Local Flaps in Facial Reconstruction

596
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 22-7  ■  A, A 1.5-cm full-thickness defect of helix. B, Unilateral chondrocutaneous composite helical advancement flap planned
for repair. Burow triangle marked for excision to facilitate advancement. C, Flap in place. Bolster dressing secured with sutures to
maintain contour of scapha. D, Postoperative result at 7 days. (Courtesy of Shan R. Baker, MD.)
A
B
C
D

22  RECONSTRUCTION OF THE AURICLE
597
FIGURE 22-8  ■  A, Squamous cell carcinoma of helix marked for excision. Broken lines outline planned incisions for bilateral chon­
drocutaneous composite helical advancement flaps after excision of tumor. B, Tumor excised. One-third of helix removed.
C, Advancement flaps incised. D, Apposition of flaps demonstrates requirement for reduction of scapha and superior antihelix.
E, Wound closed after reduction. (Courtesy of Shan R. Baker, MD.)
A
B
C
D
E

598
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 22-9  ■  Preauricular interpolated cutaneous tube flap for repair of defects confined to helix. A, First stage: tube created from
preauricular skin. B, Second stage: division of inferior pedicle and flap transfer to helical root. C, Third stage: division of superior
pedicle and flap inset. D, Final appearance after inset.
A
B
C
D

22  RECONSTRUCTION OF THE AURICLE
599
FIGURE 22-10  ■  A, Helical defect. B, Postauricular interpolated cutaneous tube flap designed. C, Three weeks after first-stage tube
creation. D, After second-stage transfer of flap to ear. E, Third-stage flap inset. F, One month after third surgical stage.
A
B
C
D
E
F

600
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 22-11  ■  A, Subcutaneous tissue pedicled island advancement flap designed on postauricular skin. Flap is divided to provide
medial and lateral surface cover for defect. B, Subcutaneous tissue pedicle tunneled beneath medial auricular skin. C, Flap folded
on itself to provide skin cover of medial and lateral aspect of defect. D, E, Flap sutured in place. Donor defect closed.
A
B
C
D
E

22  RECONSTRUCTION OF THE AURICLE
601
and postauricular and preauricular interpolated tube
flaps. The use of autogenous cartilage framework grafts
combined with temporoparietal fascia and split-thickness
skin graft coverage may be required for larger defects.
Primary wound closure and helical advancement flaps are
reserved for more limited auricular defects. Primary
closure is used when the defect is less than 1.5 cm in
width and extends from the helical rim into the scapha
or triangular fossa. In such cases, repair is accomplished
by converting the defect into a wedge-shaped resection,
which is closed primarily with minimal distortion. In
some cases, small Burow triangles on either border of the
wedge must be excised from the skin and cartilage of the
antihelix to permit adequate wound closure without dis­
tortion or cupping of the ear.
Helical chondrocutaneous advancement flaps are pref­
erable to primary wound closure when the defect is
limited to the helix and is between 1.5- and 2.5-cm in
linear width (Fig. 22-14).22 This flap takes advantage of
the movement of tissue that is possible when the helix is
advanced once it is released from its attachment to the
ear. An additional opposing advancement may be achieved
with a V-Y island advancement flap consisting of the root
of the helix. When necessary, incising both lateral and
medial auricular skin to create the flap allows even greater
helical mobility. The cartilage and skin of the flap are
approximated independently of each other with sutures,
avoiding wound closure tension. It may be necessary to
excise portions of the scapha to prevent excess wound
closure tension or cupping of the ear (Fig. 22-15).
For defects larger than 2.5 cm in width and confined
to the helical rim, a postauricular or preauricular inter­
polated tube flap is optimal for reconstruction (see Fig.
22-9).28,29 This flap is randomly based, and the operation
is a multistaged procedure. The preauricular skin pro­
vides an excellent donor site to create a flap used to
proximity to the defect. This flap is an excellent choice
for repair when lateral skin and cartilage of the concha
are missing because it eliminates the requirement for a
full-thickness skin graft. The flap is transferred from pos­
terior to anterior toward the concha, followed by primary
closure of the postauricular donor site (Fig. 22-11). The
flap is dissected from the surface of the mastoid bone in
a posterior to anterior direction to maintain a thick sub­
cutaneous tissue pedicle that incorporates branches of the
postauricular artery and, if present, the postauricular
muscle. The flap may be bivalved, as shown in Figure
22-11, when there is a requirement for both medial and
lateral skin coverage.
The helical root provides one of the four basic contour
lines of the ear. Defects of the root of the helix are seen
after resection of cutaneous lesions or after otologic
surgery. Limited defects of the root may be reconstructed
with a helical advancement flap, in which the remaining
helix is advanced inferiorly toward the defect. An incision
is made in the lateral skin and cartilage along the helical
rim and the rim is advanced in a Y to V fashion to restore
the helical root. The flap is composed of both lateral skin
and cartilage. It derives its random blood supply from
medial soft tissue attachments. The technique is effective
for small defects (Fig. 22-13). Larger defects may require
the excision of a small Burow triangle of skin and carti­
lage from the scapha to ensure adequate advancement.
Defects of Superior Third of Auricle
Although the superior third of the auricle can be
concealed by hair, it is of functional importance for
many patients, particularly those who wear eyeglasses.
Many surgical options are available for reconstruction of
these defects, including primary wound closure, full-
thickness skin grafting, helical advancement procedures,
FIGURE 22-12  ■  A, Full-thickness defect of concha cavum, with intact helical rim. B, Defect repaired with postauricular island advance­
ment flap pedicled on postauricular muscle and subcutaneous tissue. Skin island folded to provide medial and lateral coverage.
C, Postoperative result at 6 months.
A
B
C

602
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 22-13  ■  Chondrocutaneous flap for closure of large mastoidectomy defect. A, Large conchal bowl. B, Root of helix mobilized
as a composite flap and advanced posteriorly. C, Flap in place. D, Postoperative result at 6 months.
A
B
C
D

22  RECONSTRUCTION OF THE AURICLE
603
A
B
C
FIGURE 22-14  ■  Reconstruction of helix with chondrocutaneous advancement flaps. A, Superficial melanoma of helix. B, Outline for
resection and design of chondrocutaneous advancement flaps. C, Defect, measuring 2.5 cm.
Continued

604
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
D
E
F
D, Drawing showing two advancement flaps. E, Postoperative result at 6 months with 1 cm of vertical shorten­
ing. F, Contralateral ear that was not operated on.
FIGURE 22-14, cont’d  ■

22  RECONSTRUCTION OF THE AURICLE
605
Full-thickness defects of the superior auricle, with an
intact helical rim, present an unusual challenge (Fig.
22-16). Flaps used to repair such defects must be well
vascularized. The postauricular subcutaneous tissue ped­
icled island advancement flap provides skin and soft tissue
with a reliable blood supply to repair such defects.16 This
flap provides excellent color match, and the scar from
closure of the donor site of the flap is hidden in the post­
auricular sulcus. Based on the postauricular artery and
vein, the flap incorporates postauricular skin and the
reconstruct the anterior helix. The first stage of this pro­
cedure requires the formation of a skin tube with both
superior and inferior attachments. In the second stage,
one end of the tube is transferred to the auricle. The
other end of the flap is inset in the helical defect in a third
surgical stage. Incorporation of subcutaneous fat into the
substance of the tube helps provide contour to the recon­
structed helix, but the tube does not contain rigid struc­
tural support and thus should be used only for isolated
helical rim defects.
FIGURE 22-15  ■  A, A 2-cm defect of helix. W-plasty designed for anticipated need to excise portions of scapha and antitragus. Incision
for chondrocutaneous advancement flap marked. B, Inferior-based flap incised. C, Flap in place. D, Postoperative result at 6 months.
(Courtesy of Shan R. Baker, MD.)
A
Full thickness incision
W-shaped wedge removed
B
C
D

606
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 22-16  ■  A, Full-thickness defects of the central portion of superior auricle. B, Postauricular subcutaneous tissue pedicled island
advancement flap incised. C, Flap sutured in place. Skin island folded to provide lateral and medial surface coverage. D, Postopera­
tive result at 6 months.
A
B
C
D

22  RECONSTRUCTION OF THE AURICLE
607
A composite chondrocutaneous advancement flap is
another alternative for reconstruction of full-thickness
defects of the superior auricle that do not involve the
helix. The antihelix is advanced as a composite flap supe­
riorly into the defect located in the area of the triangular
fossa (Fig. 22-17). The flap is created by making
postauricular muscle. It can be transferred, folded on
itself, and used to reconstruct full-thickness defects of the
superior and central portions of the auricle. If the defect
involves structurally important elements of the auricle,
a cartilage graft is incorporated within the substance of
the flap.
FIGURE 22-17  ■  Auricular composite advancement flap consisting of medial and lateral auricular skin and intervening cartilage used
for repair of full-thickness defect of antihelix and triangular fossa.
A
B
C

