Phẫu Thuật Thẩm Mỹ Tạo Hình Tai Nâng Cao (Advanced Cosmetic Otoplasty)

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Advanced
Cosmetic Otoplasty
123
Melvin A. Shiﬀ man
Editor
Art, Science,
and New Clinical
Techniques

Advanced Cosmetic Otoplasty

(Trang không có chữ)

Melvin A. Shiffman
Editor
Advanced Cosmetic
Otoplasty
Art, Science, and New Clinical
Techniques

ISBN 978-3-642-35430-4 ISBN 978-3-642-35431-1 (eBook)
DOI 10.1007/978-3-642-35431-1
Springer Heidelberg New York Dordrecht London
Library of Congress Control Number: 2013941900
© Springer-Verlag Berlin Heidelberg 2013
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, speci ﬁ cally the rights of translation, reprinting, reuse of
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to prosecution under the respective Copyright Law.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a speci ﬁ c statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
While the advice and information in this book are believed to be true and accurate at the date of
publication, neither the authors nor the editors nor the publisher can accept any legal responsibility
for any errors or omissions that may be made. The publisher makes no warranty, express or
implied, with respect to the material contained herein.
Printed on acid-free paper
Springer is part of Springer Science+Business Media ()
Editor
Melvin A. Shiffman, M.D., J.D.
Tustin , California
USA

v
Foreword
It gives me great pleasure and privilege to write a foreword to this book titled
Advanced Cosmetic Otoplasty: Art, Science, and New Clinical Techniques .
Having been involved with cosmetic surgery for over 30 years, I ﬁ nd that very
little has been focused on the aesthetic otoplasty in facial rejuvenation, and
details of various techniques are lacking. The ears are a vital part in the beauty
and symmetry of the face, and it is often forgotten or neglected. Over the
years, children and adults can have a huge complex about their ears. It also
varies with trends, as adults sometimes wear their hair short, or with career
moves, for instance, if a person goes into the army. Also children are often
teased at school because of their ears.
Otoplasty (Greek ōtoûs, ear + plassein, to shape) denotes the surgical and
nonsurgical procedures for correcting the deformities and defects of the pinna
(external ear).
All those who practice otoplasty surgery are very aware that this seem-
ingly simple surgery is far from straightforward. In fact, it is very dif ﬁ cult to
achieve consistently good results. Any text to improve the knowledge of oto-
plasty is welcomed. If you as a surgeon sometimes feel overwhelmed to orga-
nize the fundamental concepts of certain ﬁ elds, it is great to have one book at
hand, as an invaluable resource to enlarge your knowledge and practice.
Very little advances have been noted over the years since otoplasty was
developed in ancient India, in the ﬁ fth century BC by Sushruta, the ayurvedic
physician. He developed otoplastic and other plastic surgical techniques and
procedures at that time. Then in the nineteenth century Johann Friedrich
Dieffenbach (1794–1847) reported the ﬁ rst surgical approach for the correc-
tion of prominent ears. This was a combination otoplasty procedure that fea-
tured the simple excision (cutting) of the problematic excess cartilage from
the posterior sulcus (back groove) of the ear and the subsequent af ﬁ xing, with
sutures, of the corrected pinna to the mastoid periosteum, the membrane cov-
ering the mastoid process at the underside of the mastoid portion of the tem-
poral bone, at the back of the head.
In 1920, Harold D. Gillies (1882–1960) ﬁ rst reproduced the pinna by bury-
ing an “external-ear support framework,” made of autologous rib cartilage,
under the skin of the mastoid region of the head, which reconstructed the pinna.
He then separated this from the skin of the mastoid area by means of a cervical
ﬂ ap. In 1937, Dr. Gillies also attempted a similar pediatric ear reconstruction
with a pinna support framework fabricated with maternal cartilage. That oto-
plasty correction technique proved inadequate, because of the problems inherent

vi
Foreword
to the biochemical breakdown and elimination (resorption) of the cartilage tis-
sue by the patient’s body. After this came the Mustardé technique for creating
an antihelical fold, the Merck method technique, and the incisionless Fritsch
otoplasty. As you can see, after that period very little advancements have been
made in this ﬁ eld, hence the importance of this book.
The trend of the last century is to look younger. This is due to many fac-
tors: improved technology and emphasis on beauty – we have become a soci-
ety of “appearance.”
This book is aimed at all types and ages of surgeons, to help them to
choose the best technique that works for them, and the preoperative and post-
operative management.
A big thank you to Dr. Shiffman on this book for imparting his time and
knowledge in this ﬁ eld.
The format is splendid. The heading and the text are richly articulate and it
is a pleasure to read. Dr. Shiffman has helped to create a beautiful surgical text
book, for all surgeons interested to learn about otoplasty, at all levels of exper-
tise. This book delivers to the reader basic principles, advanced techniques,
and innovations. This book is an essential tool for the contemporary surgeon.
It de ﬁ nes what we do, how we do it, and, most importantly, why we do it.
Congratulations to Dr. Shiffman on such hard work. I wish the book every
success.
Mr. (Dr.) Anthony Erian, M.D., FRCS (Lon), FRCS (Edin)
Consultant Plastic Surgeon
President of the International Board of Cosmetic Surgery
President of the European Society of Aesthetic Surgery
Wimpole, Cambridge, UK
Anthony Erian, M.D.

vii
Preface
There are only a few books on rhinoplasty and most are limited to the editor’s
techniques or those of a few contributors. These give restricted information
on the variety of procedures that are available and are mainly for teaching the
inexperienced and somewhat experienced surgeons how to do rhinoplasty
and possibly stay out of trouble.
This book on Advanced Aesthetic Otoplasty: Art, Science, and New
Clinical Techniques gives a history of otoplasty and a detailed analysis of the
newer techniques that are available in otoplasty. National and international
experts of newer procedures report on subjects covering ear embryology and
anatomy, surgical techniques of otoplasty, the possible risks and complica-
tions of otoplasty, and outcomes in otoplasty. This concept of gathering new
techniques from international experts is not present in any other book on
otoplasty, and the information is extensive and quite different from even
recent books on otoplasty. The book is for the inexperienced, experienced,
and the very experienced surgeon doing rhinoplasties.
The editor wishes to present advanced technology and clinical techniques
in otoplasty from unique contributors experienced with these procedures that
are modi ﬁ ed or original procedures. The contributors are inventive and elo-
quent in presenting to the reader a way to progress from inexperienced or
experienced surgeons in rhinoplasty to better understanding that there is more
than following simpli ﬁ ed techniques as a template to performing a procedure
that is fraught with possible risks and complications.
All cosmetic surgeries are potential problems if the patient is not properly
evaluated preoperatively, not only physically but also mentally. This is most
true with the patient considering otoplasty. However, the satisfaction of the
patient who has a good result is inestimable.
Tustin, CA, USA
Melvin A. Shiffman, M.D., J.D.

(Trang không có chữ)

ix
Contents
Part I Anatomy
1 Embryology and Anomalies of the External Ear . . . . . . . . . . .
3
Jeremiah C. Tracy, Arnold S. Lee, Andrew R. Scott,
and Collin S. Karmody
2 Anatomy of the External Ear . . . . . . . . . . . . . . . . . . . . . . . . . . .
15
Peter M. Prendergast
3 Anatomy, History, and Utility of the Posterior
Auricular Fascia in Otoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . .
23
Kayvan Shokrollahi and James P. Taylor
Part II Preoperative
4 The Timing of Otoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
37
Patrick M. Spielmann and Michel Neeff
Part III Techniques
5 History of Otoplasty: Review of Literature. . . . . . . . . . . . . . . .
43
Melvin A. Shiffman
6 Current Trends in Otoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . .
65
Rajanya S. Petersson
7 Hair Preparation in Otoplasty . . . . . . . . . . . . . . . . . . . . . . . . . .
81
Esta S. Bovill
8 Practical Perioperative Otoplasty Preparation. . . . . . . . . . . . .
83
Richard A.J. Wain
9 Practical Tips for Otoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . .
89
Ahmad F. Bhatti and Antonio Orlando
10 Nuances of Otoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
95
Nathan T.N. Schreiber and Steven R. Mobley
11 Anterior Versus Posterior Approach to Otoplasty . . . . . . . . . . 111
Rosa Maria Echarri, Mónica Hernando,
and Guillermo Plaza

x
Contents
12 Minimally Invasive Otoplasty: Technical Details
and Long-Term Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Antonio de la Fuente and Gustavo Sordo
13 Treatment of Prominent Ear Anomalies . . . . . . . . . . . . . . . . . . 127
Amy S. Xue, Edward I. Lee, Shayan Izaddoost, and Samuel Stal
14 Precision and Suture Positioning in Otoplasty:
Aspiring to the “Virgin” Ear. . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Kayvan Shokrollahi
15 Otoplasty with Mustarde Suture Cartilage
Scratching and Rasping. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Kutlu Sevin and Asuman Sevin
16 The Négrevergne Otoplasty Technique . . . . . . . . . . . . . . . . . . . 149
Murat Songu
17 Island Technique for Prominent Ears . . . . . . . . . . . . . . . . . . . . 163
Ivo Pitanguy and Henrique N. Radwanski
18 Otoplasty and Earlobe Repair . . . . . . . . . . . . . . . . . . . . . . . . . . 171
David J. Archibald and Edward H. Farrior
19 The Bauer Otoplasty Technique. . . . . . . . . . . . . . . . . . . . . . . . . 183
Ahmed M.S. Ibrahim, Samuel J. Lin, and Bruce S. Bauer
20 Use of Multiple Techniques for Otoplasty
(Stenstrom, Mustarde, Furnas). . . . . . . . . . . . . . . . . . . . . . . . . . 197
Jack A. Friedland and Renata Souza Maricevich
21 Combined Technique in Aesthetic Otoplasty . . . . . . . . . . . . . . 209
Marzia Salgarello and Giuseppe Visconti
22 Incisionless Otoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Yaşar Çokkeser
23 Incisionless Otoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Michael H. Fritsch
24 Carbon Dioxide Laser-Assisted Cartilage
Reshaping Otoplasty for Prominent Ears . . . . . . . . . . . . . . . . . 249
Ahmed Ragab
25 Sutureless Otoplasty: Anterior Scoring of the
Antihelical Fold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Asif Zubair Bhatti and Muhammad Ijaz
26 Anterior Scoring of the Upper Helical Cartilage
as a Reﬁnement of the Chong-Chet Technique
in Otoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Corrado Rubino, Franceso Farace, and Mario Faenza
27 Anterior Scoring Technique in Otoplasty . . . . . . . . . . . . . . . . . 279
Louise Caouette-Laberge and Patricia Bortoluzzi

