiente, generalmente a partir de los 6 años.
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Background:. The Earfold system, a new treatment for the correction of prominent ears, consists of 3 components: the Earfold implant, the Earfold introducer, and the Prefold positioner. Methods:. This is an interim report based on an ongoing analysis of safety in a series of patients treated for prominent ears with the Earfold implant between February 2013 and September 2014. Safety was assessed based on adverse event reports and the need for implant revision; follow-up is ongoing. Results:. Seven surgeons used 1,200 Earfold implants to treat 403 patients (ages, 7–70 years; 63% male); the time since the initial implant procedure now ranges from 30 to 48 months. To date, 145 patients (36%) have returned for a follow-up visit (mean, 7.7 months [range, 1–34 months]). Adverse events requiring intervention have affected 39 of 403 (9.7%) patients; these include implant revisions (n = 17 [4.2%], most often due to implant visibility), skin erosion over the implant (n = 15 [3.7%]), and infection (n = 7 [1.7%]). Bleeding, recurrence of prominence, hematoma, deformity, or adverse scarring did not occur. Conclusions:. This interim analysis has shown that Earfold prominent ear correction system is associated with relatively few adverse events that require intervention; a small number of patients experienced infection, implant extrusion, or implant visibility that required revision. Most adverse events were related to either patient selection or technical errors at implantation. It is expected that with continued use of Earfold by surgeons experienced in otoplasty, the adverse event incidence will decrease.
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Congenital auricular anomalies can be categorized either as malformational or deformational. The first are characterized by a partial absence of the skin or cartilage resulting in a constricted or underdeveloped pinna and require surgical correction. Deformations are characterized by a misshaped but fully developed pinna and are best treated by auricular molding. Authors want to present their case load in treatment of infants affected by deformational auricolar anomalies and describe their techniques using early splinting for congenital auricular deformities, like prominent ear, lop ear, constricted ear, Stahl's ear Between 2009 to 2011, in Maxillo and Oral Surgery Unit, a nonsurgical technique was used to treat 22 ears affected by deformational anomalies in 12 patients soon after birth. Four patients were female. This kind of nonsurgical correction of the deformed auricle was performed on lop ears (n=6), constricted ears (n=8), prominent ears (n= 4), Stahl's ear (n=4). Children more than two months old were also excluded. The mean of treatment time was 5.5 weeks. according to the Authors and the parents 100% of treated auricles improved. Improving at the end of the molding treatment was observed in 18% of the auricles, but recurrence to one year of stopping treatment. There were not complications caused by this procedure. The nonsurgical molding has the advantage to correct at a very early age a cosmetic abnormality, giving a natural and in the most of the time a satisfactory results, with a prevalence rate of complications of much less than surgical corrections.
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Congenital auricular anomalies are heterogeneous, with various descriptive and eponymous terms being used. Current classification systems are useful in guiding surgical treatment of severe anomalies. However, they do not generally account for the less severe anomalies, which form the majority of congenital auricular anomalies, nor their contemporary treatment. In this article, the authors review the anatomy and embryology of the external ear and propose a simple classification of congenital auricular anomalies that encompasses all forms of congenital auricular anomalies, facilitates proper diagnosis, and guides treatment. Congenital auricular anomalies should be classified as malformational or deformational anomalies. Malformational auricular anomalies are caused by embryologic maldevelopment that occurs between the fifth and ninth week of gestation resulting in deficient and/or supernumerary auricular components. Deformational auricular anomalies result from in utero or ex utero deformational forces, including those caused by an aberrant insertion of the intrinsic or extrinsic auricular muscles. Malformational auricular anomalies generally require surgical correction during childhood or adolescence. For practical purposes, deformational auricular anomalies have a full complement of chondrocutaneous components that can be digitally manipulated to a normal shape. These anomalies are best treated by auricular molding, which is effective if it is initiated within the first 3 months of life. Deformational auricular anomalies are best regarded as a pediatric public health issue and are best managed nonsurgically. Education of neonatal pediatricians, obstetricians, family doctors, and midwives will allow proper early diagnosis of all congenital auricular anomalies, which is vital to appropriate treatment. These practitioners should be encouraged to manage deformational auricular anomalies early in life so that surgery can be largely avoided in these patients.
