Pediatric Plastic and Reconstructive Surgery

Surgical management of VPI with either radical intravelar
veloplasty or Furlow double-opposing Z-palatoplasty is associ-
ated with inherent complications of any palatal surgery, which
include flap loss and development of oronasal fistulae. Further-
more, it may result in insu cient gain in velum length and
residual hypernasality. Pharyngeal flaps are static and thus its
e cacy depends on the precise design of the size of the flap. If
it is too narrow, there may be persistent nasal airway emission
and hypernasality, whereas a flap that is too wide may obstruct
the passage and lead to hyponasality or obstructive sleep apnea
(OSA). Medial displacement of internal carotid artery can occur
in patients with velocardiofacial syndrome; thus, it is important
to obtain preoperative vascular imaging if posterior pharyngeal
flap is planned in this patient population.
OSA may be a late complication of any surgery for VPI. Pha-
ryngeal flap in particular is associated with a higher incidence
of OSA; thus, signs and symptoms of OSA including snoring,
daytime sleepiness, hypertension, and di culty sleeping
should be noted. Intraoperative corticosteroid administration
should be considered to reduce postoperative edema. OSA that
persists past the postoperative period may require continuous
positive airway pressure or surgical treatment including divi-
sion of the pharyngeal flap or tailored orthognathic surgery.
Formal polysomnography may be required.
18.6 Conclusion
VPD can result from a broad range of etiologies and can be div-
ided into velopharyngeal incompetence, VPI, or velopharyngeal
mislearning. VPI results from anatomic abnormalities and is
common after cleft palate repair. Evaluation should include per-
ceptual speech assessment and instrumental assessments of
the pharyngeal closure mechanics. While no one operation
have demonstrated clear superiority, the choice of operation
should depend on the patient’s velopharyngeal closure pattern.
When properly performed, the commonly performed opera-
tions for correction of VPI all have shown significant improve-
ment in speech outcomes with a low risk of complications.
18.7 Key Points
● The etiology of VPD can be categorized into abnormal anat-
omy (VPI), abnormal neurophysiology (velopharyngeal
incompetence), or articulation error (velopharyngeal
mislearning).
● The diagnosis and management of VPD requires a multidisci-
plinary approach including speech-language pathologist,
pediatric otolaryngologist, and craniofacial surgeon.
● Surgical treatment of VPI include radical intravelar veloplasty,
Furlow’s double-opposing Z-palatoplasty, posterior pharyn-
geal flap, sphincter pharyngoplasty, and pharyngeal
augmentation.
● Selection of treatment option should be based on the closure
pattern and the size of the remaining gap.
Suggested Readings
Johns DF, Rohrich RJ, Awada M. Velopharyngeal incompetence: a guide for
clinical evaluation. Plast Reconstr Surg. 2003; 112(7):1890–1897, quiz 1898,
1982
Kummer AW. Speech evaluation for patients with cleft palate. Clin Plast Surg.
2014; 41(2):241–251
Kummer AW. Types and causes of velopharyngeal dysfunction. Semin Speech
Lang. 2011; 32(2):150–158
Woo AS. Velopharyngeal dysfunction. Semin Plast Surg. 2012; 26(4):170–177
Gart MS, Gosain AK. Surgical management of velopharyngeal insu ciency.
Clin Plast Surg. 2014; 41(2):253–270
Abyholm F, D’Antonio L, Davidson Ward SL, et al. VPI Surgical Group. Pharyn-
geal flap and sphincterplasty for velopharyngeal insu ciency have equal
outcome at 1 year postoperatively: results of a randomized trial. Cleft Palate
Craniofac J. 2005; 42(5):501–511
Armour A, Fischbach S, Klaiman P, Fisher DM. Does velopharyngeal closure
pattern a ect the success of pharyngeal flap pharyngoplasty? Plast Reconstr
Surg. 2005; 115(1):45–52, discussion 53
Gosain AK, Arneja JS. Management of the black hole in velopharyngeal
incompetence: combined use of a Furlow palatoplasty and sphincter phar-
yngoplasty. Plast Reconstr Surg. 2007; 119(5):1538–1545
Cleft Lip and Palate
184

III
Part III
Soft-Tissue Deformities of the
Head and Neck
19 Soft-Tissue Injuries

186
20 Ear Reconstruction

195
21 Microtia

210
22 Nasal Reconstruction

221
23 Facial Paralysis

227
24 Scalp, Cheek, and Neck Deformities

243

19 Soft-Tissue Injuries
Arin K. Greene
Sum m ary
Lacerations are common in the pediatric population. Iatrogenic
injury includes intravenous extravasation during hospitaliza-
tion. Management of soft tissue injuries depends on the etiol-
ogy of the problem.
Keywords: dog bite, laceration, intravenous, extravasation,
pediatric, soft tissue, trauma
19.1 Introduction
Soft-tissue injuries are one of the most common conditions
treated by plastic surgeons. Parents, pediatricians, and emer-
gency room physicians are particularly sensitive about scarring
on a child. Consequently, plastic surgeons are frequently con-
sulted to manage pediatric facial lacerations. Because wound
management is the core of our specialty, plastic surgeons also
are commonly asked to manage di cult and/or iatrogenic soft-
tissue deficits throughout the body (e.g., extravasations, pres-
sure ulcers, infections, etc.). Management of pediatric soft-tis-
sue injuries is based on the principles of wound healing. This
chapter will focus on two of the most common consultations
for soft-tissue injuries: facial lacerations and intravenous
extravasation injuries.
19.2 Diagnosis
Soft-tissue injuries are evaluated by history and physical exami-
nation. Identification of the etiology of the wound is important
because it will a ect management. For example, if the facial
wound was caused by a dog bite, the individual is at greater risk
for infection compared to being lacerated by a clean piece of
glass (Fig. 19.1). The depth of the injury must be ascertained.
Blood often camouflages the area and should be removed gen-
tly to identify the severity of the injury. A partial thickness
wound and/or abrasion may not require intervention. In con-
trast, a full-thickness injury might necessitate laceration repair.
Patients at risk for a foreign body should have the area visually
inspected. Plain radiography may be indicated to rule out mate-
rial in the wound. Soft-tissue injuries in children are managed
di erently than in adults. Patients usually require sedation and
are more likely to have absorbable sutures because they less
able to tolerate suture removal (Fig. 19.2). Traumatic wounds
are not managed the same as sterile operative incisions because
they are at greater risk for infection and unfavorable scarring.
19.3 Nonoperative Treatment
19.3.1 Lacerations
Partial-thickness wounds do not require repair and can be man-
aged similarly to an abrasion. The area is washed twice daily
with gentle soap and water followed by antibiotic ointment for
a few days. Epithelialization usually takes 7 to 10 days. The area
can appear pink for several weeks and should be kept out of the
sun for at least 12 months to avoid hyperpigmentation.
Heavily contaminated wounds can be allowed to heal secon-
darily; an open wound is a safe wound and is very unlikely to
become infected (a treatment for an infected wound is to open
it; Fig. 19.3). Human or animal bite puncture wounds inocu-
late deep tissues with bacteria; closure of these injuries (even
with antibiotics) is at high risk for infection. Washing the areas
regularly and letting them heal secondarily will significantly
reduce the risk of infection. If the scars heal unfavorably, they
can safely be revised at a later time.
19.3.2 Intravenous Extravasations
The scalp is a common site for intravenous catheter placement
in the neonate, and extravasation can cause alopecia. Other
intravenous access sites include the upper or lower extremities.
Most extravasations involve small volumes of benign fluids that
do not cause morbidity. In one series of 1,800 extravasations,
only 2% of resulted in skin injury, and no child had a compart-
ment syndrome. Catheters are located in the superficial venous
system, above the level of the muscle fascia; the risk of injury to
deep structures is low.
The most important maneuver to eliminate the extravasated
fluid is elevation of the extremity. Application of ice or heat is
contraindicated because they may exacerbate the injury. Both
ice and heat have been shown to worsen tissue damage after the
extravasation of chemotherapeutic agents. Heat can cause ther-
mal injury and ice may result in ischemia from vasoconstriction.
Sensation in the extravasated area may be impaired and thus
the patient might not be able to appreciate pain from the appli-
cation of heat or ice. In addition, young children or intubated
patients are unable to verbalize discomfort from hot or cold
packs. Thus, heat or ice may cause a “second hit,” converting a
partial-thickness skin injury into a full-thickness wound.
Our institution does not advocate for the use of antidotes
after extravasations. Hyaluronidase and phentolamine are the
most commonly prescribed, but randomized prospective stud-
ies on their e cacy are not available. If an antidote is to be
e ective, it must be administered early. Unfortunately, most
extravasations are not appreciated immediately and by the time
plastic surgical consultation arrives, the antidote is ordered and
available for administration, the substance has already di used
or its e ects have worn o . For example, phentolamine has
been used to treat epinephrine extravasation, but the e ects of
epinephrine wear o in 60 to 90 minutes, and the added vol-
ume of phentolamine may worsen tissue injury. Injection of an
antidote increases the volume of fluid and worsens pressure
necrosis.
Partial-thickness skin injuries are managed by topical antibi-
otic ointment; they typically heal without scarring by epitheli-
zation in 7 to 10 days. Full-thickness injuries are managed with
topical antibiotic ointment or dressings (Fig. 19.4). Debride-
ment is indicated for necrotic tissue to reduce the risk of infec-
tion and to facilitate healing by secondary intention. Following
debridement, damp-to-dry saline dressing changes twice daily
Soft-Tissue Deformities of the Head and Neck
186

are used. Full-thickness skin injuries are allowed to heal secon-
darily. If a compartment release is performed, the wound is
managed with a vacuum-assisted wound closure device for 1 to
2 weeks as the swelling resolves and is then allowed to heal
secondarily or a delayed primary closure is performed. Skin
grafts should be avoided because there is no loss of skin and
grafts cause a significant deformity.
19.4 Operative Treatment
19.4.1 Indications
Before deciding on closing a laceration, the risks of infection, se-
dation, and trauma to the patient/family must be considered.
All traumatic wounds are contaminated and the risk of infec-
tion can be significant if they are closed. Heavily contaminated
wounds (e.g., dog bite) should be closed cautiously. The goal of
repairing large, problematic injuries is to minimize the wound
burden to the child while lowering the risk of infection as much
as possible ( Fig. 19.5). If the wound becomes infected the
child, who has already undergone a significant trauma and sub-
sequent repair, must then undergo an incision and drainage fol-
lowed by secondary healing and likely scar revision. In contrast,
if small puncture wounds from a dog bite are allowed to heal
secondarily, the child may only need a scar revision in the
future.
19.4.2 Sedation
The decision to perform a laceration repair using a local anes-
thetic, sedation in the emergency room, or general anesthesia
depends on the age of the patient and extent of the injury. The
younger the child and larger the wound, the more likely it should
be repaired under general anesthesia. Lacerations in young
adolescents typically can be performed with local anesthesia.
Most infants and children require sedation administered by the
Fig. 19.1 Facial dog bite injury. (a,b) Preoperative appearance. (c,d) Following repair. Prior to closure, mucocutaneous junction landmarks were
marked and approximated to best align the white roll.
Soft-Tissue Injuries
187

emergency room sta . Sedation in this age group gives the pa-
tient a better experience compared to local anesthesia, and facili-
tates the repair because the child is still. Any large injury
(independent of the age of the patient) that involves significant
time and e ort to repair should be done under general anesthe-
sia to ensure the patient has the most favorable outcome.
19.4.3 Antibiotics
Clear data regarding the use of antibiotics for traumatic soft-tis-
sue injuries in children do not exist. Because traumatic wounds
can be considered clean contaminated or contaminated, guide-
lines for operative incisions suggest that antibiotic prophylaxis
Fig. 19.2 Ear laceration in a child repaired with dissolvable chromic sutures. (a) Appearance of injury. (b) Three weeks postrepair, the child does not
require suture removal.
Fig. 19.3 Adolescent female who suffered an
assault. Pieces of a dirty plastic bowel caused
puncture wounds, entered the sinus, and lacer-
ated mucosa. After removing the foreign bodies
and irrigating the areas, the puncture sites were
allowed to heal secondarily to reduce the risk of
infection.
Soft-Tissue Deformities of the Head and Neck
188

Fig. 19.4 A 10-month-old with full-thickness skin loss following intravenous extravasation. (a) Eschar. (b) Following separation of the eschar. (c) Seven
weeks after the injury, the wound healed secondarily.
Fig. 19.5 An 8-year-old male who suffered a significant dog bite injury. (a) Preoperative appearance. (b) Following repair. The wound was closed
loosely with interrupted, dissolvable sutures. A drain was placed to ensure that part of the wound remained open to reduce the risk of infection. (c)
Healed sites 12 months following the injury. (d) Following revision of hypertrophic facial scars. The patient subsequently underwent another scar
revision.
Soft-Tissue Injuries
189

is indicated. My practice is to give one dose of antibiotics before
wound closure in noncomplicated lacerations. I manage conta-
minated lacerations (e.g., dog bite, foreign body) with a preope-
rative dose of intravenous antibiotics followed by 5 to 7 days or
oral antibiotics. Because a postoperative infection is a more sig-
nificant problem in a child compared to an adult, I have a low
threshold to administer antibiotics. An infection in children is
more traumatic to the patient/family and incision and drainage
may require sedation or general anesthesia.
19.4.4 Wound Inspection
The first step in laceration repair is to infuse local anesthetic
containing epinephrine. The anesthetic eliminates pain while
irrigating and the epinephrine facilitates the repair by reducing
bleeding. Epinephrine can be used in any part of the body (e.g.,
nose, fingers, toes) and will not cause tissue ischemia because it
only lasts 60 to 90 minutes. Without the use of epinephrine, the
risk of iatrogenic injury and a less optimal repair is increased.
After the infusion of local anesthetic, the wound is prepped and
draped. Next, the area is inspected to determine the severity of
the injury, necrotic tissues, and the presence of foreign substan-
ces. A foreign body should be removed prior to wound closure
to reduce the risk of infection. However, if a material cannot be
located and the risks of aggressive exploration outweigh the
benefits of removing the substance, the wound can be closed
over the material (plastic surgeons routinely place foreign
materials throughout the body). Ideally, facial nerve transec-
tions are repaired at the time of the laceration repair
(Fig. 19.6). A laceration of the parotid duct is determined by
cannulating it intraorally and injecting saline (Fig. 19.7). Duct
injuries are repaired over a stent (Fig. 19.8).
Fig. 19.6 Teenage male who suffered traumatic stab wounds to the face. Preoperative examination was consistent with division of the marginal
mandibular branch of the facial nerve that was repaired at the same time as the skin lacerations. (a) Stab wound sites. (b) Divided facial nerve branch.
(c) Following repair of the facial nerve injury.
Fig. 19.7 A 3-year-old male fell off his bed with a toothbrush in his mouth that lacerated the oral mucosa and became embedded in his cheek. After
removing the foreign body, the parotid duct was irrigated with saline to ensure its patency. (a) Preoperative appearance. (b) Removed toothbrush. The
area distal to the wooden tongue blade was located in the cheek. (c) Postoperative appearance.
Soft-Tissue Deformities of the Head and Neck
190

