Operative Technique in Plastic Surgery – Kevin C.Chung

■ Diode and alexandrite: rupture of hair follicle with flash of light
and audible crackle.
Complications
■ Blistering can occur with PDL, especially in patients with higher
Fitzpatrick scores; this is very superficial and is treated with
topical ointment until wound re-epithelializes.
■ Hypopigmentation is quite common.
■ Postinflammatory hyperpigmentation can occur with UV
radiation exposure and should be treated with topical
corticosteroids.
■ Allergy to topical antibiotics can occur after prolonged use of
these agents and typically resolves with cessation of use.
■ Cellulitis is rare but does respond quickly to oral antibiotics,
which include coverage of MRSA.
■ Wound breakdown and infarction is extremely uncommon and
may be due to a combination of technical issues with too much
energy delivered and superimposed infection.
Cessation of
therapy
■ Most patients achieve maximum benefit after 4–6 sessions, but
continued improvement can occur well beyond this series of
treatments. We typically stop treatments when both the patient and
provider agree that signs and symptoms have reached maximum
improvement.
POSTOPERATIVE CARE
■ The patient should be advised to expect reactive erythema, bruising, and
occasional superficial blistering within 3 to 5 days.
■ The patient should apply bacitracin ointment daily to the treated area.
■ Patients must avoid sunlight to prevent UV radiation exposure.
■ Postprocedure pain should be adequately covered by over-the-counter
analgesics such as acetaminophen and NSAIDs.
■ We do not routinely prescribe narcotic analgesics after PDL.
■ The CO2 laser is painful, and we routinely prescribe a small amount of
narcotic analgesics for postprocedure pain.
■ Dressings can be taken down by the family 1 to 3 days after treatment.
■ Occupational and physical therapy can be started at that time.
■ Compression garments can be worn when the scab formation occurs, typically
5 days after treatment.
■ Children often go back to school, and adults return to work, within 1 to 2 days.

OUTCOMES
■ Some degree of symptomatic improvement can be expected in all patients,
though returns tend to diminish with each successive treatment (Clayton, Levi).
We objectively measure improvement with the Vancouver Scar Score, in which
the provider rates thickness, redness, color, texture, and pliability. Patients
provide subjective feedback through the use of the UNC 4P scale, in which
patients rate pain, paresthesias, pliability, and pruritus. Interestingly, patients
often report continued subjective improvement, after the provider notes plateau
in objective clinical findings.
■ Patients who reach maximum improvement are re-evaluated in 2 to 3 months
and then at yearly intervals thereafter. Children will often experience
recurrence of symptoms during and after puberty and may benefit from an
additional series of sessions, sometime many years later.
■ One unexpected finding is that many burn patients with chronic neuropathic
pain, whose hypertrophic scars have been treated with lasers, present with focal
anatomic causes of their pain, such as nerve compression or neuroma
formation. Laser therapies treat the generalized inflammatory and hypertrophic
response, often unmasking surgically treatable causes of chronic neuropathic
pain. Diagnosis of an anatomic cause can be made by clinical exam, with
elicitation of a Tinel sign, as well as nerve block, which can be assisted with
ultrasound guidance. If an anatomic cause is identified, then patients may
undergo a combination of nerve decompression and transposition, neuroma
resection with subfascial or intramuscular implantation, or fat grafting. In our
experience, laser treatment of hypertrophic burn scars improves chronic
neuropathic pain in 80% to 90% of patients, as defined by reduction of
symptoms and de-escalation of pharmacologic regimen. In the remaining
patients, 80% to 90% have an anatomic cause of neuropathic pain that is
amenable to surgical intervention. One guiding observation is that over the past
10 years of treating hypertrophic burn scars with laser therapies, the more we
look for discrete anatomic causes of neuropathic pain, the more likely we are to
find abnormalities that respond to a combination of nerve decompression and
neuroma resection. Fat grafting has also proven to be a highly successful form
of treatment in refractory cases.
COMPLICATIONS
■ Adverse events are minor and include hyperpigmentation, hypopigmentation,
mild blistering, pain, rash, fever, and infection (Clayton).

■ In our 10-year experience, involving 800 sessions per year, we have observed
one case of herpetic whitlow, one case of wound breakdown with delayed
healing, and two cases of postoperative pulmonary insufficiency, requiring
intubation (one patient with aspiration at end of case, the other patient with
myasthenia gravis).
REFERENCES
1. Friedstat JS, Hultman CS. Hypertrophic burn scar management: what does the
evidence show? a systematic review of randomized controlled trials. Ann Plast
Surg. 2014;72(6):S198-S201.
2. Tredget EE, Levi B, Donelan MB. Biology and principles of scar management
and burn reconstruction. Surg Clin North Am. 2014;94(4):793-815.
3. Hultman CS, Edkins RE, Wu C, et al. Prospective, before-after cohort study to
assess the efficacy of laser therapy on hypertrophic burn scars. Ann Plast Surg.
2013;70(5):521-526.
4. Hultman CS, Edkins RE, Lee CN, et al. Shine on: review of laser- and light-
based therapies for the treatment of burn scars. Dermatol Res Pract.
2012;2012:243651.
5. Jin R, Huang X, Li H, et al. Laser therapy for prevention and treatment of
pathologic excessive scars. Plast Reconstr Surg. 2013;132(6):1747-1758.
6. Hultman CS, Friedstat JS, Edkins RE, et al. Laser resurfacing and remodeling
of hypertrophic burn scars: the results of a large, prospective, before-after
cohort study, with long-term follow-up. Ann Surg. 2014;260(3):519-529.
7. Edkins RE, Hultman CS, Collins P, et al. Improving comfort and throughput
for patients undergoing fractionated laser ablation of symptomatic burn scars.
Ann Plast Surg. 2015;74(3):293-299.
8. Clayton JL, Edkins R, Cairns BA, Hultman CS. Incidence and management of
adverse events after the use of laser therapies for the treatment of hypertrophic
burn scars. Ann Plast Surg. 2013;70(5):500-505.
9. Levi B, Ibrahim A, Mathews K, et al. The use of CO2 fractional
photothermolysis for the treatment of burn scars. J Burn Care Res.
2016;37(2):106-114.

32
CHAPTER
Fat Grafting for Nerve
Entrapment Within Burn
Scars
C. Scott Hultman and Yuen-Jong Liu
DEFINITION
■ Mortality from burn injury has markedly decreased in the second half of the
20th century as wound sepsis, wound coverage, kidney failure, and shock have
been largely remedied.
■ Patients who have undergone tangential excision of burn injuries,
escharotomies, and autografting often develop symptomatic scars.
■ Superficial sensory nerves may become entrapped in burn scars and cause
debilitating paresthesias, such as burning pain, tingling, or hyperesthesia.
■ Although nerve decompression and neurolysis are the primary treatments for
entrapment, fat grafting is a low-risk adjunct procedure that can mitigate
neuropathic symptoms by capitalizing on anti-inflammatory effects and
physical cushioning by autologous fat.1–7
■ The principles of fat grafting for burn scars may also be applied to scars from
other etiologies, such as chemical exposure, frostbite, abrasion, electrical
injury, or a combination of injurious energy transfer to the skin and superficial
soft tissues.
ANATOMY
■ Nerve entrapment may occur at any location of the body where there are
sequelae of burn injury.
■ Superficial sensory nerves are affected, frequently in the extremities, such as
the superficial radial nerve, the medial antebrachial cutaneous nerve, the
saphenous nerve, the sural nerve, and lateral dorsal cutaneous nerve.