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Age-related growth changes in the ear were analyzed by measuring the width and length of ears in 1,590 North American Caucasians between 1 year and 18 years of age. By 1 year, ear width reached 93.5% of adult size in both sexes, only 2.3 mm less than the mean value at 18 years. In contrast, ear length attained a developmental level of only 76.4% by 1 year in both sexes, requiring an increment five times greater (12.3 mm) to reach the size of the ear at 18 years of age. At 5 years, the developmental level in width (96.7%) was almost equal to that of an adult, while the length reached 86.6% in both sexes, and requires 8.2 additional millimeters to attain adult size. Annual growth increments in ear width are small, interrupted with a few periods of no growth. Ear length in males showed an early rapid growth rate (between 2 and 3 years); subsequent growth was generally limited, interrupted with short periods of no changes. The same growth pattern appeared in females. Ear width reached its mature size in males at 7 years and in females at 6 years; ear length matured in males at 13 years and in females at 12. At the time of maturation, the ear was shorter than at 18 years by a mean of 1.1 to 1.4 mm.
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The technique of using permanently buried mattress sutures to form or reform an antihelix fold is described and illustrated.
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Background The earlobe demonstrates stereotypical signs of aging, including wrinkles and volume depletion. Objectives The purpose of this study is to review the outcome of the earlobe rejuvenation developed by the senior author. Methods We describe our earlobe rejuvenation technique refined over 10 years that uses fat grafting to the earlobe. Three raters assessed preoperative and postoperative photographs of 40 earlobes in 20 patients. Each earlobe was evaluated for volume deficiency, number of deep creases, depth of creases, and number of fine wrinkles. Inter-rater reliability was calculated. Earlobe length was also measured. Results Seventeen females and 3 males with average age of 63 years were followed for an average of 26 months. Postoperative improvements were observed in earlobe volume deficiency and number of fine wrinkles (P < .05). Improvements were seen in number and depth of creases and the earlobe height, but these were not significant (P > .05). No complications relating to the earlobe were observed in these patients. Conclusions Fat grafting can be an effective means for earlobe rejuvenation. Level of Evidence 4 Therapeutic
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The authors describe a reconstructive method for the earlobe using a local flap with a cartilage graft. Primarily, cartilage of the concha was transplanted to the mastoid region. Secondarily, about three months later, the anterior surface of the new earlobe was made by a flap taken from the mastoid region with the transplanted cartilage. The posterior surface of the new earlobe was made by a local flap from the postauricular and temporal regions. The donor site was closed directly by a local advanced flap. This method requires no skin graft. This technique of using a local flap with cartilage graft gives us good color, texture and appearance and prevents contracture.
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Background: The term 'constricted ear' was coined by Tanzer. The classification and corrective methods for these malformations, however, continue to be controversial. To clarify them, we have reviewed and analyzed cases operated at our Center from January 1992 to January 2014. Methods: A total of 164 ear cases (involving 139 patients), showing features of lidded helix, compression of scapha and fossa triangularis, and/or cup-like protrusions were included in our study (constricted ear-featured microtias were excluded) and reviewed through medical records, photographs, analysis of surgical methods, and postoperative outcomes. Results: The deformed ears were classified into four graded types by antihelical tubing test and scapha-helix push test: Type I (n=21), Type II (n=63), Type III (n=38), and Type IV (n=42). Throughout our series, we've continued the improvement and performance of consistent operative techniques. Antihelical tubing, concha cartilage grafting, tumbling concha-cartilage flap, antihelical wrapping, or helical expansion were the preferred techniques. A total of 144 ear cases (88%) were followed up between 1 month and 14 years (an average of 13.2 months). The average score of aesthetic outcomes, rated on a 4-point Likert scale (1=poor, 2=fair, 3=good, 4=excellent) was 3.3 points. Corrective methods and aesthetic outcomes for patients with each graded type of deformity were described. Conclusion: Constricted ears were effectively corrected by a graded surgical approach. All corrections were performed in one stage, without removal of deformed auricular cartilage (though some of them were made with the addition of conchal or costal cartilage).
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Background: Otoplasty for prominent ears is a routine procedure that is generally met with satisfaction by patients and family members. A significant percentage of patients requesting otoplasty, however, have some degree of macrotia in addition to protruding ears. Combining ear reduction with traditional otoplasty allows correction of these deformities. There are few studies in the literature that describe ear reduction, and those that do, describe small subsets of patients. Methods: A retrospective review was performed of the senior author's (C.H.T.) otoplasty procedures from 2010 to 2013. Charts were reviewed for patient demographics, preoperative assessment, surgical technique used, complications, and need for revision. All otoplasty procedures, primary or secondary, were included in the series. Results: Over a 3-year period, 84 total otoplasty procedures were performed. Of these, 30 patients had some degree of scaphal reduction as a component of the procedure. Five patients (6 percent) also had shortening of the earlobes in addition to the scaphal reduction. Nineteen of the patients (23 percent) had an otoplasty previously (none performed by the senior author) but were not completely satisfied. Complications of reduction otoplasty were limited to a single patient with a suture protrusion behind the ear. None of the patients in this series have required reoperation. Conclusions: Scaphal reduction to modify the contour of the upper auricle and/or decrease the overall size of the ear can be a valuable adjunct to otoplasty and may be indicated in a larger than expected percentage of patients presenting for otoplasty. Clinical question/level of evidence: Therapeutic, IV.