xi
Contents
28 Prevention of Intra-Auricular Deformity in Prominent
Ear Correction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
Tomohisa Nagasao
29 Can Diathermy Enhance Scoring in Otoplasty?. . . . . . . . . . . . 311
Terry Gourlay and Ekpemi Irune
30 Diamond Burr Drill Use in Otoplasty . . . . . . . . . . . . . . . . . . . . 323
Yogesh Bajaj and Natasha Choudhury
31 Conchal Setback Without Resection
in Prominent Ear Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
Naci Karacaoglan, Mustafa Keskin, and Bulent Cigsar
32 Cartilage Folding Technique in Otoplasty. . . . . . . . . . . . . . . . . 337
Cristina Isac and Aurelia Isac
33 Cartilage-Sparing Aesthetic Otoplasty . . . . . . . . . . . . . . . . . . . 363
Fernando D. Burstein
34 Posterior Suturing with Postauricular Fascial
Flap Otoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Mark V. Schaverien and Kenneth J. Stewart
35 The Role of the Postauricular Fascia in Otoplasty:
A Complete System for Otoplasty . . . . . . . . . . . . . . . . . . . . . . . 381
Kayvan Shokrollahi
36 Posterior Auricular Muscle Flap with Otoplasty . . . . . . . . . . . 399
Ilker Yazici
37 Various Applications of Retroauricular
Advancement Skin Flap to Treat the Surgical
Defect of the Ear. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407
Peter Kim
38 The Tubular Technique in Otoplasty . . . . . . . . . . . . . . . . . . . . . 415
Vladimir Kljajic, Ljiljana Vlaski, Jovan Radmanovic,
and Slobodan Savovic
39 The Deep Conchal Bowl: Accentuation
of the Helical Crus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
Sapna Patel and Kathleen C.Y. Sie
40 Otoplasty for the Treatment of Protuberant Ears . . . . . . . . . . 425
Payal Patel, Emil Bisaccia, and Dwight A. Scarborough
41 Separating the Helix from the Antihelix: A New
Concept in Prominent Ear Correction. . . . . . . . . . . . . . . . . . . . 437
Augusto Sette Câmara Valente
42 Balanced Otoplasty: Dividing the Ear
into Vertical Thirds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453
Samuel M. Lam

xii
Contents
43 Reduction Otoplasty for Correction of the Large
or Asymmetrical Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469
Christopher J. Coombs and Alex Yuen
44 Correction of the Protruding Lobule . . . . . . . . . . . . . . . . . . . . . 477
Cristina Isac and Aurelia Isac
45 Repair of Split Earlobe with Free Conchal
Cartilage Sandwich Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 481
Rajiv Agarwal
46 Prominent Lobule Correction in Otoplasty: With
Step-by-Step Description of the “Y to V Setback”
Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493
Yigit Ozer Tiftikcioglu and Ufuk Bilkay
47 Compression Treatment of Ear Keloids by a
Modiﬁed Oyster Splint Technique . . . . . . . . . . . . . . . . . . . . . . . 499
Jessica C. Hassel, Alexander Kreuter, and Alexander J. Hassel
Part IV Postoperative
48 A New Postoperative Otoplasty Dressing Technique
Using Cyanoacrylate Tissue Adhesives . . . . . . . . . . . . . . . . . . . 509
Volker Wedler, Miriam Vetter, and Matthias Foehn
49 Head Bandage After Otoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . 511
Ahmad A. Orabi
50 Postoperative Care Using a Silicone-Based
Occlusive Dressing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517
Jonathan K. Frankel and Diana C. Ponsky
Part V Complications of Otoplasty
51 Otoplasty Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523
Melvin A. Shiffman
52 Understanding and Correcting the Unfavorable
Results After Otoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 527
Ashley K. Lentz and Bruce S. Bauer
53 Solving Sharp Edges of the Antihelix
After Otoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535
Renato da Silva Freitas, Maria Cecilia Closs Ono,
and Nivaldo Alonso
54 Prophylactic Z-Plasty to Prevent the Notch
Deformity of the Helical Rim Following
the Wedge Excision of the Ear . . . . . . . . . . . . . . . . . . . . . . . . . . 539
Peter Kim

xiii
Contents
55 Otoplasty Revision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 543
Philip A. Young
Part VI Outcomes
56 Sensibility of the Ear After Otoplasty . . . . . . . . . . . . . . . . . . . . 557
Pedro Soler Coltro and Marcus Castro Ferreira
57 Measurement of Postoperative Cephaloauricular
Distance to Evaluate and Compare Results of Otoplasty. . . . . 565
Stuart D. Richards
58 Otoplasty: Focusing on Patient Beneﬁt and
Health-Related Quality of Life . . . . . . . . . . . . . . . . . . . . . . . . . . 569
Thomas Braun, Alexander Berghaus, and John Martin Hempel
59 Psychosocial, Behavioral, and Emotional Effects
Following Otoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 575
Raquel Aguilar Cuesta and Carmen Soto Beauregard
Part VII Miscellaneous
60 Evolution of Consent and Alternatives
to Traditional Consent Forms. . . . . . . . . . . . . . . . . . . . . . . . . . . 583
Kayvan Shokrollahi and Adeyinka Molajo
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 587

Part I
Anatomy

3
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_1, © Springer-Verlag Berlin Heidelberg 2013
1
Introduction
A basic knowledge of normal ear development
allows for an understanding of the full spectrum
of congenital auricular abnormalities. The embry-
ology of the ear provides insight into the funda-
mentals of surgical reconstruction and support to
the concepts that guide our approaches to com-
plete excision of redundant elements. The exter-
nal ear develops from ectodermal and mesodermal
elements of the ﬁ rst and second branchial arches.
Anomalies of the ear may therefore re ﬂ ect abnor-
mal development of either ﬁ rst or second arch
structures. Accurate recognition of syndromic
ear anomalies also allows for the potential detec-
tion of other systemic conditions.
Embryology
Overview
The external ear is divided broadly into three com-
ponents: auricle, cartilaginous external auditory
canal (EAC), and bony EAC. These structures are
formed over the course of fetal development, pre-
dominantly in weeks 5 through 20. The structures
of the external and middle ear are made up of
endodermal, mesodermal, and ectodermal ele-
ments of the ﬁ rst and second branchial arches.
The external auditory canal is itself the physio-
logic remnant of the ﬁ rst branchial cleft.
In brief, inner ear structures develop from the
otic placode. This ectodermal structure is ﬁ rst
J. C. Tracy , M.D. (*)
Department of Otolaryngology ,
Tufts University School of Medicine ,
800 Washington Street ,
Boston , MA 02111 , USA
Department of Otolaryngology ,
Tufts University School of Medicine ,
116 Harrison Avenue , Boston ,
MA 02111 , USA
e-mail: jtracy@tuftsmedicalcenter.org
A. S. Lee , M.D.
Facial Plastic & Reconstructive Surgery,
Otolaryngology-HNS ,
Tufts University School of Medicine,
Tufts Medical Center , 860 Washington Street, South 1 ,
Boston , MA 02111 , USA
e-mail: alee2@tuftsmedicalcenter.org
A. R. Scott , M.D.
Department of Otolaryngology – Head & Neck Service ,
Tufts Medical Center , 800 Washington St. ,
Box 850 , Boston , MA 02111 , USA
Department of Otolaryngology Pediatries ,
Tufts University School of Medicine ,
Boston , MA , USA
Divisions of Pediatric Otolaryngology
and Facial Plastic & Reconstructive Surgery ,
Tufts Medical Center ,
Boston , MA , USA
Cleft Lip and Palate Team ,
Floating Hospital for Children,
Tufts Medical Center ,
Boston , MA , USA
e-mail: ascott@tuftsmedicalcenter.org
C. S. Karmody , M.D.
Department of Otolaryngology ,
Tufts University School of Medicine ,
116 Harrison Avenue , Boston , MA 02111 , USA
e-mail: ckarmody@tuftsmedicalcenter.org
Embryology and Anomalies
of the External Ear
Jeremiah C. Tracy , Arnold S. Lee , Andrew R. Scott ,
and Collin S. Karmody

4
J.C. Tracy et al.
visible in the embryo at week 3, and as develop-
ment proceeds, it invaginates medially. By week
4, this structure has lost its connection with the
ectodermal surface and has migrated medially,
forming what is termed the otocyst. This structure
will give rise to all inner ear structures with the
signi ﬁ cant exception of the stapes footplate [ 1 ] .
It is therefore notable that inner ear structures
develop independent of middle ear and outer ear
elements and that critical periods of development
occur at different times. This is why children with
inner ear malformations may have normal exter-
nal anatomy and children with markedly abnor-
mal surface anatomy may in fact have perfectly
normal inner ear structures.
The development of the external ear is gener-
ally complete by 20 weeks’ gestation and always
complete by birth. Through childhood, the exter-
nal ear and EAC will grow in size but in relative
proportion to the scale present at birth. In con-
trast, the middle and inner ear are fully formed
and of adult size at birth and do not grow
signi ﬁ cantly with the child.
Auricle
Development of the external ear begins at about
the ﬁ fth week of fetal growth. The ﬁ rst stages of
auricular development manifest in the form of
small mesenchymal prominences around the ﬁ rst
branchial cleft, an ectodermal groove that will
eventually develop into the external auditory
canal. There are six discrete prominences, which
are termed the hillocks of His. It is generally
accepted that hillocks 1–3 develop from ﬁ rst
branchial arch mesoderm (rostral to the ﬁ rst bran-
chial cleft) and hillocks 4–6 develop from the sec-
ond branchial arch, just caudal to the cleft. As
development proceeds, the relative contribution
of cells from the ﬁ rst arch decreases, such that
second branchial arch derivatives contribute about
85 % of the mature external ear (Fig. 1.1 ) [ 2– 5 ] .
Some recent studies have questioned this clas-
sic division of the hillocks of His, indicating that
only the ﬁ rst hillock is derived from the ﬁ rst
branchial arch and that hillocks 2–5 are second
branchial arch derivatives [ 6 ] .
The hillocks of His achieve maximal promi-
nence by the end of week 6. In the seventh week
of fetal development, the hillocks undergo direc-
tional growth such that they fuse and begin to
form the shape of the auricle. Hillock 1 gives rise
to the tragus. Hillocks 2 and 3 form the crus of
the helix and the helix proper. Cells of hillock 4
and 5 constitute the anti-helix; and the anti-tragus
and lobule are formed from hillock 6 [ 3 ] . These
assignments are general and there almost cer-
tainly is overlap in terms of the primordial contri-
butions to the developed ear (Fig. 1.1 ).
The formation of the auricle centers on the
growth and migration of the hillocks of His.
5
1
2
3
4
5
6
a
b
c
6
1
2
4
5
6
1
2
3
4
3
Fig. 1.1 Auricular development. ( a ) Hillocks 1–3 are
derived from the ﬁ rst branchial arch and 4–6 from the sec-
ond. ( b ) Fusion of the hillocks begins to form the auricle
in the seventh week of gestation. ( c ) Contributions of the
hillocks of His to the fully formed ear