608
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
(Fig. 22-21). The first stage involves creating a cutaneous
advancement flap based posteriorly on the scalp. The
width of the flap is equal to the height of the defect, and
the flap is elevated from the skin of the medial aspect of
the remaining auricle and from the postauricular sulcus
skin immediately adjacent to the defect. The flap is
advanced over the lateral aspect of the defect. The medial
aspect of the auricular cartilage is exposed as a result of
dissecting the skin away from it in the process of creating
the flap. The exposed cartilage is attached to and nour­
ished by the denuded postauricular soft tissue. During
the first stage, septal or conchal cartilage is implanted
beneath the advancement flap to replace missing portions
of the auricular cartilage. The cartilage graft is sutured
directly to the borders of the auricular cartilage defect.
The advancement flap provides soft tissue coverage for
the cartilage graft and replaces the missing skin of the
lateral ear. The second surgical stage, performed 3 weeks
later, involves detachment of the advancement flap from
the scalp. The flap is then folded on itself as a hinge flap
to cover the medial aspect of the cartilage graft. For this
to occur, the medial aspect of the cartilage graft and the
auricular cartilage attached to the postauricular denuded
soft tissue during the first surgical stage are released from
their attachments to the postauricular soft tissue. Flap
inset must provide adequate skin coverage of the cartilage
graft and prevent exposure of any auricular cartilage
medially. A full-thickness skin graft is used to close the
postauricular donor area if it cannot be closed primarily.
In cases of extensive cartilage loss in the central third of
the ear, a more complex framework using the sixth to
eighth ribs is carved and tailored to the missing segment
of auricular cartilage. The framework is then covered by
a postauricular skin advancement flap (Fig. 22-22). This
procedure requires release of the framework cartilage
a full-thickness incision in the scapha from the defect
inferiorly to the earlobe. Depending on the size of the
defect and the corresponding distance of advancement
required, a Burow triangle may be excised from the sub­
stance of the earlobe.
Small lateral skin defects on the central portion of the
superior and middle third of the auricle may be closed
with rotation advancement flaps (Fig. 22-18).30 An advan­
tage of these flaps is that the incisions may be hidden in
the scapha to make them inconspicuous. When the defect
requires extensive soft tissue mobilization, with the risk
of distortion of the helix, a full-thickness skin graft may
be a better alternative (Fig. 22-19).
Reconstruction of large defects of the superior third
of the auricle, where cartilage from the helix, scapha,
and triangular fossa are missing, mandates incorporation
of a rigid framework fashioned from autogenous rib
cartilage. The framework is covered by a temporoparietal
fascia flap, which in turn is covered with a skin graft
(Fig. 22-20).
Defects of Middle Third of Auricle
Absence of the central third of the auricle is a conspicu­
ous deformity. Small defects (<1.5 cm) may be closed by
converting the defect into a wedge-shaped excision,
although this approach will have a direct impact on the
vertical height of the ear. Full-thickness helical defects
less than 2.5 cm are amenable to helical chondrocutane­
ous advancement flaps. Defects that are larger than
2.5 cm in width and confined to the helical rim may be
repaired with an interpolated cutaneous tube flap.31 Large
defects of the central third of the auricle involving the
helix and antihelix require cartilage grafting to achieve
the necessary structural support.32,33 In some cases, repair
is accomplished by use of a two-stage postauricular flap
FIGURE 22-18  ■  Chondrocutaneous advancement skin flap for skin defect of triangular fossa. A, Lateral auricular skin defect. Broken
line indicates full-thickness incisions. B, Immediately after repair with rotation advancement flap. C, Postoperative result at 6 months.
A
B
C
Text continued on p. 613

22  RECONSTRUCTION OF THE AURICLE
609
A
FIGURE 22-19  ■  Full-thickness skin graft repair of defect involving lateral skin and underlying cartilage. A, Proposed surgical excision.
B, Defect of lateral skin and cartilage after excision . C, Full-thickness skin graft, ready for bolster dressing. D, Bolster dressing in
place. E, Postoperative result at 6 months.
B
C
D
E

610
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 22-20  ■  Autogenous cartilage framework with overlying temporoparietal fascia flap and skin graft to reconstruct superior
auricle. A, Hemiauricular defect from human bite injury. Incision marked for dissection of temporoparietal fascia flap. B, Scalp
elevated to expose temporoparietal fascia in preparation for coverage of costal cartilage framework. C, Flap turned down to cover
cartilage. Flap covered with skin graft. D, Postoperative result at 8 months, after creation of superior auricular sulcus.
A
B
C
D

22  RECONSTRUCTION OF THE AURICLE
611
A
B
Septal
cartilage
graft
STAGE I
STAGE II
Skin graft
C
FIGURE 22-21  ■  Two-stage postauricular advancement flap for repair of defect of central third of auricle. A, Traumatic auricular defect.
B, Design of postauricular advancement flap. C, Drawings showing stages of reconstruction. D, First stage completed. Skin from
medial aspect of ear and postauricular sulcus advanced to provide skin to cover lateral border of defect.
D
Continued

FIGURE 22-22  ■  Reconstruction of central and inferior auricular defect with costal cartilage framework. A, Defect resulting from motor
vehicle accident. B, Drawings showing stages of reconstruction.
E
F
E, Second stage. Release of flap from posterior attachment and incorporation of supporting septal cartilage
graft. Graft, shown outside of flap, was inserted beneath flap to provide framework for constructed helix. F, Postoperative result at
6 months.
FIGURE 22-21, cont’d  ■
A
Skin graft in
postauricular sulcus
Costal cartilage
STAGE I
STAGE II
B

22  RECONSTRUCTION OF THE AURICLE
613
C
D
E
C, Costal cartilage graft tailored to replace missing cartilaginous segment. D, Framework implanted beneath
postauricular skin. E, Postoperative result 4 months after framework elevation with overlying skin and full-thickness skin grafting of
medial surface of constructed area.
FIGURE 22-22, cont’d  ■
graft from the head in a staged procedure with full-
thickness skin grafting of the postauricular sulcus.
Another approach to reconstruction of the middle
third of the helix when the skin of the medial aspect of
the concha and the postauricular sulcus are intact is to
use a postauricular interpolated advancement flap in two
surgical stages. Unlike most interpolated flaps that are
transferred by pivotal movement, this flap is transferred
by advancement over the intervening skin of the postau­
ricular sulcus. In contrast to the previous discussion, in
which the skin of the medial ear is incorporated into the
advancement flap, in this case the skin of the medial
aspect of the ear and of the postauricular sulcus is left
undisturbed. The advancement flap is incised posterior
to the postauricular sulcus. It is advanced over the skin
of the postauricular sulcus and sutured to the margins of
the lateral auricular skin defect. This creates a skin-lined
channel representing the postauricular sulcus beneath the
pedicle of the flap (Fig. 22-23).
The second stage is performed 2 to 3 months after the
first stage. The pedicle of the interpolated flap is divided
from its posterior attachment to the scalp. The flap is
folded over like a hinge to restore the absent helix and is
sutured to the border of the skin defect of the medial
aspect of the concha. A cartilage graft may be positioned
under the flap during the second stage if structural
support is necessary. The donor defect resulting from flap
inset is closed primarily or with a local scalp flap. Detach­
ing the pedicle of the flap restores the postauricular
sulcus to its original condition.
The advantage of using the interpolated postauricular
advancement flap compared with the technique of incor­
porating the postauricular skin into an advancement flap
is that the medial aspect of the concha is not denuded
and does not require subsequent release from attach­
ments to the mastoid periosteum. A skin graft is not
required to cover the medial aspect of the reconstructed
ear and any cartilage graft that may have been used for
the framework of the ear. In addition, skin grafts are not
required to restore the postauricular sulcus because the
skin of the postauricular sulcus is left in situ by the inter­
polated flap technique (Fig. 22-24).
When the skin of the medial ear and postauricular
sulcus is absent from traumatic loss or from excision, the
remaining auricle is sutured to the postauricular skin as
the first surgical stage. When the ear has completely
healed, a second stage is performed in which a hinge flap
based on the auricle is designed so that the flap can be
constructed from the postauricular skin. Cartilage grafts
are included during the second stage to provide a frame­
work for the constructed ear. The donor site of the hinge
flap is covered with a full-thickness skin graft harvested
from the groin or supraclavicular fossa or closed with a
scalp advancement flap (Fig. 22-25).
Defects of Inferior Third of Auricle
Reconstruction of defects of the inferior third of the
auricle is generally less difficult than repair of defects
elsewhere on the ear because of the relative pliability and
laxity of auricular and periauricular skin in this region.
Up to 50% of the earlobe may be removed by a wedge-
shaped excision followed by primary wound closure,
yielding only minimal deformity. Tissue from the earlobe
provides a resource for construction of small advance­
ment flaps used to repair helical defects of the inferior
third of the ear. When the entire inferior third of the ear
is being reconstructed, cartilage grafting is necessary for

614
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
C
D
A
B
FIGURE 22-23  ■  A, Loss of central third of helix after micrographic surgery for basal cell carcinoma. B, First stage. Interpolated flap
from postauricular skin attached to lateral margin of auricular defect. Skin of postauricular sulcus left undisturbed. C, Hinge flap
based on auricle is designed for reconstruction of helix. D, Second stage. Pedicle of interpolated flap divided and hinge flap folded
medially and sutured to exposed skin margin of postauricular sulcus.