PATHOGENESIS
■ Hypertrophic scarring and contractures develop in burn scars or in split-
thickness skin grafts over excised burn scars.
■ The fibrotic tissues constrict around superficial sensory nerves and cause a
combination of pain, hyperesthesia, and paresthesia.
■ Sensory receptors in the damaged skin may also received aberrant innervation
from sensory nerves, as the integument heals.
NATURAL HISTORY
■ The neuropathic symptoms are a source of frustration for the patient, often
preventing return to school and work.
■ They require narcotic and non-narcotic analgesics and may become tolerant.
■ Adjunct analgesics include gabapentin and pregabalin, which have adverse
effects of varying severity.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Complete patient history should be elicited, focusing on the type of energy
delivered: scald, electrical, flame, contact, chemical, cold, friction, or abrasion.
■ Previous treatments and their effects should be noted, including skin grafting,
laser treatments, topical scar treatments, and medications.
■ Complete physical exam should be performed, focusing on the burned area,
noting whether it is a native burn scar or burn scar after skin grafting.
■ Total body surface area of the burn injury should be observed, as this often
dictates algorithms for treatment, that include medical therapy (compression,
silicone), laser photothermolysis and ablation, nerve decompression, and fat
grafting.
■ Functional deficits should be noted, such as loss of range of motion or loss of
sensation.
■ Gentle percussion around the symptomatic area can elicit Tinel sign
corresponding to the location of nerve tethering or entrapment.
■ The Tinel sign can be followed to assess the effectiveness of treatment.
DIFFERENTIAL DIAGNOSIS
■ Nerve compression amenable to decompression and possible transposition
■ Discrete neuroma formation that may benefit from exploration, resection, and
implantation of nerve below fascia or into muscle or even bone
■ Persistent hyperemia of hypertrophic burn scar, which may respond to laser

resurfacing
IMAGING
■ Imaging is not required, although ultrasound may be helpful in guiding
diagnostic nerve blocks, to confirm diagnosis of entrapped nerve vs neuroma,
and to provide temporary relief.
SURGICAL MANAGEMENT
■ Fat grafting is a modality that can offer significant relief of neuropathic
symptoms, after patients have been considered for or treated with laser
resurfacing, nerve decompression, or neuroma resection.
■ Fat grafting involves surgically controlled incisional release of the integument
from the underlying subcutaneous tissues and fascia.
■ The grafted fat contains adipocytes and possibly stem cells, which are thought
to have anti-inflammatory effects on the entrapped nerves and scar tissue.
■ The grafted volume provides mechanical padding that decreases nerve
sensitivity by effectively burying afferent end fibers, deeper and away from
direct contact.
■ Other reasonable surgical options include scar subcision and open neurolysis.
■ LipiVage is the preferred system for small volume grafting, and Puregraft is
preferred for large volume, structural fat grafting.
Preoperative Planning
■ Overall, fat grafting is indicated for patients with any of the following criteria:
■ Require significant pharmacologic therapy for neuropathic pain
■ Have previously undergone laser therapies for hypertrophic burn scars
■ Have multiple areas of dysesthesias not necessarily corresponding to the
anatomic distribution a sensory nerve
■ Have already undergone major peripheral nerve decompression, neurolysis,
and neuroma resection
■ The senior author prefers to use fat grafting as “rescue” therapy for patients
with chronic, neuropathic burn scar pain, who have undergone other modalities
with documented success in the literature, such as laser resurfacing and
peripheral nerve decompression.
■ Patients with large burn scar surface areas, who are on medications for
neuropathic pain, should first undergo laser treatments with pulsed dye laser to
reduce hyperemia, fractional CO2 laser resurfacing to improve pliability of

burn scar, and laser-assisted drug delivery (usually kenalog) to reduce
inflammatory component.
■ Patients with a discrete Tinel sign, suggestive of neuroma or entrapment, as
well as those with motor dysfunction, should first undergo surgical exploration,
nerve decompression, and possibly neuroma resection.
■ Patients who have multiple Tinel sign, who have undergone other modalities
such as laser resurfacing, and who have previously had peripheral nerve
surgery, can be considered optimal candidates for fat grafting.
■ Another indication for fat grafting is the patient who is on an aggressive
pharmacologic regimen for chronic neuropathic pain and who wants or needs
to de-escalate medications, which often lose efficacy and cause side effects of
decreased level of alertness, poor sleep hygiene, and peripheral swelling.
■ The role for early fat grafting, within the first 6 to 12 months after wound
closure, is unknown and would benefit from prospective clinical studies.
■ The role for fat grafting in prepubertal children is also not known and requires
prospective clinical trials.
Positioning
■ Supine, to access fat from anterior abdominal wall and lateral trunk
■ Shoulders abducted at 85 degrees for upper extremity surgery, with pressure
points padded
■ Lower extremities prepped such that ankles, knees, and hips can be mobile
Approach
■ Fat grafting is often performed in multiple sessions, as there is a limit to how
much fat can be grafted into and below a burn scar, especially when there is a
paucity of subcutaneous tissue present.
■ The authors plan harvest and use 0.5 to 1.0 cc of fat for every cm2 of surface
area grafted.
■ Regular liposuction or power-assisted liposuction may be used to harvest the
fat.
T E C H N I Q U E S

■ Port Creation and Cannula Use
Video p8-c032_01
■ The port sites of the donor and recipient sites are first injected with a wheel
of local anesthetic, typically 1% lidocaine with epinephrine, to minimize
bleeding at locations.
■ Donor sites ports typically include the inferior umbilicus, the flanks near the
anterosuperior iliac crest, or previous surgical scars on the abdomen.
■ The donor sites are tumesced with approximately 200 mL, targeting above
and below the superficial fascial system using a solution of 1 L lactated
Ringer’s containing 1 mL of 1:100 000 epinephrine and 50 mL of 1%
lidocaine.
■ Tumescent is allowed to diffuse for 10 minutes.
■ Port sites, of 1 to 2 mm, are made with stab incisions, proximal to the
symptomatic burn scar. At least two port sites are made, to allow for a radial,
fanning, cross-hatched matrix, with overlapping tunneling and at different
levels in the burn scar.
■ A subcision cannula is tunneled anterograde, from proximal to distal, to
decrease risk of avulsing nerve branches (TECH FIG 1).
■ Rigotomy is performed with advancement of the cannula. Usually, a blunt-
tipped or semi–blunt-tipped cannula can be advanced through the scar, but
occasionally, a sharp pickle-fork cannula is needed to perform discrete
rigotomies.
■ Fat is injected on withdrawal of the cannula, in aliquots of 0.1 to 0.2 cc, up
00:00 / 00:00