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It has been suggested that there is a close association of abnormality in auricular muscles with various congenital auricular deformities. However, there has been no investigation to determine what muscles are involved and how they affect the deformity. The authors examined abnormalities of auricular muscles for patients with various auricular deformities. The authors examined 77 auricles of 62 patients with congenital auricular deformities, including cryptotia, Stahl's ear, prominent ear, lop ear, and others. The superior and posterior auricular muscles from the extrinsic auricular muscle group and the auricular oblique and transverse muscles from the auricular intrinsic muscle group were investigated. The authors found characteristic features of the abnormality of the muscle for each auricular deformity. In nearly all cases of cryptotia, abnormality was found in the superior auricular, auricular oblique, and auricular transverse muscles. Abnormal insertion was found mainly in the superior auricular muscle and was the main cause of cryptotia. In Stahl's ear, the major abnormality was abnormal insertion of the auricular transverse muscle, which creates an abnormal cartilaginous prominence in the scapha. The abnormality in cases of prominent ear was clearly limited mostly to the auricular transverse muscle and, in some cases, to the posterior auricular muscle. In lop ear, abnormality was mostly found in the auricular transverse muscle, with elongation, and in the superior auricular or auricular oblique muscle in some cases. There is a tendency for a specific muscle abnormality to be found in each deformity. It is important to identify the abnormal muscle and correct the abnormality during the operation.
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Secondary to circulating maternal estrogens, a baby's ear cartilage is unusually plastic during the first few weeks of life, providing an opportunity to correct ear deformities by molding. If molding is initiated during the first days of life with a more rigid molding system than previously described in the literature, the authors hypothesized that treatment time would be reduced and the correction rate would increase. An interdisciplinary team identified and assessed all infants born with ear deformities at New York-Presbyterian Hospital/Weill Cornell Medical Center. The authors conducted a prospective, institutional review board-approved study on the first consecutive 100 infants identified. Parents were surveyed initially, immediately after treatment, and at 6 and 12 months. One hundred fifty-eight ears in 96 patients underwent ear molding using the EarWell Infant Ear Correction System. Eighty-two percent of the children had the device placed in the newborn nursery and 95 percent had it placed before 2 weeks of life. Average treatment time was 14 days, and 96 percent of the deformities were corrected. Complications were limited to mild pressure ulcerations. Ninety-nine percent of parents stated that they would have the procedure repeated. The molding period can be reduced from 6 to 8 weeks to 2 weeks by initiating molding during the first weeks of life and using a more secure and rigid device. Through an interdisciplinary approach, the authors were able to identify patients and to correct the deformity earlier and faster than has been previously published, eliminating the need for surgical correction in many children. Therapeutic, IV.
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Learning objectives: After reviewing this article, the participant should be able to understand: 1. The epidemiology and genetics of microtia. 2. Refinements in surgical technique for microtia. 3. Outcomes of treatment. 4. Challenges in treatment selection, hearing restoration, surgical training, and tissue engineering. Summary: Microtia reconstruction is both challenging and controversial. Our understanding of the epidemiology and genetics of microtia is improving. Surgical techniques continue to evolve, with better results. Treatment selection continues to be controversial. There are strong proponents for reconstruction with costal cartilage, Medpor or a prosthesis. More realistic models for teaching surgeons how to do the procedures are becoming available. Our approach to hearing rehabilitation is changing. Better solutions using percutaneous and implantable devices are under evaluation to help both unilateral and bilateral microtia patients. Tissue engineering will offer some exciting new treatment possibilities in the future.
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For the correction of constricted ears many techniques are described in the literature, the majority based on Tanzer’s classification of 1975. The improvements in ear reconstruction published by Brent, Nagata, Firmin and Park make better outcomes possible. It is therefore that a new classification for constricted ears is proposed, together with a alternative technique for correction of group IIA and IIB deformities, using a T-strut of costal cartilage to reconstruct the underdeveloped or missing superior crus of the antihelix.
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Twenty years experience with the tubing technique has proved it to be reliable and adaptable to the usual abnormalities associated with the protruding ear. The technique is especially dependable when all components of the auricle are involved, when the antihelical fold is absent, and there is a large or protruding concha. The recurrence rate of 2.6% is quite acceptable when compared with other techniques.
