Phẫu Thuật Tạo Hình (Tập 3): Sọ Mặt, Đầu Cổ Và Nhi Khoa – Neligan (Ấn bản 4)

168.e1
The repair of nasal defects – treatment options
B
D
F
(BDFH) During the subsequent intermediate operation, forehead skin with 2–3 mm of subcutaneous fat is elevated entire nasal inset, maintaining the proximal
supratrochlear pedicle. Underlying excess forehead subcutaneous fat and frontalis muscle are excised to sculpt a nasal shape. An additional tip graft is placed. The “thin”
forehead skin flap is returned to the recipient site.
Fig. 6.45
H

169
The repair of nasal defects – treatment options
Operation 4
One month later, the forehead pedicle is divided.
Further debulking of the airway, by excising excess soft
tissue between the lining and cartilage grafts, can be per­
formed through nostril marginal incisions at pedicle division
or during a later revision.
Operation 5
Four months later, a revision is performed to improve the
forehead scar, define the alar creases by direct incision, add a
secondary tip graft, open the airway, or trim the nostril
margins or columella.
The result of any reconstruction will be determined by the
choice of donor materials, methods of transfer, flap design,
and the capacity to modify tissues to the needs of the defect.
The ability to adjust the dimension and outline of each ana­
tomic layer, correct imperfections, or salvage complications is
vital. This blending of a microvascular distant folded radial
forearm lining, timed rib grafts for support, and a three-stage
full-thickness forehead flap for cover permits the integration
of “unlike” tissues which can restore a nose which looks and
functions normally. It is reliable, efficient, and reproducible.
Good results – an attractive nose with patent airways – can
be obtained in the repair of complex heminasal, subtotal, and
total injuries.
correction. Two months later, excess external skin is discarded
or hinged downward to adjust nasal length and modify the
nostril rim and the alar base positions in symmetry. External
forearm skin, with a few millimeters of subcutaneous fat, is
elevated and turned over inferiorly. The hinged-over skin is
trimmed to refine or reposition the nostril margins or alar
bases, if needed. The external cutaneous surface of the colu­
mella is split in the midline. If lining for the columella was
not included in the initial vault design or is unavailable due
to tissue loss or wound separation with retraction, the external
vault excess can be turned over to provide additional columel­
lar or alar lining without delaying the repair or impairing the
final result.
The vascular pedicle is not elevated and remains adherent
to the underlying lining. The radial vessels, which perfused
the folded flap through its external skin surface, are effectively
“prelaminated” to the underlying lining. After elevation of
external radial skin, the lining remains perfused through the
radial pedicle and by its peripheral inset to the recipient site.
Excess subcutaneous fat and fascia, on the exposed surface
of the underlying lining, are excised, protecting the radial
vessels. This exposes thin, supple, unscarred lining. Delayed
primary rib support (a columellar strut, tip graft, alar battens,
and sidewall cartilage grafts) are fixed to each other and to
the previously positioned dorsal graft to complete the subunit
support framework. The base of the columellar strut is sutured
to the nasal spine through a buccal incision. A full-thickness
forehead flap, with or without expansion and without distal
thinning, is transferred for permanent nasal cover.
Operation 3
One month later, the forehead flap is delayed. Forehead skin
with 2–3 mm of subcutaneous forehead fat is completely
elevated from the recipient site, maintaining an intact supra­
trochlear pedicle. With complete visualization, the underlying
exposed subcutaneous fat and frontalis muscle are artistically
excised over the entire nasal surface, including the tip and ala.
Previously placed cartilage grafts are sculpted, repositioned,
or augmented to shape an ideal 3D support framework.
Forehead skin, now with the thinness of nasal skin, is replaced
on the recipient site.
Fig. 6.46  (AC) Postoperative result after
pedicle division and subsequent alar crease
creation. A nostrils and create nasal shape.
A
C
The causes of intranasal lining injury:
• Intranasal cocaine
• Wegener’s granulomatosis
• Killer “T” cell lymphoma
• Infectious disease – syphilis, leishmaniasis, yaws, leprosy,
TB, actinomycosis
• Trauma – s/p septorhinoplasty, nasoethmoid fracture,
intranasal cancer excision and radiation, pediatric foreign
body insertion, iatrogenic catheterization injury, or corrosive
inhalation

169.e1
The repair of nasal defects – treatment options
B
(B) Postoperative result after pedicle division and subsequent alar crease
creation. A nostrils and create nasal shape.
Fig. 6.46