19.4.5 Irrigation and Debridement
An important step in laceration repair is ensuring the most
favorable environment prior to wound closure. After the area
has been inspected, it is irrigated to reduce the amount of
bacteria and foreign material in the wound. The greater the
contamination, the more the wound should be washed out. Irri-
gation is critical to reduce the risk of postrepair infection by
converting a contaminated wound to a cleaner environment.
Following irrigation, damaged skin edges that are ischemic or
have traumatic tattooing should be debrided (Fig. 19.7).
Suturing fresh, noninjured skin edges will give the best possible
scar and reduce the risk of infection and wound dehiscence.
19.4.6 Wound Repair
Complicated reconstructions at the time of injury should be
avoided. Wounds are closed linearly or allowed to heal secon-
darily. Placing a skin graft or doing a local–regional free tissue
transfer has a higher risk of failure and complications compared
to reconstruction of a healed/stable area ( Fig. 19.8). Traumatic
wounds are closed di erently than sterile operative incisions. A
major principle is that the wound should not be closed tightly
or occluded. Instead, the laceration is closed loosely and
allowed to drain to reduce the risk of infection (Fig. 19.9).
Generally, I place one-half of the amount of sutures that I would
use to close a sterile operative incision. For the intradermal
layer I prefer Vicryl because it handles better than Monocryl
and is less likely to unravel. To close the epidermis and superfi-
cial dermis, I typically use interrupted chromic in children and
nylon in adolescents.
Placing nylon sutures in children should be avoided because
(1) removing them will be stressful to the child and parents
who have already su ered a traumatic experience (laceration
and repair) and (2) the likelihood of iatrogenic wound dehis-
cence is high when removing sutures in an uncooperative child.
For facial lesions in children, we use 7–0 chromic, which lasts 3
weeks until the wound strength is approximately 20%; suture
marks do not occur because the diameter of 7–0 approximates
that of pore size. A general rule is that if sedation was required
to place sutures, then the sutures should be absorbable because
removing them will likely require sedation as well.
Fast-absorbing plain gut of 6–0 should not be used because
although the suture dissolves in 5 to 7 days, it causes significant
Fig. 19.8 Repair of a parotid duct injury. (a) Lacerations sustained when the patient fell into glass. (b) Glass removed from the cheek wounds. (c)
Parotid duct cannulated and irrigated; saline in the cheek wound indicated a parotid duct laceration. (d) Stent located in parotid duct laceration. (e)
Parotid duct repaired over a stent.
Soft-Tissue Injuries
191

inflammation and leaves visible suture marks on the face. Also,
after the suture dissolves, the wound only has 5% strength and
the scar is likely to widen. Continuous sutures should not be
placed in traumatic wounds because they prevent drainage and
increase the risk of infection. Similarly, cyanoacrylate glue is
avoided because it seals the wound, prevents drainage, and
increases the risk of infection (Fig. 19.10). Cyanoacrylate glue
only provides strength for 7 to 10 days and the scar is likely to
spread after the glue has dissolved.
19.4.7 Dressing
Nonocclusive dressings should be applied to traumatic wounds
to allow drainage. On the face topical antibiotic, steri-strips, or
gauze with tape can be applied. For significantly contaminated
wounds, a Penrose drain can be placed to ensure adequate
wound drainage. The parents remove the drain in 48 hours at
home. Drainage from the site usually continues for another 2 to
3 days until the wound edges become approximated. Generally,
the laceration can be washed with soap and water in the
shower beginning 24 hours after the injury. Cleaning the area
removes dried blood favorable for bacteria, and gives the most
favorable environment for scarring.
19.4.8 Postoperative Management
Patients who have su ered human or animal bite wounds are
examined 3 to 5 days after the injury to ensure that an early
infection is not occurring. Noncomplicated injuries are re-
examined 3 weeks following the injury. At the postoperative
appointment, steri-strips are placed over the scar and the
parents are instructed to replace them for 3 weeks when the
wound has achieved its maximal strength. Placing steri-strips
prevents the scar from widening, protects the area from sun
exposure, and reduces the risk of the accidental injury from the
child. The parents are instructed to place sunblock and protec-
tive clothing for 12 months to prevent hyperpigmentation of
the scar. I do not favor scar products for normal scars that are
not hypertrophic/keloid. Patients are instructed to return 1 year
following the injury if they are unhappy with the appearance of
the scar. At this time, a decision can be made to determine if a
scar revision should be done under sterile, nontraumatic
conditions.
19.5 Complications
The most common acute problems following soft-tissue injury
repair are infection and wound dehiscence. Early infections
with cellulitis may be treated with oral antibiotics. If purulent
drainage is present, then the wound should be partially or com-
pletely opened, depending on the severity of the infection and
length of the wound. Generally, gauze is placed for 2 days to
ensure drainage and prevent reapproximation of the wound
edges. After 2 days, the gauze is removed and the wound is
washed twice a day and allowed to heal secondarily. Severe
infections may require intravenous antibiotic therapy.
Fig. 19.10 Adolescent female who suffered a dog bite injury to the lips. (a) Significant loss of tissue. (b) After irrigation and linear closure of
lacerations. Remaining open areas were allowed to heal secondarily. An attempt was not made to reconstruct the lips with grafts and/or flaps. (c)
Appearance 12 months postoperatively. She subsequently underwent scar revision and lip augmentation using dermal-fat grafting.
Fig. 19.9 Dog bite injury to the face with ischemic wound edges. (a) Initial appearance. (b) After irrigation and debridement of damaged skin edges.
(c) Loose closure over a drain.
Soft-Tissue Deformities of the Head and Neck
192

If a laceration closure dehisces, then it should be washed
twice a day and allowed to heal secondarily. Delayed primary
closure should not be performed because it is better for the scar
to fully mature and perform a scar revision if necessary. Revi-
sing the scar will give a more favorable long-term outcome
compared to delayed primary closure in a nonsterile, inflamma-
tory environment.
The most common long-term problem following the repair of
a soft-tissue injury is an unfavorable-appearing scar. Because a
traumatic wound has a greater bacterial burden, inflammation,
and injured wound edges, the scar is more likely to be worse
compared to closure of an operative incision. Decisions regard-
ing whether or not a scar may be improved with scar revision
should be made after it has fully matured 12 to 18 months fol-
lowing the injury. Often a scar will improve significantly over
the first year and patients will avoid having an unnecessary
procedure.
19.6 Conclusion
Pediatric plastic surgeons commonly manage soft-tissue inju-
ries, particularly facial lacerations. Soft-tissue trauma in chil-
dren is managed di erently than in adults or sterile operative
incisions. There should be a low threshold to repair injuries
using sedation/general anesthesia and to administer antibiotics.
Absorbable sutures are used whenever possible to avoid suture
removal, which is another traumatic experience for the child.
19.7 Key Points
● Because lacerations are not clean wounds, they are managed
di erently than a sterile operative incision.
● An open wound is a safe wound; allowing heavily contami-
nated wounds to heal secondarily should be considered.
● Most pediatric patients require sedation or general anesthesia
to repair their wound.
● Absorbable sutures should be used when possible.
● Intravenous extravasation injuries have a very low risk of
compartment syndrome (unless it is a chemotherapeutic
agent) and definitive management is elevation.
Suggested Readings
Madden JW, Peacock EE , Jr. Studies on the biology of collagen during wound
healing. I. Rate of collagen synthesis and deposition in cutaneous wounds of
the rat. Surgery. 1968; 64(1):288–294
Fig. 19.11 A 6-year-old male who suffered a dog bite injury to the cheek. (a) Initial appearance. (b) The area was closed loosely to reduce the risk of
infection. (c) Cheek scar 12 months postoperatively. (d) Improved appearance following scar revision.
Fig. 19.12 Dog bite injury to the cheek closed at an outside hospital
using cyanoacrylate glue. He presented 3 days later with a wound
infection that was managed by incision, drainage, and intravenous
antibiotics.
Soft-Tissue Injuries
193

Monaco JL, Lawrence WT. Acute wound healing an overview. Clin Plast Surg.
2003; 30(1):1–12
Greene AK, Hergrueter CA. Intravenous extravasation injuries. In: Hansen A,
Puder M, eds. Manual of Neonatal Surgical Intensive Care. 2nd ed. Hamilton,
Ontario: BC Decker; 2009
Mioton LM, Jordan SW, Hanwright PJ, Bilimoria KY, Kim JYS. The relationship
between preoperative wound classification and postoperative infection: A
multi-institutional analysis of 15,289 patients. Arch Plast Surg. 2013; 40
(5):522–529
Couto JA, Sullivan JE, Greene AK. Facial wound closure in children using a 7–0
absorbable suture dressing. J Craniofac Surg. 2015; 26(1):76–78
Nuzzi LC, Greene AK, Meara JG, Taghinia A, Labow BI. Surgical site infection
after skin excisions in children: is field sterility su cient? Pediatr Dermatol.
2016; 33(2):136–141
Soft-Tissue Deformities of the Head and Neck
194

20 Ear Reconstruction
Arin K. Greene
Sum m ary
Ear deformities are common in the pediatric population. Disor-
ders include: constricted ears, microtia, accessory cartilage,
lobule anomalies, prominent ears, cryptotia, Stahl deformity,
keloids, and traumatic defects. The reconstructive procedure
and timing depends on the type of deformity.
Keywords: ear, reconstruction, otoplasty, cryptotia, Stahl, keloid,
pediatric
20.1 Introduction
Several types of ear anomalies a ect the pediatric population.
These are reconstructed using di erent otoplasty strategies.
Construction of an absent ear (microtia) is presented in a sepa-
rate chapter. The primary morbidity of an ear anomaly is psy-
chosocial. Children can develop lowered self-esteem if peers
notice their malformation. Ear anomalies are not painful and
reconstruction does a ect hearing; consequently, insurance
companies may not cover the procedure. Correction of some
deformities (e.g., cryptotia) can facilitate the use of eyeglasses.
Ear anomalies may be broadly divided into three categories: (1)
excess structures, (2) deficient structures, and (3) structures
present but malformed.
In contrast to most other types of congenital anomalies man-
aged by pediatric plastic surgeons, ear malformations can cause
increased anxiety for families because (1) they often have to
pay for the procedure and (2) they are subjecting their child to
general anesthesia for a “cosmetic” problem. Consequently, sur-
geons treating ear anomalies should be well trained on the sub-
ject and ensure that patients and families have reasonable
expectations (similar to rhinoplasty). For example, I emphasize
that the goal of the operation is to improve the child’s appear-
ance, but that I “guarantee” there will be some residual asym-
metry between the ears.
20.2 Diagnosis
Diagnosis of an ear anomaly is made by physical examination
(Fig. 20.1, Fig. 20.2). The surgeon should be able to identify
the abnormality and list reconstructive options. A framework
for the operative approach usually can be made by determining
if structures need to be removed, added, or rearranged. Ear
anomalies can be better understood by knowing the embryol-
ogy of ear development. The first mandibular arch gives three
anterior hillocks: (1) tragus, (2) root of helix, and (3) superior
helix. The second hyoid arch results in three posterior hillocks:
(1) antihelix, (2) antitragus, and (3) lobule. The external audi-
tory meatus is formed by the first branchial groove (Fig. 20.3).
The surgeon must understand normal ear anatomy and
can use a contralateral normal ear, if present, as a guide
(Fig. 20.4). The axis of the ear is angled approximately 20
degrees more posterior than a vertical line. The top of the helix
is at the level of the eyebrow and the lobule is at the base of the
columella. The height of the ear is 6.5 (±1) cm and its width is
Fig. 20.1 Types of ear anomalies. (a,b) Accessory cartilage. (c) Prominent ear. (d) Cryptotia. (e) Stahl deformity. (f) Abnormal helical root and antihelix.
(g) Lobule abnormality.
Ear Reconstruction
195

Fig. 20.2 Examples of a constricted ear. (a) Mild.
(b) Moderate. (c) Severe.
Fig. 20.3 Ear development. Six hillocks from the
first and second arch form the ear.
Fig. 20.4 Anatomy of the ear.
Soft-Tissue Deformities of the Head and Neck
196