5
1 Embryology and Anomalies of the External Ear
Failure of fusion, or duplications of the hillocks
can be observed in the form of auricular appen-
dages (Fig. 1.2 ). The earliest event is the fusion
of hillocks 2 and 3 and the growth of these tissues
in a caudal direction, eventually creating the
auricular helix. The fusion of hillocks 4 and 5
begins shortly thereafter, and then growth of the
antihelix continues concurrently with that of the
helix. The overall migration of the developing
auricle is cephalad relative to other ﬁ rst and sec-
ond branchial arch derivatives. This is re ﬂ ected
in the sensory innervation of the mature auricle,
which is predominantly from branches of the cer-
vical plexus, with only minor contributions from
cranial nerves V, VII, IX, and X. Additionally,
syndromic children with ﬁ rst arch anomalies will
often exhibit posteriorly rotated, low-set ears.
The dimensions of the external ear are well charac-
terized, and knowledge of the appropriate proportions
is essential to the clinician. The height of the adult
ear is 5.5–6.5 cm. On average the width of the ear is
55 % that of the height. The overall angle of the auri-
cle seen laterally is about 25–30 % from the vertical.
Normal protrusion from the mastoid is about 2 cm (or
an angle of 15–25°). The ear at birth is about 66 %
of the total size of the adult ear, although, as noted
above, the proportions at birth remain unchanged
throughout life. Adult ear size is generally achieved in
adolescence at about 13–15 years of age, though the
majority of growth is complete by 5–7 years of age.
External Auditory Canal
The development of the cartilaginous and bony
EAC is not so well-de ﬁ ned. The EAC itself is the
remnant of the ﬁ rst branchial cleft, and mesen-
chymal elements of the canal are derived from
the ﬁ rst branchial arch. The cartilaginous canal is
in continuity with the cartilage of the auricle and
likely develops and fuses with the cartilaginous
elements of the hillocks of His at the time of auri-
cle formation.
The canal itself forms as the ﬁ rst branchial
cleft extends medially. Eventually, the endoder-
mal lining of the ﬁ rst branchial pouch is in close
proximity to the ectoderm of the cleft. In this
location the mesoderm thins to a single translu-
cent layer, contributing the ﬁ brous middle layer
of the mature tympanic membrane. At this point
in development of the EAC, the entire canal is
cartilaginous. At about week 12 of development,
ossi ﬁ cation of the medial-most aspect of the canal
begins, forming the bony tympanic annulus and
(more laterally) the bony canal [ 3, 7 ] .
Dysmorphogenesis of the Auricle
Congenital deformities of the ear may be second-
ary to genetic abnormalities or through sporadic
developmental anomalies. The second category
Fig. 1.2 Auricular appendages representing duplications
of the hillocks of His. ( a ) Three preauricular appendages
likely representing a duplication of the 1–3 hillocks. ( b )
Auricular appendage at the root of the helix likely repre-
senting a duplication anomaly versus failure of incorpora-
tion of the second hillock into the mature auricle. ( c ) An
auricular appendage at the lobule likely representing a
duplication anomaly of the sixth hillock

6
J.C. Tracy et al.
is believed to be the more common cause,
although twin studies have indicated that genetic
contributions are important as well [ 8 ] . Further, it
is estimated that about 50 % of external ear
anomalies are associated with other congenital
abnormalities [ 9 ] . Sporadic anomalies are most
commonly assumed to be related to fetal malpo-
sition or vascular insults in development.
Dysmorphogenesis has been broadly classi ﬁ ed
as agenesis, hypoplasia, hyperplasia, dysplasia,
heterotopia, or duplication. In the case of the
auricle, the terms anotia, microtia, and macrotia
are used. The term microtia is often used broadly
to refer to auricular anomalies representing hyp-
oplasia, dysplasia, and perhaps inappropriately,
heterotopia as well. Duplication of the auricle is
an extremely rare event.
The development of the ear allows for a broad
range of different anomalies, and classi ﬁ cation
can be a challenge. Further, as noted above the
auricle, canal, and middle ear all develop concur-
rently and from tissues of the ﬁ rst and second
branchial arches. Therefore, congenital anoma-
lies frequently involve more than one part of the
ear. Anomalies of the external ear will be catego-
rized based on clinical appearance.
Auricular Pits, Cysts, and Sinuses
Preauricular pits, cysts, and sinuses represent a
spectrum of congenital ear anomalies. The under-
lying developmental problem is a failure of fusion
of two of the hillocks of His. The most common
location is at the anterior aspect of the root of the
helix, indicating a residual sinus tract or cyst
between the second and third hillocks. These
anomalies (as a group) make up the most common
congenital anomaly of the ear, with an incidence
of 0.3–0.9 %. They are most commonly found as
isolated anomalies, in individuals with no other
congenital malformations. However, there is a
documented increased incidence of auricular pits,
cysts, and sinuses in many different syndromes
including branchio-oto-renal syndrome, Beckwith-
Wiedemann syndrome, and mandibulofacial dys-
ostosis. Isolated, non-syndromic preauricular pits
are inherited in an autosomal dominant fashion.
Because these defects are a result of failure of
fusion of the hillocks, they generally extend down
to mesenchymal elements, namely, auricular per-
ichondrium or cartilage. The course of this condi-
tion may be marked by recurrent infections, and
surgical excision is recommended for symptom-
atic cases. Complete removal of the cyst or sinus
tract requires following it to the auricular carti-
lage and removing it en bloc with a small cuff of
normal tissue and cartilage (Fig. 1.3 ). Incomplete
excision has been shown to result in unacceptable
levels of recurrence.
Microtia
Microtia refers to hypoplasia and sometimes dys-
plasia of the auricle. This anomaly is the result of
abnormal development or fusion of the hillocks of
His (as described above). Microtia may be bilateral
in the case of syndromic or genetic clinical presen-
tations; however, it is most often unilateral. There
have been many classi ﬁ cation systems described;
perhaps the most commonly utilized is the Marx
classi ﬁ cation of microtia types I–IV (Fig. 1.4 ) [ 10 ] :
Type I: All anatomic subunits are present but
slightly dysmorphic in proportions.
Type II: Some identi ﬁ able auricular subunits
present, but not all of them. The auricle is gen-
erally smaller than usual with abnormal, often
thickened appearing cartilage. Lobule is
present.
Type III: There are no identi ﬁ able auricular
subunits. Cartilage is present but in an abnor-
mal, often cylindrical con ﬁ guration.
Type IV: Anotia.
Microtia occurs in 1:12,500 live births [ 11 ] . It
is more common in males and for unknown rea-
sons the right side is more commonly affected
than the left [ 12 ] . Type III microtia is the most
common form.
Anomalies of the Antihelical Cartilage
“Lop ear” refers to deformity of the auricle, caus-
ing the superior helix and sometimes antihelix to
fall inferiorly. This is secondary to cartilaginous

7
1 Embryology and Anomalies of the External Ear
abnormality. Speci ﬁ cally, a loss of the convex
anterior surface of the antihelix will result in this
deformity. Involvement that is isolated to the part
of the antihelix superior to Darwin’s tubercle
results in a mild form of this deformity. The
resultant appearance of the ear is almost normal,
however, with slightly decreased superior to infe-
rior length. When the cartilage of the antihelix
inferior to Darwin’s tubercle is involved, the
appearance is more abnormal. This condition
leads to a widening of the auricular angle, giving
the appearance of proptosis.
When this cartilaginous abnormality involves
the entire antihelix down to the rise of the antitra-
gus, the term “cup ear” is applied. In this case,
the lack of convexity of the antihelix to balance
the anteriorly concave structures of the helix and
concha results in abnormal anterior positioning
Fig. 1.3 Preauricular sinus. ( a ) Preoperative view dem-
onstrates a small preauricular pit with some overlying
skin change. ( b ) Dissecting along the sinus tract down
onto helical perichondrium. ( c ) Surgical specimen
including a small cuff of normal tissue and helical carti-
lage, a probe stents the sinus tract, which has been stained
with methylene blue
Fig. 1.4 Microtia. ( a ) Type I – All anatomic subunits are
present but slightly dysmorphic in proportions. ( b ) Type II
– Some identi ﬁ able auricular subunits present, but not all
of them. The auricle is generally smaller than usual with
abnormal, often thickened appearing cartilage. Lobule is
present. ( c ) Type III – There are no identi ﬁ able auricular
subunits. Cartilage is present but in an abnormal, often
cylindrical con ﬁ guration. ( d ) Type IV: Anotia

8
J.C. Tracy et al.
of the helix. In such cases the helical and conchal
cartilages are often abnormally formed as well.
The term Stahl ear describes a similar congen-
ital abnormality of the antihelical cartilage. In
this case there is an additional cartilaginous fold
of the antihelix, oriented in a vertical direction.
The resultant loss of the scaphoid depression
gives the pinna a pointed appearance (Fig. 1.5 ).
Protruding Ears
A variety of anomalies may lead to the appear-
ance of protruding ears. Although many patients
with such anomalies may complain of having
“big ears,” the majority of such cases are the
result of abnormal position of the ear or auricular
subunits. Dysplasia of the helix or antihelix may
cause the appearance of protruding ears. As noted
above, loss of the normal antihelical roll will
result in this appearance.
Often the cause is related to the size and shape
of the conchal cartilage and its position relative to
the mastoid and other auricular subunits. The nor-
mal auricle projects from the mastoid at an angle
of 15–20°. It has been observed that, in a normal
appearing ear, the distance on posterior view from
mastoid to the lateral extent of the auricle should
be about 2 cm. In assessing the patient with
protruding ears, it is essential to determine the
exact anatomic cause of protrusion (Fig. 1.6 ) [ 6 ] .
Cryptotia
Cryptotia is a rare congenital ear anomaly in which
the cartilage of the auricle is tethered to the tempo-
ral portion of the head. This is the result of a
de ﬁ ciency of skin. There is a loss of the usual skin
over the posterior aspect of the helix. The cartilage
in cryptotia is normally formed. This condition
occurs almost entirely in individuals of Japanese
descent, indicating a likely genetic contribution.
Anomalies of the External
Auditory Canal
Anomalies of the EAC may be categorized as
aplasia, atresia, stenosis, or duplication. In assess-
ing an abnormality of the auricle, it is important
to diagnose a concurrent EAC or middle ear
abnormality.
The distinction between aplastic and atretic
anomalies lies in the position of the condyle rela-
tive to the mastoid. In a case of true EAC aplasia,
there is complete lack of development of a canal
and the glenoid itself is displaced posteriorly. The
Fig. 1.5 Helical cartilage dysmorphology. ( a ) Lop ear. ( b ) Cup ear. ( c ) Stahl ear

9
1 Embryology and Anomalies of the External Ear
mandibular condyle essentially articulates with the
anterior surface of the mastoid. In EAC aplasia,
there may be a minimal remnant of the ﬁ rst bran-
chial cleft represented by a sinus or ﬁ stula tract.
EAC atresia refers to a canal that has devel-
oped normally to a point, but has not been suc-
cessfully canalized. That is, the EAC is occluded
by bony or ﬁ brous tissue. This condition is more
common than EAC aplasia. Jahrsdoerfer has pre-
sented a set of criteria in order to evaluate the
likelihood of improving hearing through surgical
repair of EAC atresia. These criteria include the
presence of a normal stapes, oval window, and
round window; articulation between the malleus-
incus and incus-stapes; facial nerve anatomy; the
appearance of the auricle; and pneumatization of
the mastoid and middle ear space [ 13, 14 ] .
Stenosis of the EAC may occur along the carti-
laginous or bony canal. In most cases of canal
stenosis, the TM and middle ear structures are nor-
mal. Canal stenosis must be severe in order to con-
tribute to hearing de ﬁ cits. However, patients with
severe stenosis (less than 2 mm) are at high risk of
developing canal cholesteatomas (Fig. 1.7 ) [ 15 ] .
Duplication of the EAC may occur. This is
more commonly termed a ﬁ rst branchial cleft
anomaly. These are categorized as work types I or
II. Work type I anomalies represent an EAC
duplication that extends from the preauricular
skin and runs parallel to the EAC, often opening
into the middle ear space. Type I anomalies are
made up of ectodermal tissue only. A work type II
anomaly is a ﬁ stulous tract extending from the
skin (or possibly from a subcutaneous cyst), typi-
cally overlying or just inferior to the angle of the
mandible. Type II ﬁ rst branchial cleft anomalies
generally open into the EAC itself, at the bony
cartilaginous junction. Work type II anomalies
are made up of both ectodermal and mesodermal
elements (contain cartilage) and are notoriously
involved with the facial nerve [ 16 ] .
Syndromic Ear Anomalies
The majority of congenital abnormalities of
the ear occur in otherwise normally devel-
oped individuals. However, there are many
genetic syndromes that are associated with an
increased incidence of certain congenital ear
anomalies. Identi ﬁ cation of such patterns can
be important in diagnosing additional, systemic
abnormalities.
Oculo-Auriculo-Vertebral syndrome (OAV),
also known by the eponym Goldenhar’s syn-
drome, is a congenital syndrome characterized by
defects of the ﬁ rst and second branchial arches.
OAV has an incidence of about 1/3,000 live
Fig. 1.6 Protruding ears. ( a ) Loss of normal antihelical fold, causing a lop ear defect. ( b ) Manual recreation of normal
antihelical fold. ( c ) Signi ﬁ cantly widened auricular angle (normal angle of 20° illustrated by dotted line )