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Otoplasty can be performed safely and effectively under local anesthesia in children as young as 5 years of age. Child preparation, local anesthetics, detailed infiltration technique, surgical procedure, and complications are discussed.
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Cryptotia is one of the most common auricular anomalies among East Asians and it is frequently associated with upper auricular malformation. Various surgical techniques have been described in the literature, such as V-Y plasty, Z-plasty, skin grafts, local skin flaps, and so on. Although relatively favorable results were obtained by these techniques, some problems remain, such as conspicuous scars, undercorrected or noncorrected auricular cartilage deformities, irregular contour, hair growth, and shallow auriculocephalic sulcus. Because both skin deficiency and cartilage deformities must be corrected for cryptotia with upper auricular deformity, the author has developed new surgical techniques, namely double V-Y advancement flap and cartilage strut graft techniques. These methods provide enough skin to the deformed areas and also good auricular contour with expanded upper auricular portion.
Article
1.Autogenous cartilage as a grafting material for nasal bridge reconstruction has largely fallen into disuse because of the high incidence of distortion. An analysis of ninety-one of Professor T. P. Kilner's cases showed that about two-thirds warped to some extent within one or two weeks after operation, although the grafts had been freed from fibrous perichondrium before insertion.2.Experiments in vitro demonstrated that in rib cartilage a state of tension exists in which the taut outer layer of cartilage acts as a "skin" which controls the tendency of the main mass to expand.3.Distortion results from the contraction of the outer layer when the rib is so carved that the natural equilibrium is upset. In this the fibrous perichondrium plays little or no part.4.The "principle of the balanced cross-section" has been introduced: if the distorting forces are balanced at all points along a cartilage graft as viewed in cross-section it will not warp.5.Applying this principle, methods are detailed whereby stable grafts for nasal bridge reconstruction may be obtained.6.Although the amount of carving permissible is limited, the shape and size of the costal margin cartilages are peculiarly suitable for nasal bridge grafts.7.Forty-six grafts, carved according to the principle of the balanced cross-section, have been inserted during the past three years, and none has become distorted.8.When used as described, autogenous rib cartilage is considered to be the material of choice in nasal bridge restoration.
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Background: The earlobe plays an important part in the aesthetic appearance of the auricle. Congenital cleft earlobe may vary considerably in severity from a simple notching to extensive tissue deficiency. Most patients with cleft earlobe require surgical correction because of abnormal appearance. In this article, a new surgical technique for correcting congenital simple cleft earlobe using diametric hinge flaps is introduced. Methods or design: We retrospectively reviewed 4 patients diagnosed with congenital cleft earlobe between 2008 and 2010. All of them received this new surgical method. The patients were followed up from 3 to 6 months. All patients attained relatively full bodied earlobes with smooth contours, inconspicuous scars, and found their reconstructed earlobes to be aesthetically satisfactory. One patient experienced hypoesthesia in the area operated on, but recovered 3 months later. No other complications were noted. Conclusions: This simple method not only makes full use of the surrounding tissues to reconstruct full bodied earlobes but also avoids small notch formation caused by the linear scar contraction sometimes seen when using more traditional methods.
Article
Cryptotia is a congenital anomaly in which the superior aspect of the helical cartilage is buried beneath the scalp, resulting in an absence of the auriculocephalic sulcus. Treatments have included splinting, skin grafts, and a variety of local flaps. We present a modification of the trefoil flap, initially described by Wesser in 1972. The modifications include wider undermining of the opposing trefoil flap (≤ 2-4 cm), staggering the closure of the helical apices, and expanding the base of the auricular trefoil flap such that it extends over a larger circumference of the helical rim. The senior author (K.S.) has achieved excellent results with this method and has alleviated the need for skin grafts or local preauricular flaps to close the donor site.
Article
Although the physiologic effects of ear deformity are negligible, the aesthetic and psychological impact on the patient can be profound. Significant ear malformations are prevalent in today's society and affect more than 5 percent of the population. Although the prominent ear results from either underdevelopment of the antihelix or an enlarged conchal bowl, the constricted ear is a product of helical down-folding and height deficiency. After a thorough evaluation, surgical management of the prominent ear must be approached in a careful, rational fashion. Although the surgeon may enjoy the wide latitude that hundreds of corrective techniques offer, he or she must always proceed with an algorithmic application of technique best suited to the specific auricular deformity. By using this approach, correction of the prominent ear can go beyond patient satisfaction to predictably maximize outcome in both form and symmetry. From the clinical evaluation and anatomical basis to surgical management of the deformed ear, the true art of otoplasty is in the surgeon's ability to thoroughly understand auricular structure and appropriately apply technique for maximal aesthetic outcome.