to 0.5 mL with the bevel up and another 0.5 mL with the bevel down, over a
distance of 2 to 6 cm.
■ Additional passes of the subcision cannula are repeated in a fanning fashion
through each fat grafting port, centering on the focus of nerve entrapment.
Care is taken to stay superficial, directly under the burn scar, to avoid
disruption of the deeper afferent neural plexus.
TECH FIG 1 • A subcision cannula is tunneled
anterograde, from proximal to distal, to decrease risk
of avulsing nerve branches.
LipiVage
■ The tubing set attached to the LipiVage Harvester is connected to an
aspirator and the vacuum level is set to approximately 60% of its capacity,
ensuring a gentle vacuum (TECH FIG 2).
■ The transfer adapter is removed, and the recommended aspiration cannula is
attached. The senior author prefers to use a serrated, 1 to 2 mm cannula with
multiple side ports, which is helpful for extracting fat during repeat harvests.
■ Fat is harvested for approximately one minute, and then fluids are drained
for a few seconds, from the trap mechanism with the LipiVage system.
■ The nearly bloodless lipoaspirate is then washed with normal saline, within
the closed system, before processing on the back table. Fat is then transferred
into 3 cc injection syringes using the transfer adapter supplied. Harvesting

steps are repeated for additional fat if needed.
■ The filter is simply rinsed for a few seconds, and the plunger tip is used to
wipe the inner walls of the filter clean in between harvests.
■ Fat cells collect in the filter chamber suspended within the harvester body.
■ Fat cells are gently pulled toward the inner walls of the filter and collect
along the length of the front of the blue plunger tip, while fluids wash
through.
■ Once inside, the fat is gently cleaned by the accompanying tumescent fluid.
■ Fluid and oils pass through the fat and the filter walls and are then carried to
the waste receptacle via the tubing set.
■ Due to the low vacuum levels, there is very little oil present to begin with
because fewer fat cells are damaged during harvesting.
■ After fluids are drained, the concentrated and cleaned fat is immediately
ready for injection.
■ The unique LipiVage plunger tip design gently wipes the fat from the inner
filter walls and transfers the fat as the plunger is pushed forward gradually.
■ The processed fat grafts are allowed to settle on the back table for at least 10
minutes, with the 3 cc syringes upside down, so that any additional tumescent
fluid and oil can separate and be discarded, prior to fat grafting.
TECH FIG 2 • Attaching tubing set to the LipiVage
Harvester.

■ Puregraft
Video p8-c032_02
■ Fat is aspirated into a syringe.
■ The lipoaspirate is injected into a Puregraft drain bag (TECH FIG 3).
■ The lipoaspirate is washed lactated Ringer’s solution.
■ The filtered fat is aspirated from Puregraft drain bag into small syringes for
grafting.
TECH FIG 3 • The lipoaspirate is injected into a
Puregraft drain bag.
00:00 / 00:00

PEARLS AND PITFALLS
Port sites:
harvest
■ Usually, all of the lipoaspirate needed for fat grafting can be
obtained through an infraumbilical incision.
■ If multiple rounds of fat grafting are anticipated, we usually harvest
fat from the right and left lower quadrants first, followed by the
central infraumbilical fat second, and possibly the flank on repeat
harvests. This is done to yield a desirable, symmetric abdominal wall
contour.
■ We always avoid harvesting fat from the right and left upper
abdominal wall quadrants, to avoid injury to the liver or spleen, in
case an aberrant pass is deflected deeper from the costal margin and
into the peritoneal cavity.
■ Recipient sites are closed with 4.0 plain gut and a Steri-Strip.
Port sites:
recipient
■ Port sites are almost always placed proximal to area of concern, so
that the rigotomy can be done from proximal to distal, parallel to the
topical distribution of the cutaneous nerves.
■ Several port sites enable a cross-hatched matrix, which increases the
amount of fat that can be transferred and should survive.
■ Recipient sites are closed with 4.0 plain gut and a Steri-Strip.
Fat harvest
■ We recommend against energy-assisted liposuction, such as laser or
ultrasound, as this may decrease the viability of the grafted fat.
■ The LipiVage system is used most of the time, as this allows for
efficient harvest of the small volumes required for fat grafting.
Structural fat grafting, which requires larger volumes to replace
deficient tissue, is better served by the Puregraft system.
Engraftment
■ For burn scars in the extremities, no tourniquet is used.
■ After the cannula is advanced from proximal to distal, effecting a
rigotomy, fat is injected in 0.1 to 0.2 cc aliquots, from distal to
proximal.
■ Pre-tunneling is not performed in order to decrease the risk of
hematoma.
■ We use 3 mL syringes for injecting fat during grafting, as the small
size gives adequate control over delivering 0.2 mL aliquots without
having to change syringes often.
■ Our formula for volume of final processed and purified fat needed
for grafting is 0.5 to 1.0 cc of fat for every cm2 of surface area
treated. Of note, we typically harvest lipoaspirate 2–3 times the

volume needed for fat grafting ultimately needed, discarding
tumescent fluid and oil as these elements separate.
POSTOPERATIVE CARE
■ Acute postoperative pain from donor sites and at fat grafting sites lasts no
more than 2 weeks. Typically, the patient experiences more pain in the donor
site than the recipient site.
■ Patients are kept on their neuropathic pain regimen but do require additional
narcotics, especially for the donor-site pain.
■ One dose of IV antibiotics is given at induction of anesthesia, and 5 days of
oral antibiotics are given in the immediate postoperative period.
■ The donor site is wrapped with gentle compression for 4 weeks to minimize
the risk of seroma and hematoma. For abdominal donor sites, an abdominal
binder is recommended at all times except when showering.
■ The patient is advised against strenuous physical activity and heavy lifting
(greater than ten pounds) for 4 weeks.
■ The recipient site is dressed in clean, dry, gauze to absorb any drainage from
the injection ports, and the initial postoperative may be removed on the 2nd
day and reapplied as needed.
■ The recipient site is treated with moderate compression during early
engraftment, to prevent significant edema or hematoma. We believe that
similar to the principle of needing a bolster to immobilize a skin graft, during
the imbibition and inosculation phases, this compression helps with
engraftment of the fat, in recipient sites, which may have less than optimal
vascularity. The patient is advised to avoid direct pressure on the recipient site
for 4 weeks, to prevent fat liquefaction or fat necrosis.
OUTCOMES
■ Fat grafting reduces neuropathic pain, in approximately 90% of patients,
permitting reduction in medication regimens.
■ Fat grafting reduces scar symptoms such as pruritus, hyperesthesia,
paresthesia, and tethering to deep structures.
■ Fat grafting can improve tendon gliding in the hand and foot.
■ Fat grafting improves scar pliability, texture, and color.
COMPLICATIONS
■ Complications at the donor site are essentially complications from liposuction,