22  RECONSTRUCTION OF THE AURICLE
615
E
F
G
E, Donor defect from inset of interpolated flap closed primarily. F, G, Four months after inset of flap. (Courtesy
of Shan R. Baker, MD.)
FIGURE 22-23, cont’d  ■
an aesthetic result. Total earlobe reconstruction is per­
formed by employing a composite flap containing conchal
cartilage in a two-staged procedure (Fig. 22-26). First, a
segment of cartilage, the shape of the earlobe obtained
from the contralateral concha, is embedded in a subcuta­
neous pocket below the auricle in a location correspond­
ing to the desired position of the earlobe. Six weeks later,
the cartilage and overlying skin are elevated as a compos­
ite flap, based superiorly on the auricle. The medial
surface of the composite flap is skin grafted and the donor
site of the composite flap is closed primarily by advancing
the adjacent skin. This technique provides an excellent
skin color match between the flap and the ear, results in
minimal local distortion of tissues, produces a naturally
shaped and contoured earlobe, and allows precise earlobe
positioning.
Defects of Preauricular Area
Preauricular defects arise most commonly from excision
of cutaneous malignant neoplasms. The function of the
facial nerve should be carefully examined before recon­
struction is undertaken. Surgical options for repair of
preauricular cutaneous defects include primary wound
closure and transposition, unipedicle advancement, and
V-Y subcutaneous tissue pedicled advancement flaps34
(Fig. 22-27). With careful planning, scars may frequently
be positioned within the preauricular crease, with excel­
lent scar camouflage.
LARGE AURICULAR DEFECTS
For ear defects encompassing one-third or more of the
entire auricle, reconstruction often involves use of a
temporoparietal fascia flap (TPFF). Large auricular
defects may require only a portion of the standard fabri­
cated cartilaginous framework required for microtia
repair (Fig. 22-20). Skin adjacent to the defect may be
adequate for coverage of the framework cartilage grafts,
but often it is insufficient or scarred, causing it to be
nonpliable with suboptimal vascularity. In these circum­
stances, the framework should be covered with a TPFF
and an overlying split-thickness skin graft.35
Principles of Microtia Reconstruction with
Temporoparietal Fascia Flaps
In reconstruction of large auricular defects, alloplastic
implants may be avoided by employing a framework
fashioned from autogenous cartilage. Synthetic frame­
works are at greater risk of becoming infected and
are fraught with problems of extrusion. 36,37 The carti­
laginous portions of the sixth, seventh, and eighth ribs
provide the raw material for creation of a framework for
construction of the ear (Fig. 22-28). The synchondrosis
between the sixth and seventh ribs serves as the body of
the framework, forming the concha, antitragus, and
curve of the antihelix. The helix is fashioned from the
eighth rib, identical to the technique employed in
microtia repair. The size and individual shape of the
framework are determined by use of a template designed
from the contralateral auricle. The helix is customized
by removing the perichondrium from the medial aspect
of the eighth rib and progressively thinning the carti­
lage until it becomes sufficiently flexible to simulate the
curvature of the helix. The cartilaginous segment is
then secured to the body framework by sutures, with
Text continued on p. 622

616
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
A
B
C
D
E
FIGURE 22-24  ■  A, Defect of inferior third of helix and antihelix after micrographic excision of basal cell carcinoma. B, Interpolated
flap from postauricular skin designed for reconstruction of ear. Skin of postauricular sulcus left undisturbed. C, First stage completed.
Interpolated flap sutured to lateral margin of auricular defect. Rubber band drain placed in postauricular sulcus beneath pedicle of
flap. D, One week after transfer of flap. E, Two months after transfer of interpolated flap. Probe has been inserted beneath pedicle
of flap in postauricular sulcus. Hinge flap based on auricle is designed for reconstruction of ear.

22  RECONSTRUCTION OF THE AURICLE
617
H
I
F
G
F, Pedicle of interpolated flap divided. G, Second stage completed. Hinge flap folded medially and sutured to
exposed skin margin of postauricular sulcus. Rotation scalp flap designed for closure of donor defect of hinge flap. H, Donor defect
closed. Skin of postauricular sulcus left undisturbed. I, Postoperative result at 2 months. (Courtesy of Shan R. Baker, MD.)
FIGURE 22-24, cont’d  ■

618
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 22-25  ■  A, Traumatic avulsion of inferior two-thirds of auricle with loss of skin of postauricular sulcus and medial ear. Skin
margin of antihelix was sutured to postauricular skin margin. B, Hinge flap based on auricle is designed for reconstruction of ear.
C, Hinge flap dissected. Auricular cartilage graft harvested from contralateral ear inserted beneath flap for framework. Full-thickness
skin graft (FTSG) in place to cover donor defect of hinge flap. D, Hinge flap folded medially over cartilage graft and sutured to skin
graft used to reconstruct postauricular sulcus. E, Postoperative result at 1 year. No revision surgery performed. (Courtesy of Shan R.
Baker, MD.)
A
B
C
Auricular cartilage
graft
Hinge flap
FTSG
D
E

22  RECONSTRUCTION OF THE AURICLE
619
FIGURE 22-26  ■  Earlobe reconstruction. A, Traumatic defect of earlobe. B, Drawings showing stages of reconstruction. C, Contralateral
conchal cartilage sculpted into appropriate shape for framework of new earlobe. D, Conchal cartilage graft placed in subcutaneous
tissue pocket for 6 weeks. E, Six months postoperatively, after second-stage lobular release and full-thickness skin grafting of medial
surface of reconstructed earlobe.
A
Auricular
cartilage
graft
Skin graft
STAGE I
STAGE II
B
C
D
E

620
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
A
B
C
FIGURE 22-27  ■  Preauricular skin defect closure by opposing V-Y subcutaneous tissue pedicled advancement flaps. A, Defect. Broken
lines indicate incisions made to create flaps. Note involvement of hair-bearing skin. B, Closure with opposing V-Y advancement
flaps. C, Postoperative result at 6 months.
A
B
FIGURE 22-28  ■  Carving of costal cartilage framework for auricular reconstruction. A, Template created from contralateral, normal
ear. B, Costal cartilage harvested for auricular framework.

22  RECONSTRUCTION OF THE AURICLE
621
C
D
E
F
C, D, Template used to sculpt segments for construction of helix and body of framework. E, Body of framework
consisting of scapha and triangular fossa and helix sculpted from costal cartilage. Segments of cartilage integrated with 3-0 stain­
less steel wire and clear nylon sutures. F, Vertical and horizontal dimensions of framework should match template.
FIGURE 22-28, cont’d  ■

622
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
defect. Split-thickness skin grafts provide external cov­
erage over the fascia flap. For the first 72 hours after
flap transfer, a wound drain is attached to a closed
system suction device that is fixed to the patient’s dress­
ing. The TPFF may also be used to cover exposed
native auricular cartilage when large areas of the
cartilage are exposed (Fig. 22-31).48 Split-thickness skin
grafts applied directly to auricular cartilage without a
surface covering of perichondrium have limited success.
Incorporation of a TPFF to serve as the recipient bed
for the split-thickness skin graft markedly enhances
healing.
Although the TPFF may be tunneled under the skin
of the superior auricular sulcus, it is frequently easier to
place the flap across the sulcus, thereby obliterating it. In
such instances, the sulcus is reestablished in a second
surgical stage. This involves release of the reconstructed
auricle from its attachment superiorly and covering of the
medial aspect of the upper ear with a skin graft, restoring
the superior auricular sulcus.
Resurfacing of Temporal Cavity
After Auriculectomy
On occasion, large cancers of the auricle that do not
involve the temporal bone necessitate complete removal
of the ear. Several options are available for resurfacing of
the exposed bone after total auriculectomy, including
bilobed cutaneous flaps transposed over the temporal
bone. These can be designed to preserve the external
auditory canal (Fig. 22-32). Cervical rotation flaps,
regional chest and shoulder flaps, and microsurgical
tissue transfer may also be used. A disadvantage of a
musculocutaneous flap is that the bulk of the flap may
constrict the external auditory canal, compromising
hearing. In certain cases, temporal bone defects may be
covered with a TPFF and skin grafted. In these situa­
tions, the patient may subsequently be fitted for an auric­
ular prosthesis (Fig. 22-33).
SUMMARY
When auricular reconstruction is approached systemati­
cally, successful results may be achieved. The morpho­
logic uniqueness of the auricle, consisting of medial and
lateral cutaneous cover over a thin, flexible, and highly
convoluted cartilage, causes auricular reconstruction to
be a challenge. Constituent components of the defect
must be carefully analyzed and a plan conceived for
reconstruction of each component. Depending on the
size, depth, and anatomic location of the defect, different
repair techniques are employed. These range from
primary wound closure to skin grafting or the use of local
flaps. For larger defects, the principles of microtia recon­
struction, by use of autogenous rib framework grafts and
a TPFF, are of paramount importance. The ultimate goal
is a functioning appendage that closely approximates the
position, size, and contour of its normal contralateral
counterpart.
use of a combination of 3-0 stainless steel wire and 4-0
clear nylon sutures. Care is taken in attaching the root
of the sculpted helix to the body framework. Final
contour is achieved with 5- and 7-mm gouges to create
the scaphoid and triangular fossa. Once it is crafted, the
cartilaginous framework graft is stabilized at the recipi­
ent site and properly positioned on the basis of preop­
erative measurements.38,39
The cartilaginous framework must be covered with a
thin, vascular, hairless, soft tissue flap capable of nour­
ishing a skin graft. A pedicled TPFF satisfies these
requirements and is frequently used to cover the carti­
lage framework.40-43 The TPFF also has the following
advantages: the anatomy of the flap is well known to
head and neck surgeons; a large surface area of tissue
(4 × 12 cm) may be harvested; the flap may be pivoted
inferiorly to cover a wide range of auricular defects; and
the fascia may be transferred to the contralateral auricu­
lar region, if necessary, by microsurgical techniques
(Fig. 22-29).44-46
Anatomy
The temporoparietal fascia, also known as the superficial
temporal fascia, is continuous with the superficial mus­
culoaponeurotic system as well as the galea (Fig. 22-30).
It lies deep to the skin and subcutaneous tissue of the
scalp, to which it is firmly bound, particularly in the area
of the temporal line. This fascia should not be confused
with the fascial layer surrounding the temporalis muscle.
The temporoparietal fascia attaches to the zygomatic
arch, whereas the temporalis muscle fascia is deeper, is
thicker, and divides to envelop the zygomatic arch. Mea­
suring on average 2 to 3 mm in thickness over the parietal
area, the temporoparietal fascia is highly vascular, with
an abundant and consistent blood supply provided by the
superficial temporal artery and vein.3,47
Technique
To elevate the TPFF, a 6-cm-long vertical incision is
made in the scalp immediately above the auricular
defect, exposing the superficially located temporopari­
etal fascia. In harvesting of the flap, the hair follicles
and subcutaneous fat must remain a part of the overly­
ing scalp. Careful avoidance of injury to the hair folli­
cles prevents iatrogenic alopecia. The deep plane of flap
elevation is just superficial to the temporalis muscle
fascia in the loose connective tissue that separates the
temporoparietal fascia from the temporalis fascia. The
vascular pedicle is identified and protected. The ante­
rior limit of the flap remains posterior to the location of
the temporal branch of the facial nerve. The posterior
margin of the flap should capture the posterior branches
of the superficial temporal artery and vein and can be
back cut to the level of these vessels to facilitate flap
transfer. The flap is turned 180° downward from supe­
rior to inferior in a hinge fashion such that the lateral
surface of the flap becomes the medial surface adherent
to the auricular cartilage framework. The edges of the
flap are tucked under the existing skin edges of the