10
J.C. Tracy et al.
births. It is most commonly sporadic, although
occasional familial clusters indicate a genetic
predisposition. This syndrome presents with
abnormalities of the mandible and palate, limbal
dermoids, and cervical vertebrae. It is generally
unilateral although bilateral cases have been
reported. OAV is associated with unilateral
microtia, often severe (grade II or IV). This syn-
drome is also associated with preauricular
appendages, which represent either duplications
of the hillocks of His or tissue from hillocks that
failed to fuse normally (Fig. 1.8 ) [ 17, 18 ] .
Fig. 1.7 EAC abnormalities. ( a ) Canal atresia. ( b ) Atresia of the bony canal with patent cartilaginous portion. ( c ) Canal
stenosis
Fig. 1.8 Syndromes associated with external ear anoma-
lies. ( a ) OAV syndrome with hypoplastic right midface
and loss of normal mandibular height shown in 3D recon-
struction. Grade III microtia. ( b ) BWS with characteristic
lobular clefting. Macroglossia. ( c ) CHARGE syndrome
with variable presentation of ears, generally hypoplastic
or absent lobule. Coloboma of the eye
a

11
1 Embryology and Anomalies of the External Ear
Fig. 1.8 (continued)
c
b

12
J.C. Tracy et al.
Beckwith-Wiedemann syndrome (BWS) is a
congenital
syndrome
characterized
by
exomphalos (a congenital abdominal wall
defect), macrosomia, macroglossia, and neona-
tal hypoglycemia. This syndrome is most com-
monly sporadic, although familial cases have
been identi ﬁ ed, with a common mutation on
the short arm of chromosome 11 [ 19 ] . BWS is
associated with characteristic lobular clefts (or
dimples) as well as posterior helical pits.
Patients with this disorder have a signi ﬁ cantly
increased risk of developing childhood cancers
including Wilm’s tumor and hepatoblastoma
(Fig. 1.8 ) [ 20 ] .
CHARGE syndrome (formerly CHARGE
association) is characterized by coloboma of the
eyes, heart defects, atresia of the nasal choanae,
retardation of growth/development, genitourinary
abnormalities, and ear anomalies. This condition
was previously known as an association of con-
genital abnormalities. Recent studies have
identi ﬁ ed an associated mutation of the CHD7
gene on chromosome 8 in 60–70 % of patients
with this phenotype, and as such it is now termed
a genetic syndrome. CHARGE is associated with
dysmorphology of the external, middle, and inner
ear. The auricle of patients with CHARGE often
has an absent lobule, although there is an
increased prevalence of other abnormalities as
well (Fig. 1.8 ) [ 21, 22 ] .
Conclusions
The external ear develops from ectodermal
and mesodermal elements of the ﬁ rst and sec-
ond branchial arches, primarily during the
5th–20th weeks of gestational development.
Six hillocks of His are formed initially and the
fusion of these structures forms the auricle as
well as cartilaginous EAC. An understanding
of the normal development of the ear is essen-
tial in order to understand the various congen-
ital anomalies that may develop. Accurate
recognition of congenital ear anomalies allows
for the appropriate management of these con-
ditions and also the potential recognition of
other congenital abnormalities.
References
1. Rodríguez-Vázquez JF. Development of the stapes
and associated structures in human embryos. J Anat.
2005;207(2):165–73.
2. His W. Anatomie Menschlicher Embryonem Part III.
Leipzig: FCW Vogel; 1885. p. 211.
3. Karmody CS, Annino Jr DJ. Embryology and anoma-
lies of the external ear. Facial Plast Surg.
1995;11(4):251–6.
4. Rogers BO. Anatomy embryology and classi ﬁ cation
of auricular deformities. In: Tanzier RC, Edgerton
MT, editors. Symposium on reconstruction of the
auricle. St. Louis: CV Mosby Co.; 1974. p. 3–11.
5. Bowden RE. Development of the middle and external
ear in man. Proc R Soc Med. 1977;70(11):
807–15.
6. Papel ID, Frodel JL, Larrabee WF, Holt GR, Nachlas
NE, Park SS, et al. Facial plastic and reconstructive
surgery. 3rd ed. New York: Thieme Medical
Publishing; 2002.
7. Lucente FE. Anatomy, histology, and physiology. In:
Lucente FE, Lawson W, Novick NL, editors. The
external ear. Philadelphia: WB Saunders Co.; 1995.
p. 1–16.
8. Artunduaga MA, Quintanilla-Dieck Mde L, Greenway
S, Betensky R, Nicolau Y, Hamdan U, et al. A clas-
sic twin study of external ear malformations,
including microtia. N Engl J Med. 2009;361(12):
1216–8.
9. Alasti F, Van Camp G. Genetics of microtia and
associated syndromes. J Med Genet. 2009;46(6):
361–9.
10. Marx H. Beitrag zur morholgie und genese der mitte-
lohrmissbildungen mit gehorgangsatresie. Z Hals
Nasa Ohrenheilkd. 1922;2:230.
11. Karmody CS. A classi ﬁ cation of the anomalies of the
ﬁ rst branchial groove. Otolaryngol Head Neck Surg.
1979;87(3):334–8.
12. Klockars T, Rautio J. Embryology and epidemi-
ology of microtia. Facial Plast Surg. 2009;25(3):
145–8.
13. Jahrsdoerfer RA, Hall III JW. Congenital malforma-
tions of the ear. Am J Otol. 1986;7(4):267–9.
14. Shonka Jr DC, Livingston 3rd WJ, Kesser BW. The
Jahrsdoerfer Grading Scale in surgery to repair con-
genital aural atresia. Arch Otolaryngol Head Neck
Surg. 2008;134(8):873–7.
15. Cole RR, Jahrsdoerfer RA. The risk of cholesteatoma
in congenital aural stenosis. Laryngoscope. 1990;
100(6):576–8.
16. Work WP. Newer concepts of ﬁ rst branchial cleft
defects. Laryngoscope. 1972;82(9):1581–93.
17. Passos-Bueno MR, Ornelas CC, Fanganiello RD.
Syndromes of the ﬁ rst and second pharyngeal arches:
a review. Am J Med Genet A. 2009;149A(8):
1853–9.

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1 Embryology and Anomalies of the External Ear
18. Rosa RF, da Silva AP, Goetze TB, Bier Bde A, de
Almeida ST, Paskulin GA, et al. Ear abnormalities in
patients
with
oculo-auriculo-vertebral
spectrum
(Goldenhar syndrome). Braz J Otorhinolaryngol.
2011;77(4):455–60.
19. Pettenati MJ, Haines JL, Higgins RR, Wappner RS,
Palmer CG, Weaver DD. Wiedemann-Beckwith syn-
drome: presentation of clinical and cytogenetic data
on 22 new cases and review of the literature. Hum
Genet. 1986;74(2):143–54.
20. DeBaun MR, Tucker MA. Risk of cancer during
the ﬁ rst four years of life in children from The
Beckwith-Wiedemann Syndrome Registry. J Pediatr.
1986;132(3 Pt 1):398–400.
21. Lalani SR, Sa ﬁ ullah AM, Fernbach SD, et al.
Spectrum of CHD7 mutations in 110 individuals
with CHARGE syndrome and genotype- phenotype
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2006;78(2):
303–14.
22. Vissers LE, van Ravenswaai CM, Admiraal R, Hurst
JA, de Vrie BB, Janssen IM, et al. Mutations in a new
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955–7.

15
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_2, © Springer-Verlag Berlin Heidelberg 2013
2
Introduction
The external ear comprises the auricle and the
auditory canal. The ﬁ brocartilaginous auricle fun-
nels sound waves from the environment into the
auditory canal to the tympanic membrane. This
convoluted shell-like pliable structure is function-
ally but also aesthetically important. Deviations
from the norm or aberrations in position, shape,
size, or in the architecture of the auricle are notice-
able and undesirable. Careful surgical correction
or reconstruction can restore the beauty of the ear
and a harmonious appearance with the face.
Aesthetic otoplasty techniques are elegant and
often intricate and rely on a complete understand-
ing of anatomy. As well as knowing the muscles,
nerves, and vessels supplying the auricle, every
groove, fold, concavity, and convexity of the ear
should be clearly imprinted in the mind of any
surgeon embarking on aesthetic otoplasty and
reconstruction of the auricle.
Auricle
The auricle is the irregularly shaped part of the
external ear that protrudes from the face at the
level of the temporal bone (Fig. 2.1 ). It consists
of an elastic, convoluted cartilaginous plate cov-
ered in skin. The auricle is tilted posteriorly
somewhat so that the long axis creates an angle of
approximately 8° with the retromandibular line.
The superior aspect of the auricle is ideally
located on a vertical plane with the brow [ 1 ] .
Normal projection from the mastoid is about 10
or 17–20 mm from the mastoid to the free border
of the helix. Normal projection varies between
races, with a greater mastoid to helix distance
seen in Asians. In children, the auricle is wider
and shorter. The height-to-width ratio increases
as the ear grows, reaching about 7:4 in adulthood.
Depending on the position of the auricle, its sur-
faces can be described as anterior or lateral, and
posterior or medial [ 2 ] . As the ear comes into
view, it is easy to appreciate the eminences and
cavities of the anterior auricular surface. On fron-
tal view, the helix should be visible 2–5 mm lat-
erally behind the antihelix [ 3 ] .
Anterior (Lateral) Auricular Surface
The outline or margin of the auricle is formed
by the helix, an incompletely folded tube that
creates a gutter or scaphoid fossa along most
of its length. The helix starts anteriorly, emerg-
ing from the cavity or concha of the auricle as
the helical crus. It passes anterosuperiorly ﬁ rst,
then posterosuperiorly, posteroinferiorly, and
anterosuperiorly, creating a smooth, rounded arc.
A small dimple marks the point where the heli-
cal tail merges with the lobule. Often, a small
P. M. Prendergast , M.D., MB, BCh, MRCSI
Venus Medical ,
Heritage House, Dundrum Of ﬁ ce Park ,
Dundrum, Dublin 14 , Ireland
e-mail: peter@venusmed.com
Anatomy of the External Ear
Peter M. Prendergast