4.0 (± 0.5 cm). It is located 6 to 7 cm posterior to the lateral can-
thus. Although several measurements for normal protrusion
from the mastoid have been described, I use 15 mm (top helix),
20 mm (midhelix), and 22 mm (lobule).
Imaging is rarely necessary to manage an ear deformity. If a
branchial cleft cyst or sinus is suspected, however, I will obtain
a magnetic resonance imaging to confirm the diagnosis and
determine the extent of the tract. Occasionally, a sinus can be
deep and approximate the facial nerve; this information is help-
ful prior to operative intervention.
20.3 Nonoperative Treatment
A window exists up to 3 months of age when the ear can be
molded. Because one-third of anomalies improve during the
first 2 weeks of age (particularly a prominent helical root),
molding should not be initiated until after this time. Ideally,
molding is started between 2 and 4 weeks of age when mater-
nal estrogens in the child facilitate cartilage manipulation. The
ear can be molded using wire and tape or a commercially avail-
able system (Fig. 20.5). Both methods are equally e ective;
the commercial system is easier to use, but more expensive.
Unfortunately, patients often are referred after the window
to mold their ear has passed. I will not attempt to mold the ear
after 3 months of age because of the poor response. The ear
deformity that is most amenable to molding is a prominent ear
(Fig. 20.6). The antihelical fold is straightforward to create
and the concha is able to be set back. Another anomaly that is
able to be molded includes a mild constricted ear with
overhanging helical cartilage; the cartilage can be “lifted” into
better alignment. A Stahl deformity also can be improved by
flattening the abnormal crus. Children commonly are referred
for ear anomalies that cannot be helped with molding (e.g.,
severe constricted ear, cryptotia).
20.4 Operative Treatment
20.4.1 Indications
The primary indication for correction of an ear anomaly is to
improve the patient’s self-esteem. Cryptotia and moderate-
severe constricted ears can make it di cult to wear eyeglasses.
Timing of intervention falls into three categories: (1) 6 to 12
months, (2) 3 to 4 years, (3) late childhood or adolescence. Sim-
ple excisions of excess structures can be performed during
infancy under local anesthesia. Parents with preauricular carti-
lage remnants are usually eager to remove them as soon as
possible. Most are small and able to be excised under local
anesthesia in the o ce. I prefer that he or she is at least 6
months of age, when their physiology approximates that of an
adult, before doing an elective procedure. After 12 months of
age, however, it is too di cult to restrain an awake child and I
will perform the procedure in the operating room with seda-
tion or wait until the child is old enough to be able to cooperate
in the clinic. If a child has an ear deformity that cannot be cor-
rected simply using local anesthesia during infancy, I prefer
they be at least 3 years of age before operative intervention
under general anesthesia.
Fig. 20.5 Types of ear molding. Above: commercially available system. (a) Device placed around ear. (b) Piece molds the helix. (c) Conchal bowl
conformer to flatten the root of the helix. (d) Cover applied. Below: custom wire, mold, and tape. (e) Anomaly of the helix. (f) Wire. (g) Mold and tape.
(h) Improved appearance of the ear.
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Because long-term memory and self-esteem begin to form at
approximately 4 years of age, many parents decide to correct
deficient or m alform ed structures when the child is 3 years
of age. At this time, the ear has achieved 85% of its size and
the risk of scar lim iting enlargement of the ear is reduced
(ear grow th is complete by approxim ately 6 years of age).
Although studies have shown that operating on ears before
3 years of age does not inhibit grow th, I prefer to wait until
at least 3 years of age because (1) the ear is larger, w hich
facilitates the procedure, and (2) it is not urgent to inter-
vene before this time because m em ory and self-esteem have
not yet form ed.
If a child has a severe deformity that he or she will definitely
want improved, then it is best to do the procedure prior to 4
years of age, before memory and self-esteem form. Children at
this age tolerate the procedure more favorably than older
patients who are more anxious about the operation. If an indi-
vidual has a mild deformity that he or she may not want to
have improved, then it is prudent to wait until they are older to
determine if they become bothered by it.
Some families choose to wait to correct an ear anomaly until
the child is old enough to participate in the decision to have the
procedure. Children between 5 and 8 years of age typically are
bothered by a deformity, but fear of the operation outweighs
their desire to improve their appearance. After 8 years of age,
the child’s interest in correcting the anomaly begins to out-
weigh the anxiety about the operation. Girls typically present
later than boys because they are better able to camouflage their
deformity with hair. Boys often will grow their hair long to hide
their ear.
Except for small excisional procedures in infancy, I prefer to
correct other ear anomalies under general anesthesia. Even in
adolescents who may tolerate procedures under local anesthe-
sia, they typically have a better experience if they are asleep.
General anesthesia also facilitates the procedure for the surgeon
and increases the likelihood of achieving the most favorable
outcome.
During any ear procedure, I ensure that betadine has been
placed into the external auditory meatus. I do not administer a
perioperative dose of antibiotic unless I am (1) doing an exten-
sive cartilage dissection or (2) placing permanent intracartilagi-
nous sutures. Although these procedures are clean cases, the
benefit of reducing the risk of infection, chondritis, and destruc-
tion of the ear after a “cosmetic” operation outweighs the
potential disadvantages of the antibiotic. I do not prescribe
postoperative antibiotics.
The ears are particularly tolerant of asymmetry because of
their lateral position over the temporal bones. The full appear-
ance of the ears cannot be appreciated on frontal view. To com-
pare the ears, an individual must look at one ear first and then
change positions to see the contralateral side. Consequently, it is
most important to have the ears as symmetrical as possible on
frontal view. Because most ear anomalies cause a “cosmetic prob-
lem,” patients and families can be focused on minor asymmetries.
It is important that families understand that slight asymmetries
between the ears are common in the general population and that
there will be residual asymmetry following the procedure.
20.5 Types of Abnormalities
(Listed in Order of Frequency)
20.5.1 Accessory Cartilage
Accessory cartilage in the preauricular area is the most com-
mon ear anomaly ( Fig. 20.7). I do not advocate placing a
suture around the area to cause necrosis because (1) there will
be a residual bump that has a high likelihood of needing a sur-
gical procedure to improve and (2) restraining the child to per-
form a definitive excision is not much more involved than tying
a suture around the lesion. I prefer to remove the accessory car-
tilage between 6 and 12 months of age under local anesthesia
in the o ce to obviate general anesthesia. Patients who present
after 12 months of age are managed with sedation in the oper-
ating room because it is too di cult to restrain the child in the
clinic. If an infant has a large lesion with a wide cartilage base
that cannot be easily excised and closed, the procedure is per-
formed in the operating room. Only dissolving 6–0 or 7–0
Fig. 20.6 Examples of ear molding. (a,b) Prominent ear. (c,d)
Constricted ear. (e,f) Stahl ear.
Soft-Tissue Deformities of the Head and Neck
198

chromic sutures are placed followed by cyanoacrylate glue and
steri-strips.
20.5.2 Lobule Defects
Split Earlobe
This deformity results from an earring being pulled through the
lobule (Fig. 20.8). The cleft is rapidly epithelialized preventing
the edges from re-approximating. Split earlobes in adolescents
can be repaired with local anesthesia; children require general
anesthesia. The cleft is de-epithelialized and approximated
using absorbable sutures in a straight line. The end of the cleft
is closed with a mattress suture for eversion to prevent a notch
from scar contraction. A 5–0 Vicryl intradermal suture is used,
followed by interrupted 7–0 chromic for the anterior surface of
the ear and 6–0 chromic for the posterior area. The closure is
protected with cyanoacrylate glue and steri-strips. The scar can
be re-pierced 3 months later when it has achieved its maximal
strength of 80% of noninjured tissue. The advantages of re-
piercing along the scar is that the scar is camouflaged, and if
the earring pulls through again, a second scar is not formed.
The disadvantage of piercing the scar is that it is not as strong
as the adjacent lobule and thus has a higher risk of pulling
through again. If families choose to re-pierce the scar, they
should not use heavy earrings. My preference is to pierce the
ear adjacent to the scar.
Keloid
The earlobe has a greater risk of forming keloid scars from
piercings, compared to other parts of the body. Keloids are
managed with pressure, corticosteroid injection, and/or resec-
tion. Small, superficial lesions can be treated with pressure
only. Patients are advised to wear a clip-on earring or purchase
a pressure earring designed for keloids. The pressure device is
worn only at night when sleeping. A pressure earring is a good
first-line intervention for keloids in young children who are less
tolerant of undergoing a corticosteroid injection in the clinic.
Larger lesions can be managed with serial triamcinolone injec-
tions in addition to the pressure earring. I prefer 10 mg/ml
rather than 40 mg/ml to reduce the risk of fat atrophy. A 30-
gauge needle and 1-mL syringe is used. The corticosteroid lasts
approximately 2 weeks and patients return every 3 to 4 weeks
Fig. 20.7 Accessory cartilage. (a) Two preauricular lesions. (b) Following excision and repair with 7–0 chromic suture. (c) Cyanoacrylate glue and a
steri-strip are placed to reinforce the area. (d) Accessory tissue on lobule. (e) Outline of resection. (f) Following removal.
Ear Reconstruction
199

for repeat injections until the desired result is obtained. Large
keloids are best managed with resection because pressure/
injections will only give minimal improvement and the patient
will continue to have a significant deformity. Families are edu-
cated that resection is exponentially more traumatic to the ear
than the piercing that caused the keloid. Consequently, without
close follow-up and the use of postoperative compression and
injections, the keloid will return and can be worse. After resect-
ing the keloid, I inject triamcinolone at the end of the proce-
dure. Dissolvable sutures are used and the patient wears a
pressure earring immediately at night. Four weeks postopera-
tively, the patient returns for monthly corticosteroid injections.
After 6 months, the injections are discontinued and the patient
continues to wear the nightly pressure earring for another 6
months until the scar has matured. Using this regimen, I have
not had a keloid recur and I counsel patients that the original
size of the keloid can be reduced by at least 80%. Although radi-
ation has been described as a treatment for recurrent keloids, I
have not had a patient require this intervention.
Expanded Lobule
Recently, ear gauges that expand the lobule have become
popular. Patients who discontinue the gauge may present for
lobule reconstruction. The earlobe is expanded in both a ver-
tical and a horizontal plane. In order to reduce the size of the
lobule in two planes, I have reconstructed the defect by first
de-epithelizing the area and then closing it using a purse-
string suture or by removing horizontal triangles to lift the
lobule, leaving the patient with a vertical and horizontal scar
( Fig. 20.9).
Congenital Deficiency
The most common lobule deficiency is a cleft that causes a
deformity and obviates the ability to place earrings (Fig. 20.10).
The cleft is de-epithelialized and corrected by advancing the tis-
sue on both sides to form a lobule. Rarely, a patient can have an
absent lobule, on the spectrum of microtia. The lobule can be
constructed using staged skin flaps from the adjacent neck, or by
placing a conchal cartilage graft. I have reconstructed the lobule
using both methods and found that using cartilage results in the
most favorable outcome (Fig. 20.11).
20.5.3 Sinus Tracts
Auricular sinus tracts are a common ear anomaly. They may
express keratin and can become infected. Sinus tracts cause
minimal deformity and do not mandate excision. Patients are
instructed to massage the area once a day with a warm com-
press to express keratin and prevent the tract from being
obstructed. Excision of sinus tracts should only be considered if
a patient has repeated infections and has failed warm com-
presses. Resection of a sinus tract is at risk for recurrence, infec-
tion, and nerve injury if the tract extends significantly.
20.5.4 Prominent Ear
Approximately 5% of the population has a prominent ear caused
by an (1) absent or weak antihelical fold and/or (2) overgrown
conchal bowl. Most patients will require strengthening of the
antihelix and setback of the concha. Rarely, a patient will have a
normal antihelix and only require a procedure on the concha.
Fig. 20.8 Split earlobe deformity. (a) Preoperative appearance. (b) Following repair.
Soft-Tissue Deformities of the Head and Neck
200

Similarly, a child may have a normal concha and only require
creation of the antihelix. Although many definitions of a promi-
nent ear exist, generally an ear will appear prominent if its supe-
rior or middle aspect is greater than 20 mm from the mastoid.
Although many techniques have been described to correct a
prominent ear, I prefer (1) suture-only strengthening of the
antihelix (Mustarde’s technique: scapha–concha sutures) and
(2) concha excision. Cartilage scoring (Stenstrom’s technique)
for the antihelical fold increases the complexity of the opera-
tion, is less predictable than suture placement, and is associated
with contour abnormalities. In the pediatric population, the
cartilage is easily positioned using sutures and does not
require weakening. To set back the middle third of the ear, I
perform cartilage resection instead of concha–mastoid (Fur-
nas) sutures. Suturing the hard cartilage to the weak mastoid
fascia/periosteum has a high likelihood of suture dehiscence,
stretching, and recurrence of the prominent ear. In contrast,
removing cartilage from the concha ensures that the middle
third of the ear is reduced and eliminates the possibility of
recurrence.
Fig. 20.9 Lobule deformity from an ear gauge. (a) Preoperative appearance with outline of horizontal wedge resection. (b) Following repair.
Fig. 20.10 Congenital lobule deficiency. (a) Preoperative view. (b) Outline of bilateral flaps. (c) Following advancement and rearrangement of tissue.
Ear Reconstruction
201