170
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
2. Lining necrosis – As the injury increases in severity and
extent, the lining necroses and heals by secondary
intention. The injury is often asymmetric. When isolated
to the nasal vault, the nose increasingly collapses,
shortens, and loses projection and the nostril margins
retract. If it extends onto the floor, with circumferential
360° destruction of the airway mucosa, the upper lip is
pulled superiorly with retrusion.
Although loss of support contributes to deformity,
release of scar contraction and replacement of the
missing lining are paramount.
If the upper lip deformity is mild and can be corrected
by premaxillary grafting alone, the vault lining
deficiency can be corrected with a composite skin graft,
unilaterally or bilaterally. Simultaneously, a cantilever
bone graft and a columellar support are placed through
an open rhinoplasty. When the injury involves both
nasal vaults and floor, the scar contracture of the nasal
floor must also be released to reposition the upper lip.
The lining deficit is resurfaced circumferentially with a
microvascular radial forearm flap with primary dorsal
and columella support grafts.
3. External skin destruction – If severe contraction of the
external nasal skin or full-thickness necrosis occurs, all
layers must be replaced. Commonly, skin loss is
extensive but may be isolated to the columella or ala.
Collapse and contraction may lead to nasal obstruction,
with or without true stenosis of the nostril margins.
Scarred external skin must be discarded and the nose
resurfaced with a forehead flap after lining and support
replacement.
If the nostril orifices are adequate in size to permit
satisfactory breathing, the nasal shortening is moderate,
and the position of the upper lip can be corrected by
soft tissue augmentation without lining replacement,
hingeover flaps of external nasal skin are turned over
along the nostril margin to line the distal nose. Support
is restored with reconstructive grafts for the dorsum,
columella, and ala. A forehead flap resurfaces the nose
in three stages.
If lining for the vault and floor must be replaced
circumferentially or the nostrils are stenotic and must be
opened to maintain the airway, the scarred and
contracted nose is discarded and a folded forearm flap
placed to line both vaults, columella, and the floor. It is
turned on itself to temporarily cover the external nose
and envelop a primary dorsal bone graft. Subsequently,
additional alar and columellar support are placed and
the missing external skin replaced with a forehead flap
to resurfaces a subtotal nose or an isolated alar or
columellar defect.
Reconstructive methods and materials must be reliable,
efficient, and available and minimize facial scarring and
complication. Most importantly, the procedure must
address each aspect of the patient’s specific deformity.
Some patients require simple support; others require
local or circumferential lining; others need isolated or
complete skin cover replacement and the complete array
of reconstructive support grafts (Figs. 6.47–6.55
).
Figs. 6.48A–C, 6.50A–C, 6.51A–D, 6.52A–C appear
online only.
Primary intranasal lining injury
Nasal mucous membranes may be injured by immune disease,
infection, trauma, or cocaine. The pathophysiology is similar
– mucositis, lining necrosis, loss of underlying cartilage and
bone followed by scar contraction.
The mucosal damage may be isolated to the septum,
creating a septal fistula and subsequent collapse of the
dorsum and tip and columellar retraction. It may extend
onto the nasal vault and circumferentially onto the floor with
destruction of the underlying bone and cartilage, leading to
circumferential scar contraction and severe nasal shortening
and lip retraction, respectively. Injury to the external skin
may progress to full-thickness nasal necrosis, due to devas­
cularization and infection. The process may also extend to
the upper lip, hard and soft palate, maxilla, pharynx, and
cranial base.
Isolated trauma (iatrogenic intranasal pressure or chemical
injury) causes more local destruction.
The clinical deformity is determined by the site, extent, and
depth of injury which dictate the technical approach to repair,
not by the etiology of the injury. Surgical correction requires
an accurate preoperative diagnosis to identify each aesthetic,
functional, and anatomic deficiency.
The size of the septal fistula, the extent and strength of the
residual dorsal and caudal strut (determined by palpation),
the degree of lining contracture and external skin scarring
(illustrated by the ability of soft tissues to be repositioned by
soft tissue manipulation) and the presence of full-thickness
nasal necrosis must be evaluated. Widespread necrosis of
lining and subsequent scar contraction, rather than structural
compromise of septum, is the primary cause of the severe
deformity.
Restoration of central support alone, if vault and floor
lining injury are minimal, may restore dorsal contour and tip
projection. Extensive vault and floor lining loss require the
release of scar contraction, recreation of the lining defect, and
replacement of missing vault and/or floor lining with com­
posite grafts, a microvascular flap, or hingeover lining flaps
of scarred external skin. A forehead flap may be needed to
resurface the nose if the external nasal skin cannot be
re-expanded due to scar contraction or is missing. An exten­
sive septal fistula is not repaired due its size and residual
mucosal scarring.
Clinically, patients are classified by presentation.
1. Loss of support – Mild saddling, columellar retraction,
and lip retrusion are due to a lack of support with
otherwise normal cover and lining. The deformity is
corrected by support replacement only.
Onlay dorsal grafting and a columellar strut are
sufficient if the residual dorsal and septal strut remain.
In more severe cases, a cantilevered rib graft is
fixed to the nasal bones and supported by a columellar
strut fixed to the nasal spine. This re-establishes
a strong septal “L” onto which the residual tip
cartilages are advanced and fixed in position with
or without an onlay tip graft. Mild retrusion of
the upper lip is primarily due to loss of caudal
septal support and is corrected by maxillary
augmentation.

170.e1
Primary intranasal lining injury
Fig. 6.50  (ABC) Due to intranasal lining injury, the
septum has been destroyed and the nasal bridge and
tip are unsupported. A relatively localized injury to the
nasal floor and vault lining with significant scar
contraction on the left has cause significant nostril
collapse and retraction.
A
B
C
Fig. 6.48  (ABC) Through an open rhinoplasty approach, the external nasal skin is elevated, a cantilever rib cartilage graft placed to support the bridge and combination
with a columellar strut which is fixed to the nasal spine through buccal incision. The retruded upper lip is augmented with rib cartilage.
A
B
C

170.e2
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
Fig. 6.52  (ABC) Postoperative result
without further surgery. The airway is
open and the nasal shape normal.
A
B
C
Fig. 6.51  (ABCD) An open rhinoplasty is performed. The nose is
resupported with a cantilever dorsal rib graft and columellar strut. The
residual tip cartilages are advanced onto the columellar strut. The
lining defect within the left ala is simultaneously recreated by incision
of scar and the defect filled with a 2 × 2 cm composite skin graft.
A
B
C
D

171
Primary intranasal lining injury
A
Fig. 6.47  (AB) Primary intranasal lining injury can lead to a septal fistula, loss of
nasal support, significant nasal collapse and shortening due to scar contracture,
and retrusion of the upper lip. In this case, a large septal fistula, the septum is
destroyed and dorsal and tip support missing. The upper lip is retruded. But the
injury to vault and floor lining is minimal and the external covering skin normal.
B
A
Fig. 6.49  (AB) Postoperative result after restoration of support. The septal fistula
remains.
B

172
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
A
Fig. 6.53  (AB) Severe primary intranasal lining injury to the
septum, nasal vault, and floor with subsequent scar contraction
has collapsed and shortened the nose. A huge septal fistula is
present. The overlying external nasal skin is relatively normal.
B
Fig. 6.54  (A–E) Through an open rhinoplasty approach, the poorly supported but uninjured tip cartilages are exposed. The mid-vault scarring is excised transversely at the
dorsum, extending laterally along each nasal vault and then along the nasal floor to create a 360° circumferential release of the deformity. A 2.5 × 7 cm microvascular radial
forearm flap is positioned to circumferentially replace the missing lining. A primary cantilever dorsal graft and columellar strut are also placed.
A
B
C
D
E

