Reconstruction of ear

1. EAR RECONSTRUCTION
Dr. Chunu Darnal
Resident, ORL&HNS
Bir Hospital, NAMS
Kathmandu, Nepal

2. OUTLINE OF PRESENTATION
 Relevant embryology
 Relevant anatomy
 Historical perspectives
 Pinnaplasty
 Partial and total ear reconstruction
 Brent and Nagata technique
 Complications

3. DEVELOPMENT OF AURICLE OR PINNA: AURICULAR HILLOCKS

4. CONGENITAL ANOMALIES OF EXTERNAL EAR

5. CONGENITAL ANOMOLIES

6. MICROTIA: MARX GRADING OF MICROTIA

7. Anotia Bat Ears

8. STAHL’S BAR CONSTRICTED EAR

9. BUMPS OR DARWIN’S TUBERCLE MACROTIA

10. CRYPTOTIA (HIDDEN EAR) Low Set Ears
Only Lower 2/3rd of ear is visible

11. EXTERNAL EAR

12. ANATOMY OF PINNA

13. BLOOD SUPPLY

14. NERVE SUPPLY –SENSORY
 Greater auricular nerve
 Auriculotemporal nerve
 Lesser occipital nerve
 Auditory branch of vagus

15. Nerve supply: motor
Motor: Posterior auricular branch of facial nerve

16. 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
 In 1950s: Ranford Tanzer laid foundation of current ear reconstruction
 Refined by contemporary surgeons ;Brent and Nagata

17. PINNAPLASTY –OBJECTIVES
 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

18. 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

19. FORMATION OF UNDER-DEVELOPED ANTIHELICAL FOLD
Two techniques:
 Cartilage sparing/suturing technique (Mustarde’)
 Cartilage excising/scoring technique(Stenstrom)

20. FORMATION OF UNDERDEVELOPED ANTIHELICAL FOLD

21. 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

22. KAPLAN AND HUDSON TECHNIQUE FOR STAHL’S EAR

23. PARTIAL AND TOTAL EAR RECONSTRUCTION

24. EAR RECONSTRUCTION
Three key measurements
 Appropriate angle of rotation for longitudinal axis
 Vertical level for upper border of ear
 Horizontal distance of ear from lateral orbital
margin

25. EXTERNAL EAR ANATOMY: SIZE AND PROPORTIONS

26. EAR RECONSTRUCTION
Indications
 Complex congenital ear deformities ( microtia and anotia)
 Congenital and acquired deformities involving up to two-
thirds of the ear
 Trauma (e.g. bites, avulsions and burns) and carcinoma

27. MULTIDISCIPLINARY MANAGEMENT
 Maxillofacial prosthetist
 Otorhinolaryngology
 Audiologist
 Radiologist
 Plastic surgeon
 Psychologist
 Speech and language therapist

28. GENERAL RECONSTRUCTIVE OPTIONS
 Stick on ear prosthesis
 Osseointegrated ear prosthesis
 Use of synthetic auricular frames
 Total autologous reconstruction

29. EAR RECONSTRUCTION- EVALUATION OF PATIENTS
o Detailed history including age and thorough physical examination
o Medical history including antenatal history
o Family history : clue on any syndromic deformities

30. EAR RECONSTRUCTION: EVALUATION OF PATIENTS
 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

31. EAR RECONSTRUCTION :EVALUATION OF PATIENTS
 In unilateral deficits, key aspects of normal ear are measured
 Clinical photographs of both ears
 Audiology assessment
 Assessment by a Prosthetist, Psychiatrist
 Prosthetic options
 Patient expectations and preferences

32. SPECIAL INVESTIGATIONS AND PLANNING
 Doppler assessment of STA
 Chest xray for presence of and contour of costal margin
o 2D templates and 3D models important for planning
o Nagata has designed a series of standardized templates
Source: Scott-Brown ORL&HNS
volume 3, Plastic surgery

33. PRINCIPLES OF EAR RECONSTRUCTION SURGERY
 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

34. PRINCIPLES OF EAR RECONSTRUCTION SURGERY(CONTD..)
 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

35. 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

36. PARTIAL EAR RECONSTRUCTION
 Upper third defects: involves helix, superior and inferior
crus and superior antihelix
 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

37. PARTIAL EAR RECONSTRUCTION: UPPER THIRD

38. RECONSTRUCTION OF EAR- UPPER THIRD

39. PARTIAL EAR RECONSTRUCTION
 Peripheral middle-third defects: options
 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

40. PARTIAL EAR RECONSTRUCTION
Figure. Antia-Buch helical chondrocutaneous advancement flap

41. PARTIAL EAR RECONSTRUCTION

42. PARTIAL EAR RECONSTRUCTION
Lower-third ear defects: affect earlobe and antitragus
 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

43. PARTIAL EAR RECONSTRUCTION
Conchal defects
 Partial defects: full thickness skin
grafts
 Complete defect: Swinging Trapdoor
flaps
Defects upto 1.5cm wide
 Can be excised as a wedge and closed
directly in an adult sized ear

44. PARTIAL EAR RECONSTRUCTION

45. 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

46. 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

47. AUTOLOGOUS 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

48. BRENT TECHNIQUE OF EAR RECONSTRUCTION

49. NAGATA TECHNIQUE OF EAR RECONSTRUCTION

50. NAGATA TECHNIQUE OF EAR RECONSTRUCTION

51. COMPARISON OF BRENT AND NAGATA TECHNIQUES

52. COMPLICATIONS OF EAR RECONSTRUCTION
 Hematoma, pain, infection
 Perichondritis
 Cartilage and soft tissue necrosis
 Pneumothorax due to costal cartilage grafts
harvesting
 Problems with sutures
 Keloids and hypertrophic scars
 Hypoesthesia, cold susceptibility
 Alopecia along scalp incision scars
 Undercorrection and asymmetry
 Unsatisfactory results
Early complications Late complications

53. Sometimes, it feels good to be different ....Thank You!

54. REFERENCES
1. Scott-Brown’s Otorhinolaryngology Head and Neck Surgery 8th Edition, volume 3, Plastic surgery
2. Scott-Brown’s Otorhinolaryngology Head and Neck Surgery 7th Edition, volume 3, Plastic surgery
3. Stell and Maran’s Textbook of Head and Neck Surgery and Oncology 5th Edition
4. Dhingra’s Diseases of Ear, Nose and throat & Head and Neck Surgery 7th Edition
5. 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