16
P.M. Prendergast
protuberance or tubercle, known as Darwin’s
tubercle, exists where the helix superior meets
the helix posterior (Fig. 2.1 ).
Inside the helix lies the antihelix, making up
part of the ﬂ oor of the auricle and circumscribing
the concha. Superiorly, the antihelix has two ele-
vations, superior and inferior crura, between
which lies the triangular fossa. Inferiorly, the
antihelical tail joins the antitragus at the posterior
auricular sulcus. Both the helix and antihelix are
visible in a frontal view, but the antihelix pro-
trudes more as it passes from superiorly to inferi-
orly, creating an angle of approximately 20°
between the helical and antihelical planes [ 4 ] .
The inferior crus of the antihelix is oriented more
superiorly in taller people with longer ears. In
those with shorter ears and in children, the infe-
rior crus is oriented more horizontally.
The concha is an incomplete cavity that leads
into the auditory canal. The sharp superior edge
of the concha is formed by the inferior crus of
the antihelix, the inferior edge by the sharp edges
of the tragus and antitragus, which overhang the
concha and make it appear smaller. In contrast,
the lateral edge is smooth and rolled and formed
by the antihelix. The tragus projects from the
face to partially cover the anteroinferior part of
the concha, whereas the antitragus projects
superiorly rom the lobule to cover part of the
inferior region of the concha. A prominent,
sharp-edged, intertragic notch lies between the
tragus and antitragus. In older patients, a tuft of
hair—barbula hirci—often protrudes from this
notch.
The lobule is the only part of the auricle with-
out an underlying cartilaginous framework.
About one-third of its perimeter is attached ante-
riorly to the cheek, with the remainder dangling
as a free border. Above, an antitragal gutter or
depression separates the lobule from the
antitragus.
The skin of the anterior auricular surface is
closely adherent to the underlying perichon-
drium, with almost no fat between them. Vessels
and nerves lie within a slip of fascia that sepa-
rates the skin and perichondrium. Sebaceous and
sudoriparous glands are present in the triangular
fossa and around the external auditory meatus,
respectively. Ceruminous glands predominate in
the auditory canal. The integument of the postau-
ricular surface differs greatly from the tightly
bound, fat-free skin found on the anterior auricu-
lar surface. In contrast, the posterior surface is
characterized by skin that can wrinkle and glide
over the underlying cartilage. There are two lay-
ers of fat that allow this, a super ﬁ cial dense layer
Helix
Tubercle
of Darwin
Scaphoid fossa
Antihelix
Antitragus
Helical tail
Lobule
Intertragic notch
Eminence of
concha
Antihelical fossa
Eminence of
triangular
fossa
Eminence of scapha
Tragus
Cavum conchae
Cymba conchae
Crus of helix
Inferior crus
Triangular fossa
Superior crus
Fig. 2.1 Auricle surface. ( Left ) Anterior. ( Right ) Posterior

17
2 Anatomy of the External Ear
and a looser deep layer. A layer of fascia between
the super ﬁ cial and deep layers of adipose tissue
envelopes the nerves, vessels, and lymphatics
that supply and innervate the posterior surface of
the auricle [ 4 ] . A subdermal vascular network
also exists more super ﬁ cially. This subdermal
architecture extends over the helical margin to
the helical rim where the transition from one type
of integument to the other occurs. The lobule
contains ﬁ rm trabecular fat and a network of sub-
dermal and deep vessels and is covered in ﬁ ne
hairs. Over the inferior aspect of the auricle, the
transition from skin that is adherent to that which
glides is less sharp but occurs from the posterior
auricular sulcus, antitragus, tragus, and anterior
auricular sulcus.
Posterior (Medial) Auricular Surface
The posterior auricular surface is mostly hidden
from view since the auricle projects only 10 mm
from the mastoid. The surface is characterized by
prominences and sulci in an inverse pattern to
that seen on the anterior auricular surface
(Fig. 2.1 ). The main eminences are formed by the
scapha, the concha, and the triangular fossa. The
antihelical fossa lies between these eminences.
Cartilage
The auricle obtains its shape, appearance, and
ﬂ exibility from the underlying convoluted carti-
laginous plate. The entire auricle, except for the
lobule, has cartilage as its framework. The
unique structure of the auricle, including creases
and folds in the cartilage, allows it to be bent,
folded, and compressed without discomfort or
consequence. A thin, very adherent, layer of
perichondrium covers the cartilage of the
auricle.
The anterior/lateral surface of the cartilage
greatly resembles the auricle itself since it is cov-
ered only in a thin layer of skin (Fig. 2.2 ). The
helix curves anterosuperiorly from the crus and
then backward to form the cartilaginous margin
of the auricle. The scapha represents the valley
between the helix and antihelix. The cartilagi-
nous tragus and antitragus are separated by the
intertragic notch. The concha and tragus continue
medially to form the cartilaginous part of the
external auditory canal. This cartilaginous part
ﬁ ts into and fuses with the socket of the bony part
of the external auditory canal. The posterosupe-
rior part of the helix and the scapha are peppered
with numerous tiny openings [ 5 ] . Otherwise, the
lateral cartilaginous plate of the auricle is smooth.
Helix
Scaphoid
fossa
Antitragus
Intertragic fossa
Eminence of
concha
Helix
Eminence of triangular fossa
Tragus
Cavum conchae
Cymba conchae
Crus of helix
Inferior crus
Superior crus
Triangular fossa
Fig. 2.2 Cartilage of the auricle. ( Left ) Anterior. ( Right ) Posterior

18
P.M. Prendergast
Foramina that transmit vessels and nerves are
present throughout the cartilage of the auricle,
particularly in the scapha, triangular fossa, and
concha.
The medial surface of the cartilage of the auri-
cle appears as fossae and eminences in a reverse
pattern to its lateral counterpart (Fig. 2.2 ). The
cartilage is almost uniform in thickness through-
out the auricle, so the triangular fossa and concha
appear as eminences on the medial surface of the
auricle. Similarly, the antihelix appears as an
antihelical fossa on the medial surface. Parts of
the antihelix and concha on the medial surface
are rough in texture where external auricular
muscles attach.
The lobule hangs from the auricle inferiorly
and has no underlying structural cartilaginous
support. The entire cartilaginous auricle ﬁ ts into
the socket of the cartilaginous external auditory
canal and is supported by ligaments and
muscles.
Muscles
The small extrinsic muscles and ligaments of
the ear provide anchorage and support for the
auricle, holding it ﬁ rmly in place over the bony
skull. The resting tone of the tiny rudimentary
intrinsic muscles provides structural support
for the auricle and contributes to its characteris-
tic
convoluted
and
folded
con ﬁ guration
(Fig. 2.3 ).
The extrinsic muscles consist of the posterior,
superior, and anterior auricular muscles. The pos-
terior muscle comprises a superior and inferior
slip, supported by the posterior auricular liga-
ment. Posteriorly, the muscles arise from the
mastoid periosteum. The superior part attaches to
the eminentia cymba, the upper part of the con-
chal eminence. The inferior part of the posterior
auricular muscle inserts into the cartilage of the
ponticulus, the lower part of the conchal
eminence. The posterior auricular ligament rein-
forces the posterior auricular muscle and runs
parallel to the two slips of muscle from the mas-
toid periosteum to the conchal eminence. These
muscles are innervated by the posterior auricular
branch of the facial nerve and supplied by poste-
rior auricular vessels. The superior auricular
muscle is a short but strong muscle arising from
the epicranial aponeurosis above and inserts into
the eminence of the triangular fossa on the poste-
rior auricular surface. It is enveloped in layers of
the super ﬁ cial temporal fascia and receives inner-
vation from temporal branch of the facial nerve.
The superior auricular muscle receives its blood
supply from small branches of the super ﬁ cial
temporal vessels. The anterior auricular muscle
provides further support for the auricle anteriorly.
Posterior
auricular m.
Posterior
auricular
ligament
Antitragicus m.
Posterior
auricular m.
Transversus
auriculae m.
Obliquus
auriculae m.
Tragicus m.
Anterior auricular m.
Helicis minor m.
Superior auricular m.
Temporoparietal m.
Superior auricular m.
Fig. 2.3 Extrinsic and intrinsic muscles of the auricle

19
2 Anatomy of the External Ear
It passes from the zygomatic arch and epicranial
aponeurosis anteriorly to the spine of the helix
posteriorly. It is supplied by branches of the
super ﬁ cial temporal vessels and receives innerva-
tion from the auriculotemporal nerve and tempo-
ral branch of the facial nerve. The anterior
auricular muscle is supported by a ligament of
the same name that tethers the tragus and helical
spine to the zygomatic arch and epicranial
aponeurosis.
The intrinsic muscles consist of tiny anteri-
orly and posteriorly arranged slips that connect
and bridge the convexities and concavities of
the auricle (Fig. 2.3 ). Anteriorly, the helicis
major, helicis minor, tragicus, and antitragicus
muscles are arranged around the concha. They
are not under voluntary control and are essen-
tially remnants of what was once a sphincter
controlling sound entry. Posteriorly, there are
four main intrinsic ligaments as well as verti-
cally and horizontally arranged muscle ﬁ bers
connecting and supporting the cartilaginous
convolutions of the auricle.
Nerves
The auricle receives innervation from branches
of the greater auricular nerve, lesser occipital
nerve, auriculotemporal nerve, facial nerve, and
vagus nerve (Fig. 2.4 ). Most of these are sensory,
with some vasomotor and secretory ﬁ bers arising
from the facial nerve [ 6 ] .
The greater auricular nerve provides most sen-
sory innervation of the auricle. It arises from ﬁ bers
of the second and third cervical nerves. It emerges
onto the posterior border of sternocleidomastoid
as a root, between the sternocleidomastoid fascia
and platysma. The nerve passes in this plane
toward the ear and divides into anterior and poste-
rior branches below the auricle. The anterior
branch pierces the lobule and sends sensory
branches to the inferior, posterior, and superior
parts of the lateral auricular surface. The posterior
branch of the greater auricular nerve passes under
the lobule and supplies the cranial surface of the
auricle. The greater auricular nerve also innervates the
anterior and superior walls of the external auditory
Auriculotemporal n.
Greater auricular n.
Lesser
occipial n.
Fig. 2.4 Sensory innervation of the auricle