173
Revision
patient and surgeon. Correction may prolong the reconstruc­
tion and increase the number of stages. The patient may have
to live with undivided pedicle until the problem is resolved,
the tissues have matured, and unplanned procedures are
performed. This may require an early reoperation or a post­
ponement of a previously scheduled operation. But the
complication must be dealt with. Most importantly, save the
repair. If not, limit the damage. Preserve viable donor materi­
als for another day, at the very least. Watchful waiting for the
resolution of tissue loss or infection, with or without antibiotic
coverage, is rarely successful.
Forehead flap necrosis is uncommon. It may be caused by
inadequate flap dimension or aggressive suturing of the flap
to the recipient site leading to tension on wound closure,
failure to identify a significant old scar within the flap’s terri­
tory, injury to the vascular pedicle, overzealous thinning at
transfer, or excessive re-elevation of the flap from the recipient
site at pedicle division. Ensuing cartilage infection is pre­
vented by early local debridement of a significant covering
flap necrosis (more than a few millimeters) and immediate
resurfacing with a second vascularized flap (often as a
subunit). This approach is often preferable to watchful waiting
which may lead to progressive cartilage exposure, infection,
and late severe soft tissue contraction.
Fulminant acute infection is extremely uncommon but may
follow a failure in aseptic technique or lining necrosis. If
limited necrosis of lining is identified prior to gross infection,
early debridement of the necrotic lining, removal of overlying
primary cartilage grafts, and skin grafting of the lining deficit
are performed. The forehead flap is replaced. One month later,
the skin graft will be revascularized from adjacent lining and
the forehead flap can be re-elevated and resupported with
delayed primary grafts. If the infection is severe, aggressive
debridement of infected and necrotic nasal tissues and return
of the forehead flap to the donor site, to preserve it for a later
reuse, may be required.
Chronic cartilage infection presents as local redness with
purulent discharge several weeks after surgery. It should be
treated quickly with limited flap re-elevation and debride­
ment of infected cartilage. It does not respond reliably to
simple antibiotic coverage. Once controlled, delayed primary
cartilage grafts are placed to resupport the deficient area 6–8
weeks later.
Revision
Complex nasal reconstructions often require a revision to
re-establish ideal nasal form and function.83 Exact templates,
based on the contralateral normal or ideal, guide the revision,
which is performed under general anesthesia, without local
anesthesia, to avoid intraoperative distortion and blanching
(Figs. 6.56–6.62).
Revisions can be classified25,82,83 as:
Minor: Essential quality, outline, and contour are restored
with inadequate landmark definition.
Major: Failure of dimension, volume, contour, and symmetry
or function.
Redo: Cover and lining are grossly deficient. Normal must
be returned to normal and the repair redone with a second
regional flap.
Outcomes, prognosis, and
complications
Complications are uncommon.22,25,81 Fortunately, the abundant
blood supply of the face limits ischemia and infection.
However, badly scarred tissues, a history of multiple past
operations, prior alloplastic implant, or previous infection
increase the risk of complication.
If a complication ensues, the repair is almost always sal­
vageable. The rich vascularity of the soft tissues of a full-
thickness forehead flap, transferred in three stages, may lessen
the risk of complications and allow more reliable treatment.
However, a complication is of great concern due the potential
loss of the building materials and the emotional stress on the
A
Fig. 6.55  (AB) Postoperative result.
B

174
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
Fig. 6.56  The contour and function of the reconstructed nose can be improved by
secondary revision. Four to 6 months after reconstruction, soft tissues can be
sculpted and secondary cartilage grafts placed. If the overall dimension, position, and
volume of the nose are correct, the revision can be performed through direct incisions
to reestablish fine landmarks. If not, the transferred flap is re-elevated along its
periphery, based on its inset into the recipient site blood supply. Soft tissues are
excised, secondary cartilage grafts added, and the flap is returned to the recipient
site. A secondary revision may be necessary to further define the alar crease. The alar
crease is re-created by direct incision, based on the contralateral normal or on the
ideal. Disregarding old scars, an incision at the ideal alar crease position, thin skin
flaps were elevated superiorly and inferiorly a sculptured excision to restore the shape
of the convex ala, a crisp alar crease, and a flat sidewall. A thick alar rim and a
stenotic nostril can be improved. The ideal alar margin is incised and lining elevated
thinly. Excessive subcutaneous bulk is excised between the lining and deep surface of
the old alar margin Support grafts to thin the lining and the nostril margin. The
stenotic lining is incised at right angles to the nostril margin. Excess skin along the
inferior edge of the nostril margin is transferred as a superiorly or inferiorly based
skin flap to fill the lining gap and increase the dimension of the nostril.
Pattern from
contralateral
right side
Template flipped and
marked on left side
Excess soft tissue trimmed
to shape ala and sidewall
Nasal units
marked
Quilting sutures
A
B
Old alar batten graft
Excised tissue
Lining transected

175
Revision
Fig. 6.57  (A–E) After complex facial fractures and soft tissue avulsion of the forehead, cheek, and nose, a
full-thickness defect of the right tip and ala was repaired with a cervical tube flap and cartilage grafts. The
right alar rim is thick; the nostril small; the nostril margins asymmetric; and the alar crease and nasal labial
fold absent. The ideal alar crease, nasal labial fold, and nostril are marked with ink based on pattern to the
contralateral normal. The nostril margin is incised and the lining elevated thinly. Excess bulk is excised
between the lining and the previously positioned alar margin support graft. The lining was transected laterally
at the alar base and excess tissue within the thick nostril margin transposed with inferior base to fill a lining
deficiency.
A
B
C
D
E

176
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
Fig. 6.58  (A–C) At the same time, direct incisions were made within the ideal alar crease and nasal labial fold based on pattern to the contralateral normal. Skin flaps were
elevated and soft tissues are excised to sculpt a round ala, flat sidewall, and flat hairless triangle of the upper lip.
A
B
C
Fig. 6.59  (A–C) Postoperative result.
A
B
C
The minor revision
When the overall dimension and volume of the nose are
correct, “finesse definition” is achieved through direct inci­
sions hidden in the joins between subunits, disregarding old
scars. The alar crease or nasolabial fold is defined and second­
ary support placed. A minor revision can often be accom­
plished in one stage.
The nostril margin and columella are thick and the airway
stenotic. The nostril margin is incised, separating cover and
lining. Lining is elevated thinly into the airway. Excess sub­
cutaneous fat and scar are excised between the lining layer
and the deep surface of previously positioned support grafts,
debulking the airway. The lining is incised in the anterior
vestibule and/or nasal floor at right angles to the nostril
margin. Skin excess, from the thick reconstructed alar rim and
columella or from the lip, inferior to the nostril floor, is trans­
posed, as small flaps, to fill the gap and augment the lining
deficiency, opening the airway.
The major revision
When the nose is shapeless and bulky, “gross debulking” is
performed through peripheral incisions around the border of
the flap. The random blood supply of the old flap permits
re-elevation of at least 80% of inset, permitting wide exposure.
Underlying soft tissue and support are modified by sculpting
excision and secondary cartilage grafting.