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The correction of an unfavorable outcome after otoplasty requires a thorough understanding of the anatomy of prominent ear and recognition of the spectrum of secondary deformities and their origin. The goal of this article is to describe the causes of postotoplasty deformity, including both undercorrection and overcorrection. The latter presents the more complicated reconstructive problem, as both skin shortage and permanent cartilage disruption need to be addressed. The authors propose an algorithm for revision otoplasty based on clinical findings and patient concerns. Finally, a case with overcorrection secondary to both skin deficiency and cartilage disruption is illustrated showing the sequential steps needed for optimal correction.
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Microtia, prominent ear, and cryptotia are the most common types of auricular malformations. This review provides updated information on these types of reconstructions, in addition to recalling previously accepted surgical methods. Autogenous costal cartilage is still considered as an ideal material for framework fabrication in microtia reconstruction. Many surgeons have adopted the Nagata approach, the Brent approach, or variations of the two, in their work. With these employed techniques, auricles reconstructed by experienced surgeons have proven to be aesthetically promising. However, with regards to the harvesting of the costal cartilage, the underdevelopment of the chest wall donor site, alopecia of the scalp, and scarring of the postauricular-mastoid region are still considered problematic aspects of these approaches. Some articles have described attempts to solve these problems, whereas some experiments in cartilage production using tissue engineering techniques have shown promise in their initial stages of development.It is generally accepted that prominent ears should be corrected through a combination of sculpting and suture techniques, according to the individual shape and the quality of the ear prominence.Most of the cryptotia malformations show not only embedded upper auricles, but also associated adhesions of the upper auricular cartilage. Their correction should therefore resolve both deformities. A number of articles highlighting clinical experiences with auricular reconstructions for microtia, prominent ear, and cryptotia have been included in this review. We believe that the information synthesized here will become a basis for further development of auricular reconstruction techniques.
Article
A review of a single physician's experience in managing over 831 infant ear deformities (488 patients) is presented. The authors' methods of molding have advanced from the use of various tapes, glues, and stents, to a comprehensive yet simple system that shapes the antihelix, the triangular fossa, the helical rim, and the overly prominent conchal-mastoid angle (EarWell Infant Ear Correction System). The types of deformities managed, and their relative occurrence, are as follows: (1) prominent/cup ear, 373 ears (45 percent); (2) lidding/lop ear, 224 ears (27 percent); (3) mixed ear deformities, 83 ears (10 percent) (all had associated conchal crus); (4) Stahl's ear, 66 ears (8 percent); (5) helical rim abnormalities, 58 ears (7 percent); (6) conchal crus, 25 ears (3 percent); and (7) cryptotia, two ears (0.2 percent). Bilateral deformities were present in 340 patients (70 percent), with unilateral deformities in 148 patients (30 percent). Fifty-eight infant ears (34 patients) were treated using the final version of the EarWell Infant Ear Correction System with a success rate exceeding 90 percent (good to excellent results). The system was found to be most successful when begun in the first week of the infant's life. When molding was initiated after 3 weeks from birth, only approximately half of the infants had a good response. Congenital ear deformities are common and only approximately 30 percent self-correct. These deformities can be corrected by initiating appropriate molding in the first week of life. Neonatal molding reduces the need for surgical correction with results that often exceed what can be achieved with the surgical alternative.
Ear reconstruction is considered to be a challenging form of surgery. In cases of microtia, surgeons must reconstruct complex missing contours, which necessitates the use of a support and skin remnants to cover this support. Although the use of synthetic material has been proposed in order to avoid harvesting and carving cartilage, the best long-term choice for reconstructing an ear is autologous rib cartilage. This procedure requires good understanding of the 3-dimensional architecture of the ear and learning the step-by-step construction of a harmonious framework (which with practice will become the most straightforward part of the procedure). Surgery, usually performed at the age of 9 or 10 years, is planned in 2 stages. In the first stage, the framework is placed under a skin pocket. Six months later, the sulcus is created using an additional cartilage graft for projection and a skin-grafted galeal fascial flap. In order to shorten the learning curve, a detailed carving process is described here, as well as a tool to enable training before surgery. Remnants of the microtic ear can have many different shapes; therefore, a comprehensive approach to skin management is proposed, providing a simple surgical classification for all types of microtia. Furthermore, some refinements of the cartilage framework and the construction of the retroauricular sulcus have improved results. Whenever possible, successful reconstruction of a microtic ear with autologous rib cartilage, as opposed to synthetic materials, is by far the best option.