After the patient is under general anesthesia, I measure the
distance of the ears to the mastoid from the most prominent
part of the superior helix and from the midhelix at the level of
the root. The ear is folded and the position of the antihelical
fold is marked. Local anesthetic is infiltrated to hydrodissect
the anterior skin o the cartilage to facilitate suture place-
ment. A posterior skin excision is performed to facilitate the
procedure by enhancing exposure. Four 4–0 permanent mat-
tress sutures (mersilene) are placed along the antihelical fold.
It is important not to overcorrect the antihelical fold, which
should have a curved, soft appearance. On frontal view, the
helix should be visible beyond the antihelix. An approxi-
mately 2- to 3-cm piece of superior conchal cartilage is
removed. The width of the area should be 5 to 7 mm . The car-
tilage defect is repaired with interrupted 4–0 PDS suture.
After the cartilage excision, a line of excess skin may be
present anteriorly, but this improves over the next 12
months. If more than a 7-mm width of cartilage is removed,
then it is possible that the excess skin anteriorly might be
bothersome to the patient and require excision. Some sur-
geons perform an anterior skin excision at the same time as
the posterior concha resection, but this places a scar on the
front of the ear and if cartilage greater than or equal to 7-
mm width is removed, the patient is at minimal risk for
needing excess skin removed.
To set back the lobule, one Mersilene suture is placed through
the tail of the helix and is sutured to the base of the conchal
bowl. A posterior lobule skin excision also is perform ed. The
concha resection further helps to reduce the prominence of
the lobule. Before closing the incision, I ensure that the helix
appears straight, is not curved, and that a telephone deform -
ity is not present. I also perform repeat m easurem ents; the
superior distance of the helix to the mastoid must be 15
(±3) mm and the middle distance 18 (±3) m m . These m eas-
urements should have a di erence of ≤3 m m between the
ears to ensure adequate sym m etry. The incision is closed
using interrupted 5–0 Vicryl suture followed by a running
6–0 chromic suture. Cyanoacrylate glue and a steri-strip are
placed.
Postoperatively, I use a headwrap (large piece of cotton over
the ear followed by a gauze wrap) that is worn for ≤1 week
until the first clinic appointment. I do not attempt to place pres-
sure on the ear with bolster sutures or pieces of cotton soaked
in mineral oil. Patients then are instructed to wear a soft head-
band at night for 3 months postoperatively to prevent acciden-
tal anterior displacement of the ear that could dehisce the
antihelical sutures causing recurrent prominence. Twelve weeks
postoperatively, scar tissue is strong enough to maintain the
shape of the ear (Fig. 20.12).
20.5.5 Constricted Ear
Awide spectrum of constricted (e.g., “lop,” “cup”) ear anomalies
exist, generally consisting of deficient structures. They can
Fig. 20.11 Absence of lobule and prominent ear. (a,b) Preoperative appearance. (c) Normal contralateral ear. (d) Correction of ear prominence by
strengthening the antihelix. Conchal cartilage is used to re-create the lobule. (e) After subcutaneous placement of the cartilage. Tip of instrument
shows inferior position of the graft. (f) Outline of staged elevation of the soft-tissue and cartilage graft. The solid line marks the inferior aspect of the
cartilage and the dashed line is skin that will be turned over to cover part of the posterior surface. An advancement flap and skin graft were used to re-
create the retro-lobule sulcus. (g,h) Postoperative appearance. (i) Normal contralateral ear.
Soft-Tissue Deformities of the Head and Neck
202

range from minor helical problems to a variant of microtia and
consist of (1) lidding of the helix, (2) prominence, and/or (3)
reduced size from deficient structures. If possible, I prefer to
manage these deformities as low on the reconstructive latter as
possible before considering cartilage grafts and retroauricular
flaps. Minor deformities of the helix can be improved with
simple excisions ( Fig. 20.13, Fig. 20.14). Moderately con-
stricted ears that contain a su cient amount of structures may
be improved using techniques employed for prominent ear
deformities ( Fig. 20.15, Fig. 20.16). Generally, the primary
morbidity of a constricted ear is that it is prominent. If the ear
is set back by strengthening the antihelical fold and placing
sutures from the cartilage to the mastoid fascia/periosteum to
lengthen the vertical dimension of ear, the appearance of the
child can be significantly improved. Excision of overhanging
helix also may be performed. Severely constricted ears that
approximate conchal-type microtia require total auricular con-
struction using costal cartilage.
20.5.6 Cryptotia
Patients with cryptotia have a superior helix that is attached to
the postauricular skin; a sulcus is not present. In addition to
causing a deformity, patients have di culty wearing eyeglasses.
Many techniques have been described to reconstruct the anom-
aly, including local flaps and skin grafts. In my opinion, the
most straightforward method to release the ear and provide a
sulcus is to perform a local flap. I prefer using a one-stage V-Y
advancement flap, which leaves a scar behind the ear and in
the hairline ( Fig. 20.17). To protect the flap, I place a head
dressing for 1 week.
Fig. 20.12 Correction of a prominent ear deformity. Above: unilateral anomaly. (a) Preoperative view. (b) Postoperative appearance. (c,d) Bilateral
prominent ears.
Fig. 20.13 Correction of mild constricted ear. (a)
Preoperative image shows abnormal helix cover-
ing a portion of the superior crus of the antihelix.
(b) Improved appearance following excision of
cartilage.
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203

Fig. 20.14 Treatment of a moderate constricted ear. (a) Preoperative image shows a wide helix obstructing the antihelix, scaphoid fossa, and
triangular fossa. (b) Outline of the skin and cartilage resection. (c) Intraoperative view of the abnormal cartilage. (d) Following resection. (e) Skin
closure along helix. (f) Two months postoperatively.
Fig. 20.15 Treatment of a moderate constricted ear. (a–c) Preoperative view shows that the left ear is prominent and vertically short. (d,e)
Postoperative appearance after removing the accessory piece of cartilage, setting back the ear, and lengthening the ear using cartilage–mastoid
sutures. (f) Contralateral normal ear.
Soft-Tissue Deformities of the Head and Neck
204

20.5.7 Stahl Deformity
This abnormality describes the presence of a third crus of
the antihelix, which can cause the helix to have a pointed
appearance. Usually, the deformity is minor and does not cause
psychosocial morbidity. Operative intervention may be indi-
cated to treat a severe deformity. The anomaly is improved sur-
gically through an anterior incision at the junction of the helix
and scapha, elevating the skin, and resection of the abnormal
crus (Fig. 20.18). If the superior crux of the antihelix is miss-
ing, then the excised crus can be grafted or rotated to recon-
struct this structure.
20.6 Upper/Middle Third Defects
Congenital anomalies in this area are uncommon and usually
consist of abnormally formed structures that can be improved
with excisional procedures (Fig. 20.19). Upper and middle
third ear defects most commonly result from trauma. Concha
injuries typically do not require cartilage replacement and the
overlying soft tissue can be allowed to heal secondarily, closed
linearly, or healed with a skin graft. To restore soft tissue over
helix injuries with minimal cartilage loss, postauricular skin flaps
rather than skin grafts should be used (Fig. 20.20). If a signifi-
cant amount of cartilage is absent, then cartilage grafts are
Fig. 20.16 Management of a severe constricted ear. This patient could have been managed by complete ear construction for microtia. However, he
had significant scarring in the area because of attempted otoplasty when he was an infant at an outside institution. Because his previous procedure
complicated complete ear construction, he was managed more conservatively. (a,b) Preoperative appearance. Note vertically short and prominent ear.
(c,d) After setting back and lengthening the ear.
Ear Reconstruction
205

placed and covered with postauricular skin flaps in staged proce-
dures. Usually, costal cartilage (hyaline) is preferred over conchal
cartilage (elastic) because it is better able to maintain its shape
and withstand contractile forces from scarring (Fig. 20.21).
20.7 Complications
Rarely, a skin abrasion or full-thickness wound can occur with
ear molding; molding is discontinued until the area has healed.
The most common problem when reconstructing an ear is
an unfavorable “cosmetic” outcome. Infection, hematoma, or
wound dehiscence is uncommon. Before reconstructing an ear,
patients/parents must have reasonable expectations. The ears
are tolerant to asymmetry and the primary goal is to improve
their appearance on frontal view.
20.8 Conclusion
Ear reconstruction is based on principles. The surgeon must be
able to identify the deformity and determine if there are excess
structures, deficient structures, or adequate structures that
need to be rearranged. Although many options often exist to
improve a specific type of ear deformity, the simplest technique
often is preferred.
20.9 Key Points
● Ear molding may correct some anomalies during the first 12
weeks of life.
● Excision of excess structures can be performed in infancy, but
other ear procedures are best performed after 3 years of age
when most of the ear growth is completed.
● Ear anomalies can be broadly characterized by having excess
structures, deficient structures, or adequate structures that
need to be rearranged.
● Most ear reconstructions should be done under general anes-
thesia in the pediatric population.
● Ear reconstruction should aim to give the best symmetry on
frontal view.
Fig. 20.17 Correction of cryptotia. (a) Preoperative appearance. (b) Illustrating the normal components of the helix by pulling the ear away from the
head. (c) Outline of the V-Y advancement flap to recreate the retroauricular sulcus. (d) Flap raised. (e) After advancement of the flap. (f,g)
Postoperative views.
Soft-Tissue Deformities of the Head and Neck
206

Fig. 20.18 Correction of a Stahl deformity. (a) Preoperative view. (b) Marking of abnormal crus to be removed and incision along the junction of the
helix and scaphoid fossa. (c) Anterior skin flap elevated to expose the abnormal cartilage. (d) Resection of the abnormal crus. (e) Following resection.
(f) Repair of cartilage defect. (g) Closure of the incision. (h) Appearance 6 weeks postoperatively.
Fig. 20.19 Correction of middle and superior ear anomaly. (a) Preoperative appearance. (b) Excess helical and conchal cartilage was removed. (c)
Postoperative result shows opening of concha, improvement of abnormal helical root, and smoother contour of superior helix.
Ear Reconstruction
207

Fig. 20.20 Correction of superior ear deformity following a dog bite injury. (a) Loss of soft tissue and exposed cartilage. (b) Outline of first-stage
postauricular flap. (c) Elevation of the flap. (d) The cartilage is placed underneath the postauricular flap. (e) Outline of second-stage division of the
base of the flap. (f) Separation of the ear from the postauricular area. (g,h) Flap inset and closure of donor defect. (i) Postoperative appearance.
Fig. 20.21 Correction of helix deficiency using a costal cartilage graft. (a) Patient underwent microtia construction by another surgeon. Note deficient
helix. (b) Outline of skin flap. (c) Donor site incision. (d) Harvested costal cartilage. (e) Exposed ear construct. (f) Placement of cartilage graft. (g)
Closure of skin flap. (h) Prior to second-stage elevation of the construct to improve the definition of the helix. (i) Intraoperative view following
separation of the cartilage graft from the mastoid. (j) Appearance 6 weeks postoperatively.
Soft-Tissue Deformities of the Head and Neck
208