20
P.M. Prendergast
canal. The lesser occipital nerve also arises from
ﬁ bers of the second, and sometimes third, cervical
nerves. It courses along the posterior border of
sternocleidomastoid, behind the auricle, to inner-
vate the scalp as well as the superior part of the
cranial auricular surface.
The auriculotemporal nerve is a branch of the
posterior trunk of the mandibular branch of the
trigeminal nerve. Although it is mainly a sensory
nerve, it also carries sympathetic and parasympa-
thetic ﬁ bers and ganglionic branches that communi-
cate with the otic ganglion. Its two roots encircle the
middle meningeal artery and then unite behind the
artery and pass super ﬁ cially to lie between the exter-
nal acoustic meatus and temporomandibular joint.
The auriculotemporal nerve passes superiorly with
the super ﬁ cial temporal vessels, over the zygomatic
arch toward the temple. Sensory branches from the
auriculotemporal nerve supply the tragus, inferior
crus of the antihelix, anterosuperior part of the
scapha and helix, and crus of the helix. It also inner-
vates the posterior wall of the auditory canal and
tympanic membrane.
The auricular branch of the vagus nerve arises
from the superior ganglion below the jugular
foramen. It passes through the temporal bone and
exits the tympanomastoid ﬁ ssure at the opening
of the external acoustic meatus. It divides into
two branches, one supplying the concha and
cymba conchae of the auricle and the other anas-
tomosing with the posterior auricular branch of
the facial nerve. The auricular branch of the vagus
nerve, or nerve of Arnold, also innervates the
ﬂ oor of the external auditory canal.
Motor branches of the facial nerve innervate
the extrinsic and intrinsic auricular muscles. After
emerging from the parotid capsule, the temporal
branch of the facial nerve passes beneath the
super ﬁ cial
musculoaponeurotic
system
and
anterosuperiorly toward the temporal area and lat-
eral canthus. During its course, it gives off several
branches that innervate tragicus, helicis major,
helicis minor, and anterior auricular muscle. More
superiorly, branches innervate the superior auric-
ular muscle, and others continue to supply the
posterior auricular muscle and the tiny intrinsic
muscles of the posterior auricular surface.
Autonomic sympathetic ﬁ bers traveling with the
facial nerve provide vasomotor and secretory
function to the vessels and glands of the auricle.
Vascular Supply
The external ear receives its arterial supply
through branches of the super ﬁ cial temporal
artery anteriorly and posterior auricular artery
posteriorly (Fig. 2.5 ). The super ﬁ cial temporal
Perforating
branches
External carotid a.
Posterior auricular a.
Inferior auricular a.
Medial auricular a.
Superior auricular a.
Superficial temporal a.
Perforating
branches
Fig. 2.5 Arterial supply of the auricle

21
2 Anatomy of the External Ear
artery arises within the parotid as the anterior
branch of the external carotid artery. It emerges
from the parotid capsule and runs superiorly
toward the temporal area, about 1 cm anterior to
the auricle and beneath the anterior auricular
muscle and deep to the super ﬁ cial temporal vein.
As it travels superiorly, it sends three main
branches posteriorly toward the auricle: inferior,
medial, and anterosuperior auricular arteries.
These vessels form a richly branching and anas-
tomosing network between the skin and per-
ichondrium of the anterior auricular surface. The
caliber of these vessels varies, but there are fairly
consistent perforating vessels that pass from the
regions of the antitragus, cymba conchae, and tri-
angular fossa to the posterior auricular surface.
The posterior auricular artery arises as the
posterior branch of the external carotid artery. It
courses below the greater auricular nerve toward
the mastoid process. A mastoid branch supplies
the skin in this area. The main posterior auricular
artery continues behind the auricle and passes
superiorly behind the posterior auricular muscles.
Three main branches supply the posterior (cra-
nial) auricular surface: inferior, medial, and pos-
terosuperior auricular arteries. These arteries
form a super ﬁ cial anastomotic arcade just below
the skin and a deeper subcutaneous vascular
layer. The latter is ensheathed in fascia that sepa-
rates the fat on the posterior auricular surface into
a super ﬁ cial trabecular layer and deep layer. The
posterior auricular artery branches also perforate
the auricular cartilage to anastomose with the
anterior vessels.
The anterior and posterior auricular veins
follow the arteries, although there is often more
than one vein per artery. The veins are slightly
larger in diameter, up to 2 mm. Posteriorly, the
posterior auricular vein drains the posterior sur-
face of the auricle and runs inferiorly between the
posterior auricular artery and greater auricular
nerve to drain into the external jugular vein.
References
1. Adamson PA, Litner JA. Aesthetic parameters and
speci ﬁ c deformities. In: Litner JA, Adamson C, Adamson
PA, editors. Aesthetic otoplasty, connecticut. People’s
Medical Publishing House, Beijing, China. 2011. p. 15.
2. Weerda H. Anatomy of the external ear. In: Weerda H,
editor. Surgery of the auricle. Tumors, trauma, defects,
abnormalities. Stuttgart: Georg Thieme; 2007. p. 1.
3. Wright WK. Otoplasty goals and principles. Arch
Otolarygol. 1970;92(6):568–72.
4. Davis J. Surgical artistry and the levels of otoplasty. In:
Davis J, editor. Aesthetic and reconstructive otoplasty.
Berlin: Springer; 1987. p. 61.
5. Vidic B, O’Rahilly R. Lateral surface of isolated carti-
lage of auricle. In: Vidic B, O’Rahilly R, editors. An
atlas of the anatomy of the ear. Philadelphia: Saunders;
1971.
6. Gilroy AM, MacPherson BR, Ross LM. External ear
and auditory canal. In: Gilroy AM, McPherson BR,
Ross LM, editors. Atlas of anatomy. New York:
Thieme; 2008. p. 529.

23
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_3, © Springer-Verlag Berlin Heidelberg 2013
3
Historical Perspective
The anatomy of the fascia posterior to the ear,
often referred to as the “retroauricular” or
“super ﬁ cial mastoid” region, is interesting due to
its variety of applications within plastic surgery
in general and more speci ﬁ cally in otoplasty. Its
versatility relates to a number of factors includ-
ing a de ﬁ ned and complex blood supply [ 1 ] and
its thin but strong constitution [ 2, 3 ] . This fascia
has been used in a variety of indications ranging
from lip enhancement [ 4 ] and repairs of nasal [ 5 ]
and auricular defects [ 2 ] to an adjunct in the man-
agement of congenital or acquired defects includ-
ing microtia-atresia [ 1, 6 ] .
In relation to otoplasty speci ﬁ cally, the post-
auricular fascia gained recognition as a useful
entity when used as cover for suture knots in
Mustarde-style otoplasty [ 7 ] , with the purpose of
reducing recurrence and palpability or extrusion
of permanent suture material. This ﬂ ap is based
posteriorly and sutured with ﬁ ne absorbable
sutures back up towards the helical rim after
placement of chondral sutures. The posteriorly
based ﬂ ap is demonstrably useful for this indica-
tion [ 8 ] , although it has minimal mechanical
value in terms of shaping the ear or correcting the
deformity.
Subsequently, the fascia was used as an
intrinsic part of the otoplasty technique to give
a natural look with minimal recurrence by rais-
ing it based anteriorly on the helical rim itself
and suturing it to the mastoid [ 9 ] . Through its
attachments along the helical rim, the fascia-
mastoid juxtaposition creates a natural ear con-
tour dif ﬁ cult to achieve with sutures alone
while maintaining suture cover and removing
tension from Mustarde sutures. It was sug-
gested [ 9 ] that the fascia-to-mastoid suture
alone could correct the prominent ear, and this
was partially con ﬁ rmed by other authors
subsequently [ 10 ] , who described a similar
technique. However, these authors [ 10 ] still
used a permanent conchomastoid (Furnas)
suture and advocated overcorrection as part of
the procedure. The results were presented as
“A total of 72 patients (87.8 %) underwent a
single procedure. In ten patients, there was an
excessive loss of medialization of the upper
pole, 2 bilaterally, leading to a total of 12 reop-
erated ears (7.41 %). In seven ears (4.34 %)
there was a partial extrusion of the suture
thread, in its conchal portion, which was
K. Shokrollahi , M.D., BSc, MB, ChB, MSc, LLM,
MRCS(Eng), FRCS(Plast) (*)
Mersey Regional Burns and Plastic Surgery Unit,
Ward 4D , Whiston Hospital , Warrington Rd ,
Liverpool L35 5DR , UK
e-mail: kshokrollahi@hotmail.com
J. P. Taylor , MA (Cantab), MBBChir, MRCS (Eng)
Core Surgical Trainee,
Guys and St Thomas’ NHS Foundation Trust,
St Thomas’ Hospital ,
Westminster Bridge Road ,
London , UK
e-mail: jamesptaylor23@gmail.com
Anatomy, History, and Utility
of the Posterior Auricular Fascia
in Otoplasty
Kayvan Shokrollahi and James P. Taylor

24
K. Shokrollahi and J.P. Taylor
removed in the of ﬁ ce and did not require
additional corrections” [ 10 ] .
It therefore remains inconclusive as to whether
fascial repair alone can truly, reliably, symmetri-
cally, and aesthetically correct prominent ears in
the long term without sutures. We believe that for
consistent and symmetrical results with minimal
recurrence, Mustarde sutures are still required in
the form of what is best termed fascia-augmented
otoplasty and are not associated with high extru-
sion and revision rates [ 9 ] as experienced with
Furnas sutures [ 10 ] . Overcorrection as an intrin-
sic part of this or any procedure is not desirable
as it does not allow suf ﬁ cient surgical control of
the end result or suf ﬁ cient control over ﬁ nal
symmetry.
A further advantage of augmenting suture-
based otoplasty with a de-tensioning anteriorly
based fascial ﬂ ap is that it works synergistically
with our technique of glue instead of head ban-
dages as postoperative splints [ 9, 11– 13 ] , allow-
ing patients to wash their hair and for girls to
hide all stigmata of surgery beneath long hair.
The utility of this strategy has been reviewed
recently [ 12 ] . The glue is used to af ﬁ x the ear
temporarily to the side of the head and usually
lasts for up to 2 weeks but depends on the brand
of glue.
Based on our own anatomical studies, we
describe herein the macro- and microscopic
detail of the fascia. The auriculocephalic sulcus
demarcates the region previously described as
the postauricular, or retroauricular, fascia from
the fascia directly adherent to the posterior
surface of the ear. The authors have termed
these the extrinsic postauricular fascia (EPF)
and
intrinsic
postauricular
fascia
(IPF),
respectively.
Anatomy of the Postauricular
Region
Our anatomical cadaveric studies have elucidated
that the anatomy of the IPF, from super ﬁ cial to
deep, comprises the skin, subcutaneous fascia
and fat, blood vessels and nerves, perichondrium,
and ﬁ nally cartilage (Figs. 3.1 and 3.2 ). Auricularis
posterior, when present, is enveloped by the
fascia. The IPF, in comparison to the tough
ﬁ brous tissues of the super ﬁ cial peri-mastoid
fascia of the EPF, is less ﬁ brous and is not in
Fig. 3.1 Access incision with
intrinsic fascia removed