177
Revision
A
Fig. 6.60  (AB) Some years previously, a congenital
nevus of the nose and cheek had been excised in
this eight-year-old boy and the nose resurfaced with
a two-stage forehead flap. No alar rim support had
been placed. The nose remains shapeless and the tip
and alar rims collapsed and unsupported.
B
A
B
C
Fig. 6.61  (A–E) The old forehead flap is elevated
on a superior base. Approximately 80% of the flaps
inset were re-elevated to expose excess bulky soft
tissue and inclusion cysts. The soft tissues were
excised to sculpt a nasal shape and secondary ear
cartilage grafts placed to support the alar rims and
projected tip. The forehead flap was then returned
to the recipient site with peripheral and quilting
sutures.
D
E

178
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
A
Fig. 6.62  (AB) Postoperative results without revision. An old
forehead flap can be extensively re-elevated, underlying soft
tissue sculpted, secondary cartilage grafts added. The overlying
flap can be resupported and shaped by soft tissue sculpting
and secondary cartilage grafts.
B
When all anatomical layers are fibrotic, the forehead flap is
re-elevated with a few millimeters of subcutaneous fat.
Scarred soft tissue and poorly designed support are com­
pletely excised. After excision of scar, the thinned cover and
lining often re-expand and can be reshaped with a new,
complete rigid support.
A second finesse revision, through direct incisions, will
often be needed to improve landmark definition.
The redo
If tissues are grossly deficient, the repair must be redone using
a second regional flap. The defect is recreated, tissues are
returned to their normal position, the deficiencies of cover,
lining, and support identified and replaced.
Fig. 6.5 (A–E) Nasal defect after excision of basal cell carcinoma of the medial
ala and tip resurfaced with one stage nasolabial flap. No revision.
Fig. 6.7 (A–E) Subunit reconstruction of left ala with two-stage nasolabial flap.
The subunits of the nose are marked with ink. A template of the right
contralateral alar subunit will define the dimension and outline of the nasal
labial flap and the primary cartilage graft. Residual skin within the left alar
subunit is excised. A primary ear cartilage graft is fixed to support the alar
lining. A subunit superiorly based axial nasolabial flap was elevated to resurface
the alar subunit.
Fig. 6.8 (A–E) One month later, the pedicle is divided, the nasal inset is
partially elevated, and the underlying excess soft tissue bulk excised to create a
convex alar contour and deep alar crease. Excess skin is excised and the flap
inset completed. The cheek is closed to lie exactly within the nasal labial fold.
No revision.
Fig. 6.9 (A–E) Two-stage paramedian forehead flap resurfacing of the ala as a
subunit. After Mohs excision of a basal cell carcinoma, greater than 50% of the
left alar skin is missing. The nasal subunits are marked with ink. Excess skin
within the alar subunit is discarded. The lining is supported with a primary ear
cartilage graft. A right paramedian forehead flap is designed vertically over the
supratrochlear vessels. It is thin distally and transferred to the defect.
Fig. 6.10 (A–F) One month later, the forehead pedicle was divided. Skin within
the superior aspect of the recipient site is elevated thinly an underlying the
cutaneous fat and primary cartilage graft is excised to sculpt a convex ala and
deep alar crease. Excess skin history and in the inset is completed with quilting
sutures in a single layer of fine peripheral sutures. No revision.
Fig. 6.12 (B) A new Mohs defect of the nasal tip lies within a nose previously
reconstructed with skin grafts and a left composite flap for cover and lining. The
left rim is retracted.
Fig. 6.13 (A,B) The subunits of the nose are marked. A subunit excision of the
tip and both ala, but not of the dorsum is performed. Skin of the old composite
skin graft is hinged over for a left nasal rim lining. Primary cartilage grafts of
ear cartilage are placed to support, brace, and shape the lining and future cover.
Fig. 6.14 (A,C,D) A full-thickness paramedian forehead flap is elevated under
the frontalis. The forehead flap contains skin, subcutaneous fat, and all its
frontalis layers. It is transferred to resurface the nose without thinning.
Fig. 6.15 (B) One month later, forehead skin with 2–3 mm of subcutaneous fat
is elevated completely to expose the entire reconstruction. The flap is
temporarily placed on the forehead.
Fig. 6.16 (B–D) Remaining subcutaneous fat and frontalis are now excised to
sculpt a nasal shape. Previous primary cartilage grafts healed to the underlying
lining can be modified. The uniformly thin forehead flap is returned to the
recipient site. It is fixed in place with peripheral sutures and temporarily molded
to the contoured surface with percutaneous quilting sutures.
Fig. 6.20 (A,C) A preliminary operation was performed to place a forehead
expander and perform an open rhinoplasty to lower the radix, narrow the nasal
bones, harvest septal cartilage for a future procedure, and advance the old scars
onto the nasal subunit. Two months later, the nasal tip and ala were excised as a
subunit and all scars excised over the dorsum and sidewall. Lateral skin was
advanced almost to the dorsal line to modify the defect. A columellar strut with
advancement of the residual medial crura and ear cartilage alar battens
Bonus images for this chapter can be found online at