Suggested Readings
Tan ST, Abramson DL, MacDonald DM, Mulliken JB. Molding therapy for
infants with deformational auricular anomalies. Ann Plast Surg. 1997; 38
(3):263–268
Gosain AK, Recinos RF. A novel approach to correction of the prominent
lobule during otoplasty. Plast Reconstr Surg. 2003; 112(2):575–583
Gosain AK, Kumar A, Huang G. Prominent ears in children younger than 4
years of age: what is the appropriate timing for otoplasty? Plast Reconstr
Surg. 2004; 114(5):1042–1054
Bauer BS, Margulis A, Song DH. The importance of conchal resection in cor-
recting the prominent ear. Aesthet Surg J. 2005; 25(1):72–79
Bauer BS. Congenital and acquired deformities of the ear. In: Bentz M, Bauer
B, Zucker, eds. Pediatric Plastic Surgery. St. Louis, MO: Quality Medical Pub-
lishing; 2007: 801-850
Janz BA, Cole P, Hollier LH , Jr, Stal S. Treatment of prominent and constricted
ear anomalies. Plast Reconstr Surg. 2009; 124(1) Suppl:27e–37e
Byrd HS, Langevin CJ, Ghidoni LA. Ear molding in newborn infants with auric-
ular deformities. Plast Reconstr Surg. 2010; 126(4):1191–1200
Driessen JP, Borgstein JA, Vuyk HD. Defining the protruding ear. J Craniofac
Surg. 2011; 22(6):2102–2108
Thorne CH, Wilkes G. Ear deformities, otoplasty, and ear reconstruction. Plast
Reconstr Surg. 2012; 129(4):701e–716e
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21 Microtia
Akira Yamada
Sum m ary
The auricle is located away from the facial triangle (eye–nose–
eye). Therefore, the auricle is not the primary attention of peo-
ple when they look at someone. The goal of ear reconstruction
is to restore/create a natural-looking auricle. The surgeon’s
focus will be to create the natural helical curve, eliminate
unnatural curve, correct excessive protrusion, and restore the
missing anatomical parts of the auricle.
Basic knowledge of normal anatomy, proportion, and dimen-
sion of the auricle helps prevent mistakes in ear reconstruction.
Thin, supple, well-vascularized skin is a must to achieve clear
definition of the auricle. It is imperative to create the balance
between the amount of skin flap envelope and the cartilage
framework to achieve the definition of the auricle.
To be able to create a new auricle from zero, it requires full
knowledge and complete skill set of plastic surgery: meticulous
skin flap dissection, delicate skin suture techniques, harvesting
rib cartilage without perichondrium, elevating temporoparietal
fascia flap, and skin harvesting/grafting. Mastering ear frame-
work carving/fabrication techniques requires dedicated, inten-
sive training before starting clinical cases.
Further, it is critical to recognize that what makes a recon-
structed auricle beautiful is creating the natural curve of the
auricle, especially helix–lobule curve, and concha outline.
Keywords: microtia, secondary ear reconstruction, cartilage
framework, hemifacial microsomia, Treacher Collins syndrome
21.1 Clinical Characteristics
Microtia varies from complete absence of auricular tissue (ano-
tia) to a small ear with an ear canal. Nagata classifies microtia
into three types: lobule type, small concha type, and concha
type. Microtia is nearly twice as frequent in males as in females,
and the right-to-left-to-bilateral ratio is roughly 6:3:1. Approx-
imately one-third to one-half of the patients exhibit character-
istics of craniofacial microsomia. Brent found that 15% of his
1,000 patients had paresis of the facial nerve. Dellon has shown
that the palatal muscles are rarely spared in this syndrome.
21.2 Timing of Surgery
Brent begins ear construction at the age of 6, when the normal
ear has grown to within 6 to 7 mm of its full vertical height.
Nagata begins auricular construction at the age of 10, and chest
circumference has grown over 60 cm at this age, at the xiphoid
level. These two di erent timings could be explained by the dif-
ference in the amount of cartilage required.
21.3 Epidemiology and Genetics of
Microtia
Microtia (= small ear) is a congenital condition with unknown
cause. Prevalence of microtia varies significantly among ethnic
groups (0.83–17.4 per 10,000 births), and is higher in Asian
countries for unknown reason. About 80 to 90% of microtia is
unilateral, and 10 to 20% is bilateral. There are more than 18
di erent microtia-associated syndromes with single-gene or
chromosomal aberrations; however, there is no causal genetic
mutation confirmed to date. Relatively common syndromes
associated with microtia are hemifacial microsomia and
Treacher Collins syndrome. Isolated microtia rarely runs in fam-
ilies. Treacher Collins Syndrome, inherited in an autosomal-
dominant fashion, often presents with bilateral microtia.
21.4 Middle Ear Problem
Ideally, treatments of microtia involve reconstruction of the
external ear and the restoration of normal hearing. Hearing
impairment in microtia is related to abnormal auditory canal,
tympanic membrane, and middle ear. The problem is conduc-
tion. Regarding middle ear surgery for hearing restoration, most
surgeons presently feel that potential gains from middle ear
surgery in unilateral microtia are outweighed by the potential
risks and complications for the surgery and that this surgery
should be reserved for bilateral cases. The bone-anchored hear-
ing aid (BAHA; Cochlear, Mölnlycke, Sweden; and Ponto, Oticon,
Kongeballen, Denmark) has been used since 1977 and does not
require a functioning middle ear or patent canal. In microtia
patients, BAHA was initially used for bilateral conducting hear-
ing loss. Only 1 BAHA is usually placed because a single aid will
stimulate both cochleae simultaneously. Although traditional
teaching has been that hearing on a single side is su cient for
speech development and education, evidence indicates audio-
logic and subjective benefits when treating unilateral conduc-
tive hearing loss with a BAHA. Indications are evolving, and
reconstructive surgeons and otologists should work together to
achieve long-term success in hearing restoration and auricular
construction.
21.5 History of Autogenous Ear
Reconstruction
Sushuruta (6 BC) was probably the first surgeon to perform
auricular construction, repairing the ear lobe with cheek flap.
Tagliacozzi described repair of ear deformities with retroauricu-
lar flaps. Early surgical attention focused mainly on traumatic
deformities. However, by the end of the 19th century, surgeons
began to address congenital defects, in particular prominent
ears (Ely, 1881). The concept of microtia repair began in 1920
when Gillies buried carved costal cartilage under mastoid skin
and elevated it with cervical flap. Gillies (1937) also used
maternal ear cartilage for more than 30 microtic ears; these
were found to have progressive resorption. Peer (1948) diced
autogenous rib cartilage and placed it in a Vitallium ear mold
beneath the abdomen. After 5 months, he retrieved the banked
mold, opened it, and harvested the ear framework for microtia
repair. Ste ensen (1955) attempted to use preserved cartilage
and found it progressively resorbed.
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Tanzer is the father of modern auricular construction. Tanzer’s
excellent results (1959) determined the dominance of autoge-
nous construction with rib cartilage in reconstructive surgery. In
the United States, Brent succeeded Tanzer in the early 1970s,
and Brent’s artistry has influenced reconstructive surgeons even
today. Nagata’s method (two-stage method) gradually gained
popularity, and currently is the most popular choice. To this day,
autogenous cartilage remains the most reliable material that
produces results with the least complications.
21.6 Alloplastic Implants
Although silicone breast implant survives even today, silicon
ear framework is seldom used. Silicon framework, introduced
by Cronin in 1966, like any other types of synthetic materials,
extrudes, causes infection, and loses definition in the long term.
Porous polyethylene (PPE) framework, a newer synthetic mate-
rial, was first introduced by Reinisch in 1991. The disadvantage
of the Medpor framework includes use of temporoparietal fas-
cial flap, long-term risk of implant exposure or loss, and com-
promise of any future autogenous options.
21.7 Prosthesis
Controversies remain regarding appropriate treatment selec-
tion for patients with major ear deformities. This is especially
true for severe trauma cases, such as extensive third-degree
facial burns. Osseointegrated auricular prosthetic reconstruc-
tion is complementary to other approaches and provides a rea-
sonable alternative for poor autogenous options and/or failed
autogenous reconstruction. The disadvantages of a prosthesis
include intermittent soft-tissue problems, long-term mainte-
nance, requirement of a new prosthetic every 2 to 5 years,
ongoing cost, inability for future autogenous options, and the
need for a compliant patient.
21.8 Total Auricular Construction
in Microtia: Author’s Methods
21.8.1 Patient Assessment
About 20 to 60% of children with microtia have associated
anomalies or an identifiable syndrome; therefore, individuals
with microtia should be examined for other dysmorphic fea-
tures. Microtia is a common feature of craniofacial microsomia,
mandibular dysostoses (e.g., Treacher Collins and Nager syn-
dromes), and Townes–Brocks syndrome. These conditions
should be considered among the di erential diagnoses when
evaluating an individual with microtia.
Facial Symmetry
Asymmetry of the face will make it complicated to locate the
ear position. The location of vestige skin is sometimes mislead-
ing, and it influences the decision-making of surgeons. Even for
expert surgeons, it is tempting to make the auricle based on the
current location of the vestige skin, so the surgeons could apply
their typical techniques.
Skin Envelope
Assessing the available, soft elastic skin is critical, since it will
determine the volume, dimension, and size of the three-dimen-
sional (3D) structure of the ear framework needed. Unbalance
between skin envelope and framework may make definition of
the auricle poor. Scar interferes the normal stretching of the
supple skin envelope and may prevent good definition of the
auricle. Scar along the course of the STA (superficial temporal
artery) could be a sign of a severed STA, the pedicle of temporo-
parietal flap, which is an important salvage tool for auricular
reconstruction. This is especially important for microtia
patients with craniofacial deformities, such as Treacher Collins
syndrome. These patients may have bicoronal scarring due to
previous skeletal reconstruction.
Vestige Skin
Since microtia has inherent skin envelope deficiency, how sur-
geons utilize vestige skin strongly influences the definition of
the new auricle. Surgeons need to evaluate the location, shape,
and volume of the vestige. These factors will influence the
design of skin incision, and surgical strategy. If the vestige skin
is located inside or near the auricular rectangle, the vestige skin
is ready to be utilized for auricular construction. If the vestige is
located far away from auricular rectangle, staged transposition
of vestige skin may be necessary prior to the framework place-
ment procedure.
Hairline
Surgeons need to recognize the presence of low hairline at the
time of initial evaluation to formulate their surgical strategy
(Fig. 21.1). The extent of a low hairline influences the choice
of surgical procedures. If the hairline exceeds beyond the upper
one-third of the auricular framework, either preoperative laser
Fig. 21.1 An 8-year-old female with microtia, complicated with low-set
vestige plus low hairline, diagnosed with ear positioning template.
Microtia
211

hair removal or intraoperative, fascia flap coverage of the
framework, after hair-bearing skin removal, may be necessary.
If the extent of a low hairline is mild, hairs down to the scapha
fossa can be removed during the second-stage procedure (ear
elevation).
21.8.2 Trapezium Space behind
Sideburns
The sideburn is often missing in microtia patients, especially in
hemifacial microsomia. If the patient has a normal sideburn, it
is an anatomical landmark useful for locating the proper ear
position. Anthropometrical study shows that the auricle is nor-
mally located approximately 20 mm behind the sideburn
(Fig. 21.2). There is a trapezium-shaped non–hair-bearing
space between the sideburns and auricle normally (Fig. 21.3).
Avoid placing the ear framework in this trapezium to prevent
anterior inclination of the auricle.
21.8.3 Location of the Normal Auricle
Leonardo da Vinci analyzed the facial proportion in the same
way that anthropologists do today. Recognition of the normal
location of the auricle is critically important to avoid misplace-
ment of the construct (Fig. 21.4). The normal auricle is located
at the edge of the face mask (Fig. 21.5). Surgeons should avoid
placing the new auricle inside the face mask, especially in hemi-
facial microsomia.
21.8.4 Auricular Rectangle
A critical step in preoperative planning is to identify the “auricu-
lar rectangle,” where the framework will be placed (Fig. 21.6).
Identifying the auricular rectangle is more challenging in hemi-
facial microsomia. Once the auricular rectangle is identified, the
next step is to evaluate the relationship between the auricular
rectangle and vestige skin. A decision has to be made whether
vestige skin can be utilized or not.
Fig. 21.2 The normal auricle is approximately 20 mm posterior to
sideburn at the cephalic end of the tragus.
Fig. 21.3 There is a nonhair trapezium-shaped skin area between the
normal auricle and sideburn.
Fig. 21.4 The normal auricle is one ear length behind the lateral orbital
rim.
Soft-Tissue Deformities of the Head and Neck
212

21.8.5 Ear Positioning Template
An ear positioning template (EPT) is a tool to identify the auric-
ular rectangle, which the author developed with Nagata. It is
especially helpful for secondary auricular construction, when
many landmarks are missing. Harada and Yamada modified EPT
in 2011; more anthropological references are added to the tem-
plate, and a new template is made of acrylic that facilitates eas-
ier surgical marking (Fig. 21.7). EPT may be used to visualize
the extent of low hairline (Fig. 21.1).
21.8.6 Auricular Curve Analysis
Harada and Yamada developed an auricular shape classification
based on a curve ratio analysis study. They identified two key
lines in ear shape. The helix–lobule curve and the concha out-
line curve. There are three major helix–lobule curves (types A,
B, and C) and two major concha outline curves, types 1 and 2
(Fig. 21.8). Normal ear shape may be classified into six groups
based on this analysis, and six types of auricular framework
templates were developed as a guide for ear framework con-
struction (Fig. 21.9).
21.8.7 Auricular Template
When surgeons plan for auricular reconstruction, most use a
template as a guide for fabricating the framework. The most
widely used method has been to trace the normal auricle with
transparent film. The manual tracing tends to be too big and
gives poor definition due to skin deficiency. Nagata developed a
single ear template for auricular construction. Harada and
Yamada then created six types of templates in 2009. The aim of
the six templates is to express the subtle, individual di erence
of the auricular shape rather than a single “ideal” template for
all patients.
Fig. 21.5 The normal auricle is located immediately behind the face
mask.
Fig. 21.6 The key to avoid malpositioning of the new auricle is to
identify the auricular rectangle.
Fig. 21.7 Ear positioning template is a useful tool
to identify the proper new auricle location.
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213

21.8.8 First Stage of Total Auricular
Construction
Markings
After the induction of general anesthesia, the author performs
markings with permanent marker before the surgical prepara-
tion. He uses an EPT as a guide for the markings ( Fig. 21.10).
Patient Position
The author uses semilateral position to facilitate simultaneous
access to the auricle site and cartilage harvest. Since typical
duration of surgery will be 5 to 7 hours, preventive measures of
pressure sore are mandatory. The neck is placed in neutral posi-
tion to prevent C1 and C2 rotary subluxation.
Skin Flap Preparation
Lobule Splitting Technique for Lobule Type
Microtia
Nagata solved the problem of skin shortage in typical lobule
type microtia. Creating a deep concha bowl may be achieved by
splitting the lobule into two flaps (Fig. 21.11). Contrary to
Tanzer/Brent (full-thickness) lobule rotation, splitting the
Fig. 21.8 Based on the curve analysis, there are three helix–lobule curves ( Fig. 21.1) and two concha outline curves (Fig. 21.2) in normal auricles.
Fig. 21.9 Six types of new auricular template,
based on the curve analysis.
Soft-Tissue Deformities of the Head and Neck
214

lobule creates two flaps: anterior and posterior flaps. Splitting
continues down to the fascia level. After completion of the
lobule split, the anterior flap is transposed backward to cover
the anterior lobule portion of the framework. The posterior flap
is moved anteriorly to cover the posterior aspect of tragus and
concha. A subcutaneous pedicle is preserved for the posterior
skin flap to maintain the vascular supply.
Skin Incision for Small Concha Type Microtia
Nagata defines small concha type by the presence of small
indentation in the concha region. The skin incision is made
along the margin of small indentation. The indentation is
turned inside out to form an inverted cone pocket to cover the
framework. The remaining procedure is similar to lobule type
microtia.
Skin Incision Design for Concha Type Microtia
Nagata originally (1994) described the skin incision with a pos-
terior V-shaped design ( Fig. 21.12). Recently, Nagata modified
the skin incision (Fig. 21.13) at the posterior aspect of the
lobule. In case of concha type with a higher location of vestige
than normal, a W-shaped incision has better freedom to trans-
pose the lobule into the optimal location.
Removing Vestige Auricular Cartilage
The author removes all of the remnant auricular cartilage in
lobule type microtia. Excising vestige cartilage will create a
space to accommodate a new framework. In contrast, in concha
type microtia the part of remnant concha cartilage should be
preserved as a cu to facilitate smooth transition of concha
cavity.
Skin Pocket Dissection
The author uses small straight blunt scissors, aiming to create
2-mm-thick skin flap. The author does not use epinephrine
injection for hemostasis purpose, because injection of fluids
makes dissection less accurate, and it may cause vascular
compromise of the delicate skin flaps. The extent of the skin
pocket dissection usually goes beyond the hairline border, up to
1 cm beyond the hairline. The author does not violate the tra-
pezium-shaped space in front of the new auricle ( Fig. 21.3) to
prevent anterior inclination.
Harvesting Costal Cartilage
Harvesting rib cartilage with perichondrium left at the donor
site is a safer technique than harvesting cartilage with peri-
chondrium, in terms of pneumothorax risk. Preserving peri-
chondrium at the donor site, and placing extra diced cartilage
into the perichondrial sleeve can regenerate cartilage/bone.
This technique may cause less chest wall deformity. If there is
clinical suspicion of pneumothorax, a portable chest X-ray,
while under general anesthesia, should be taken for possible
chest tube placement.
Auricular Framework
Creating an auricular framework is a di cult technique to mas-
ter. There are several training modules available ( Fig. 21.14),
which may be helpful prior to treating patients. The architec-
ture of the auricular framework is critical to create the delicate
definition of the auricle. Nagata type 3D framework is distinct
from previous 2D framework: the helix connects the bottom of
the base frame (first level), climbing as a spiral staircase, to the
top of the frame (second level). The tragus is also unique to
Nagata type 3D framework and is covered by a posterior W-
shaped skin flap, using the lobule split technique.
Bolster Sutures
Nagata uses bolster sutures for his postoperative dressing that
was popularized by Tanzer. Brent uses suction drain postopera-
tively. At the first stage of total auricular construction, the
author uses suction only temporally during the surgery to visu-
alize optimal skin adaptation to the framework (Fig. 21.11.f).
After completion of bolster sutures, the author removes the
temporary suction. Based on the author’s experiences, bolster
sutures cause minimal hematoma formation. Dense roll and
excessive fixation may be the cause of pressure necrosis under-
neath a bolster.
21.8.9 Second Stage of Total Auricular
Construction (Auricular Elevation)
The di culty of auricular elevation is often underestimated.
The normal auricle is separated from the mastoid area by sup-
porting cartilage. The simplest way to divide the auricle from
head is to place skin graft in between head and auricle without
skeletal support. Since the resultant defect after division of
auricle from head is relatively large, popular choice of skin
donor site has been groin area. The disadvantage of auricular
division with groin skin grafting include less optim al eleva-
tion, persistent edem a of the auricle, pubic hair grow th,
m ism atched skin color, and di cult skin cleaning. To over-
come the disadvantage described earlier, Nagata proposed
m ore complex auricular elevation than the author routinely
perform s ( Fig. 21.15).
Fig. 21.10 Ear positioning template is applied to identify the auricular
rectangle.
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215