22  RECONSTRUCTION OF THE AURICLE
623
FIGURE 22-29  ■  Microsurgical hair-bearing temporoparietal scalp flap used to reconstruct area of alopecia and scarring. A, Preopera­
tive photograph showing site of prior excision of basal cell carcinoma with skin graft coverage. B, Microsurgical scalp flap outlined
on contralateral temporal area. C, Flap transferred to recipient site. D, Postoperative result at 6 months.
A
B
C
D

624
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 22-30  ■  Anatomy of temporoparietal fascia. A, Superficial temporal artery provides blood supply to flap. B, Layers of scalp
in temporal region. Flap consists of only temporoparietal fascia.
Temporoparietal fascia
Superficial
temporal artery
A
Bone
Pericranium
Temporalis muscle
Temporalis fascia
Areolar tissue
Temporoparietal fascia
Galea
Subcutaneous fat
Skin
B

22  RECONSTRUCTION OF THE AURICLE
625
A
B
C
D
FIGURE 22-31  ■  Angiolymphoid hyperplasia of auricle affecting medial and lateral skin but not auricular cartilage. Total resurfacing
of cartilage required. A, Preoperative view. B, Defect after complete removal of diseased soft tissue. C, D, Temporoparietal fascia
flap dissected and ready for transfer over framework.
Continued

626
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
E
F
G
E, Temporoparietal fascia flap transferred as an inferiorly based hinge flap to cover native auricular cartilage.
F, Skin graft placed over fascia flap. G, Postoperative result at 12 months, after superior auricular sulcus creation with skin graft.
FIGURE 22-31, cont’d  ■

22  RECONSTRUCTION OF THE AURICLE
627
FIGURE 22-32  ■  Total auriculectomy defect repaired with bilobed cervical flap. A, Total auriculectomy defect, with posteriorly based
cervical bilobed cutaneous flap designed for repair. Incision marked at superior border of defect not used. B, Flap elevated. C, Flap
in place. D, Postoperative result at 6 months.
A
B
C
D
A
B
FIGURE 22-33  ■  Repair of subtotal auriculectomy defect and external auditory canal preservation. A, Extensive squamous cell carci­
noma of conchal bowl. Incision marked for elevation of temporoparietal fascial flap. B, Resection of cancer, with preservation of
superior remnant of auricle, and elevation of fascial flap.
Continued

628
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
C
D
E
F
C, Flap hinged downward to cover wound. D, Flap in place over mastoid cavity. E, Flap covered with skin graft
with hole for external auditory canal. F, Postoperative result at 6 months.
FIGURE 22-33, cont’d  ■

22  RECONSTRUCTION OF THE AURICLE
629
G
G, Auricular prosthesis in place.
FIGURE 22-33, cont’d  ■
REFERENCES
1. Allison G. Anatomy of the external ear. Clin Plast Surg 1978;5:419.
2. Hayashi R, Matsuo K, Hirose T. Tension lines of the auricular
cartilage. Plast Reconstr Surg 1991;87:869.
3. Abul-Hassan HS, von Drasek Ascher G, Acland RD. Surgical
anatomy and blood supply of the fascial layers of the temporal
region. Plast Reconstr Surg 1986;77:17.
4. Park C, Lineaweaver WC, Rumly TO, Buncke HJ. Arterial supply
of the anterior ear. Plast Reconstr Surg 1992;90:38.
5. Adamson JE, Horton CE, Crawford HH. The growth pattern of
the external ear. Plast Reconstr Surg 1965;36:466.
6. Farkas LG. Growth of normal and reconstructed auricles. In:
Tanzer RC, Edgerton MT, editors. Symposium on reconstruction
of the auricle. St. Louis: Mosby; 1974.
7. Thomson HG, Correa A. Unilateral microtia reconstruction: is the
position symmetrical? Plast Reconstr Surg 1993;92:852.
8. Tolleth H. Artistic anatomy, dimensions and proportions of the
external ear. Clin Plast Surg 1978;36:466.
9. Tolleth H. A hierarchy of values in the design and construction of
the ear. Clin Plast Surg 1978;36:466.
10. Postnick JC, Al-Qatta MM, Whitaker LA. Assessment of the pre­
ferred vertical position of the ear. Plast Reconstr Surg 1993;91:1198.
11. Skiles MS, Randall P. The aesthetics of ear placement: an experi­
mental study. Plast Reconstr Surg 1983;72:133.
12. Brent B. Reconstruction of traumatic ear deformities. Clin Plast
Surg 1978;5:437.
13. Bumsted RM, Ceilley RI. Auricular malignant neoplasms. Arch
Otolaryngol 1982;108:225.
14. Cotlar SW. Reconstruction of the burned ear using a temporalis
fascial flap. Plast Reconstr Surg 1983;71:45.
15. Donelan MB. Conchal transposition flap for postburn ear deformi­
ties. Plast Reconstr Surg 1989;83:641.
16. Elsahy NI. Ear reconstruction with a flap from the medial surface
of the auricle. Ann Plast Surg 1985;14:169.
17. Eriksson E, Vogt PM. Ear reconstruction. Clin Plast Surg 1992;
19:637.
18. Herberhold C. Reconstruction of the auriculum. Facial Plast Surg
Monogr 1988;5:385.
19. Rosenthal JS. The thermally injured ear: a systematic approach to
reconstruction. Clin Plast Surg 1992;19:645.
20. Song R, Chen Z, Yang P, Yue J. Reconstruction of the external ear.
Clin Plast Surg 1982;9:49.
21. Songharoen S, Smith RA, Jabaley ME. Tumors of the external ear
and reconstruction of defects. Clin Plast Surg 1978;5:447.
22. Antia NH, Buch VI. Chondrocutaneous advancement flap for the
marginal defect of the ear. Plast Reconstr Surg 1967;39:472.
23. Ramirez OM, Heckler FR. Reconstruction of nonmarginal defects
of the ear with chondrocutaneous advancement flaps. Plast Recon­
str Surg 1989;84:32.
24. Gingrass RP, Pickrell KL. Techniques for closure of conchal and
external auditory canal defects. Plast Reconstr Surg 1968;14:568.
25. Krespi YP, Ries WR, Shugar JMA, Sisson GA. Auricular recon­
struction with postauricular myocutaneous flap. Otolaryngol Head
Neck Surg 1983;91:191.
26. Tanzer RC, Bellucci RJ, Convers JM, Brent B. Deformities of the
auricle. In: Converse JM, editor. Reconstructive plastic surgery.
Philadelphia: WB Saunders; 1977.
27. Tanzer RC. Total reconstruction of the external ear. Plast Reconstr
Surg 1959;23:1.
28. Renard A. Postauricular flaps based on a dermal pedicle for ear
reconstruction. Plast Reconstr Surg 1981;68:159.
29. Scott MJL, Klaassen MF. Immediate reconstruction of the helical
rim after bite injury using the posterior auricular flap. Injury 1992;
23:333.
30. Elsahy NI. Ear reconstruction with rotation-advancement compos­
ite flap. Plast Reconstr Surg 1985;77:567.
31. Lawson VG. Reconstruction of the pinna using preauricular flaps.
J Otolaryngol 1984;13:191.
32. Millard DR. The chondrocutaneous flaps in partial auricular repair.
Plast Reconstr Surg 1966;37:523.
33. Millard DR. Reconstruction of one-third plus of the auricular cir­
cumference. Plast Reconstr Surg 1992;90:475.
34. Sutton AE, Quatela VC. Bilobed flap reconstruction of the tempo­
ral forehead. Arch Otolaryngol Head Neck Surg 1992;118:978.
35. Bardsley AF. Primary reconstruction of a severed ear fragment
using a flap of temporoparietal fascia. Br J Plast Surg 1986;39:524.
36. Brent B. Auricular repair with autogenous rib cartilage grafts: two
decades of experience with 600 cases. Plast Reconstr Surg 1992;90:
355.
37. Nagata S. A new method of total reconstruction of the auricle for
microtia. Plast Reconstr Surg 1993;92:187.
38. Brent B. The acquired auricular deformity: a systematic approach
to its analysis and reconstruction. Plast Reconstr Surg 1977;59:475.
39. Brent B. The correction of microtia with autogenous cartilage
grafts. I: The classic deformity. II: Atypical and complex deformi­
ties. Plast Reconstr Surg 1980;66:1.
40. Brent B, Byrd HS. Secondary ear reconstruction with cartilage
grafts covered by axial, random, and free flaps of temporoparietal
fascia. Plast Reconstr Surg 1983;72:141.
41. Brent B, Upton J, Acland RD, et al. Experience with the temporo­
parietal fascial free flap. Plast Reconstr Surg 1985;76:177.
42. Jenkins AM, Finucan T. Primary nonmicrosurgical reconstruction
following ear avulsion using the temporoparietal fascial island flap.
Plast Reconstr Surg 1989;83:148.
43. Rose EH, Norris MS. The versatile temporoparietal fascial flap:
adaptability to a variety of composite defects. Plast Reconstr Surg
1990;85:224.
44. Tegtmeier RE, Gooding RA. The use of a fascial flap in ear recon­
struction. Plast Reconstr Surg 1977;60:406.
45. Smith RA. The free fascial scalp flap. Plast Reconstr Surg 1980;66:
204.
46. Cheney ML, Varvares M, Nadol JB. The temporoparietal fascia
flap in head and neck reconstruction. Arch Otolaryngol Head Neck
Surg 1993;19:618.
47. Marty F, Montandon D, Gumener R, Zbrodowski A. Subcutaneous
tissue in the scalp: anatomical physiological and clinical study. Ann
Plast Surg 1977;60:406.
48. Cheney ML, Bhatt S, Googe P, Hibbard D. Angiolymphoid hyper­
plasia with eosinophilia. Ann Otol Rhinol Laryngol 1993;102:303.