179
Revision
supported the tip. A septal cartilage graft shaped the dorsum. A full-thickness
forehead flap was transferred to resurface the defect. The position and symmetry
of the alar rims seems correct intraoperatively.
Fig. 6.21 (A,B,D,E,H) One month later, due to scar contracture, support shift,
or an imperfect design, the alar rims were asymmetric. During the planned
intermediate operation, the forehead skin was elevated with 2–3 mm of
subcutaneous fat. The excess underlying subcutaneous fat and frontalis were
excised to sculpt an ideal nasal shape. Lining along each rim was released,
hinged inferiorly, and positioned with additional delayed primary ear cartilage
grafts to reposition the nostril margins inferiorly and in symmetry. The thin
forehead flap was returned to the recipient site. The forehead flap pedicle was
divided 1 month later.
Fig. 6.25 (A–D) Blood supply and design of intranasal lining flaps.
Fig. 6.26 (A,B) Reconstruction of a complex full-thickness nasal defect with a
three-stage full-thickness forehead flap and intranasal lining flaps. A large,
full-thickness defect is present after skin cancer excision. Skin is missing from
the dorsum tip left sidewall and medial cheek. The tip cartilages and left upper
lateral cartilage are missing. Lining for the left ala and sidewall are absent. The
medial cheek defect was initially repaired with a fat flip-flap and cheek
advancement to allow reconstruction on the stable platform. This will be
repaired with intranasal lining flaps and a three-stage, full-thickness forehead
flap.
Fig. 6.27 (A–C) Six weeks later, the ipsilateral septal mucoperichondrium is
elevated off the underlying septal cartilage and a hinged downward and laterally
on the septal branch of the left superior labial artery. Cartilage within the
exposed septum is harvested, maintaining dorsal and caudal septal support. The
contralateral septum is incised maintaining a superior base perfused by the
anterior ethmoidal arteries. Ipsilateral septal flap is fixed laterally to line the
nostril margin and ala and the contralateral septal flap is transposed to provide
lining of the nasal sidewall. Because the defect included part of the right ala,
additional skin within the residual right ala was discarded to allow resurfacing of
the nose as a subunit.
Fig. 6.31 (D) The intermediate operation of the modified folded forehead flap.
One month later, the folded forehead flap lining extension is healed to the
adjacent normal nasal lining and is no longer dependent on the forehead flap
for its supratrochlear blood supply. The regional units of the nose and ideal alar
margin are marked with ink. The forehead flap is incised between covering and
lining along the nostril margin and the covering flap was elevated with 2–3 mm
of subcutaneous fat. This exposes the underlying unsupported subcutaneous fat
and frontalis muscle which is excised from the underlying lining of folded
forehead skin. A delayed primary cartilage graft is positioned to support the ala
(and sidewall, if needed). The thin forehead flap is returned to the recipient site
for nasal cover. One month later (2 months after the initial flap transfer), the
proximal pedicle is divided.
Fig. 6.32 (A,B,D) A full-thickness defect of the right ala and sidewall is
present after Mohs excision. The regional units of the nose and the ideal alar
base position are marked with ink based on the template of the contralateral
normal upper lip. Templates were designed to replace the missing cover and
lining exactly in dimension and border outline. A full-thickness forehead flap is
elevated with the distal extension for lining and folded to replace missing nasal
lining and the more proximal distal flap is turned back to resurface the defect.
No primary cartilage grafts were placed. The raw pedicle of the forehead flap
was skin grafted for cleanliness.
Fig. 6.33 (B,C) One month later, the reconstruction is bulky and unsupported.
The lining extensions are now vascularized by the residual nasal lining and are
no longer dependent on the forehead flap for vascularity. The ideal nostril
margin is marked with ink and incised. The proximal forehead flap was elevated
with 2–3 mm of subcutaneous fat. The folded double layer of so and is fat and
frontalis muscle is exposed. The excess is excised in the lining skin is
supported and shaped with a delayed primary conchal cartilage graft. The thin
forehead skin flap is returned to the defect and fixed with quilting sutures and
peripheral sutures.
Fig. 6.34 (B,C) Postoperative result after pedicle division and right alar crease
creation.
Fig. 6.37 (A,D) One month later, the cover and lining flaps are separated along
the ideal nostril margin and excess subcutaneous fat and frontalis sculpted to
refine the nasal shape. The forehead flap is then returned to the recipient site.
Fig. 6.42 (A–C) A rib cartilage graft was fixed to the residual nasal bones to
provide primary dorsal support and prevent soft tissue shortening and collapse.
Because the missing nasal floor had been repaired with nasolabial flaps, a
microvascular radial forearm flap was designed without a distal extension for the
nasal floor. Its ulnar border is folded inward to create columella and pulled
lining. The skin extension resurfaces the nasal floor. More proximal forearm skin
and the radial vessels are turned back to provide temporary cover and permit
placement of a primary dorsal osteocartilaginous graft.
Fig. 6.43 (B,D) Two months later, external radial skin is hinged inferiorly. The
reconstructed “columella” is split in the midline. The nostril margin and alar
base insets are adjusted. The radial vessels are left adherent to the underlying
folded lining. Excess forearm soft tissue is excised to thin the lining.
Fig. 6.44 (A,B,F) Subunit support is completed with a columellar strut, tip
graft, and bilateral alar margin rib grafts. The repair is resurfaced with a
full-thickness forehead flap.
Fig. 6.45 (B,D,F,H) During the subsequent intermediate operation, forehead
skin with 2–3 mm of subcutaneous fat is elevated entire nasal inset, maintaining
the proximal supratrochlear pedicle. Underlying excess forehead subcutaneous
fat and frontalis muscle are excised to sculpt a nasal shape. An additional tip
graft is placed. The “thin” forehead skin flap is returned to the recipient site.
Fig. 6.46 (B) Postoperative result after pedicle division and subsequent alar
crease creation. A nostrils and create nasal shape.
Fig. 6.48 (A–C) Through an open rhinoplasty approach, the external nasal skin
is elevated, a cantilever rib cartilage graft placed to support the bridge and
combination with a columellar strut which is fixed to the nasal spine through
buccal incision. The retruded upper lip is augmented with rib cartilage.
Fig. 6.50 (A–C) Due to intranasal lining injury, the septum has been destroyed
and the nasal bridge and tip are unsupported. A relatively localized injury to the
nasal floor and vault lining with significant scar contraction on the left has
caused significant nostril collapse and retraction.
Fig. 6.51 (A–D) An open rhinoplasty is performed. The nose is resupported
with a cantilever dorsal rib graft and columellar strut. The residual tip cartilages
are advanced onto the columellar strut. The lining defect within the left ala is
simultaneously recreated by incision of scar and the defect filled with a 2 ×
2 cm composite skin graft.
Fig. 6.52 (A–C) Postoperative result without further surgery. The airway is open
and the nasal shape normal.