which are rare, but include seroma, hematoma, and infection at the donor site.
■ Complications at the recipient site have not been reported but may include
infection and graft loss. Infections are exceedingly rare. In the author’s
practice, postoperative cellulitis occurs less than 2% of the time and can
successfully be treated with oral antibiotics, continued compression, and
extremity elevation.
■ A small subset of patients report no improvement in neuropathic symptoms
after fat grafting, but the overwhelming majority of patients report relief,
measured by reduction of pain and/or reduction in need for medications. In
fact, relief from neuropathic symptoms can be dramatic, suggesting that
rigotomy may be the primary mechanism of early improvement. Maintenance
of relief argues toward the mechanical cushioning effects of the fat graft, or
possibly the ability of the adipocyte stem cells to stabilize fibrotic recipient
sites or even regenerate normal afferent innervation.
REFERENCES
1. Byrne M, O’Donnell M, Fitzgerald L, Shelley OP. Early experience with fat
grafting as an adjunct for secondary burn reconstruction in the hand: technique,
hand function assessment and aesthetic outcomes. Burns. 2016;42(2):356-365.
2. Condé-Green A, Marano AA, Lee ES, et al. Fat grafting and adipose-derived
regenerative cells in burn wound healing and scarring: a systematic review of
the literature. Plast Reconstr Surg. 2016;137(1):302-312.
3. Fredman R, Edkins RE, Hultman CS. Fat grafting for neuropathic pain after
severe burns. Ann Plast Surg. 2016;76(suppl 4):S298-S303.
4. Fredman R, Katz AJ, Hultman CS. Fat grafting for burn, traumatic, and
surgical scars. Clin Plast Surg. 2017;44(4):781-791.
5. Huang SH, Wu SH, Chang KP, et al. Autologous fat grafting alleviates burn-
induced neuropathic pain in rats. Plast Reconstr Surg. 2014;133(6):1396-1405.
6. Klinger M, Caviggioli F, Klinger FM, et al. Autologous fat graft in scar
treatment. J Craniofac Surg. 2013;24(5):1610-1615.
7. Piccolo NS, Piccolo MS, Piccolo MT. Fat grafting for treatment of burns, burn
scars, and other difficult wounds. J Craniofac Surg. 2015;42(2):263-283.

33
CHAPTER
Section VIII: Ear
Reconstruction
Auricular Reconstruction for
Microtia and Post-Traumatic
Deformities
Charles H. Thorne
DEFINITION
■ Microtia literally means small ear but is used to refer to a spectrum of
auricular anomalies (FIG 1) that are almost always associated with aural
atresia (absence of the external auditory canal).
■ From a practical point of view, any congenital deformity of the auricle that
requires insertion of a complete or near-complete cartilage or synthetic
framework is an example of microtia.
■ As discussed below, the principles for reconstruction of other auricular
deformities such as post-traumatic deformities are similar.
ANATOMY
■ As depicted in FIG 1, the anomalies that constitute microtia vary from almost
complete anotia to cases that demonstrate an almost normal lower 2/3 of the
auricle. Microtia has been classified in various ways, but the most useful is the
classification of Nagata: lobular microtia, small concha microtia, and large
concha microtia. Complete anotia is almost never seen.
■ Patients with microtia almost always have absence of the external auditory
canal (aural atresia) with complete bony separation of the auricular remnant
and the middle ear structures (FIG 2).

■ The middle ear is underdeveloped and also presents variable abnormalities. If
an apparent external auditory canal is present, it is almost always blind or
stenotic. Patients with microtia, therefore, almost always have total conductive
hearing loss on the affected side.
■ Microtia is more common on the right side; 90% of cases are unilateral, and
those patients usually have normal hearing in the contralateral ear.
FIG 1 • Variable presentation of microtia. The term
microtia refers to a wide variety of presentations. A.
Small conchal-type microtia. B. Lobular-type microtia.
C. Almost complete anotia. D. Atypical microtia with
hemifacial microsomia.
■ In the 10% with bilateral involvement of microtia and aural atresia, the
patients are functionally deaf and require bone conductive hearing aids on an
urgent basis in order to develop speech.
■ There are several anatomic differences between microtia and post-traumatic
deformities:
■ The skin quality in post-traumatic cases may present problems because of
scarring around the remnant.
■ Post-traumatic auricular remnants almost always contain a canal and a tragus,
making reconstruction of near-normal auricle more likely.
■ Post-traumatic remnants may be distorted by scar but are almost always in
the correct position, as opposed to microtic remnants that are often
malpositioned.
PATHOGENESIS
■ The auricle and the middle ear develop together from the first and second
branchial arches, explaining the concomitant anomalies of those two structures.

■ The inner ear is almost always normal in microtia patients because it arises
separately in embryonic development and is not a branchial arch derivative.
■ Microtia is the second most common congenital deformity affecting the head
and neck (after cleft lip and palate) and is more common in patients of
Southeast Asian descent.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Microtia and aural atresia fall within the larger spectrum of craniofacial
microsomia or first and second branchial arch syndrome. Craniofacial
microsomia can present with either unilateral (ie, hemifacial microsomia) or
bilateral involvement.
FIG 2 • Aural atresia. Microtia is almost always
accompanied by aural atresia. Note the absence of an
external auditory canal and, in this case, an extremely
hypoplastic mandibular ramus.
■ Most patients with microtia have symmetrical or nearly symmetrical faces, but
radiographs usually show some asymmetry of the ipsilateral mandibular
condyle indicating that microtia is part of the craniofacial microsomia
spectrum.
■ A minority have more obvious underdevelopment of the tissues of the face
including mandible, soft tissue, facial nerve, and auricle.
SURGICAL MANAGEMENT
■ The autogenous method of auricular reconstruction is the technique with
which this author is most familiar.1-3 If the reader is interested in a technique

using synthetic frameworks, the publications of John Reinisch are
recommended.4
■ The ideal age to perform reconstruction of a missing auricle is age 10 years.
■ At this age, the contralateral ear has reached adult size, and the rib cartilages
are large enough to create an adult size ear framework. In a patient who is
small for his/her age, delaying surgery until the patient is approximately the
size of an average 10-year-old is recommended.
■ Prior to age 10, the focus of patient management is on the hearing.
■ As mentioned, a patient with unilateral microtia has a total conductive
hearing loss on the affected side but normal hearing in the unaffected ear.
These patients can hear normally in quiet environments, but the lack of
binaural input causes difficulty with localizing sound and in discriminating
sounds in noisy environments. For example, a unilateral patient will have
difficulty playing football when his/her name is yelled. The patient may have
trouble immediately determining the direction of the sound and may look in
the incorrect direction initially. In addition, in a room with multiple voices, it
is more difficult for a microtia patient to screen out the background noise to
focus on a conversation. These patients benefit from a bone conduction
hearing aid (FIG 3).
■ Patients with bilateral microtia, on the other hand, absolutely require
conduction aids because they are functionally deaf and will not develop
normal speech without appropriate aids.
■ Hearing can be restored either surgically or by use of a bone-anchored hearing
aid (BAHA).
■ Reconstruction of the external auditory canal and ossicles can be surgically
performed in approximately half the cases of aural atresia. In the other 50% of
cases, the anatomy is too deranged for surgical repair.