630
C H A P T E R 2 3 
RECONSTRUCTION OF CONGENITAL
AURICULAR MALFORMATIONS
E. Fred Aguilar III
INTRODUCTION
Reconstruction of auricular malformations requires a
comprehensive knowledge of microtia for selection of the
proper surgical approach. Inadequate knowledge and
experience of reconstruction of the ear has led to disas­
trous results. For this reason, the plastic surgeon should
be well aware of the many surgical options that exist
to treat microtia. This chapter covers ear deformities
ranging from simple protruding ears to major congenital
deformities. The single most important ingredient for a
successful result is the surgical experience of the surgeon.
Adequate study and meticulous attention to detail will
lead to the best possible outcome. In addition, the plastic
surgeon should realize that the care of the patient with
an ear deformity might necessitate a team approach that
includes an otologist, psychiatrist, audiologist, and radi­
ologist. The family of the patient afflicted with an auricu­
lar malformation deserves a coordinated approach and
should be aware of the complete plan at the outset of
treatment.
ANATOMY AND EMBRYOLOGY
Topographic landmarks of a normal ear are shown
in Figure 23-1. Development of the auricle is first
observed in the 5-week-old embryo. The auricle begins
as six mesenchymal proliferations at the dorsal ends of
the first and second pharyngeal arches surrounding the
first pharyngeal cleft. Initially, the external ear is located
in the lower neck of the embryo. As the mandible devel­
ops, the ear ascends to the side of the head at the level
of the eyes. The commonly accepted embryologic
theory (Fig. 23-2) is that the six hillocks correlate
directly with the tragus, helix, cymba, scapha, antihelix,
and antitragus.1
The auricle receives its blood supply from the super­
ficial temporal, posterior auricular, and occipital arteries.
The venous drainage of the auricle is by the posterior
auricular, external jugular, superficial temporal, and ret­
romandibular veins. The lymphatics of the ear drain
anteriorly to the parotid lymph nodes and posteriorly to
the cervical lymph nodes. The auricular muscles are
innervated by branches of the seventh cranial nerve. The
temporal branch of the facial nerve supplies the anterior
and superior auricular muscles, and a posterior auricular
branch of the same nerve supplies the posterior auricular
muscle. Sensory innervation of the auricle is from the
lesser occipital, great auricular (C2, C3), and auricular
temporal nerves. Arnold’s nerve, a branch of the tenth
cranial nerve, supplies the concha.
A normal auricle is shown in Figure 23-3. The vertical
axis of the normal auricle is tilted posteriorly approxi­
mately 20°. The vertical height of the normal ear is
approximately equal to the distance between the lateral
bony orbital rim and the root of the helix at the level of
the eyebrow (about 6-cm). The width of the ear is
approximately 55% of its height. Typically, the helical
rim protrudes 1- to 2-cm from the skull, and the angle
of protrusion should be between 25° and 30°. The supe­
rior aspect of the ear is usually level with the eyebrow.2
PREOPERATIVE CONSIDERATIONS
A number of congenital auricular deformities exist that
may require surgical intervention. To achieve the
most natural appearing ear possible through surgery,
the surgeon must assess the deformed ear for the pres­
ence of several important auricular landmarks. Recog­
nizing and grading the deformity will allow the surgeon
to craft the proper surgical options. Involving family
members of the patient with an ear deformity is impor­
tant. Eavey3 observed that children with microtia and
significant auricular malformations require comprehen­
sive attention directed to early family counseling and
evaluation of the patient for expected and unexpected
hearing loss, impaired language development, and asso­
ciated medical conditions. Both auricular and otologic
reconstructive procedures may be necessary and must
be coordinated. In 1999, Wang4 identified that the early
use of an auricular prosthesis is psychologically benefi­
cial to children who have an ear defect resulting from
congenital malformation. Wang also described tech­
niques to establish the proper location and orientation
of auricular implants used to secure auricular prostheses
by using information from computed tomography
(CT) scans. The techniques were applied to children
and adults to ensure accurate implant placement, leading
to improved positioning and orientation of auricular
prostheses.

23  RECONSTRUCTION OF CONGENITAL AURICULAR MALFORMATIONS
631
In 1977, Tanzer11 proposed a clinical classification of
auricular deformities. This has been used by others and
consists of the following:
Anotia
Complete hypoplasia (microtia)
With atresia of the external auditory canal
Without atresia of the external auditory canal
Hypoplasia of the middle third of the auricle
Hypoplasia of the superior third of the auricle
Constricted (cup and lop) ear
Cryptotia
Hypoplasia of entire superior third
Prominent ear
In 1974, Rogers12 published a similar classification that
divided deformities into four groups: macrotia, lop ear,
cup ear, and prominent ear. Weerda13 combined all of the
classifications proposed by Marx and Tanzer and modi­
fied by Rogers.14 This classification is included for
completeness, and demonstrates the awkwardness of clas­
sification schemes that are too comprehensive or detailed.
Weerda’s system included surgical guidance for each
classification:
First-degree dysplasia. Average definition: most struc­
tures of a normal auricle are recognizable (minor
deformities). Surgical definition: reconstruction nor­
mally does not require the use of additional skin or
cartilage.
CONGENITAL MALFORMATIONS
External ear deformities exist in 1% of births. Correcting
major congenital malformations of the auricle tests the
plastic surgeon’s surgical skills. Microtia has been the
subject of numerous publications as clinicians have
attempted to establish a method of classification of the
severity of a given deformity. Tanzer5,6 in 1959 published
the first scientific article on auricular reconstruction with
autogenous rib cartilage. In 1966, Cronin7 popularized
the use of silicone as an implant material to reconstruct
auricles. Brent,8 who first reported his work in 1974, is
considered the world’s foremost authority on auricular
reconstruction.
Classification
In 1988, Aguilar and Jahrsdoerfer9 amended the 1926
grading system used to classify the severity of microtia
described by Marx. In 1996, Aguilar10 reaffirmed this
concise classification of congenital ear malformations:
grade I is a normal ear; grade II has some of the auricular
framework present, but there are obvious deformities;
and grade III is the standard “peanut ear” deformity (Fig.
23-4), which encompasses anotia (Marx’s grade IV).
FIGURE 23-1  ■  Topographic anatomy of auricle.
Auricular tubercle
Scapha
Cymba of concha
Concha of auricle
Cavum of concha
Helix
Helix
Crura of antihelix
Triangular fossa
Crus of helix
Tragus
Ext. auditory meatus
Intertragic notch
Antitragus
Labule
Antihelix
FIGURE 23-2  ■  Auricle in 5-week human embryo develops from
six hillocks. OV, otic vesicle; AF, auricular fold.
FIGURE 23-3  ■  Normal-appearing auricle.