Article
The author carried out follow-up studies on 167 patients who had had otoplasties for prominent ears using the Stenstrom technique during the period 1965 to 1976. In 31 patients the ear deformity was unilateral. All the rest were bilateral. The follow-up period ranged from 3 mth to 2 yr and was over 1 yr in almost all cases. The ages ranged from 5 to 25 yr at the time of surgery. The follow-up visits were all carried out by the author along with a nurse who served as coinvestigator. The patients' own subjective assessments of the result were elicited. A set protocol was used to determine results by various subjective and objective measurements.
Article
The constricted or cup ear is a defect whose two central features are lidding or lid-like turning down of the helix and compression or narrowing of the scapha and fossa triangularis. These and other elements of the deformity have recently received renewed critical examination.
Article
Three cases of partial defect of the helix reconstructed by an advancement of the chondrocutaneous helical flap are presented. The operative technique employed in these cases is described. The principle underlying the operative procedure is that of advancement of the adjacent, intact helical margin as a flap based on a wide postauricular skin pedicle. The defect is in fact transferred to the extensile lobule. The reconstructed helix is more consistent with the architecture of the normal ear than when repair has been accomplished by some of the other methods proposed. Safety is combined with economy of tissue and time. (C)1967American Society of Plastic Surgeons
Article
A surgical procedure using a post-auricular flap is described to reconstruct the particular type of congenital hypoplastic ear lobe cleft associated with soft tissue deficiency. Its advantages are outlined.
Article
A simplified and knifeless technique for otoplasty is presented. Correction of the prominent ear is easily achieved by subcutaneous and transcartilaginous nonabsorbable permanent sutures after cartilage resilience is weakened by needle scoring. This technique was very successful in 11 consecutive cases with up to 30 months of followup.
Article
Congenital cleft of the earlobes is rarely seen among congenital ear anomalies. These clefts show a wide range of severity and localization, from simple notching to extensive tissue deficiencies. We developed a new technique that can be used in simple cases of earlobe cleft. For this technique, we use the anterior and posterior parts of the cleft as Y-V advancement flaps and achieve a three-dimensional construction of the lobe that is symmetrical with the opposite lobe.
Article
We studied a large data set from three registries of congenital malformations (central-east France, Sweden, and California), a total of 954 cases, known chromosome anomalies excluded. The prevalence at birth varied significantly between programmes, probably to a large extent because of different ascertainment and inclusion criteria, from 0.76 per 10,000 births in the French programme to 2.35 in the Swedish. Within the California programme, there is a racial variability in prevalence with lower values among whites (and probably blacks) than in Hispanics and Asians. Also the proportion of anotia and microtia varies between races with the lowest proportion of anotia in whites. Anotia and microtia are equally often associated with other malformations and show other similar epidemiological characteristics. In unilateral cases, the right side is more frequently malformed than the left side, especially when the ear malformation is isolated. There is a male excess, most pronounced in isolated forms. Among associated malformations, facial clefts and cardiac defects are the most common ones (each about 30% of infants with associated malformations), followed by anophthalmia or microphthalmia (14%), limb reduction defects or severe renal malformations (11%), and holoprosencephaly (7%). There is a maternal parity effect seen, an increased risk at parity 4+ (standardised for maternal age), more pronounced for anotia than microtia.
Article
The correction of prominent ears requires a logical approach to address each of the anatomical defects present while bearing in mind the overall shape of the ear. The two most common problems encountered are the lack of an antihelix and a deep conchal bowl. We describe a method of reducing the depth of the conchal bowl which avoids some of the problems previously encountered such as occlusion of the external auditory meatus and visible irregularity on the external surface of the pinna. Resection of the inferomedial part of the conchal bowl and thinning of the ponticulus allow realignment of the ear and prevent prominence of the antitragus. The ear is then secured with concha-mastoid sutures and the scapha-conchal angle can then be corrected to form an antihelix if necessary.
Article
Despite the multitude of corrective procedures described, adequate surgical correction of the congenital constricted ear remains a challenge. The maintenance of the shape and elevation of the reconstructed upper neohelix poses a particular problem. In the present series, experiences with lop ear correction utilizing standard techniques and the use of the mastoid hitch as a useful adjunct to these procedures are described. A total of 19 ears were reconstructed. There were three type 1, eight type 2a, seven type 2b, and one type 3 deformities (Tanzer classification). A graded sequence of procedures was adopted. Mild deformities were corrected by cartilage scoring techniques; a V-Y advancement of the helical root was added for moderate deformities. Cartilage expansion by a banner flap was required for more severe deformities. A mastoid hitch, whereby the refashioned upper neohelix is sutured to the mastoid fascia, should be used as an adjunct to these procedures to maintain helical elevation and prevent recurrence. Severe type 3 deformities may require autologous auricular reconstruction. Mean follow-up time was 1 year. There were six excellent, seven good, four fair, and two poor results. Two patients who had not had mastoid hitch procedures developed a recurrence of the lop deformity. Adequate surgical correction of constricted ear deformities requires a variety of surgical techniques. The mastoid hitch being used for constricted ear correction has not been described elsewhere. The mastoid hitch is a useful adjunctive procedure that may be used effectively in combination with other procedures.