Fig. 21.11 (a) A 10-year-old child with anteriorly inclined lobule type microtia. (b) Topographic and skin incision markings. (c) Lobule split is
completed. (d) Anterior lobule flap is transposed posteriorly, and posterior W-shaped skin flap is transposed anteriorly. (e) The extent of skin pocket
dissection is shown. (f) A three-dimensional (3D) framework and 54-mm type A1 template. (g) Immediate postoperative view with temporally suction
catheter in place. (h) The postoperative view after the first-stage surgery.
Soft-Tissue Deformities of the Head and Neck
216

Fig. 21.12 (a) V-shape skin incision for concha type microtia. (b) A three-dimensional (3D) framework without tragus. (c) Immediate postoperative
view, with temporal suction in place.
Fig. 21.13 An 8-year-old child with concha type microtia. (a) Preoperative profile. (b) Red marking shows the modification of the skin incision design
to bring down the lobule more than 15 mm. (c) A three-dimensional (3D) framework with 52-mm type A1 template. (d) Immediate postoperative
view. (e) The postoperative view after ear elevation.
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217

Raising Temporoparietal Fascia Flap
The author uses the temporoparietal fascia flap (TPF) to cover
the entire posterior aspect of the auricle, not just cover the carti-
lage block for elevation. If low hairline is mild (hairs cover helix
to scapha fossa), TPF enables surgeons to perform intraoperative
hair removal. The author routinely uses Doppler ultrasound to
plot the course of STA on the temporal skin. If TPF is not avail-
able, either deep temporal fascia or a fascia flap based on poste-
rior vasculature is used. If local fascia flap is not available, the
third option may be a free vascularized fascia flap. Alopecia has
been reported as a complication of the TPF harvest.
Harvesting Scalp Split-Thickness Skin
The author does not use groin skin for auricular elevation
because of its poor skin color match and potential pubic hair
growth. Nagata proposed the use of split-thickness scalp skin,
which has better color match with the auricular skin.
Cartilage Block for Elevation
Many agree that without placing block underneath the ear
framework, it is not su ciently elevated from the head. The
author makes an intraoperative impression to create a 3D tem-
plate to fabricate a cartilage block for sulcus construction
(Fig. 21.16).
21.9 Hemifacial Microsomia
Auricular construction in hemifacial microsomia (HFM) is com-
plex and challenging. Even in mild form of mandibular under-
development, vestige skin tends to be located inferior and
anterior. A low hairline is present, and patients have a low set
ear canal (Fig. 21.17). If surgeons simply apply the standard
formula of auricular construction (place the auricle where ves-
tige is located), the auricle tends to be located in the face mask,
which may be aesthetically unacceptable. Surgeons should
Fig. 21.14 Example of ear carving training, de-
veloped by the author. Carrot framework parts
and framework made of rib cartilage model are
shown.
Fig. 21.15 The second stage (ear elevation) for a 10-year-old child with lobule type microtia. (a) Preoperative markings. (b) The marking for harvesting
temporoparietal flap. (c) The view immediately after the completion of ear elevation.
Soft-Tissue Deformities of the Head and Neck
218

avoid placing the new auricle inside the face mask. It is a com-
mon mistake to place the new auricle in an anteroinferior loca-
tion, trying to avoid the low hairline. In HFM, skeletal
correction prior to ear construction may help to place the
auricle in proper location. It is notable that laser hair removal
works best for black hairs with multiple sessions (could be
more than 10 sessions to complete), but currently it is not e ec-
tive against blond hairs. The author has found that in the micro-
tia patient with severe HFM there is a higher risk of cartilage
resorption.
21.10 Treacher Collins Syndrome
The patient with Treacher Collins syndrome has distinctive
facial features: high nose, deficient lateral orbit/zygoma, small
chin, and smaller overall facial size. Placing a large auricle may
be disproportional and unnatural. The size of the new auricle,
therefore, needs to be smaller than average; the author usually
selects the auricle size 45 to 50 mm in length to balance with
the rest of the face. Microtia in Treacher Collins syndrom e may
accompany a low hairline. To eliminate hairs from the auricle,
laser hair removal is one option; the other option is applying a
local fascia flap (e.g., temporoparietal fascia or fascia flap based
on posterior vascular pedicle) to cover the upper one-third of
the framework.
21.11 Unsatisfactory Outcome
The cause of unsatisfactory outcomes are multifactorial:
improper (1) evaluation of the deformities, (2) selection of the
surgical procedures, (3) recognition of the facial asymmetry, (4)
assessment of low hairline, (5) selection of the new auricular
location, (6) inclination of the auricle, (7) timing of the surgery,
(8) amount of costal cartilage, (9) cartilage harvesting techni-
ques, (10) skin pocket dissection, (11) lobule spiriting techni-
ques, (12) shape, volume, size, and width of the framework, and
(13) postoperative care.
21.12 Complications
The overall complication incidence in ear reconstruction is
reported to be 16.2% on average with a range of 0 to 72.9%.
Probably the most serious complication in total auricular
construction is cartilage infection, leading to the entire extru-
sion of the ear framework. To prevent this disaster, even
small skin necrosis has to be addressed immediately. Skin
necrosis along the helical rim may be repaired with local skin
Fig. 21.16 The view of the fabricated cartilage block for ear elevation with thermoelastic intra-operative template for elevation. (a) Caudal side view.
(b) The posterior view.
Fig. 21.17 An 8-year-old with low-set, low hairline microtia.
Microtia
219

flap, but skin necrosis in medial portion, such as concha
bowl, usually requires local fascia flap to salvage it. Long-term
complication includes collapse of ear framework and extru-
sion of wires. Total auricular construction in HFM has a
higher frequency of complications, such as malposition and
resorption of the auricle.
21.13 Secondary Construction
Secondary construction is challenging, but it is not impossible.
In many unsatisfactory outcomes, patients have lost supple
skin, have scars, and have resorbed frameworks. To create a
smooth, natural-looking auricle in such situations, surgeons
should take an aggressive approach: discard all scar tissues,
deform ed fram ework, and dam aged skin envelope, and then
replace them with well-vascularized supple, thin skin enve-
lope, and well-planned fram ework. In secondary cases, tem -
poroparietal fascia flap is a powerful workhorse to provide a
thin envelope to cover the fram ework ( Fig. 21.18). If the
local fascia flap is not available, distant free fascia flap is an
option. Brent described the use of contralateral TPF plus
hair-bearing skin to restore temporal hairline plus auricular
construct.
Suggested Readings
Brent BD. Reconstruction of the ear. In: Neligan PC, ed. Plastic Surgery. 3rd
ed. Philadelphia, PA: Elsevier Saunders; 2013:187–225
Wilkes GH, Wong J, Guilfoyle R. Microtia reconstruction. Plast Reconstr Surg.
2014; 134(3):464e–479e
Tanzer RC. Total reconstruction of the external ear. Plast Reconstr Surg Trans-
plant Bull. 1959; 23(1):1–15
Beahm EK, Walton RL. Auricular reconstruction for microtia: part I. Anatomy,
embryology, and clinical evaluation. Plast Reconstr Surg. 2002; 109(7):2473–
2482, quiz 2482
Walton RL, Beahm EK. Auricular reconstruction for microtia: Part II. Surgical
techniques. Plast Reconstr Surg. 2002; 110(1):234–249, quiz 250–251, 387
Nagata S. Auricular reconstruction: congenital auricular defects—microsia. In:
Guyuron B, Eriksson E, Persing J, eds. Plastic Surgery: Indications and Prac-
tice. Philadelphia, PA: Saunders Elsevier; 2008:671–699
Guyuron B, Eriksson E, Persing JA, eds. Plastic Surgery: Indications and Prac-
tice. Expert Consult Premium Edition: Enhanced Online Features, Print, and
DVD, 2-Volume Set. London: Elsevier; 2008
Tolleth H. Artistic anatomy, dimensions, and proportions of the external ear.
Clin Plast Surg. 1978; 5(3):337–345
Yamada A, Ueda K, Yorozuya-Shibazaki R. External ear reconstruction in
hemifacial microsomia. J Craniofac Surg. 2009; 20 Suppl 2:1787–1793
Brent B, Byrd HS. Secondary ear reconstruction with cartilage graft covered
by axial, random, and free flaps of temporoparietal fascia. Plast Reconstr Surg.
1983; 72:141–152
Yamada A, Imai K, Nomachi T, Fujimoto T, Morimoto K. Total reconstruction
of the burned auricle. Burns. 2007; 33(1):112–120
Fig. 21.18 A 16-year-old female with lobule type microtia. Tissue expander reconstruction was performed at the other institution. (a) Preoperative
view before secondary construction. (b) The 56-mm type A1 template is applied to evaluate the shape. (c) A three-dimensional (3D) framework. (d)
The upper two-thirds of the new framework is covered with temporoparietal flap. The lower one-third of the framework is covered with local skin flap.
(e) Split-thickness scalp skin was grafted over the fascia. (f) The postoperative view of the patient.
Soft-Tissue Deformities of the Head and Neck
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22 Nasal Reconstruction
Alexander Facque and Peter J. Taub
Sum m ary
While minor, and frequently nonoperative, injuries to the
pediatric nose are common, major injuries are relatively rare.
Acquired defects can occur as early as infancy due to pressure-
related necrosis of the septum, columella, or ala during nasal
oxygen administration as in continuous positive airway pres-
sure (CPAP). The more common cause of nasal defects occur
during childhood as a result of animal bites and burns. All such
injuries are important from a psychological and developmental
standpoint. The importance of self-image plays into the psycho-
social development of the pediatric patient, and reconstructive
e orts should be made in some attempt before the child starts
school, approximately by 6 years of age. Defects of the pediatric
nose are especially challenging due to the complex anatomy of
the nasal structures and the need to grow with the rest of the
face. The relative presence or absence of the various nasal com-
ponents (external skin, cartilaginous or bony support, or inter-
nal lining) should be noted and addressed as appropriate.
Keywords: pediatric, nose, ala, dorsum, cartilage, lining, bilobe,
paramedian
22.1 Introduction
Given the causes for major pediatric nasal reconstruction are
relatively rare, the importance of the nose, from both a psycho-
logical and developmental perspective, mandates that they be
done with great care. As evidenced by the existence of punitive
rhinotomy, described in historical documents since times even
before the Code of Hammurabi, undeniably the nose carries a
psychosocial importance that supersedes almost any other
aspect of the human body. Additionally, from a developmental
perspective, the nose is considered one of the growth centers of
the face, responsible for some of the development of the mid-
face during childhood as well. Subsequently, defects of the
pediatric nose from both congenital and acquired etiologies
take on a heightened level of complexity, not only due to the
complex anatomy of the nose, but also due to the overall impact
that nasal development will have on both psychosocial devel-
opment and the ultimate development of the face. Furthermore,
reconstruction of the pediatric nose carries with it special con-
cerns including whether the reconstruction will grow with the
face, how the reconstruction could alter remaining facial devel-
opment, and if or how future donor sites should be preserved
should a future revision be necessary.
22.2 Embryology
At minimum, a cursory understanding of the embryologic devel-
opment of the nose and face is important when considering
reconstruction of nasal anomalies, given these malformations are
by definition the result of aberrant embryogenesis and an ability
to assess what nasal components or subunits are absent or
malformed will subsequently lead to an understanding as to
what will need to be replaced during the course of
reconstruction.
As an overview, the pediatric face begins to take shape during
weeks 5 to 10 with the formation, fusion, and di erentiation of
five mesenchymal swellings or prominences: two mandibular,
two maxillary, and the unpaired frontonasal. The latter will
ultimately be responsible for forming the face above the exter-
nal nares, including the forehead, interorbital region, and the
majority of the external nasal structures, while the maxillary
prominences will comprise the oral opening to the external
nares and the mandibular prominences will fuse to create
structures inferior to the oral opening (Fig. 22.1).
Initially, development of the nose begins with formation of
the nasal placode from localized thickening in the superficial
ectoderm of the inferior portion of the frontonasal prominence,
immediately above the nasolacrimal groove between the fron-
tonasal and the maxillary prominences. Sensory neurons in the
placode di erentiate to form olfactory neurons, while thicken-
ing of the mesenchyme at the periphery of the placode elevates
the ectoderm above the placode to produce nasal pits at week
5. The outer areas of these pits will form the medial and lateral
nasal prominences, from the inferior portion of the frontonasal
process. The medial nasal prominences ultimately fuse together
to form the median nasal prominence at week 8 (leading to the
creation of the nasal dorsum) and will also fuse inferiorly with
the lateralized maxillary prominences to form the central and
lateral portions of the upper jaw, including the philtrum, nasal
septum, and the primary palate. The lateral nasal prominences
fuse with the more cephalad aspect of the maxillary prominen-
ces to form the nasal alae as well as lateral portions of the nose.
The maxillary prominences also will go on to form the secon-
dary palate, an example of the interconnectedness of nasal and
palatal formation explaining why cleft palate malformations are
inherently linked to nasal deformations as well.
22.3 Development
After birth, the nose continues to grow and change with the
facial profile throughout adolescence. The infant nose is noted
to have less frontal projection with a shorter dorsum, larger
nasolabial angle, and rounder nares. The main support of the
infant nose is the dorsal septal and upper lateral cartilages,
which are considered an extension of anterior cranial base. This
cartilaginous septum is considered to be a part of two nasal
growth centers, the sphenospinal zone and the sphenodorsal
zone, both of which a ect the growth of not only the nose itself,
but also the surrounding midface. The sphenodorsal zone is
described as being responsible for grow th in the length and
height of the dorsum, while the sphenospinal zone is responsi-
ble for sagittal growth, as well as outgrow th of the maxilla.
Because of the presence of these grow th zones, loss of septal
cartilage in infancy and childhood can lead to various acquired
Nasal Reconstruction
221