180
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
1. McDowell F. The Source Book of Plastic Surgery. Baltimore: Williams
& Wilkins; 1977. The modern surgeon differs from his ancient predecessors
because of the knowledge that developed over time. This book combines
reproductions of the early literature in plastic surgery with biographies and
modern commentary. The origins of skin grafting, rhinoplasty, cleft lip, and
palate, cross lip flaps, otoplasty, and facial fractures contributors are
provided. Such history provides perspective and insight.
8. Gillies HD. Plastic Surgery of the Face. London: Oxford Medical
Publishers; 1920. Gillies, the modern father of plastic surgery, clearly
describes his experience caring for the massive facial injuries which
followed the trench warfare of WW1. The modern principles of facial
reconstruction developed and are presented through clear case analysis
with excellent photography. His results are superior. Historical but
pertinent today.
16. Gillies HD, Millard DR. The Principles and Art of Plastic Surgery.
Boston: Little Brown; 1957. Gillies and his student, Millard, present a
comprehensive overview of principle and treatments between WW1 and
WW2 into the early 1950s. Core principles and ingenious solutions
remain pertinent to any surgeon interested in facial reconstruction.
22. Burget G, Menick F. Aesthetic Reconstruction of the Nose. St. Louis:
Mosby; 1993. The first modern text dedicated to nasal reconstruction. The
principles of facial repair are presented with in depth details of varied
cases and solutions for small and superficial defects and large deep defects.
The indications and use of local and regional flaps, intranasal lining, and
primary support are illustrated. The treatment of complications and
secondary late revision are detailed. This book is comprehensive, yet
useful, as an atlas for the surgeon looking for a solution to a specific
clinical problem.
23. Burget G, Menick F. Nasal support and lining: the marriage of
beauty and blood supply. Plast Reconstr Surg. 1989;84:189. The use of
thin supple intranasal lining, combined with primary cartilage grafts, and
subunit resurfacing with a two-stage forehead flap revolutionized nasal
reconstruction in the 1980s. This paper illustrates the technique with
superb clinical case presentations.
25. Menick FJ. Nasal Reconstruction: Art and Practice. Philadelphia:
Saunders–Elsevier; 2008. This text complements and expands the
fundamental principles and approaches described in Burget and Menick’s
Aesthetic Reconstruction of the Nose. Analysis, principles, materials,
and recently introduced techniques are presented to repair simple or the
most complex defects to with both traditional and more recently developed
techniques. The use of the full-thickness forehead flap for nasal resurfacing
of more difficult defects, the modified folded flap lining and skin graft
lining techniques, the treatment of complications, and late surgical
revision are presented in depth. The “table of cases”, (a compendium of
patient photographs repaired by case example within the text) provides a
quick reference to specific problems and their solutions within the text to
help the reader find the information needed to treat their patient’s
presenting defect.
29. Millard DR. Principalization of Plastic Surgery. Boston: Little Brown;
1986. Millard outlines an approach to both cosmetic and reconstruction
based on principles. Every clinical problem or defect is different. Principles
provide a tool to analyze the difficult problem and guide repair. Millard
describes his approach, based on these principles, with wide and varied
case examples that can be applied to clinical problems and how to live life
in general.
78. Menick FJ. Optimal use of microvascular free flaps, cartilage grafts,
and a paramedian forehead flap for aesthetic reconstruction of the
nose and adjacent facial units. Plast Reconstr Surg. 2007;120:1171.
Composite defects of the midface are those which combine nasal, cheek, and
lip. Their repair is especially difficult due to the complex aesthetics and
tissue requirements. The basic principles of repair and current approaches
are presented to satisfy the unique needs of these defects.
82. Menick F, Salibian A. Primary intranasal lining injury – Cause,
deformity and treatment plan. Plast Reconstr Surg. 2014;134:1045.
Nasal mucous membranes may be injured by immune disease, infection,
trauma, or cocaine. The pathophysiology is similar – mucositis, lining
necrosis, loss of underlying cartilage and bone, followed by scar
contraction.
The mucosal damage may be isolated to the septum, creating a septal
fistula, or may extend onto the nasal vault and floor, leading to
circumferential scar contraction and severe nasal shortening and lip
retraction. External skin injury may progress to full-thickness nasal
necrosis. The clinical deformity is determined by the site, extent, and
depth of injury which dictate the technical approach to repair.
83. Menick F. An Approach to the Late Revision of a Failed Nasal
Reconstruction. Plast Reconstr Surg. 2012;129:92e. Many nasal repairs
with local and regional tissues require a late revision to improve
appearance and function. “Minor” deformities, in which the overall
dimension and position are correct, require finesse landmark recreation
and airway debulking. “Major” deformities fail to restore the basic nasal
character due to significant bulk and contour inadequacies. Revisions are
performed employing peripheral border scars, new incisions, soft tissue
sculpting excision, secondary cartilage grafts, and local lining replacement
to open the airway.
Access the complete reference list online at