FIG 3 • BAHA soft band. Infants with unilateral microtia
benefit from the BAHA soft band, which will provide
binaural hearing. Patients with bilateral aural atresia
must have a bone conduction aid in order to hear and to
develop normal speech.
■ BAHAs are so effective, however, and less prone to complications when
compared to canalplasty, that they are more commonly employed than
surgical reconstruction of the canal (FIG 4).
Preoperative Planning
■ When planning the auricular reconstruction, a tracing of the contralateral ear is
made (FIG 5) that can be sterilized for intraoperative use. From that tracing,
the surgeon then makes a drawing of the framework that would be required to
produce that size auricle.
■ Because the skin has a certain thickness (approximately 2 mm), the
framework must be at least 4 mm shorter than the desired auricle (or shorter
depending on how deep in the native lobule the framework will be placed).
■ In addition, each of the convexities of the auricle must be much thinner and
the concavities wider than the desired thickness on the ultimate auricle
because the skin will make any raised portion of the framework (such as the
helical rim) much thicker.
■ Once the drawing of the framework has been made, separate drawings of
each component can be made.
■ At the time of surgery, only two markings must be made on the affected side
prior to the induction of anesthesia:

■ The lowest point on the unaffected side must be transferred to the affected
side so the craniocaudal position of the ear is accurate. If this is not
performed, then the lobules (and earrings) will not be in symmetrical
positions.
■ The angle that the ear makes with the vertical: Most auricles are
approximately 15 degrees off vertical and slightly less angulated than the line
created by the dorsum of the nose. There is some variability, however, and
the correct angle should be marked.
FIG 4 • A bone-anchored hearing aid is secured by a
magnet that is attached to a titanium implant in the
skull.
FIG 5 • Templates. Tracings are made from the
contralateral ear and sterilized for intraoperative use.

■ The remaining measurements and drawings can be made after the patient is
under anesthesia.
■ Because some patients with microtia have more severe forms of facial
asymmetry and may have airway issues, it is important to discuss airway
management with the anesthesiologist. These patients may require more
sophisticated intubation techniques or even, in the case of Treacher Collins
patients, tracheostomy.
T E C H N I Q U E S
■ Stage One
Markings and Anesthesia
■ Once the patient has been intubated and prepping and draping has occurred,
the plastic templates that were made preoperatively are used to draw the
precise location, size, and orientation of the new auricle.
■ A decision is made about the skin incision, which most commonly involves
either rotation of the vertically malpositioned lobule or an incision that will
allow dissection of the pocket and placement of the framework without
rotation of the lobule.
■ If an appropriate lobule is present and rotation will result in its being in the
correct position at the caudal aspect of the new auricle, rotation is performed.
■ If on the other hand, there is an inadequate lobule or one that is located
such that rotation into the correct position is impossible, then an incision
without lobule rotation is performed.
■ Local anesthesia with epinephrine is injected and attention is directed to
the chest.
Graft Harvest
■ An incision is made over the caudal aspect of the ipsilateral rib cage, and the
muscles are divided to expose the rib cartilages.
■ Using the sterile, plastic templates, decisions are made about which
cartilages to harvest.
■ If an entire framework is required, two free floating ribs are usually required
for the helical rim and the antihelix.

■ The synchondrosis of two ribs is needed for the base of the framework, and
sufficient additional cartilage is harvested to create the tragus-antitragus
piece, small additional pieces to provide stabilization and projection, and a
piece to be “banked” in the chest for the second stage of the procedure.
Pocket Dissection
■ The operative field then shifts back to the temporal scalp.
■ The incision is planned, with or without rotation of the lobule, and the
pocket is dissected for placement of the framework. Hemostasis is obtained
within the pocket.
■ The dissection of the pocket is tedious but extremely important. More
complications occur from soft tissue management than from management
of the cartilage or an imperfect framework.
■ When the pocket is created, the congenital cartilaginous remnant, which
varies tremendously, is removed.
■ Care is taken not to injure the skin in the process of removing that
cartilage.
Auricle Framework Construction
■ On a sterile back table, the framework is assembled (TECH FIG 1A,B).
■ The base is carved to match the template, and the details of the scapha and
triangular fossa are created using sterilized gouges.
■ The antihelix is attached as an onlay graft using nylon sutures on short, thin
straight needles (TECH FIG 1C).
■ Some surgeons prefer wire sutures.
■ Creating a good framework is extremely difficult without these specialized
sutures.
■ The helical rim is then attached with another series of sutures of nylon or
wire.
■ The last piece of the main framework to be added is the tragus-antitragus
piece with the intervening incisura, an important component of the
aesthetically pleasing auricle (TECH FIG 1D).
■ Additional small pieces are frequently attached to the deep surface of the
framework for stabilization and projection.
■ The most important of these extends from the base to the tragus, fixing the
latter in the correct position and adding to its projection. The tragus is a
thin, floppy piece of cartilage, and it is important to keep it in precisely the

correct position.
Insertion of the Framework and Wound Closure
■ The framework is then inserted into the pocket along with two suction drains
(TECH FIG 2).
■ The author prefers Axiom Petite Wound Drains (REF 201AT), which are
silicone drains with perforations at one end and a 19G needle at the other
end for insertion into the suction tubing or Vacutainer tubes.
TECH FIG 1 • Construction of the framework. A. The
base is carved from the synchondrosis of two rib
cartilages. B. The antihelix and crura of the triangular
fossa are attached as a single additional piece. C.
Attachment of the helical rim. D. The completed
framework after attachment of the tragus/antitragus
piece.
■ The drains are then attached to wall suction, and the overlying skin is sucked

into the interstices of the framework.
■ Only at this point can one decide which excess skin to excise.
■ Excision of skin prior to the application of suction may result in over-
resection of skin.
■ The incisions are closed with interrupted nylon sutures.
■ No dressing is placed.
Chest Wound Closure and Patient Transfer
■ The chest incision is closed.
■ Any holes in the parietal pleura are left alone without repair, and no chest
tube or suctioning of the air in the pleural space is required.
■ Positive pressure ventilation pushes the air out with each breath, and if a
small rim of pneumothorax remains, it is of no consequence.

TECH FIG 2 • Dissection of the pocket. A.
Preoperative markings. B. The lobule is rotated and
the pocket is dissected. C. The pocket. D. After
framework insertion and attachment of the drains to
wall suction.
■ The cartilage chips that remain after the carving of the framework are
wrapped in an absorbable mesh and used to create a “rib” to replace the
caudal margin of the rib cage.
■ The wound is closed in layers, and the piece of cartilage mentioned above is
placed in a subdermal pocket so that it can easily be found and removed at
the second stage.
■ The suction drains are left attached to the tubing, which is in turn attached to
wall suction.
■ The recovery room is informed of the patient’s imminent arrival, the suction
tubing is temporarily disconnected from the wall, the patient is transported to
the recovery room, and the tubing is reattached to wall suction.
■ Most wall suction units have a range for low, intermediate, and high
suction.
■ The nurses are instructed to keep the suction exactly on the line that
separates low from intermediate suction.
■ Stage Two
■ Approximately 6 months later, the second stage is performed (TECH FIG
3).
■ An incision is made around the posterior 180 degrees of the framework.
■ The framework is elevated as far as the antihelix at the level of the
temporalis fascia.
■ A tunnel is created within the soft tissue, deep to the antihelix.
■ The cartilage that had been left in the chest at the first stage is removed,
shaped, and placed in the pocket, deep to the framework, to provide
projection.
■ The retroauricular skin is undermined and advanced into the sulcus.
■ A full-thickness graft is taken from the inguinal crease and used to resurface