632
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
Macrotia
Protruding ears; synonyms: prominent ears, bat ears
Cryptotia; synonyms: pocket ear, group IV B
(Tanzer)
Absence of upper helix
Small deformities: absence of the tragus, satyr ear,
darwinian tubercle, additional folds (Stahl ear)
Colobomas; synonyms: clefts, transverse coloboma
Lobule deformities; synonyms: pixed lobule, mac­
rolobule, absence of lobule, lobule colobomas
(bifid lobule)
Cup ear deformities
Type I: Cupped upper portion of the helix,
hypertrophic concha, reduced height; syn­
onyms: lidding helix, constricted helix, group
IV A (Tanzer), lop ear, minor (mild or moder­
ate) cupping
Type II: More severe lopping of the upper pole
of the ear; rib cartilage is used as support when
a short ear must be expanded or the auricular
cartilage is limp
Second-degree dysplasia. Average definition: some
structures of a normal auricle are recognizable. Sur­
gical definition: partial reconstruction requires the
use of some additional skin and cartilage. Synonym:
second-degree microtia (Marx).
Cup ear deformity, type III: the severe cup ear
deformity is malformed in all dimensions; syn­
onyms: cockleshell ear, constricted helix, group
IV (Tanzer), snail-shell ear
Mini-ear
Third-degree dysplasia. Average definition: none of the
structures of a normal auricle are recognizable. Sur­
gical definition: total reconstruction requires the use
of skin and large amounts of cartilage. Synonyms:
complete hypoplasia group II, peanut ear, third-
degree microtia (Marx); normally there is a con­
comitant congenital atresia.
Unilateral: one ear is normal; no middle ear recon­
struction is performed on any child; auricular
reconstruction is begun at age 5 or 6 years
Bilateral: bone conduction hearing aid before the
first birthday; middle ear surgery at age 4 years
without transposition of the vestige; bilateral
reconstruction of the auricle at age 5 or 6 years
Anotia
The treatment recommendations by Rogers are debat­
able because of certain alternative options. For bilateral
microtia, a bone conduction hearing aid is usually
implemented at birth. In addition, even in bilateral cases,
middle ear surgery can follow the first two stages
of auricular reconstruction rather than being the first
procedure.15
Surgical Reconstruction of
Auricular Deformities
In cases of congenital microtia and concomitant atresia,
there should be complete coordination between the otol­
ogist and the plastic surgeon. Aguilar10 in 1996 presented
the concept of the integrated auricular reconstruction
protocol. As shown in Table 23-1, he recommended that
FIGURE 23-4  ■  A, B, Grade III microtia.
A
B

23  RECONSTRUCTION OF CONGENITAL AURICULAR MALFORMATIONS
633
the pores of the implant. The porous nature of the
implant material served as a scaffolding for ingrowth of
native tissue. However, in the clinical situation, the use
of this type of implant has been a problem. Exposure of
the Medpor implant usually requires débridement and
frequently removal of the implant. Historically, the use
of other materials for auricular frameworks has generally
been unsuccessful. Neither irradiated cartilage nor Silas­
tic implants have stood the test of time. Irradiated carti­
lage tends to be absorbed over time, and Silastic implants
are notorious for their inability to withstand trauma,
resulting in a tendency to extrude with time.
Surgical Planning and Treatment
Preoperative planning for reconstruction of auricular
malformations includes photographing the patient and
preparation of the template used to design the cartilagi­
nous framework. In unilateral cases, the template is based
on the patient’s contralateral ear; in bilateral cases, the
model is made from the mother’s ear. The site of implan­
tation of the cartilaginous framework on the side of the
head should be properly measured to avoid malposition­
ing of the reconstructed ear.
A high-resolution CT scan of the temporal bones is
obtained before surgical reconstruction of the auricle is
initiated. Although a CT scan is unnecessary for the
repair of microtia, the study provides information to the
surgical team caring for the patient. Using the informa­
tion from the CT scan, the team can determine the
course of planned repair and the surgical stages that will
be necessary to restore hearing in cases of atresia of the
middle ear.
The first surgical stage of auricular reconstruction
begins with framework construction from rib grafts and
implantation of the fabricated framework beneath the
skin at the recipient site. The dissection of rib cartilage
is extraperichondrial, and no stripping of the perichon­
drium of the graft is performed (Fig. 23-5). The tech­
nique to sculpt the costal cartilage framework has been
described by Brent.17 The framework is constructed of
segments of the sixth, seventh, and eighth ribs, which are
joined together with 5-0 stainless steel wire (Fig. 23-6).
The framework is placed beneath the skin of the lateral
face with proper positioning and orientation as deter­
mined by the preoperative patient assessment (Fig. 23-7).
When it is performed by trained surgeons, the technique
produces reliable results. The most common complica­
tion that occurs from the first-stage procedure is atelec­
tasis. Other complications include pleural tear (not a
complication unless it is not recognized intraoperatively),
pneumothorax, pneumomediastinum, chest wall defor­
mity, hypertrophic scarring, and pneumonia.
The second surgical stage consists of transposing the
lobule. To avoid protrusion of the lobule, the incision on
the medial aspect of the lobe should be fairly high. The
inferiorly based pedicle of the earlobe flap is quite thin;
thus, great care is taken in its handling (Fig. 23-8).
On completion of the first two surgical stages for
reconstruction of the auricle, attention is then turned to
the surgery required to restore hearing in cases of asso­
ciated atresia of the middle ear. This is considered the
TABLE 23-1  Treatment of Congenital
Malformation of the Auricle
Stage
Treatment
I
Creation of a cartilaginous framework with
autogenous rib cartilage
II
Lobule transposition
III
Atresia repair (by otologist)
IV
Tragal construction
V
Elevation
microtia repair be accomplished in five stages. The work
of the plastic surgeon should be performed first, and the
operations should be staged to facilitate total reconstruc­
tion of the microtia-atresia complex.
Despite advances made in surgical techniques and
middle and inner ear radiographic imaging in recent
decades, experienced otologists do not agree on several
key issues concerning surgery to restore hearing. These
controversial issues include the ideal age for performing
middle ear surgery, if and when to operate on cases of
unilateral atresia, and the likelihood of success when
operating on patients with severe craniofacial malforma­
tions. Most agree that the youngest age at which to
proceed with otologic surgery is 4 to 5 years. By this age,
there is usually adequate mastoid and middle ear pneu­
matization and the likelihood of adequate patient compli­
ance with postoperative wound care.
The majority of clinicians believe that otologic surgery
should be initiated at a younger age in cases of unilateral
atresia with evidence of cholesteatoma, infection, or very
thin atretic plates. However, opinions differ in regard to
treating other cases of unilateral atresia. Jahrsdoerfer
believes that the benefit of binaural hearing exceeds the
risk of facial nerve injury and other complications that
may be a result of otologic surgery to restore hearing. De
la Cruz also favors early operations on unilateral atresias
if CT findings point to a favorable outcome. Correction
of microtia typically begins at the age of 6 years for uni­
lateral cases. The preferred structural material for con­
struction of the ear is autogenous costal cartilage. By the
age of 6 years, there is sufficient costal cartilage to permit
surgical reconstruction, and the patient is old enough to
manage the necessary postoperative care. Patients with
bilateral microtia and atresia can be operated on at an
earlier age, but only if sufficient costal cartilage exists to
serve as grafts for auricular frameworks.
In 1997, Williams et al16 reported on the use of poly­
ethylene (Medpor) implants in auricular reconstruction.
The implants can be used with skin grafts to reconstruct
auricles with deficient auricular cartilage. Animal studies
demonstrated that the implant material is well tolerated
and could serve as replacement for native cartilage in
auricular reconstruction. Williams et al16 reported that
wounds in which polyethylene (Medpor) implants were
exposed to the exterior as early as 4 days after implanta­
tion could heal by secondary intention and subsequently
support a skin graft placed over the implant. The authors
concluded that this was possible because of the extent of
the fibrous tissue ingrowth from surrounding tissue into