180.e1
References
References
1. McDowell F. The Source Book of Plastic Surgery. Baltimore: Williams
& Wilkins; 1977. The modern surgeon differs from his ancient
predecessors because of the knowledge that developed over time. This book
combines reproductions of the early literature in plastic surgery with
biographies and modern commentary. The origins of skin grafting,
rhinoplasty, cleft lip, and palate, cross lip flaps, otoplasty, and facial
fractures contributors are provided. Such history provides perspective
and insight.
2. Bhishagratna KKL. Sushruta Samhita. Calcutta: Bose; 1907–1916.
3. Gnudi M, Webster J. The Life and Times of Gaspare Tagliacozzi. New
York: Herbert Reichner; 1988.
4. Miller TA. The Tagliacozzi flap as a method of nasal and palatal
reconstruction. Plast Reconstr Surg. 1985;76:870.
5. Carpue J. An Account of Two Successful Operations for Restoring a
Lost Nose. London: Longman, Hurst, Rees, Orme, and Brown;
1816.
6. Kanzanjian VH. The repair of nasal defects with the median
forehead flap: primary closure of the forehead wound. Surg
Gynecol-Ostet. 1946;83:37.
7. Mazzola RF, Marcus S. History of total nasal reconstruction with
particular emphasis on the folded forehead flap technique. Plast
Reconstr Surg. 1983;72:408.
8. Gillies HD. Plastic Surgery of the Face. London: Oxford Medical
Publishers; 1920. Gillies, the modern father of plastic surgery, clearly
describes his experience caring for the massive facial injuries which
followed the trench warfare of WW1. The modern principles of facial
reconstruction developed and are presented through clear case analysis
with excellent photography. His results are superior. Historical but
pertinent today.
9. Converse JM. New forehead flap for nasal reconstruction. Proc R
Soc Med. 1942;35:811.
10. Converse JM. Reconstruction of the nose by the scalping flap
technique. Surg Clin North Am. 1959;39:335.
11. New G. Sickle Flaps for Nasal Reconstruction Surgery. Gynecol
Obstet. 1945;80:497.
12. Washio H. Retroauricular temporal flap. Plast Reconstr Surg.
1969;43:162.
13. MacCarthy J, Lorenc T, Cutting C, et al. The median forehead flap
revisited: the blood supply. Plast Reconstr Surg. 1985;76:866.
14. Reece E, Schaverien M, Rohrich R. The paramedian forehead flap: a
dynamic anatomical vascular study verifying safety and clinical
implications. Plast Reconstr Surg. 2008;121:1956.
15. Millard DR. A Rhinoplasty Tetralogy. New York: Little Brown;
1996.
16. Gillies HD, Millard DR. The Principles and Art of Plastic Surgery.
Boston: Little Brown; 1957. Gillies and his student, Millard, present a
comprehensive overview of principle and treatments between WW1 and
WW2 into the early 1950s. Core principles and ingenious solutions
remain pertinent to any surgeon interested in facial reconstruction.
17. Keegan DF. Rhinoplastic Operations with a Description of Recent
Improvements in the Indian Method. London: Balliere, Tindall, and
Cox; 1900.
18. Gillies HA. New Free Graft Applied to the Reconstruction of the
Nostril. Br J Surg. 1943;30:305.
19. Converse JM. Composite graft from the septum in nasal
reconstruction. Trans Lat Am Congr Plast Surg. 1956;8:281.
20. Kanzanjian VH, Converse JM. The Surgical Treatment of Facial
Injuries. Baltimore: Williams & Wilkins Co.; 1974.
21. Gillies HD. Plastic Surgery of the Face. London: Oxford Medical
Publishers; 1920.
22. Burget G, Menick F. Aesthetic Reconstruction of the Nose. St. Louis:
Mosby; 1993. The first modern text dedicated to nasal reconstruction. The
principles of facial repair are presented with in depth details of varied
cases and solutions for small and superficial defects and large deep defects.
The indications and use of local and regional flaps, intranasal lining, and
primary support are illustrated. The treatment of complications and
secondary late revision are detailed. This book is comprehensive, yet
useful, as an atlas for the surgeon looking for a solution to a specific
clinical problem.
23. Burget G, Menick F. Nasal support and lining: the marriage of
beauty and blood supply. Plast Reconstr Surg. 1989;84:189. The use of
thin supple intranasal lining, combined with primary cartilage grafts, and
subunit resurfacing with a two-stage forehead flap revolutionized nasal
reconstruction in the 1980s. This paper illustrates the technique with
superb clinical case presentations.
24. Menick FJ. The use of skin grafts of nasal lining in head and neck
reconstruction. In: Kroll S, ed. Clinics in Plastic Surgery.
Philadelphia: WB Saunders; 2001.
25. Menick FJ. Nasal Reconstruction: Art and Practice. Philadelphia:
Saunders–Elsevier; 2008. This text complements and expands the
fundamental principles and approaches described in Burget and Menick’s
Aesthetic Reconstruction of the Nose. Analysis, principles, materials,
and recently introduced techniques are presented to repair simple or the
most complex defects to with both traditional and more recently developed
techniques. The use of the full-thickness forehead flap for nasal resurfacing
of more difficult defects, the modified folded flap lining and skin graft
lining techniques, the treatment of complications, and late surgical
revision are presented in depth. The “table of cases”, (a compendium of
patient photographs repaired by case example within the text) provides a
quick reference to specific problems and their solutions within the text to
help the reader find the information needed to treat their patient’s
presenting defect.
26. Burget GC, Walton R. Optimal use of microvascular free flaps,
cartilage grafts and a paramedian forehead flap for aesthetic
reconstruction of the nose and adjacent facial units. Plast Reconstr
Surg. 2007;120:1228.
27. Menick FJ. Artistry in facial surgery: aesthetic perceptions and the
subunit principle. In: Furnas D, ed. Clinics in Plastic Surgery. Vol. 14.
Philadelphia: WB Saunders; 1987.
28. Gonzalez-Ulloa M, Castillo A, Stevens E, et al. Preliminary study of
the total restoration of the facial skin. Plast Reconstr Surg. 1954;1:
151.
29. Millard DR. Principalization of Plastic Surgery. Boston: Little Brown;
1986. Millard outlines an approach to both cosmetic and reconstruction
based on principles. Every clinical problem or defect is different. Principles
provide a tool to analyze the difficult problem and guide repair. Millard
describes his approach, based on these principles, with wide and varied
case examples that can be applied to clinical problems and how to live life
in general.
30. Burget GC, Menick FJ. Subunit principle in nasal reconstruction.
Plast Reconstr Surg. 1985;76:239.
31. Menick FJ. Defects of the nose, lip, and cheek: rebuilding the
composite defect. Plast Reconstr Surg. 2007;120:887.
32. Limberg AA. Mathematical Principles of Local Plastic Surgery
Procedures on the Surface of the Human Body. Leningrad: Medgis;
1946.
33. Elliot RA Jr. Rotation flaps of the nose. Plast Reconstr Surg.
1969;44:1a47.
34. Marchac D, Toth B. The axial frontonasal flap revisited. Plast
Reconstr Surg. 1985;76:686.
35. Reiger RA. A local flap for repair of the nasal tip. Plast Reconstr
Surg. 1967;40:147.
36. Rohrich RJ, Muzaffar AR, Adams WP Jr, et al. The aesthetic unit
dorsal nasal flap: rationale for avoiding a glabellar incision. Plast
Reconstr Surg. 1999;104:1289.
37. Zimany A. The bilobed flap. Plast Reconstr Surg. 1953;11:424.
38. McGregor JC, Soutar DS. A Critical Assessment of the Bilobed Flap.
Br J Plast Surg. 1981;34:197.
39. Zitelli JA. The bilobed flap for nasal reconstruction. Arch Dermatol.
1989;125:957.
40. Herbert DC, Harrison RG. Nasolabial subcutaneous pedicle flaps: 1)
Observations on their blood supply. Br J Plast Surg. 1975;28:85.
41. Herbert DC. A subcutaneous pedicle cheek flap for reconstruction
of alar defects. Br J Plast Surg. 1978;31:79–92.
42. Hofer S, Posch N, Smit X. Facial artery perforator flaps for
reconstruction of perioral defects. Plast Reconstr Surg. 2005;115:
996.