the medial surface of the elevated framework.
■ Because the cartilage graft is in a soft tissue tunnel, the skin graft has an
appropriate bed.
■ The alternative is to cover the graft with a temporoparietal fascial flap, but
the author prefers to keep that option available in case of a complication
with cartilage exposure. With that in mind, the dissection of the original
skin pocket and the undermining at the second stage must avoid the
superficial temporal artery pedicle.
TECH FIG 3 • Second stage with elevation of the
auricle. A. A cartilage graft that had been banked in a
subdermal pocket below the original chest incision is
inserted into a fascial pocket for projection of the
auricle. B. Example after elevation. Xeroform is
packed into the sulcus for 2 weeks after bolster
removal.
PEARLS AND PITFALLS
Planning
■ Make sure the new auricle is in the best possible location and is the
correct size and at the correct angle. A beautiful ear in the wrong
place is ugly. The identification of the location is much more
difficult in the patients with significant facial asymmetry where
compromises may have to be made. Patients with microtia,

especially those with more overt asymmetry, often have low
hairlines. The management of the hairline is major topic unto itself.
One choice is to excise the hair-bearing skin, either at the time of
the initial operation or secondarily, and cover the framework with a
temporoparietal flap and skin graft. Another choice is to place the
framework under the hair-bearing skin and secondarily remove the
scalp, leaving a thin layer of tissue over the framework to support
the skin graft. This latter approach is tricky and requires both
meticulous dissection and close postoperative observation. If the
graft does not survive, the framework must be covered with
vascularized tissue on an urgent basis.
Soft tissue
management
■ More complications arise from errors in judgment regarding soft
tissue management than from poor framework construction.
Although tedious, the soft tissue dissection is a priority.
Cartilage
framework
■ The imperfections of the framework, although hidden initially by
swelling, will eventually show through the thin skin coverage.
There are materials such as Styrofoam that can be used to practice
the framework construction before attempting on a patient.
Exposed
cartilage
■ Any skin necrosis/exposed cartilage requires immediate attention
and coverage with a temporoparietal flap and skin graft.
POSTOPERATIVE CARE
■ The two main issues with the postoperative care are pain management and
making sure that suction is applied to the drains for the 1st day or so.
■ Pain from the thoracotomy is severe and requires parenteral analgesics to be
administered, at least for the first night. Pain pumps with agents such as
bupivacaine have not proven to be helpful.
■ The drains are left attached to wall suction until the following morning. At that
point the wall suction is removed and the drains are attached to red top
Vacutainer tubes (or bulb suction if preferred).
■ Patients are discharged on postoperative day 2 with the drains in place.
■ The drains are then changed every 24 hours by the parents or caregivers, but
not much fluid comes out after the 1st day, and it may be unnecessary to leave
the drains after discharge.
■ The patient is seen in the office on postoperative day 5 and the drains are
removed.
■ The sutures in the reconstructed auricle are usually left 10 to 14 days.

FIG 6 • Example of preoperative appearance (A) and
postoperative result (B) after ear piercing.
OUTCOMES
■ Examples of reconstruction for microtia and for post-traumatic deformities are
shown in FIGS 6 and 7.
COMPLICATIONS
■ By far the most significant and important complication is necrosis of the skin
with exposure of the underlying framework (FIG 8).

FIG 7 • A. Post-traumatic deformity. The remnant
contains a normal concha, canal, and tragus, making an
aesthetically pleasing result more likely. In this case,
there was no scarring around the remnant as one might
find in a burn patient or a victim of a motor vehicle
accident. B. Framework constructed to replace the
missing cartilage. C. Postoperative result.

FIG 8 • A. The most common serious complication is
necrosis of the overlying skin with impending exposure
of framework. B. After salvage with temporoparietal flap
and skin graft.
■ Small areas of necrosis (5 mm or less) over concavities will heal with
conservative management.
■ Anything larger or any necrosis over a convexity of the framework such as
the helical rim or the antihelix will not and must be treated early and
aggressively.
■ If the wound is left to heal and does not do so, the area will become
contaminated or infected and will require a more significant debridement.
■ The workhorse for closure is the temporoparietal fascial flap with a skin
graft. The proximity of this tissue and its large size makes it possible to cover
almost any area of necrosis.
■ In patients with craniofacial microsomia who have had other surgery and
may have had the superficial temporal vessels injured by a coronal incision or
a free tissue transfer, the situation becomes much more difficult. The occipital
fascia can be used but tends to be thicker, and the aesthetics of the
reconstruction tend to suffer more from the use of this flap.
■ In emergency situations, the exposed cartilage can be covered with a large
scalping flap. The hair-bearing scalp is then returned to the scalp at a second
stage, leaving skin-graftable tissue over the cartilage (crane principle).
■ In the absence of local tissue coverage, one may also consider a free
temporoparietal fascial flap harvested from the contralateral side.
REFERENCES

1. Brent B. Technical advances in ear reconstruction with autogenous rib
cartilage grafts: personal experience with 1200 cases. Plast Reconstr Surg.
1999;104(2):319-334.
2. Nagata S. A new method of total reconstruction of the auricle for microtia.
Plast Reconstr Surg. 1993;92(2):187-201.
3. Firmin F. Ear reconstruction in cases of typical microtia: personal experience
based on 352 microtic ear corrections. Scand J Plast Reconstr Surg Hand Surg.
1998;32(1):35-47.
4. Reinisch J, Li W. Medpor ear reconstruction: a 23-year experience with 1042
ears. Plast Reconstr Surg. 2014;133(4S):974.

34
CHAPTERStahl Ear
Akira Yamada and Arun Gosain
DEFINITION
■ Stahl ear was first described by Binder in 1889.1
■ Stahl ear is a congenital auricular malformation in which an abnormal third
crus traverses the scapha, resulting in posterosuperior deformation of the helix.
ANATOMY
■ Type 1: Obtuse bifurcation of antihelix: Superior crus of antihelix is missing,
and third crus is present. Therefore, the superior and inferior crura make an
obtuse angle (FIG 1A).
■ Type 2: Trifurcation of antihelix (extra crus); this is classic Stahl ear. The third
crus extends across the scapha from the antihelix (FIG 1B).
■ Type 3: Broad superior crus, broad third crus (protruded scapha fossa) (FIG
1C).
PATHOGENESIS
■ Etiology is unknown.
■ Abnormal course of an intrinsic transverse muscle may be associated with
Stahl ear.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The third crus extends from the antihelix; the superior crus may or may not be
present. The lower half of the auricle is usually normal.
NONOPERATIVE MANAGEMENT
■ If the patient presents before 1 month of age, nonsurgical correction of the
deformity with ear molding techniques may obviate the need for surgery.