25
3 Anatomy, History, and Utility of the Posterior Auricular Fascia in Otoplasty
direct continuity with any convincing muscle
mass, except via those attachments to auricularis
posterior.
Injection studies of the cadavers revealed that
the IPF has a codominant blood supply mirroring
that of the auricle itself, which arises from the
super ﬁ cial temporal artery and the posterior
auricular artery (Fig. 3.3 ). One of the main rea-
sons for the IPFs’ excellent potential for use in
plastic surgery is due to this rich vascular network
(Fig. 3.4 ). This intricate labyrinth of vessels con-
sists of multiple anastomoses (Fig. 3.5 ), which
makes it an ideal candidate as a bed for skin
grafts when used as a recipient ﬂ ap. The EPF
itself, in contrast, receives its main blood supply
via the occipital artery and auricular branches of
the posterior auricular artery. Its nerve supply
hails from the greater auricular and lesser occipi-
tal nerves [ 1 ] .
The auriculocephalic sulcus corresponds to
the junction of the EPF and IPF, which we term
the auricular fascial incisura (AFI) (Fig. 3.6 ).
There is a clear and apparent change in the nature
and quality of the fascia: the thin fascia of the
IPF, which is adherent to the ear, becomes lay-
ered and ﬁ brous up to and beyond the mastoid.
Datta et al. [ 2 ] have previously described the lay-
ers of the mastoid fascia (EPF): below the skin
and subcutaneous tissue, there exist three fascial
layers. Firstly and most caudally, a strong, heavy,
thick ﬁ brous fascia exists which was previously
referred to as the super ﬁ cial mastoid fascia. More
cranially, the previously described super ﬁ cial
temporal fascia exists, which is more elastic and
less ﬁ brous in consistency. Finally, the deep mas-
toid fascia exists below the super ﬁ cial mastoid
fascia, which is thinner and more ﬁ brous than its
super ﬁ cial counterpart. This layer of fascia then
attaches to the periosteum of the petrous tempo-
ral bone, while its cranial continuation is termed
the innominate fascia. This separates the deep
and super ﬁ cial temporal fascia, which is the deep
layer directly covering the temporal muscles
(Fig. 3.7 ).
The IPF is thinner and less ﬁ brous than its
extrinsic counterpart. It is unique in that it lies
between the posterior auricular skin and the per-
ichondrium of the ear and possesses vessels and
ﬁ ne nerves within. If the skin and cartilage of the
ear are excised, all that remains is the IPF, per-
ichondrium, ﬁ bro-fatty tissue, nerves, and
vessels.
Fig. 3.2 Dissection of the
IPF off the cartilage

26
K. Shokrollahi and J.P. Taylor
Fig. 3.3 Continuity of vascular anastomosis between head, neck, and ear

27
3 Anatomy, History, and Utility of the Posterior Auricular Fascia in Otoplasty
Clinical Applications
Thanks to the codominant bloody supply, rich
vascular network (Figs. 3.3 , 3.4 , and 3.5 ), and
inherent elasticity, the IPF has potential for
both reconstructive ﬂ aps as well as acting as a
free graft.
The IPF has the potential to reconstruct helical
defects of the ear as demonstrated (Figs. 3.8 and
3.9 ) for defects of approximately 30 % of the
pinna using IPF alone or greater with an extended
ﬂ ap using the EPF as well (Fig. 3.10 ).
There is potential to tunnel the fascia through
the ear to reconstruct conchal defects (Fig. 3.11 ),
and it may be feasible to roll the fascia to recon-
struct or de ﬁ ne the crura of the antihelix
(Fig. 3.12 ). If the entire postauricular fascia is
raised on a single or dual pedicle, it should cover
most of the ear (Fig. 3.13 ) or reach as far as the
zygoma (Fig. 3.14 ) or beyond.
By raising the IPF distally as a ﬂ ap and
suturing it to the mastoid, it is possible to pro-
vide correction of ear deformities for pinna-
plasty [ 9 ] . Suture tension is relieved thanks to
the fascia’s attachment to the underlying helical
cartilage acting as an “internal scaffold”
Fig. 3.4 Cleared and anatomical dissection of postauricular fascia
Fig. 3.5 High-power microscopy of vascular network in
IPF

28
K. Shokrollahi and J.P. Taylor
Fig. 3.6 The auricular fascial
incisura: the meeting point of
the thin intrinsic postauricular
fascia directly adherent to the
posterior surface of the ear
and the thicker extrinsic
postauricular fascia overlying
the mastoid which is
continuous with the thick
fascia of the occipital
musculature
IPF
EPF
Superficial temporal fascia
Innominate fascia
Deep temporal fascia
Temporal muscle
Posterior auricular
muscle
Posterior auricular
artery
Deep mastoid fascia
Superficial mastoid fascia
Skin
AFI
Fig. 3.7 Anatomy of the
intrinsic ( IPF ) and extrinsic
( EPF ) postauricular fascia
Fig. 3.8 Proposed helical repair utilizing the IPF in a cadaveric model

29
3 Anatomy, History, and Utility of the Posterior Auricular Fascia in Otoplasty
(Figs. 3.15 , 3.16 , and 3.17 ). This technique, com-
bined with the use of skin glue for postoperative
splinting [ 14 ] , makes head bandages obsolete and
enables patients to not only wash their hair the
day after surgery but also escape the stigma of the
surgery (this is especially useful in girls who
wear their hair long as all signs of surgery can be
hidden) (Figs. 3.18 and 3.19 ).
It is also plausible that the fascia might be
suitable for microtia reconstruction [ 1 ] . Cikelair
produced a set of goals for reconstruction of the
external ear, which included provision of skin of
appropriate thickness and texture, in addition to
the insertion of a framework for support. The IPF
would theoretically act as a suitable scaffold.
Similarly, major ear reconstructions using pros-
thetic materials may bene ﬁ t from additional (fas-
cial) soft-tissue cover to limit the high rates of
extrusion.
In addition to its use in ear reconstruction, the
super ﬁ cial temporal fascia (STF) has been suc-
cessfully utilized on a long pedicle to repair lower
nasal defects [ 5 ] . The technique reported by Ying
et al. involved marking the course of the super ﬁ cial
temporal artery with methylene blue on the skin,
in conjunction with an ultrasound Doppler probe.
Subsequently, the STF is exposed through careful
dissection and the ﬂ ap is raised. The ﬂ ap is then
transposed into the defect in question via a sub-
cutaneous tunnel.
In complex rhinoplasty cases, where the skin
is very thin or scar tissue has tethered the skin to
underlying bone or cartilage (such as in revision
rhinoplasty), the IPF can act as an excellent
adjunct. Figure 3.20 shows success utilizing the
IPF for protection of overlying fragile skin in a
case complicated by a fracture. This is an excel-
lent and autologous alternative to AlloDerm
(Lifecell Corp.), Permacol (Covidien Surgical),
or other synthetic or tissue-derived products.
Other potential applications include bony
Fig. 3.9 Helical repair, highlighting incisions utilized
and suture positions
Fig. 3.10 Helical cover – an extended ﬂ ap
Fig. 3.11 Tunneling the IPF

30
K. Shokrollahi and J.P. Taylor
remodeling – especially if the perichondrium is
included in the ﬂ ap, skin protection, and
camou ﬂ age. The ear via a posterior approach is
the commonest site for cartilage grafts in rhino-
plasty and nasal reconstruction, and hence, the pos-
tauricular fascia is already accessible in such cases.
In addition to repairs of the nose and ear, the
postauricular fascia has also been recruited for
aesthetic augmentation of the lip [ 4 ] . In the refer-
enced study, a comparison was made between an
autologous musculoaponeurotic system tissue
and the postauricular fascia, in conjunction with
lip advancement. Despite the study being limited
in patient number, the highest postoperative
scores were recorded for the group undergoing
the postauricular fascial lip augmentation with
lip advancement.
Several techniques exist for lip augmentation,
including injection of speci ﬁ c materials, implants,
grafts, and local ﬂ aps. Sternocleidomastoid mus-
cle and fascial grafts have been utilized by
Agarwal et al. [ 13 ] . Other potential tissues for lip
procedures or augmentation have included eyelid
tissue [ 15 ] , conchal cartilage [ 16 ] , orbicularis
oculi muscle [ 17 ] , free dermis-fat grafts [ 18, 19 ] ,
and even tissues as distant from the lip as the pal-
maris longus tendon [ 20 ] .
Fig. 3.12 Repairing the crura
of the antihelix
Fig. 3.13 Repair of the concha

31
3 Anatomy, History, and Utility of the Posterior Auricular Fascia in Otoplasty
Fig. 3.14 Bipedicle IPF ﬂ ap extending
to the zygoma
Fig. 3.15 Preoperative markings: fascia-augmented otoplasty
Fig. 3.16 Careful dissection of the IPF

32
K. Shokrollahi and J.P. Taylor
Fig. 3.17 Suture of IPF to mastoid
Fig. 3.18 Postoperative fascia-augmented otoplasty [ 9 ] .
( Left ) Using glue as postoperative splint. Immediate
postop – ears glued and covered with long hair; can
shower, no stigmata of surgery. ( Right ) Instead of head
bandages. Immediate postop – head bandages, poor cos-
mesis, poor hearing, nausea (and re-attendance) [ 14 ]

33
3 Anatomy, History, and Utility of the Posterior Auricular Fascia in Otoplasty
Fig. 3.19 ( Left ) Preoperative. ( Right ) Postoperative after otoplasty technique using the anteriorly based fascial ﬂ ap
showing good symmetry and natural “virgin ear” results [ 9 ]
Fig. 3.20 Use of the IPF in
rhinoplasty as a graft beneath
thin skin (Courtesy of
Professor Nicholas Jones,
Queens Medical Centre,
Nottingham, UK)