facial syndromes involving not only the nose, but also the max-
illa and the orbit. Furthermore, surgery on the nose that dis-
rupts these growth centers may have similar and predictable
deleterious e ects. Nasal growth appears to continue until early
adulthood with specific windows of accelerated growth. The
two most significant nasal grow th spurts occur in the first 2
years of life and during puberty. The end of the period of
growth was found to be at 12 to 16 years in girls and 15 to 18
years in boys.
22.4 Diagnosis
Defects of the external framework of the nose are generally
obvious on inspection. They can arise from congenital and
acquired causes. Congenital defects occur generally as a result
of failed or incomplete fusion of the mesenchymal prominences
discussed previously. For example, failed development of the
frontonasal prominence results in the characteristic deformities
seen in frontonasal dysplasia. Another class of congenital
defects arises as the result of congenital growths such as benign
hemangiomas ( Fig. 22.2), dermoid cysts, and nasal encepha-
loceles (Fig. 22.3). A classification scheme developed by Losee
et al separated nasal malformations into four broad classes.
Type 1, comprising 62%, includes defects arising from hypopla-
sia or atrophy and agenesis syndromes ranging from
whole arhinia to individual subunits including nostril stenosis
(Fig. 22.4), nasal hypoplasia, choanal atresia, and craniofacial
syndromes. Type 2 defects (1%) are the result of hyperplasia and
duplication exemplified by proboscis lateralis. Atypical clefts
comprise type 3 and arise from failure of fusion of medial or lat-
eral nasal prominences and the surrounding maxillary promi-
nence and include the Tessier 0, 1, 2, and 3 clefts as well as their
cranial extensions 11, 12, 13, and 14 ( Fig. 22.5). Neoplasm
and vascular anomalies are included in type 4 nasal defects
(20%). Examples of benign lesions include hairy nevus, glioma,
pilomatrixoma, neurofibroma, and nasal dermoid (12.4%), as
well as benign vascular lesions such as hemangiomas.
Fig. 22.1 Embryologic development of the nose.
Fig. 22.2 Nasal hemangioma.
Soft-Tissue Deformities of the Head and Neck
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Acquired defects of the nose can occur throughout infancy
and childhood and include both iatrogenic and hospital-
acquired conditions, such as pressure-related necrosis of the
septum, columella, or ala during nasal oxygen administration as
in CPAP (continuous positive airway pressure). The most com-
mon cause of nasal defects during childhood is traumatic,
resulting from animal (generally dog) bites and burns.
Further diagnostic maneuvers may include one or more
im aging modalities to better elucidate the nature of the
deform ity. If there is a question of depth or involvem ent of
surrounding tissues, a computed tom ography (CT) scan or
m agnetic resonance imaging (MRI) m ay be indicated. CT
scanning will highlight the surrounding bony structures and
determ ine if there is potential involvem ent of deeper struc-
tures. MRI w ill better elucidate the soft tissues in and
around the nose.
22.5 Nonoperative Repair
There are scant nonoperative treatment options for nasal
deformities. Scars can be managed similar to other areas of the
body, including massage, topical agents, laser therapy, and der-
mabrasion. Complete loss of the nose may be addressed with a
prosthetic device. For the pediatric patient, this, however, may
be di cult to maintain with a more active lifestyle and over a
long period of time.
22.6 Operative Treatment
22.6.1 Timing of Repair
Due to the importance of self-image in psychosocial develop-
ment, reconstructive e orts should be made in some attempt
before the child starts school, approximately by 6 years of age.
As nasal development continues throughout adolescence, wait-
ing until after this was complete would subject the child to pos-
sible years of alienation and ridicule although a more definitive
repair could be o ered at that time. In light of these concepts,
best results involve a dual reconstructive approach with an
attempt as early as possible (preferably before school age) with
knowledge that a subsequent definitive repair may be needed
in adulthood for optimal results. Part of this rationale necessa-
rily includes consideration that optimal donor sites for a later,
definitive repair may need to be spared during the pediatric,
initial reconstructive attempt.
Fig. 22.3 Nasal encephalocele.
Fig. 22.4 Stenosis of the left external nasal valve.
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223

22.6.2 Nasal Subunit Theory of
Reconstruction
In the adult, the nasal defect and their subsequent reconstruc-
tion can be analyzed by dividing the nose into aesthetic/recon-
structive subunits including the dorsum, tip, alae, sidewalls,
and soft triangles. The authors argue that replacing an entire
subunit when it is involved in the defect improves the aesthetic
outcome of the reconstruction by placing the scars into more
camouflaged locations and allowing the reconstruction to fol-
low the pre-existing concavities and convexities of the native
nose. Others argue in favor of preservation of as much native
tissue as possible. In the pediatric nose, combining subunits,
such as the tip and columella and the dorsum and sidewalls,
has been suggested to create a simplified approach with just
three subunits (dorsum, tip, ala) because in the pediatric nose
these borders are often indistinct (Fig. 22.6). Menick argues
that while the borders are indistinct, they are present, and
that following the subunit reconstruction principle with these
simplifications may lead to over-resection, which is not with-
out its own set of complications. Paramount to discussions
regarding reconstruction of the pediatric nose is that a recon-
struction must be durable, aesthetically pleasing, and impor-
tantly it must be known if the reconstruction will grow with
the developing face. Necessarily, if a reconstructive e ort is
completed that will require further revisions in the adult face,
consideration must be placed into choosing tissue that will
not preclude subsequent attempts at reconstruction.
Reconstruction Techniques
When addressing nasal defects, assessment begins with an
examination of the characteristics of the defect. The location
(upper, middle, or lower nose) and the subunit or subunits
involved should be noted. Furthermore, the relative presence or
absence of the various nasal components (external skin, cartila-
ginous or bony support, or internal lining) should be noted with
a mindfulness of the classic dictum to “replace like with like.”
This is important in preventing collapse and further disfigure-
ment. Consideration should be made not only in re-creating the
subunits, but also in reconstructing the volume/shape and func-
tion of the nose via reconstructing the lining, support, and over-
lying skin of the nose.
Fig. 22.6 Indistinct borders to the nasal subunits
in the pediatric nose.
Fig. 22.5 Bilateral Tessier 3 cleft.
Soft-Tissue Deformities of the Head and Neck
224

22.6.3 Nasal Lining
Lacking nasal lining can be addressed using native septal muco-
perichondrium, previously scarred skin that may otherwise be
discarded depending on the etiology of the nasal defect, skin
graft, and/or a variety of turnover flaps. Close attention should
be paid to the amount of septal manipulation given the concern
for growth arrest discussed earlier. More distant options for
reconstructing the nasal lining have been described involving
prefabricated galeal flaps, mucosal flaps from the buccal sulcus,
as well as islandized frontalis muscle with skin graft. Free tissue
can be also be folded on itself to create an external surface as
well as an internal lining. In this case, one or more secondary
debulking procedures will likely be required.
22.6.4 Structure
In defects involving the framework of the nose, cartilage may be
harvested from the ear or rib, typically the sixth or the seventh.
Again, septal cartilage is typically avoided depending on the age
at which the repair is completed due to future growth concerns
as well as volume able to be recovered. In older children lacking
support to the lower portion of the nose, an L-shaped septal
advancement by Millard has been described with good result. A
tempororetroauricular flap as described by Washio has also
been described to have the capacity to take bring auricular
cartilage to lateral nasal defects, which may be especially useful
in alar reconstruction. Paramount to any structural reconstruc-
tions involving the nose is the presence of a stable base on
which the reconstructions will be placed. The support given by
the maxilla should be assessed and supplemented as needed, as
is the case in the nasal component of cleft lip/palate repairs, in
which bone grafting from the iliac crest to the alveolar gap is
performed prior to performing the reconstructive rhinoplasty.
Bone for this purpose may be taken from rib, iliac crest, or cal-
varium depending on the needs and wishes of the patient and/
or parent. In older children, in which the concern for growth
arrest after manipulation of the septal cartilage is considered
negligible, the full array of septal cartilage grafts (spreader, lat-
eral crural, columellar strut) are available to the reconstructive
surgeon and can be used in combination with paramedian fore-
head flaps or other local advancement flaps in a prefabricated
or composite fashion.
22.6.5 External Skin
As with elsewhere on the body, skin coverage options cover the
spectrum of the reconstructive ladder, from skin grafts (full-
thickness preauricular/postauricular, supraclavicular) to local
flaps (bilobed, dorsal nasal, cheek advancement, nasolabial,
paramedian forehead) to microvascular free tissue transfer.
Composite grafts as was discussed in regard to recreating the
structural framework of the nose can also be created using any
of these methods. With the loss of multiple subunits, the para-
median forehead flap has been described to have the ability to
cover extensive skin loss, with acceptable donor site morbidity.
Burget describes a three-stage procedure with the caveat that
in some patients, preliminary surgeries may need to be per-
formed to debride scar or release contractures that may inhibit
the surgeon from gaining an adequate assessment of the
reconstructive needs of the patient. In his description, the first
stage of a full-thickness reconstruction provides nasal lining,
cartilaginous framework, and coverage with a paramedian fore-
head flap. The second stage involves elevation and thinning of
the forehead flap to better match the thinness of the native
nasal skin. And finally, in the third stage, the pedicle is sepa-
rated and any revisions to the donor site are performed.
22.7 Complications
The major potential complication of not repairing a nasal defect
is the social burden, which the child (and his parents) must
endure. Infants and younger children may be spared from ques-
tions and teasing from other children, but older patients are
vulnerable to negative interactions with their peers. Associated
nasal compromise from vestibular obstruction or collapse
may compromise nasal function. The potential complications
following surgical reconstruction include those common to
most operative procedures, including bleeding, infection,
wound healing problems, persistence of the deformity, and
worsening of the deformity. If tissue is recruiting from addi-
tional sources, problems may arise that relate to not only the
recipient site, but also the donor area.
22.8 Conclusion
Pediatric nasal reconstruction is a complex and interesting
topic, with special consideration given to the anatomic and psy-
chosocial importance placed on the developing nose. Special
considerations include deciding on the proper timing of the
repair, with the primary objective to balance the competing
goals of minimizing the traumatic e ects on self-image that
having a nasal defect may have on the child with the ability to
provide a definitive repair. Nasal reconstruction is further com-
plicated by the complex anatomy of the nose, with multiple dif-
ferent types of tissue that will need to be replaced in order to
recreate a functional and aesthetically pleasing nose. Once
these assessments are complete, nasal reconstruction provides
a unique challenge to the reconstructive surgeon, with the
potential for very gratifying results to all involved.
22.9 Key Points
● Deformities of the nose may have significant psychosocial
implications.
● Reconstruction of nasal deformities must take into account
potential future growth of the nose.
● Reconstruction of nasal deformities must take into account
specific structures that are involved, including lining, support,
and coverage.
● The concept of the reconstructive ladder applies to nasal
reconstruction; the concept of the subunit principle may or
may not.
Suggested Readings
Meeuwis J, Verwoerd-Verhoef HL, Verwoerd CD. Normal and abnormal nasal
growth after partial submucous resection of the cartilaginous septum. Acta
Otolaryngol. 1993; 113(3):379–382
Nasal Reconstruction
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Meng HP, Goorhuis J, Kapila S, Nanda RS. Growth changes in the nasal profile
from 7 to 18 years of age. Am J Orthod Dentofacial Orthop. 1988; 94(4):317–
326
Losee JE, Kirschner RE, Whitaker LA, Bartlett SP. Congenital nasal anomalies:
a classification scheme. Plast Reconstr Surg. 2004; 113(2):676–689
Lee WT, Koltai PJ. Nasal deformity in neonates and young children. Pediatr
Clin North Am. 2003; 50(2):459–467
Pittet B, Montandon D. Nasal reconstruction in children: a review of 29
patients. J Craniofac Surg. 1998; 9(6):522–528
Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast
Reconstr Surg. 1985; 76(2):239–247
Menick F. Nasal reconstruction with a forehead flap in children less than 10
years of age. Plast Reconstr Surg. 2004; 114(2):326–328
Washio H. Retroauricular-temporal flap. Plast Reconstr Surg. 1969; 43
(2):162–166
Maillard GF, Montandon D. The Washio tempororetroauricular flap: its use in
20 patients. Plast Reconstr Surg. 1982; 70(5):550–560
Soft-Tissue Deformities of the Head and Neck
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23 Facial Paralysis
Greg Borschel
Sum m ary
The management of pediatric facial palsy begins with the accu-
rate multidisciplinary assessment of the deficit and acute prob-
lems, the cause and associated problems, the likelihood of
spontaneous recovery and the psychological and social impact
on the child and their family. After the management of acute
issues (which are uncommon), once there is a decision to oper-
ate, an assessment is made of the surgical options. Which one is
used depends on the exact deficit, but in general in the pedia-
tric group the problem is the inability to smile. Our preferred
option is a two-stage procedure in which the first stage is a
cross-face nerve graft and the second stage a free gracilis trans-
fer. This is gone through in detail with the family, and the deci-
sion to proceed is made together with them. The outcomes are
generally good, with the vast majority of patients who have
received the two-stage procedure achieving improved facial
symmetry, developing an ability to smile spontaneously, and
also very satisfactory results for those receiving free gracilis
transfers innervated by the motor nerve to masseter and the
complication and revision rates are relatively low.
In terms of the future, recent evidence from the rat model
suggests that “super-charging” the nerve graft with a sensory
nerve at the time of grafting can improve nerve regeneration.
Brief periods of electrical stimulation of a proximal nerve stump
can also enhance nerve regeneration. Finally there are also
potential pharmacological avenues that may improve outcomes
in nerve regeneration, such as geldanamycin and FK-506.
Keywords: Facial paralysis, paralysis, reanimation, gracilis
23.1 Introduction
The muscles of facial expression are perhaps the most obvious
outward, involuntary expression of our internal emotional
state. Impairment of its actions is not life-threatening, but will
alter not only the appearance of the face at rest and in motion,
but also, possibly, ocular and oral continence. Interestingly,
these latter two are often not a significant issue in the pediatric
population. The problem that most often brings the pediatric
patient to the facial palsy clinic is in fact their inability to smile.
Simply not being able to smile spontaneously at the appropriate
time during a social interaction has a significant impact on the
individual’s psychological state and potentially also on the per-
ception of others about the individual.
Pediatric facial palsy is relatively rare, and as with many
pediatric conditions can be categorized into the congenital and
acquired. Although facial palsy present at birth has an incidence
of 2.1/1,000 in newborns, most are acquired and associated
with birth trauma such as forceps use, and the incidence of
actual congenital cases is closer to 0.24/1,000—around 90% of
birth-injury-associated palsies show complete recovery. Facial
palsy acquired after birth, while less common than in adults, is
usually associated with an infective process and typically
presents with an acute-onset facial paralysis, the most common
reasons being Bell’s palsy, acute otitis media, and Lyme disease,
and has an annual incidence of 6.6/100,000. The management
of the patient should be within a multidisciplinary environ-
ment that incudes ear, nose, and throat surgery, rehabilitation
therapy services, psychosocial support, and a pediatric medical
assessment.
23.2 Comparison with the Adult
Population
● The etiology of the disorder. In congenital or developmental
facial palsy, it is not possible to re-neurotize using the ipsilat-
eral facial nerve. Furthermore, there may be no useful muscle
units, and if dynamic reconstruction is required, the use of a
functional muscle transfer is mandated. Also, in cases of bilat-
eral facial nerve palsy even the contralateral facial nerve may
not be available to use as donors. Importantly, facial palsy
apparent at birth is not necessarily a “development” problem,
but may be secondary to birth trauma, for example, following
the use of forceps.
● Psychosocial. The ability of a child to be able to respond to a
facial expression with their own (gestural coupling) is impor-
tant for psychosocial development, and its loss may a ect not
just the perception of others about the child with facial para-
lysis, but also how the child understands others. On the other
hand, patients who acquire facial palsy already have estab-
lished social functioning. The psychosocial implications,
therefore, of a facial palsy are potentially greater in the con-
genital than the generally older, acquired group.
● Expectations. The adult population with facial paralysis tend
to have a lower expectation of what must be achieved (pri-
marily focused on functional issues) and are often keen for
less involved procedures to achieve more simple results,
whereas the opposite is the case for the younger population—
often driven by parental desire for a child who can integrate
“normally” with their peers.
● Peripheral and central neural plasticity. Peripheral nerve heal-
ing in children is much more e ective than in adults. There-
fore, greater success can be expected in techniques for facial
reanimation that depend upon it in children compared to
adults. Furthermore, central plasticity is also better in the
younger patient and is of particular merit in procedures in
which a nerve other than the facial is used to innervate a
reconstruction.
● Co-morbidities. In the elderly adult group with, for example,
malignant parotid tumors, anesthetic limitations and the
likely prognosis may limit which procedures are appropriate.
In the pediatric population, the facial palsy may be syndromic
and reanimation must be coordinated with other treatments
and may be a ected by them. For example, in hemifacial
microsomia, the final aesthetic outcome will also be very
dependent upon the craniofacial reconstruction, or where a
future maxillary osteotomy may be needed, a cross-facial
nerve graft that could be injured by such a procedure may be
contraindicated.
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23.3 Anatomy of the Facial Nerve
and Muscles of Facial Expression
The first branches of the facial nerve once it leaves the stylo-
mastoid foramen are the posterior auricular branches, which
are motor to occipitalis, and branches to the stylohyoid and
posterior belly of digastric. The nerve then has a short
course between the foram en and the parotid gland through
w hich it passes, separating it into deep and superficial
lobes; despite this intimate relationship, the facial nerve
provides no innervation to the parotid. As it passes through
the gland, the nerve branches into the pes anserinus, and by
the tim e it exits the parotid is classically said to do so in
five major branches: zygomatic, temporal, buccal, marginal
m andibular, and cervical ( Fig. 23.1). This is, however, an
oversimplification and there are not only m ultiple branches,
but also a significant degree of cross-innervation between
branches.
The nerve is deep to the superficial aponeurotic system
(SMAS), and it supplies the muscles of facial expression. The
muscles are layered into four levels, and the branches of the
nerve lie deep to all but the deepest layer (which consists of the
buccinator, mentalis, and levator anguli oris). The muscles may
be divided roughly into thirds: an upper group (in the supraor-
bital and periorbital region), a midface group, and a lower face
group. The upper group (frontalis, procerus, and corrugator
supercilii) originate laterally and superiorly and insert into the
glabellar and supraorbital area. They function to animate the
eyes and periocular regions. With the exception of nasalis, the
muscles of the midface and the lower face insert into the oral
commissure and thus animate the lips (Fig. 23.2). In 1973,
Rubin described three basic types of smile ( Fig. 23.3). The
first, the “Mona Lisa” smile, accounted for 67% of his subjects
and was due to the dominant action of the zygomaticus
muscles. The second, “canine smile”, accounted for 31% and was
due to a greater dominance of the levator labii superioris. The
third group was the rarest, the “full denture smile,” which
Fig. 23.1 The facial nerve nucleus is located in the brainstem, travels through the cerebellopontine angle, then courses intratemporally before exiting
at the stylomastoid foramen. Each of the extratemporal facial nerve branches provides specific movement. (From THIEME Atlas of Anatomy, Head,
Neck, and Neuroanatomy, © Thieme 2015, illustration by Karl Wesker.)
Soft-Tissue Deformities of the Head and Neck
228