■ Ear molding techniques are most effective during the 1st month of life and are
unlikely to work after the 2nd month of life.
SURGICAL MANAGEMENT
■ There are three major types of normal helix-lobule curve (FIG 2). If the
patient’s helix-lobule curve falls into these three normal types, surgical
correction of auricular shape may be directed toward deformities other than
Stahl ear, such as prominent ear.
Preoperative Planning
■ The possibility of ear molding is excluded if the patient presents after age 6
weeks. Ear shape analysis (especially helix type) is performed on the patient by
applying an ear template for both auricles. Photographs are taken subsequent
analysis. Based on photographic analysis, the patient shown has type A helix
on both the normal (FIG 3A) and Stahl ear sides (FIG 3B,C).
■ Two inflection points (abrupt change of the helix curve) are identified (FIG
3D), and the curve between the two inflection points is almost linear (FIG 3E).
■ These two inflection points are the important landmark for wedge skin incision
during surgery.
Positioning
■ Supine position with slight head turn.
■ Both auricles should be prepped in the sterile field, and the contralateral ear
used as a reference in unilateral correction.
Approach
■ Wedge excision is the simplest and most widely reported method.2 Wedge
excision is best indicated for type 2 Stahl ear. For type 1, excised cartilage may
be transplanted to create the superior crus.3 Other options for type 1 are to
make parallel three cartilage cuts4 or to place Mustarde sutures to accentuate
the superior crus if there is adequate cartilage elasticity (FIG 4A–D).
■ Cartilage turnover and rotation methods have been described but have mixed
outcomes when used clinically.

FIG 1 • A. Type 1 Stahl ear: Superior crus is missing. B.
Type 2 Stahl ear: There are three crus (superior crus,
inferior crus, and third crus). C. Type 3 Stahl ear: Wide
third crus and protruded scapha fossa.
FIG 2 • The classification of helix-lobule curve.

FIG 3 • Preoperative assessment of Stahl ear. A. The
normal side ear has type A helix-lobule curve. B. The
Stahl ear side: This is type 2 Stahl ear. C. Type A ear
template is overlapped to assess the curve of Stahl ear.
D. Frontal view of the patient helps to identify the
change of the curve (arrows). E. Overall helix-lobule
curve on Stahl ear is also type A, except around the
third crus. Identification of two inflection points will
determine the extent and shape of wedge excision.

FIG 4 • Surgical approach for type 1 Stahl ear. A. Skin
incision (dotted line) for type 1 Stahl ear. B. Wedge
cartilage (third crus) is excised. C. Cartilage defect after
wedge excision is closed primarily. D. There are three
options to create the superior crus: cartilage grafting,
parallel cartilage incision, or mattress sutures.
T E C H N I Q U E S

■ Excision and Suturing
■ Mark the wedge skin excision design between two inflection points (TECH
FIG 1A,B).
■ Cartilage (third crus) excision is expected to be longer than the skin wedge
excision.
■ Third crus excision is extended toward the antihelix, trying not to violate the
antihelix (TECH FIG 1C).
■ The cartilage is sutured together with 5-0 PDS (Ethicon Inc., Somerville,
NJ). The focus is to align the curve of the helix (TECH FIG 1D).
■ Suture the helix portion first and then move toward the antihelix (TECH
FIG 2A,B).
TECH FIG 1 • The marking of the wedge skin excision.
A. Anterior view. B. Posterior view. C. The marking for
wedge cartilage excision. Note that cartilage excision
is usually longer than the skin excision. Do not violate
the antihelix. D. After wedge excision, the cartilage
defect is closed primarily. The focus is to align the
helix.

TECH FIG 2 • After aligning the cartilage of the helix,
cartilage sutures are placed toward the antihelix. A.
Anterior view. B. Posterior view.
■ Skin Closure
■ Skin is closed in a single layer. Absorbable sutures can be used in children.
■ We prefer 6-0 nylon suture for skin closure in adult patients, to be followed
by suture removal in 2 weeks.
■ Bolster Sutures (TECH FIG 3)
■ Bolster sutures are used to stabilize the helix and to prevent hematoma
during the immediate post-op period.
■ 4-0 Prolene is used to secure the bolster suture.
■ Roll gauze is made with Xeroform plus Vaseline-based antibiotic ointments.
■ Bolster sutures will be removed in 2 weeks. The wound is kept dry for 2
weeks.

TECH FIG 3 • Bolster sutures are in place. Tie has to
be very gentle to prevent pressure injury.
PEARLS AND PITFALLS
Identify
inflection
points.
■ This is the most important part of surgical planning. One must
analyze the curve of the helix prior to surgery.
Photographic
analysis
■ A slight oblique photo is best to capture the shape of the helix for
analysis. Analysis of the ear on a true lateral profile is less useful
for planning.
Bolster
sutures
■ Tying very gently is the key. Even with a gentle tie, you will see
tightness at the time of maximum swelling (48–72 h).
■ Check underneath the bolster suture with bright LED light for
pressure injuries, especially 2–3 days postoperatively.
Keep the
wound dry for
2 weeks
■ Avoid showering for 2 weeks postoperatively. The bolster must
be kept clean to prevent infection.
POSTOPERATIVE CARE
■ Periodic wound check for 2 weeks is mandatory to avoid complications.
■ Keep the wound dry for 2 weeks to prevent infection. Showering may cause
redness of the wound that may be difficult to differentiate from infection.

■ Remove the bolster sutures in 2 weeks. During this time, periodic checks for
pressure sore or tightness of the bolster sutures are important to prevent skin
necrosis.
OUTCOMES
■ Satisfactory outcomes are likely following the immediate wound healing
process (FIG 5).
COMPLICATIONS
■ Incomplete correction of helical deformities
■ Infection
■ Hematoma: Careful bolster suture helps to prevent hematoma and to stabilize
the shape of the ear during the early wound healing process.
FIG 5 • Postoperative outcome.
REFERENCES
1. Binder H. Das morel’sche ohs: Eine psychiatrisch-anthroplogische studie.
Arch Psychiatr Nervenkr. 1989;20:514.
2. Ono I, Gunji H, Terashita T. An operation for Stahl’s ear. Br J Plast Surg.
1996;49:564.
3. Kaplan HM, Hudson DA. A novel surgical method of repair for Stahl’s ear: a
case report and review of current treatment modalities. Plast Reconstr Surg.
1999;103(2):566-569.
4. Ohmori S, Tange I, Fukuda O, et al. Operative procedure of Stahl’s auricle.
Jpn J Plast Reconstr Surg. 1962;5:212.