634
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 23-5  ■  A, B, Costal cartilage harvested from sixth,
seventh, and eighth ribs and dissected extraperichondrially.
A
B
third stage of treatment and is performed by an otolo­
gist. The location of the temporal bone remnant dic­
tates the location for the opening of the external canal
in the overlying skin. It is easy to manipulate the fabri­
cated framework and position it so that an otologist may
properly reconstruct the external auditory canal. If the
external canal is created before the first two stages of
auricular reconstruction, the complication rate of micro­
tia repair is much higher. This is because it is difficult to
properly position and orient the auricular framework
around an external auditory canal as a result of the
adjacent scarring created by the canal surgery. The scar­
ring also impairs the vascular supply to the region of
reconstruction, and this may contribute to an increased
risk of complications.
The third stage of auricular reconstruction (fourth
stage of treatment) is performed after the creation of the
external auditory canal. It is directed toward reconstruc­
tion of the tragus (Fig. 23-9). This is accomplished by
obtaining a composite auricular graft from the opposite
ear. The composite graft is fashioned into a triangle-
shaped graft, which is transferred to the appropriate loca­
tion at the reconstructive site. Auricular elevation with
creation of a supra-auricular and postauricular sulcus is
performed during stage V of treatment (Fig. 23-10). This
is accomplished by dissecting the cartilaginous frame­
work with the overlying skin as a large composite flap.
The flap is elevated away from the head superiorly and
posteriorly, creating a tissue void where the anticipated
superior and posterior sulci will be. The area of the tissue
void as well as the medial aspect of the dissected flap is
covered by a full-thickness skin graft.
Complications
Complications are possible during auricular reconstruc­
tion. The cartilage framework places severe strain on the
overlying skin, and skin necrosis may occur. Skin necrosis
of 1- to 2-mm is treated by the application of ointment
and careful observation until healing occurs. If the necro­
sis is more than 5-mm, débridement is performed with
wound closure by a pedicled temporoparietal fascia flap
and skin graft. Infection may result in partial absorption
of the cartilaginous framework, altering the contour of
the reconstructed ear. Any grafting procedure always
involves the risk of graft loss. The possibility of keloid
formation at the recipient site is higher when skin grafts
are harvested from the abdomen or the buttocks. Skin
grafts obtained from the abdominal pubic interface show
less risk of keloid formation.
SUMMARY
Auricular reconstruction is difficult, and with each of the
steps described, complications may occur, even in the
hands of experienced surgeons. Reconstruction always
requires postoperative evaluations, and often the surgeon
will not be totally satisfied. Surgical correction of con­
genital microtia requires commitment by the plastic
surgeon to be adept at the various reconstructive surgical
techniques. The surgeon should be performing more
than five such operations per year to maintain proficiency
(Fig. 23-11). The team approach described here is invalu­
able to the patient and the patient’s family. Failure to
offer such an approach to treatment is a significant dis­
service to the patient. The field of tissue engineering
promises to change auricular reconstruction. The nexus
of cell growth biology and cell scaffolding technology is
rapidly changing and may at some point in the future
provide a biocompatible synthesized implant that serves
as an auricular framework. The technology must over­
come issues such as tissue rejection, integrity of form, and
structural strength for synthesized implants to withstand
overlying skin tension after implantation.

23  RECONSTRUCTION OF CONGENITAL AURICULAR MALFORMATIONS
635
FIGURE 23-6  ■  By use of template as guide, cartilage framework is sculpted from costal cartilage and assembled with 5-0 stainless
steel wire. A-C, Sculpting of left auricular framework.
A
B
C

636
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 23-7  ■  A, B, Cartilaginous framework beneath skin for reconstruction of right and left auricles.
A
B
FIGURE 23-8  ■  A, Cartilaginous framework beneath skin and malpositioned lobule. B, Drawing showing incisions for transposition of
lobule. C, Lobule transposed. Superior aspect of malpositioned lobule discarded.
A
Incision
Pedicle of
lobule flap
B
This portion
is removed
C

23  RECONSTRUCTION OF CONGENITAL AURICULAR MALFORMATIONS
637
FIGURE 23-9  ■  Tragus reconstructed with composite auricular graft from contralateral ear. A, Recipient site incision. B, Conchal bowl
excavated. Skin graft beneath bolster resurfaces conchal bowl. C, Composite graft sutured in place. Rubber catheter stent used to
maintain position and orientation of graft.
A
B
C
FIGURE 23-10  ■  A, B, Views of auricular elevation and creation of supra-auricular and postauricular sulci by placement of skin graft
medial to elevated framework.
A
B

638
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
A
B
C
D
FIGURE 23-11  ■  A-H, Preoperative views and results after staged auricular reconstruction.

23  RECONSTRUCTION OF CONGENITAL AURICULAR MALFORMATIONS
639
E
F
G
H
FIGURE 23-11, cont’d

640
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
REFERENCES
1. Gulya AJ. Developmental anatomy of the ear. In: Glascock ME III,
Shambaugh GE Jr, editors. Surgery of the ear. 4th ed. Philadelphia:
WB Saunders; 1990.
2. Farkas LG. Anthropometry of normal and anomalous ears. Clin
Plast Surg 1978;5:401.
3. Eavey RD. Microtia and significant auricular malformation.
Ninety-two pediatric patients. Arch Otolaryngol Head Neck Surg
1995;121:57.
4. Wang R. Presurgical confirmation of craniofacial implant locations
in children requiring implant-retained auricular prosthesis. J Pros­
thet Dent 1999;81:492.
5. Tanzer RC. Total reconstruction of the external ear. Plast Reconstr
Surg 1959;23:1.
6. Tanzer RC. Correction of microtia with autogenous costal carti­
lage. In: Tanzer R, Edgerton M, editors. Symposium on recon­
struction of the auricle, vol. 10. St. Louis: CV Mosby; 1974.
7. Cronin TD. Use of a Silastic frame for total and subtotal recon­
struction of the external ear: preliminary report. Plast Reconstr
Surg 1966;37:399.
8. Brent B. Ear reconstruction with an expansible framework of
autogenous rib cartilage. Plast Reconstr Surg 1974;53:619.
9. Aguilar EA III, Jahrsdoerfer RA. The surgical repair of congenital
microtia and atresia. Arch Otolaryngol Head Neck Surg 1988;
98:600.
10. Aguilar EA III. Auricular reconstruction of congenital microtia
(grade III). Laryngoscope 1996;106(Suppl. 82):1.
11. Tanzer RC. Congenital deformities. In: Converse JM, editor.
Reconstructive plastic surgery. 2nd ed, vol. 3. Philadelphia: WB
Saunders; 1977.
12. Rogers B. Anatomy, embryology and classification of auricular
deformities. In: Tanzer R, Edgerton M, editors. Symposium on
reconstruction of the auricle, vol. 10. St. Louis: CV Mosby;
1974.
13. Weerda H. Classification of congenital deformities of the auricle.
Facial Plast Surg 1988;5:385.
14. Rogers B. Microtic, lop, cup and protruding ears. Plast Reconstr
Surg 1968;41:208.
15. Aguilar EA III. Classification of auricular congenital deformities.
In: Papel ID, Nachlas NE, editors. Facial plastic and reconstructive
surgery. St. Louis: Mosby−Year Book; 1992.
16. Williams JD, Romo T III, Scalfani AP, et al. Polyethylene implants
in auricular reconstruction. Arch Otolaryngol Head Neck Surg
1997;123:578.
17. Brent B. Auricular repair with autogenous rib cartilage grafts:
two decades of experience with 600 cases. Plast Reconstr Surg
1992;90:355.