accounted for just 2% of the study group and was felt to be due
to roughly equal forces being applied to the lips from all the
muscles inserting into them. We believe aiming for a line that
mimics the zygomaticus muscles gives the best results.
At the nasolabial fold, the facial musculature integrates with
the dermis. The consequence of this uniquely intimate relation-
ship between the underlying muscle and the overlying integu-
ment is that relatively small movements have a significant
e ect on the overlying skin and soft tissues. Also, as a result,
unlike in muscle transfers elsewhere, it is our experience that
the insertion of the muscle should be to the dermis in order to
e ect the best results. Following denervation, the motor end-
plates at the neuromuscular junctions atrophy such that by 2
years following the loss of their nerve supply, they are not func-
tionally re-neurotizable. Following facial nerve injury, therefore,
this defines the window of opportunity available to re-inner-
vate the muscles.
23.4 Diagnosis and Assessment
It is important to recognize that facial paralysis is not necessa-
rily a diagnosis in itself, but often a sign or symptom of an
underlying condition. The assessment of the child with a facial
paralysis is aimed at the following:
● Recognizing underlying or associated symptoms.
● Evaluation of the nature of the paralysis and its e ects (and
particularly any acute functional problems).
● Working out reconstructive goals.
● Working out reconstructive options.
Fig. 23.2 The muscles of facial expression. (From THIEME Atlas of Anatomy, Head and Neuroanatomy, © Thieme 2010, illustration by Karl Wesker.)
Facial Paralysis
229

Assessment is performed in a multidisciplinary environment
including the surgeon, therapy services, a pediatrician, and
potentially other specialities as required, such as ear, nose, and
throat surgery. A targeted history and examination is per-
formed to elucidate the likely cause of the facial palsy and
therefore the prognosis and possible other medical problems,
as well as therapeutic options. A list of the possible causes of
the facial palsy is given in Box 23.1. In the history, the pertinent
points are whether the palsy has been present since birth (and
if so the type of delivery) or whether it was acquired, its dura-
tion, whether it is bilateral or unilateral, whether it is static,
improving, worsening, or episodic, and other symptoms such as
strabismus (as may occur in Moebius syndrome). If the child is
old enough, information on the function of other parts of the
facial nerve is also useful, such as whether there is reduced lac-
rimation or if hearing and taste have been a ected. Further-
more, questions regarding functional problems such as
epiphora and ocular trauma, speech impairment, and problems
with feeding should be enquired about. Finally any history that
may be suggestive of a specific neoplastic lesion should be
aggressively pursued. The physical examination should focus on
working out the level of the facial nerve injury, the branches
a ected, and the severity of the e ect on the brow, periorbital
area, midface, and lower face (Fig. 23.4, Fig. 23.5). Particular
attention is paid to whether the eyes are a ected, whether eye
closure is complete, and if not the quality of the protective Bell’s
reflex, as the combination of an inadequate Bell’s reflex and
poor lid closure exposure is potentially sight threatening due to
the resultant corneal exposure, though, ocular problems in the
pediatric group are rare compared to adults. Other points of
note on physical examination include any evidence of hemifa-
cial microsomia, the position of the cupid’s bow on attempted
smile—in congenital cases this tends to be more centralized—
the function of the muscles of mastication and tongue (given
the motor nerve to masseter and the hypoglossal are poten-
tial donors), the vector of the una ected lateral lip element
on smiling, and a “gestalt” view of the face. In our experience,
electrophysiology does not alter management. Imaging will
rarely usefully visualize the facial nerve, but may be relevant
to identify other potentially important pathologies such as
space-occupying lesions. Through this process, one should be
able to determine the following factors: Is this congenital or
acquired? What are the deficits? What does the patient/parents
feel are the problems relating to appearance? What is the
chronicity of this palsy? What are the available donors? What
are the goals?
Fig. 23.3 The three smile types described by Rubin from his 1973 article. (a) The “Mona Lisa” smile, in which the primary movement is due to the
action of the zygomaticus muscles. (b) The canine smile, where the dominant muscle acting is the levator labii superioris. (c) The full denture smile,
which is due to comparably forceful contraction of all the muscles inserting into the lips.
Soft-Tissue Deformities of the Head and Neck
230

Box 23.1 Summary of Conditions That May Cause
Facial Paralysis
● Extracranial
○ Traumatic
– Facial lacerations
– Blunt forces
– Penetrating wounds
– Mandible fractures
– Logogenic injuries
– Newborn paralysis
○ Neoplastic
– Parotid tumors
– Tumors of the external canal and middle ear
– Facial nerve neuromas
– Metastatic lesions
○ Congenital absence of facial musculature
● Intratemporal
○ Traumatic
– Fractures of petrous pyramid
– Penetrating injuries
– Larogenic injuries
○ Neoplastic
– Glomus tumors
– Cholesteatoma
– Facial neuromas
– Squamous cell carcinomas
– Rhabdomyoma
– Arachnoidal cysts
– Metastatic
○ Infectious
– Herpes zoster oticus
– Acute otitis media
– Malignant otitis externa
○ Idiopathic
– Bell palsy
– Melkersson–Rosenthal syndrome
● Congenital osteoporosis
● Intracranial
○ Iatrogenic injury
○ Neoplastic: benign, malignant, primary, metastatic
○ Congenital
– Absence of motor units
○ Syndromic
– Hemifacial macrosomia (unilateral)
– Mobius syndrome (bilateral)
Fig. 23.4 A young girl with a congenital right-sided facial palsy. In (a), she has been asked to smile. (b) The preoperative markings. N refers to the
normal side and P to the paralyzed side. While there is clearly asymmetry at rest, it is most marked during the attempted smile. And while all branches
of the facial nerve are affected, the asymmetry is most noticeable around the lips and in particular when the child is asked to smile. Also, of note, the
eye is not as markedly affected as the mouth. The arrow on the right cheek in (b) corresponds to the vector of pull on the oral commissure that is felt,
which would give the most similar result to that of the left side of the face seen in (a). The intended nasolabial crease is also marked in (b) with
reference to the normal contralateral side.
Facial Paralysis
231

23.5 Reconstructive Aims
Broadly speaking, reconstructive objectives fall into two main
groups: amelioration of functional impairment and ameliora-
tion of the appearance. These two concerns can themselves be
further classified hierarchically according to their potential con-
sequences for the patient. This grading is to a degree arbitrary,
but enables a structured approach to management planning.
23.5.1 Problems Relating to
Physiological Functional Impairment
● Ocular protection. Though often not a problem in the pediatric
group of patients, facial paralysis can lead to a significantly
increased risk of corneal ulceration, which itself can lead to
blindness, and in one study of Bell’s palsy, over half of the
a ected patients developed signs of corneal ulceration at 1
year. This is a particular problem in the patient in whom there
exists a poor Bell’s reflex (the reflex upward movement of the
globe on attempted lid closure). In addition to the risk of cor-
neal ulceration, the combination of dry eyes due to corneal
exposure and epiphora due to lack of apposition of the lower
lacrimal punctum to the globe is quite distressing for patients.
● Oral continence. While in adults and older children oral
sphincter incompetence may be socially embarrassing, it can
actually lead to a failure to thrive in neonates—in particular if
bilateral. Furthermore, speech development may be a ected
and dental decay accelerated. Though, again, these problems
are rare.
● Nasal continence. Nasal airway obstruction can occur due to
loss of functional musculature (nasalis and levator alaeque
nasi). However, this is rarely an issue when unilateral and
only potentially so when bilateral—in general, this is not a sig-
nificant presenting complaint in the pediatric population.
Fig. 23.5 A 5-year-old girl with a partial bilateral
facial palsy (Moebius syndrome) with the right
side being more affected than the left. In image
(a), she is at rest and in (b) she is attempting to
smile. As with the child in Fig. 23.4, the
asymmetry is most marked at the oral commis-
sure, with the rest of the face (and of particular
note the eyes) being relatively unaffected.
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