35
CHAPTERConstricted Ear
Akira Yamada and Julia Corcoran
DEFINITION AND ANATOMY
■ The concept of constricted ear was proposed by Tanzer.1 The helix and scapha
are hooded, and the body and crura of the antihelix are flattened in varying
degrees.
■ Group 1 is the mildest form of constricted ear, often called lop ear, in which
only the helix is involved (FIG 1A).
■ Group 2 is a moderate form of constricted ear that involves helix and scapha.
• Group 2 is divided into 2A and 2B: 2A has only cartilage deficiency (FIG
1B); 2B has both skin and cartilage deficiencies (FIG 1C,D).
■ Group 3 is the most severe form of cupping and is characterized by a tubular
structure (FIG 1E).
• Differentiation between group 3 constricted ear and microtia can be
difficult.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Constricted ear is congenital, and the etiology is unknown.
■ Ear height2 is significantly shorter than normal.
■ The helix tends to be cupped.
■ The upper portion of the antitragus (superior and inferior crus) is difficult to
see.
■ The shape of the lower half of the auricle is likely to be normal, especially in
mild to moderate constricted ear (see FIG 1C,D).
NONOPERATIVE MANAGEMENT
■ Nonsurgical manipulation of the ear cartilage in infancy does not work for the

constricted ear due to intrinsic deficiency of skin and/or cartilage.
FIG 1 • Tanzer constricted ear classification. A. Group
1: Mild helix cartilage deformity without skin defect. B.
Group 2A: Helix and scapha cartilage deformity without
skin defect. C,D. Group 2B: Helix and scapha
deformities with both cartilage and skin defects. E.
Group 3: Most severe form of cupping; characterized by
a tubular structure.
■ Molding techniques in infancy may change the shape of the auricle but is
unlikely to expand skin/cartilage.
■ “Constricted” means there is cartilage and/or skin deficiencies that must be
augmented by surgical procedures.
SURGICAL MANAGEMENT

Preoperative Planning
■ Age-matched anthropometric data of ear dimension, especially vertical height,
help to distinguish deviation of the patient’s ear from norms (FIG 2).
Positioning
■ Supine position with mild head turn. Both sides should be prepped, even with
unilateral surgery, so that the contralateral ear can serve as a normal reference.
Approach
■ If there is no skin defect and the cartilage defect is mild (Tanzer group 1), the
Musgrave4 procedure alone is effective to correct the deformities. If there is
moderate skin and cartilage defect (Tanzer group 2B), a local skin/fascia flap
plus floating rib cartilage grafting5 is a good choice (presenting case).
■ If the skin or cartilage defect is severe, microtia surgery6 may be indicated.
■ Recommended surgical options for skin envelope augmentation, based on the
severity:
■ Mild: Grotting skin flap
FIG 2 • A type A-2, 48-mm template is used to evaluate
the degree of skin and cartilage defect of the upper half
of the auricle of the left ear (A) and right ear (B). 3
Although the left ear has more severe skin and cartilage
defect, both auricles are diagnosed as Tanzer group 2B

constricted ear.
■ Moderate: Park procedure (Grotting skin flap plus fascia flap)
■ Severe: Nagata microtia construction
■ Recommended surgical options for cartilage defects, based on the severity:
■ Mild: Musgrave procedure
■ Moderate: floating rib (Park)
■ Severe: total framework (Nagata)
T E C H N I Q U E S
■ Markings
■ The Grotting skin flap7 measuring approximately 1.0 to 1.5 cm in width and
3.0 to 3.5 cm in length, is designed and elevated on the posterior surface of
the superior auricle to drape the skin defects of the anterior and posterior
helix and scapha.
■ A bilobed flap is marked: the superior flap is a fascia flap, and the inferior
flap is a Grotting skin flap. The fascia flap and the Grotting flap share a
common base (TECH FIG 1A,B).
■ A portion of the superficial temporal fascia will be attached beneath the
proximal 1.5 cm of the Grotting flap to increase the vascularity of the
Grotting flap (TECH FIG 1C).
■ Three small, transverse skin incisions are marked at the helical crus, at or
near the otobasion superius (the point of attachment of the superior helix to
the temple), and at the descending helix (TECH FIG 1D).

TECH FIG 1 • A,B. Design of the bilobed flaps. 1:
Fascia flap. 2: Grotting skin flap. 3: Skin incision at
otobasion. 4: Skin incision at crus helicis. Dotted
areas indicate shared pedicle. C. The Grotting skin
flap and the fascia flap are raised as a combined flap,
sharing common pedicle at the base. D. Three small,
transverse skin incisions are marked at the helical
crus, at or near the otobasion superius (the point of

attachment of the superior helix to the temple), and at
the descending helix.
■ Harvesting the 8th Rib Cartilage
■ A 3-cm traverse skin incision is marked at the right lower costal margin
(TECH FIG 2). After local epinephrine injection, the skin is incised.
■ After identifying the fascia of the external oblique muscle, the fascia is
incised transversely. The course of the external oblique muscle is examined,
and the muscle fibers are split along the course of the fibers and retracted to
identify the costal cartilage.
■ Care is taken to identify any perforator vessels that emerge from intercostal
spaces. These vessels are coagulated with bipolar cautery well above the
intercostal space.
■ Prior to incising the perichondrium, a small amount of local anesthetics (eg,
0.125%–0.25% bupivacaine) is injected in the intercostal space as a nerve
block.
■ The anterior perichondrium of the 8th rib cartilage is gently incised with a
no. 15 blade in the midline, beginning at the bone-cartilage junction.
■ A 360-degree subperichondrial dissection is performed to completely
dissect the cartilage from the perichondrium.
■ After 8th rib cartilage is cut at the bone-cartilage junction and removed,
saline irrigation of the wound is performed.
■ Once homeostasis is confirmed, the perichondrium is closed with 4-0 Vicryl.
The wound is then closed in layers.

TECH FIG 2 • A 3-cm transverse skin incision at lower
costal margin for harvesting 8th rib cartilage.
■ Splitting the Rib Cartilage and Creating the Skin
Tunnel
■ The cartilage is split longitudinally into two pieces (TECH FIG 3A,B).
■ Splitting must be precisely in the middle for simultaneous bilateral
constricted ear reconstruction.
■ Through the three small skin incisions described above, a skin tunnel is
created above the existing helix (see TECH FIG 1C).
■ The split cartilage is inserted into the helical tunnel through the skin incision
site at or near the otobasion superius (TECH FIG 3C).

TECH FIG 3 • Split 8th rib cartilage for right (A) and
left (B) ears is laid over a type A-2, 48-mm template.3
C. The split cartilage is inserted into the helical tunnel
through the skin incision site at or near the otobasion
superius.
■ Transpositioning the Fasciocutaneous Grotting
Flap
■ After helix expansion with newly inserted helical cartilage, the skin envelope
defect at or near the otobasion superius will be identified (the point of
attachment of the superior helix to the temple). A bilobed skin/fascia flap will
be transposed to fill the defect (TECH FIG 4A).
■ The size and location of the skin defect varies, depending on the severity and
the nature of the constricted ear.
■ In the example case, both skin flap and fascia flap are transposed to cover
the anterior helix and scapha on the left side (TECH FIG 4B,C), and only
skin flap is used to cover anterior helix and scapha on the right side (TECH
FIG 4D).

TECH FIG 4 • A. A bilobed skin/fascia flap will be
transposed to fill the defect. B,C. Both skin flap and
fascia flap are transposed to cover the anterior helix
and scapha on the left ear. G, Grotting skin flap; F,
fascia flap plus skin graft. D. Immediate postoperative
view of the right ear showing a Grotting skin flap (G).