Article
Stahl's ear is a congenital malformation of the auricle, which is uncommon in non-Oriental societies. A number of different treatment modalities have been suggested, many of which yield unpredictable results. We review current treatment modalities from the English literature and describe a novel, simple surgical method of repair. First, a helical rim incision is made to expose the abnormal third crus and upper pole of the ear. The third crus is excised as a narrow wedge of cartilage and posterior skin, and the defect is closed primarily. The free third crus cartilage is then grafted onto the scaphal cartilage in an anatomically correct position to form a superior crus. The anterior skin flap is redraped and bolstered over this graft. Only a very small scar on the helical rim remains visible anteriorly.
Article
The author presents his otoplasty technique, a variation on Mustardé's original procedure, which he has used for more than 30 years in more than 200 otoplasties. Timing, indications, and photographic documentation are discussed, and the operative procedure, including the preoperative work-up and anesthesia, is described in step-by-step detail. Postoperative care and early and late complications, from infection to the dissatisfied patient, are discussed extensively.
Article
Corrective otoplasty is a commonly performed procedure to change the shape of the auricular cartilage. Many techniques use permanent sutures to maintain the cartilage folding, whereas other techniques rely on cartilage incisions (partial thickness or full thickness). At this institution, a cartilage cutting and anterior scoring technique has been used for more than 30 years with pleasing results. The surgical techniques published in the past have been reviewed and compared with the procedure used at this institution to point out the advantages, disadvantages, and differences of these various techniques. Also reviewed were 500 consecutive cases operated on under local or general anesthesia between January of 1993 and December of 1995 to determine the incidence of early and late complications. The patients were contacted by mail to return for a follow-up examination or answer a questionnaire, at least 2 years after the procedure. Early complications were bleeding in 13 cases (2.6 percent) and hematoma in 2 cases (0.4 percent). There were no infections or ear necrosis. A small cutaneous wound was present on the anterior skin in three patients (0.6 percent), and there was one wound dehiscence (0.2 percent). Late complications were keloids in two cases and inclusion cysts in three cases. Residual deformity was noted in 22 cases and asymmetry in 28 cases. Secondary surgery was performed in six cases. The questionnaire was answered by 387 patients (77.4 percent response rate): pain when the ear is touched was present in 22 cases (5.7 percent), hypesthesia in 15 cases (3.9 percent), occasional cutaneous irritation in 38 cases (9.8 percent), asymmetry in 71 cases (18.4 percent), and abnormal ear shape in 17 cases (4.4 percent). Twenty-nine patients (7.5 percent) also noted that the ear was more sensitive to cold or touch. The satisfaction rate was 94.8 percent: very satisfied, 74 percent; satisfied, 20.8 percent; dissatisfied, 4.2 percent; and very dissatisfied, 1 percent. These results were compared with other published series of complications and late results after otoplasty; the complication rates are similar or lower in this study. Therefore, it can be concluded that the cartilage cutting and anterior scoring technique otoplasty is a safe procedure with a high patient-parent-surgeon satisfaction rate.
Article
A large Z-plasty on the postauricular surface of the ear has been used for successful reconstruction of cryptotia. This technique provides extensive skin coverage of the posterior auricle without skin grafting. The technique is easy and simple. The natural hairline is not disturbed and the temporoauricular sulcus is emphasised. Almost all of the scar is hidden behind the auricle. It has been performed on 17 patients with no recurrence of the cryptotia. One patient had partial congestion in the cranial-flap tip, which improved within 1 week. There were no other complications.
Article
Anterior riberation methods of otoplasty have been criticized because of the risk of anterior hematoma that can cause anterior skin necrosis, scarring, and even cartilage destruction caused by infection. As a result, cartilage-sparing otoplasty such as the Mustardé and Furnas types has been increasingly popular. However, postauricular suture extrusion may result, and recurrence rates of up to 25 percent have been recorded. In this study, cartilage-sparing otoplasty is refined by the addition of a postauricular fascial flap to reduce suture extrusion and recurrence rates. Fifty-one patients underwent otoplasty (45 bilateral, six unilateral). This technique involves the elevation of a fascial flap from the postauricular region. A new antihelical fold is then created by Mustardé sutures, and the conchal bowl is rotated by Furnas-type concha-mastoid sutures. The fascial flap is then advanced to cover the sutures with a supplementary vascularized layer to prevent suture extrusion. In addition, the advancement of the flap acts as a postauricular support to prevent recurrence. A natural-looking antihelical fold and helical rim is created by this technique. There were no hematomas. There was recurrence in eight ears (8 percent) in six patients. Two patients requested further surgery. No patients developed suture extrusion or granuloma. This is a simple and intrinsically safe procedure and does not cause irreparable complications such as anterior scarring or skin necrosis. The postauricular fascial flap seems to prevent suture extrusion. It may also help to reduce recurrence rates to acceptable levels.