34
K. Shokrollahi and J.P. Taylor
Conclusions
The anatomy of the posterior auricular fascia
has been distinguished in detail, and a clear
distinction has been made between the fascia
overlying the mastoid continuous with the
scalp musculature and the fascia adherent to
the ear itself anterior to the auricular fascial
incisura. The IPF is a thin and elastic fascial
layer bound super ﬁ cially by the skin and
deeply by the cartilage of the ear, continuous
with the perichondrium; it is a separate entity
from the multilayered and more ﬁ brous EPF
and simply consists of the thin subcutaneous
tissue directly adherent to the posterior side of
the ear itself. Its potential and actual clinical
applications have been demonstrated, though
its use in reconstructive and aesthetic proce-
dures is still in its infancy. The versatility of the
tissue, thanks to its vascular network, hidden
donor site, accessibility, and elastic properties,
provides an excellent tool for the surgeon in
reconstructive or aesthetic practice.
Further clinical studies would be valuable
to highlight the areas where the IPF can be of
greatest bene ﬁ t as well as its limitations.
References
1. Wang Y, Zhuang X, Jiang H, Yang Q, Zhao Y, Han J,
et al. The anatomy and application of the postauricu-
lar fascia ﬂ ap in auricular reconstruction for congeni-
tal microtia. J Plast Reconstr Aesthet Surg. 2008;61
Suppl 1:S70–6.
2. Datta G, Carlucci S. Reconstruction of the retroau-
ricular fold by ‘nonpedicled’ super ﬁ cial mastoid fas-
cia: details of anatomy and surgical technique. J Plast
Reconstr Aesthet Surg. 2008;61 Suppl 1:S92–7.
3. Park C, Lee TJ, Shin KS, Kim YW. A single-stage
two- ﬂ ap method of total ear reconstruction. Plast
Reconstr Surg. 1991;88(3):404–12.
4. Recupero WD, McCollough EG. Comparison of lip
enhancement using autologous super ﬁ cial muscu-
loaponeurotic system tissue and postauricular fascia
in conjunction with lip advancement. Arch Facial
Plast Surg. 2010;12(5):342–8.
5. Ying Z, Jianlin F, Guoxian Z, Min W, Wei W, Zuoliang
Q. Ultralong pedicled super ﬁ cial temporal fascia
island ﬂ aps for lower nasal defect. J Craniofac Surg.
2009;20(3):864–7.
6. Romo 3rd T, Morris LG, Reitzen SD, Ghossaini SN,
Wazen JJ, Kohan D. Reconstruction of congenital
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anchored hearing aid-approach. Ann Plast Surg. 2009;
62(4):384–9.
7. Horlock N, Misra A, Gault DT. The postauricular
fascial ﬂ ap as an adjunct to Mustarde and Furnas type
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2001;108(6):1487–90.
8. Schaverien MV, Al-Busaidi S, Stewart KJ. Long-term
results of posterior suturing with postauricular fascial
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63(9):1447–51.
9. Shokrollahi K, Cooper MA, Hiew LY. A new strategy
for otoplasty. J Plast Reconstr Aesthet Surg. 2009;
62(6):774–81.
10. Frascino LF. The use of a retroauricular fascioper-
ichondrial ﬂ ap in the recreation of the antihelical fold
in prominent ear surgery. Ann Plast Surg. 2009;63(5):
536–40.
11. Vetter M, Foehn M, Wedler V. A new postoperative
otoplasty dressing technique using cyanoacrylate tissue
adhesives. Aesthetic Plast Surg. 2010;34(2):212–3.
12. Patel AJ, Price RD. The use of tissue glue in promi-
nent ear correction surgery. Aesthetic Plast Surg.
2011;35(2):245–7.
13. Agarwal A, Gracely E, Maloney RW. Lip augmenta-
tion using sternocleidomastoid muscle and fascia
grafts. Arch Facial Plast Surg. 2010;12(2):97–102.
14. Shokrollahi K, Tanner B. “Glue Ear”: beginning of the
end for head bandages after prominent ear correction?
J Plast Reconstr Aesthet Surg. 2008;61(9):1077.
15. Fezza JP, Cartwright M, Mack W, Flaharty P. Lip aug-
mentation using eyelid tissue from upper blepharo-
plasty surgery. Ophthal Plast Reconstr Surg. 2003;
19(3):225–8.
16. Saha SS, Kumar V, Khazanchi RK, Agarwal A.
Correction of the nose in patients with unilateral cleft
lip with composite grafts. Scand J Plast Reconstr Surg
Hand Surg. 2005;39(6):344–8.
17. Tarallo M, Monarca C, Rizzo MI, Scuderi N. Upper-
lip augmentation by graft of preseptal orbicularis
oculi muscle through blepharoplasty. Aesthetic Plast
Surg. 2010;34(2):167–71.
18. Patel IA, Hall PN. Free dermis-fat graft to correct the
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19. Niechajev I. Lip enhancement: surgical alternatives
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20. Trussler AP, Kawamoto HK, Wasson KL, Dickinson
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Plast Reconstr Surg. 2008;121(3):1024–32.

Part II
Preoperative

37
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_4, © Springer-Verlag Berlin Heidelberg 2013
4
Introduction
Nonsurgical and surgical otoplasty may be
indicated in the prevention or treatment of psy-
chosocial issues resulting from prominent ears
in children. It is a successful and well-tolerated
intervention to correct prominent ears, but coun-
seling a parent as to the optimum age for their
child to undergo correction can be a dif ﬁ cult
process. This chapter will present the literature
regarding the timing of otoplasty; the evidence
in this chapter is based on a literature search per-
formed in March 2012.
There are common scenarios when children
are brought for consideration of otoplasty: Firstly
a parent may request correction for a young child
to prevent future teasing and psychological harm.
Secondly a child perceives the deformity and
requests correction (often after they have been
bullied or stigmatized). Finally, corrective surgery
may be requested in adulthood. Three relevant
areas must be considered: the anatomical aspects
of ear cartilage and growth, the psychosocial
functioning of the child, and the practical consid-
erations of surgery.
Anatomical
Cartilage remains pliable for a short time after
birth, probably due to the in ﬂ uence of maternal
estrogens [ 1, 2 ] . This allows effective splint-
ing to correct protruding ears within the ﬁ rst
3–6 weeks but ideally within the ﬁ rst week of life
[ 3– 6 ] . Some authors advocate splinting beyond
this age but before 3 months [ 1, 7 ] . Splints have
to be applied for longer, and outcomes are less
favorable in older patients as cartilage becomes
progressively less pliable [ 1, 5 ] .
Adamson et al. [ 8 ] studied the growth of nor-
mal ears and found that 85 % of full size had been
achieved by the age of 3 years. In contrast Farkas
[ 9 ] reported that 85 % of full size was achieved
only by 6 years of age. Balogh and Milesi [ 10 ]
examined ear growth after otoplasty in a cohort
of 76 cases using cartilage-cutting techniques
including children aged 5–8 years: They identi ﬁ ed
no signi ﬁ cant growth differences between the
operated ears and controls. Songu [ 11 ] reported
satisfactory outcomes in 10 children undergoing
otoplasty aged 4–5 years with no observed growth
restriction at 1 year follow-up. Furthermore,
Gosain et al. [ 12 ] followed 12 children undergo-
ing otoplasty under 3 years of age (youngest 9
months) and also observed no signi ﬁ cant differ-
ences between ears in the three unilateral cases
P. M. Spielmann , M.D. (*)
Department of Otolaryngology ,
Ninewells Hospital and University of Dundee ,
Dundee DD1 9SY , UK
e-mail: patrickspielmann@nhs.net
M. Neeff , M.D.
Department of Otolaryngology ,
Auckland City Hospital and Starship Children’s Hospital ,
Auckland , New Zealand
e-mail: micheln@adhb.govt.nz
The Timing of Otoplasty
Patrick M. Spielmann and Michel Neeff

38
P.M. Spielmann and M. Neeff
with at least 39 months follow-up. No growth
restriction was observed in the bilateral cases
with median 41 months follow-up.
These authors comment that cartilage at young
age is more pliable, so repositioning techniques
rather than cartilage weakening and cutting tech-
niques are utilized, and an incision rather than
excision of postauricular skin is made. These
factors may explain why there is no signi ﬁ cant
change in growth characteristics following this
minimally “destructive” surgery, if there is an
in ﬂ uence of surgery on cartilage growth at all.
While the numbers studied are small and the
follow-up does not continue to adulthood, there
is some evidence to suggest that otoplasty can be
performed at a very young age without adversely
affecting future growth.
In the management of prominent macrotic ears,
where potential growth restrictions due to surgery
may be advantageous, otoplasty in patients as
young as 2 years has been performed.
Psychological
Being teased is a common experience of child-
hood; however, children with prominent ears
experience more teasing than their peers. This
difference was present up to but not beyond the
age of 13 years in a study of 30 children undergo-
ing otoplasty [ 13 ] . Gasques [ 14 ] identi ﬁ ed many
anxiety traits and substantial distress in children
with prominent ears, all of which improved fol-
lowing otoplasty. The level of distress expe-
rienced appears independent of the degree of
prominence [ 13 ] . Children with microtia are
aware of their own deformity from an early age
– Jiamei [ 15 ] demonstrated that the majority of
children recognized their deformity at 3 or 4 years
of age. However, teasing or ridicule does not usu-
ally begin until a few years later; thus, while they
themselves are aware, other children either do
not notice or have the motivation to tease. On the
other hand, Songu [ 11 ] asserts that psychologi-
cal pressures in the preschool age group are often
underestimated and that increasing socialization
outside the family home exposes the child to early
stigmatization, but there is insuf ﬁ cient evidence
to con ﬁ rm this. Bradbury et al. reported onset of
self- consciousness in children with prominent
ears anywhere between 4 and 13 years of age [ 13 ] .
After the onset of psychosocial problems due to
prominent ears, otoplasty has been shown to sub-
stantially reduce and in many cases eliminate bul-
lying, improving psychosocial functioning and
health-related quality of life [ 13, 14, 16– 19 ] . But it
is dif ﬁ cult to predict whether a child will become
self-conscious of their ears and if so at what age.
The adage “prevention is better than cure” may
not apply to the surgical correction of prominent
ears in some children. While parents wish to pre-
vent their children suffering at a formative stage
in their socialization and development, they may
submit their child to an unnecessary cosmetic pro-
cedure. If the child becomes self-conscious or a
victim of bullying, a successful and well-tolerated
intervention is available. There is no evidence to
suggest that early otoplasty results in less psycho-
logical distress than delayed surgery.
While teasing and bullying for prominent ears
appear to be less prevalent in adolescence [ 13 ] ,
self-image and con ﬁ dence may be adversely
affected and thus a strong motivator for surgery.
Adolescents are able to provide informed consent
for surgery and comply with postoperative care.
Kamburoglu [ 19 ] concludes that appropriately
selected adolescents are good candidates for a
variety of cosmetic procedures including otoplasty
as they are motivated and experience signi ﬁ cant
improvements in self-esteem, body image, and
life satisfaction. Adults who underwent surgery
in early childhood reported resentment and anger
(towards their caregivers) after unfavorable out-
comes of aesthetic surgery. An engaged and moti-
vated child would likely be more accepting of an
unfavorable result or complication.
Practical
Psychosocial complications of prominent ears
can be prevented by correction of prominent ears
using splinting techniques in the neonatal period.
The practical aspects of undergoing surgery must
be considered: These include the child’s ability
to cooperate with the aftercare, the fact that the

39
4 The Timing of Otoplasty
surgery is purely cosmetic and carries risks of
complications and worsening of the appearance
of the ears. Unfortunately very young children
are often unable to comply with the postopera-
tive care required, particularly prolonged head
bandaging as required by some techniques. Thus,
a young or unmotivated child will ﬁ nd the post-
operative course stressful and unpleasant. Songu
et al. [ 11 ] advocate surgery in children aged 4 or
over and report a series of ten children with satis-
factory outcomes but noted that all had returns to
hospital for repeated head bandaging and a single
revision procedure due to the children getting
ﬁ ngers underneath the bandage. There is no pro-
spective series comparing outcomes of surgery
(including recurrence rates) performed in very
young compared with older children.
Current Practice
Surveys of surgeon practice have been per-
formed in the USA and UK: 174 members of
the American Association of Aesthetic Plastic
Surgeons responded to a postal survey (a 37 %
response rate), and 57 % of respondents routinely
performed surgery over the age of 5 years [ 12 ] .
The commonest reasons cited for performing sur-
gery at this age were near-adult size of the ear
(38 %), greater patient cooperation (25 %), and
increased peer ridicule (19 %). One hundred and
twenty members of the British Association of
Plastic, Reconstructive and Aesthetic Surgeons
responded to a similar but independent survey (a
65 % response rate), and 79 % felt that the opti-
mum age to perform surgery was over 6 years.
The majority of parents (79 %) and child psy-
chologists (63 %) surveyed also agreed that 6
years or older was the preferred age for surgery.
The most important factors cited by all three
groups were the child’s awareness of prominent
ears, the child suffering bullying, and school
absence due to embarrassment [ 20 ] . The studies
concur that most surgeons tend to favor perform-
ing the surgery when the child has reached a level
of maturity ﬁ rstly to express concern over their
ears and secondly to cope with the postoperative
aftercare required. Interestingly although surgery
appears to be feasible in the younger age group,
the majority of surgeons responding to these sur-
veys prefer to delay surgery.
Conclusions
The timing of otoplasty should therefore take
into account child’s wishes, the psychosocial
burden of the perceived deformity, and the
maturity/motivation of the child to cooperate
with the postoperative care.
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P.M. Spielmann and M. Neeff
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