641
C H A P T E R 2 4 
RECONSTRUCTION OF THE SCALP
John F. Hoffmann
INTRODUCTION
The scalp is a common site for cutaneous malignant neo­
plasms and is frequently subjected to trauma. As such, the
surgeon is often faced with complex scalp defects in need
of repair. The scalp presents unique challenges to the
reconstructive surgeon: it is thick and inelastic; it is hair
bearing; it covers a convex surface; and it provides the
sole soft tissue covering for the cranium. In particular,
the lack of elasticity of the scalp makes the repair of even
small defects difficult. This chapter is intended to provide
an overview of the relevant anatomy of the scalp and the
techniques that are often used in its repair.
ANATOMY
The anatomic layers of the scalp are well described by
the convenient acronym SCALP (Fig. 24-1): S, the skin;
C, the subcutaneous tissue; A, the galea aponeurosis; L,
the loose connective tissue; and P, the periosteum, also
known as the pericranium. The scalp has the thickest skin
on the body. However, the thickness of scalp skin not
only varies across the surface of the head but also may
change throughout one’s life. The scalp skin is thickest
when hair growth is at its most robust. If the hair thins,
as in male pattern baldness or pathologic alopecia, scalp
thickness significantly decreases. The subcutaneous fat
layer contains hair follicles and integumentary structures
such as sweat and sebaceous glands. It provides a tight
connection between the skin and the underlying galea.
The galea is a dense, inelastic layer that provides a fibrous
connection between the frontalis muscle anteriorly and
the occipitalis muscle in the nape of the neck. Within and
adjacent to the galea run numerous vascular and neural
structures. In the forehead region, the galea envelops the
frontalis muscle, which has no direct attachment to bone.
Posteriorly, the galea encompasses the occipitalis, which
inserts in the bone along the nuchal line. The periosteum
is usually tightly affixed to the cranium and possesses its
own vascular supply.
In the region of the temple, the anatomic layers of the
scalp are more complex. Medial to the temporal line,
which represents the superior aspect of the temporalis
muscle, the SCALP acronym applies. However, over the
temporalis muscle, the layers of the scalp differ slightly
from the remaining scalp (Fig. 24-2). Over the superior
aspect of the temporalis muscle, the first three layers of
the scalp, the skin, subcutaneous fat, and galea, remain
the same. Inferiorly, however, the galeal layer of the tem­
poral region becomes the temporoparietal fascia. The
temporoparietal fascia is loosely attached to the subcuta­
neous fat and is continuous with the fascia of the frontalis
muscle in the forehead region. The temporoparietal
fascia accounts for the difference between the loose and
tight attachment of the scalp to the cranium (Fig. 24-3).
The tight region of the scalp has a dense galeal layer, no
underlying muscle, and poor distensibility. In the loose
regions of the scalp, the galea is thinner and overlies
muscle anteriorly as well as posteriorly below the nuchal
line and is considerably more distensible. It is important
to understand this anatomic difference to be successful in
planning scalp flaps. For example, small advancement and
transposition flaps are effective for repair of medium-
sized (3 cm) defects in the loose regions of the scalp. Such
flaps are not as effective for repair of similar-sized defects
in the tight regions of the scalp because of the inelastic
nature of the tissues in these areas.
Within the temporoparietal fascia run the branches of
the superficial temporal artery and the temporal branches
of the facial nerve. A layer of loose connective tissue
separates the temporoparietal fascia from the dense fascia
of the temporalis muscle. Below the muscle is the peri­
osteum of the temporal fossa. A few centimeters above
the zygomatic arch, the fascia of the temporalis muscle
splits to encase the temporal fat pad. At the level of the
arch itself, the temporoparietal fascia, the superficial
layer of the temporalis fascia, and the periosteum of the
zygomatic arch fuse into a single dense layer that is tightly
attached to the arch. It is here that the temporal branch
of the facial nerve is vulnerable to injury as it passes over
the arch on its way to the frontalis and corrugator muscles
of the forehead.
The scalp has a rich and redundant vascular supply
(Fig. 24-4). The external carotid artery provides the
majority of the blood supply to the scalp through the
superficial temporal, posterior auricular, and occipital
arteries. The internal carotid system also supplies the
scalp anteriorly through its terminal supraorbital and
supratrochlear arteries, which course up the forehead
after exiting the orbit. The robust vascular network of
the scalp will usually support large random patterned
local flaps with variable configurations. However, there
are limited anastomotic connections across the midline.
Thus, flaps that extend a considerable distance across the
midline may benefit from delay. This is particularly true
in children.1 When designing flaps, the surgeon should
be cognizant of the location and typical course of the

642
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 24-1  ■  Scalp anatomy.
Skin
Subcutaneous
tissue
Dura mater
Bone
Pericranium
Galea
Subaponeurotic
connective tissue
FIGURE 24-2  ■  Anatomy of temporal region. SMAS, superficial musculoaponeurotic system.
Pericranium
Superficial
temporoparietal fascia
Temporal line of fusion
Superficial layer of
deep temporal fascia
Frontal branch of
facial nerve
Parotid masseteric
fascia
SMAS
Masseter muscle
Coronoid process
of mandible
Zygoma
Deep temporal fat
Temporalis muscle
and tendon
Superficial temporal
fat pad
Deep layer of
deep temporal fascia
Deep temporal fascia
Periosteum

FIGURE 24-3  ■  A, B, Tight and loose regions of scalp. Tight region has dense galeal layer, no underlying muscle, and poor distensibil­
ity. In loose region, the galea is the thin fascial layer overlying muscle, and scalp is more distensible.
LOOSE
LOOSE
TIGHT
TIGHT
FIGURE 24-4  ■  Vascular anatomy of scalp.
Posterior
auricular a.
posterior branch
anterior branch
Superficial temporal
artery:
Supratrochlear a.
Supraorbital a.
Occipital arteries

644
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
and good reliability. Flaps dissected in the subcutaneous
plane compared with subgaleal dissection are consider­
ably more difficult as this is a “nonanatomic” plane that
requires sharp surgical dissection. Typically, these types
of flaps are elevated just below the hair follicles within
the subcutaneous fat. Numerous small vessels are encoun­
tered and hemostasis can be difficult. In addition, elec­
trocautery used to secure hemostasis can injure the hair
follicles. For these reasons, scalp flaps consisting only of
skin and subcutaneous fat are rarely employed. In the
area over the temporalis muscle, the temporoparietal
fascia can be raised as an independent flap on a pedicle
or as a microsurgical free flap and transferred to an adja­
cent or distant site.2,3 Incisions for the flap must remain
posterior to the course of the temporal branch of the
facial nerve to avoid denervation of the frontalis and cor­
rugator muscles. The temporoparietal fascia flap is useful
in auricular and orbital reconstruction as it provides thin,
supple, and highly vascular tissue supplied by the poste­
rior branch of the superficial temporal artery.4,5 Details
of this flap are discussed elsewhere in this chapter. Flaps
consisting of periosteum can also be developed indepen­
dent of the overlying scalp tissues.
GOALS
The primary goal of scalp reconstruction is to provide a
viable and durable covering for the cranium. The second­
ary goal is to maintain the hairline and contour of the
scalp. The need to restore hair-bearing scalp creates
unique challenges and greatly limits the surgeon’s options.
If a scalp defect is full thickness, including the pericra­
nium, a scalp flap is the preferred method of repair. The
thick and inelastic nature of the scalp is advantageous
because of its ample vascular supply and disadvantageous
because of the inelasticity of the tissue. By necessity, scalp
flaps are designed relatively large compared with the
defect size, yet they are usually robust and can tolerate
more wound closure tension than flaps elsewhere on the
face. Tissue expansion can be helpful as an adjunct pro­
cedure but requires a stable wound and as such is rarely
applicable to the repair of a fresh wound created by
trauma or by an oncologic resection.
HEALING BY SECONDARY INTENTION
In some instances, allowing a scalp defect to heal by
secondary intention may be a good option.6 However,
several criteria should be met before this option is selected
for the treatment of defects of the scalp. Most important,
there must be a base of viable tissue, such as pericranium,
on which granulation tissue can form. On occasion, bare
bone may support the formation of granulation tissue on
its own, but the process is exceedingly slow and fraught
with problems. The surgeon can enhance the formation
of granulation tissue by removing the outer table of the
cranium to the level of the diploic space, which is quite
vascular. This may allow islands of granulation to form,
which will then coalesce into a continuous layer that can
support re-epithelialization of the wound or a skin graft.
principal arterial branches that supply the scalp and try
to incorporate them in the base of the flap. A Doppler
probe may be helpful in outlining the course of these
vessels through the thick overlying skin. Many of the
larger vascular branches run within the galea and tempo­
roparietal fascia. For preservation of these vessels, scalp
flaps are ideally dissected just deep to this layer within
the loose connective tissue, creating a fasciocutaneous
flap. The galea provides some protection to the vascular­
ity of scalp flaps by limiting the elongation and crimping
of vessels. The skin and subcutaneous tissue layers of the
scalp also have a dense vascular plexus, but there is a
greater risk of ischemia when flaps are dissected in the
subcutaneous tissue plane. In addition, elevating a flap in
the subcutaneous tissue plane subjects the hair follicles to
the risk of injury and subsequent hair loss. The principal
disadvantage of flaps that include the galeal layer is that
the flaps are inelastic and nondistensible. Hence, scalp
flaps must be designed with a large surface area relative
to the size of a defect the flap is intended to repair. In
addition, wound closure tension is likely to be higher
compared with local cutaneous flaps used in other areas
of the head and face.
The lymphatic network of the scalp is extensive and
lacks nodes, so flow is unimpeded. The scalp lymphatics
drain into the parotid, anterior and posterior auricular,
and occipital regions in roughly the same pattern as the
venous drainage of the scalp.
The sensory innervation of the scalp is provided by
multiple branches of the trigeminal nerve. The supraor­
bital nerve is the most easily identified nerve as it passes
over the superior bony orbital rim through either a notch
or foramen extending up the forehead and into the ante­
rior scalp. The supratrochlear nerve provides sensation
for the central forehead after it passes through the cor­
rugator muscle. The lateral and posterior scalp is inner­
vated by multiple branches of the temporal, auricular, and
occipital sensory nerves. The only motor nerve of concern
when dissecting scalp flaps is the temporal branch of the
facial nerve. As discussed previously, the nerve enters the
temple region within the fascia over the zygomatic arch.
It then runs within the galeal layer (temporoparietal
fascia) until it innervates the frontalis and corrugator
muscles on their deep surfaces. In most areas, if the surgi­
cal dissection is deep to the galea, the nerve is not at risk
for injury. The exception is in the vicinity of the zygo­
matic arch, where the dissection plane should be beneath
the superficial layer of the temporalis fascia and perios­
teum of the arch. In this way, the temporal branch of the
facial nerve will remain superficial to the plane of dissec­
tion and within the flap itself. However, for most cutane­
ous defects in the areas of the temple and zygomatic arch,
dissection should be in the subcutaneous tissue plane and
hence superficial to the branches of the nerve. It is essen­
tial that the surgeon become familiar with the anatomy
of the scalp and forehead skin in the region of the temple
before embarking on the transfer of local flaps or other
surgical procedures in this region of the face.
The layers of the scalp provide convenient surgical
dissection planes. Dissection beneath the galeal layer is
simple, swift, and relatively avascular. Large flaps can be
readily dissected in this tissue plane with minimal effort