Article
The appearance and symmetry of the auricle is crucial for the maintenance of facial cosmetic harmony. The earlobe is considered to be an important attribute of beauty in most cultures, and earlobe decoration with color or earring is a common practice in many societies. A reconstructive technique for congenital or acquired deformity of the earlobe is described. In addition, the postauricular chondrocutaneous flap is very convenient for reconstruction of various auricular parts.
Article
The vascular anatomy for design and execution of various flaps of the auricular region is outlined with emphasis on clinical correlation. A new classification of various flap compositions from the postauricular region based on histologic and anatomic observations is proposed, together with a corresponding clinical example used in different clinical situations. Sound knowledge of the vascular pattern surrounding the auricle provides immense versatility in performing flap operations in this region. A summary of the controversy and updates on auricular embryology is provided in relation to various congenital malformations.
Article
The failure to correctly analyze the complex deformity that comprises the prominent ear is the most common cause of the undesired surgical result. Recognizing conchal hypertrophy as one of the leading causes of the prominent ear deformity has led to a versatile and reproducible otoplasty technique that is easily modified to the common side-to-side variation in deformity. From January of 1993 to August of 2000, chondrocutaneous conchal resection has been used as the cornerstone to a combined sequence of maneuvers in otoplasty. The operation was performed on 47 patients (40 bilateral cases and 7 unilateral), and the total number of ears operated on was 87. There were three complications requiring revision surgery, and follow-up periods ranged from 6 months to 7 years, with all patients achieving a satisfactory result. Detailed methods of chondrocutaneous conchal resection along with the sequence of the authors' combined otoplasty techniques are presented.
Article
A method of reconstruction of the antihelix by anterior scoring in the correction of bat ears is described. The results are satisfactory with a normal-looking fold of antihelix. A firm bandage and dressing are essential to prevent h˦matoma and maintain the new ear shape.
Article
This was a retrospective study examining the psychosocial morbidity of patients before and after ear reconstruction. Semistructured questionnaires were sent to 90 patents with significant congenital or acquired auricular deformity 2.2 years (range 3 months to 5 years) following autogenous or osteointegrated reconstruction. Sixty-two patients (69%) responded. Twenty-two of the patients below 12 years, who had undergone reconstructive surgery, also completed the Childhood Experience Questionnaire. These were compared with a cohort of 362 normal patients. There was significant psychosocial morbidity in both children and adults with auricular deformity. Seventy-one percent of patients reported reduced self-confidence that affected both social life and leisure activity. Teasing was a prominent symptom in both children (88%) and adults (85%) but was a motivational factor for surgery in children only. Dissatisfaction with the appearance (73.1%), on the other hand, was the main reason for treatment in adults. Following ear reconstruction, 74% of adults and 91% of children reported an improvement in self-confidence resulting in enhanced social life and leisure activities in both adults and children. There was no difference between osteointegrated and autogenous reconstruction. Sixty percent of patients reported their result as excellent. The patients scored their result better than the surgeon. We conclude that auricular reconstruction has significant psychosocial benefit in the majority of children and adults despite donor-site morbidity and a range of technical result.
Article
The pinna anatomically should sit within the boundaries of the middle 1/3 of the face. It has an extremely variable and intricate internal anatomy. There are four main anatomical subunits of the pinna. These are the helix, the conchal bowl, the antihelix, and the lobe. It is the anatomical relationships of these that create the overall appearance of the pinna. The proportions of the pinna are described. The key to a successful outcome for ear reduction surgery is appropriate preoperative assessment to determine where the excess is and strategic placement of incisions to hide the resultant scars at the junctions of the aesthetic subunits of the ear. The placement of scars at the junctions of aesthetic subunits in the face leads to the least notable scars. Similarly, incisions on the anterior surface of the pinna at the junction of its anatomic subunits (the helical rim, the antihelix with the superior and inferior crura, the conchal bowl, and the lobe) will reliably produce scars that become virtually imperceptible. The surgical technique is discussed.