180.e2
SECTION II
CHAPTER 6 • Aesthetic nasal reconstruction
43. Menick F. The two-stage nasolabial flap for subunit reconstruction
of the ala. In: Cordeiro P, ed. Operative Techniques in Plastic and
Reconstructive Surgery. Vol. 5. Hoboken: John Wiley; 2006.
44. Converse JM, Wood-Smith D. Experiences with the forehead island
flap with a subcutaneous pedicle. Plast Reconstr Surg. 1963;31:521.
45. Menick FJ. Nasal Reconstruction – The Paramedian Forehead Flap.
Nose Section; 2001.
46. Menick FJ. Nasal Reconstruction. Plast Reconstr Surg.
2010;125:138e–150e.
47. Radovan C. Tissue expansion in soft tissue reconstruction. Plast
Reconstr Surg. 1993;91:624.
48. Manders K, Schenden MJ, Furrey JA, et al. Soft tissue expansion:
concepts and complications. Plast Reconst Surg. 1984;74:493.
49. Keskin M, Kelly CP, Yavuzer R, Miyawaki T, Jackson IT. External
filling ports in tissue expansion confirming their safety and
convenience. Plast Reconstr Surg. 2006;117:1543.
50. Adler N, Dorafshar AH, Bauer BS, Hoadley S, Tournell M. Tissue
expansion infection in the pediatric patient: management and
outcome. Plast Reconstr Surg. 2009;124:484.
51. Burget G, Menick F. Nasal support and lining: the marriage of
beauty and blood supply. Plast Reconstr Surg. 1989;84:189.
52. Gibson T, Davis WB. The distortion of autogenous grafts: its cause
and prevention. Br J Plast Surg. 1958;10:257.
53. Tessier P. Autogenous bone grafts taken from the calvarium for
facial and cranial applications. Clin Plast Surg. 1982;9:531.
54. Posnick JC, Seagle MB, Armstrong D. Nasal reconstruction with
full-thickness cranial bone grafts and rigid internal skeleton fixation
through a coronal incision. Plast Reconstr Surg. 1990;86:894–902.
55. Menick FJ. Anatomic reconstruction of the nasal tip cartilages in
secondary and reconstructive rhinoplasty. Plast Reconstr Surg.
1999;104:2187.
56. Gillies HD. A new free graft applied to the reconstruction of the
nostril. Br J Surg. 1943;30:305.
57. Barton FE Jr. Aesthetic aspects of nasal reconstruction. Clin Plast
Surg. 1988;15:155–166.
58. Pribaz J, Fine N, Orgill D. Flap prelamination in the head and neck:
a 10 year experience. Plast Reconstr Surg. 1999;103(3):808–820.
59. Guo L, Pribaz J. Clinical flap prefabrication. Plast Reconstr Surg.
2009;124:e340–e350.
60. Pribaz J, Weiss DD, Mulliken JB, Eriksson E. Prelaminated free flap
reconstruction of complex central facial defects. Plast Reconstr Surg.
1999;104(2):357–365.
61. Pribaz J, Stephens W, Crespo L, Gifford G. A new intraoral flap:
facial artery musculomucosal (FAMM) flap. Plast Reconstr Surg.
1993;91:1170.
62. Kanzanjian VH. Reconstruction of the ala using septal flap. Trans
Am Acad Ophthalmol Otolaryngol. 1937;42:338.
63. Millard DR. Versatility of the chondromucosal flap in the nasal
vestibule. Plast Reconstr Surg. 1972;50:580–587.
64. Millard DR. Total reconstructive rhinoplasty and a missing link.
Plast Reconstr Surg. 1966;37:167.
65. Millard DR. Hemirhinoplasty. Plast Reconstr Surg. 1967;40:440–445.
66. Millard DR. Reconstructive rhinoplasty for the lower half of the
nose. Plast Reconstr Surg. 1974;53:133.
67. Millard DR. Reconstructive rhinoplasty for the lower two-thirds of
the nose. Plast Reconstr Surg. 1976;57:722.
68. Millard DR. Aesthetic reconstructive rhinoplasty. Clin Plast Surg.
1981;8:169.
69. Burget G, Menick F. Nasal support and lining: the marriage of
beauty and blood supply. Plast Reconstr Surg. 1989;84:189.
70. Burget GC, Menick FJ. Nasal reconstruction: seeking a fourth
dimension. Plastic Reconstr Surg. 1986;78:145.
71. Menick FJ. Ten-year experience in nasal reconstruction with the
three-stage forehead flap. Plast Reconstr Surg. 2002;109:1839.
72. Menick FJ. Options in nasal lining. In: Jurkiewicz M, Culbertson J,
eds. Operative Techniques in Plastic and Reconstructive Surgery. Vol. 8.
New York: Appleton and Lange; 1999.
73. Menick FJ. A new modified method for nasal lining: the Menick
technique for folded lining. J Surg Oncol. 2006;94:509–514.
74. Menick FJ. The use of skin grafts of nasal lining. Clin Plast Surg.
2001;28:311.
75. Menick FJ. Facial Reconstruction with local and distant tissue: the
interface of aesthetic and reconstructive surgery. Plast Reconstr Surg.
1999;102:1424.
76. Guo L, Pribaz J. Clinical flap prefabrication. Plast Reconstr Surg.
2009;124:e340–e350.
77. Burget GC, Walton R. Microsurgical reconstruction of nasal lining.
Plast Reconstr Surg. 2005;115:1813.
78. Menick FJ. Optimal use of microvascular free flaps, cartilage grafts,
and a paramedian forehead flap for aesthetic reconstruction of the
nose and adjacent facial units. Plast Reconstr Surg. 2007;120:1171.
Composite defects of the midface are those which combine nasal, cheek, and
lip. Their repair is especially difficult due to the complex aesthetics and
tissue requirements. The basic principles of repair and current approaches
are presented to satisfy the unique needs of these defects.
79. Burget GC, Walton R. Optimal use of microvascular free flaps,
cartilage grafts and a paramedian forehead flap for aesthetic
reconstruction of the nose and adjacent facial units. Plast Reconstr
Surg. 2007;120:1228.
80. Menick F, Salibian A. Microvascular repair of heminasal, subtotal,
and total nasal defects with a folded radial forearm flap and a
full-thickness forehead flap. Plast Reconstr Surg. 2011;127(2):637–651.
81. Menick FJ. Nasal and facial reconstruction. In: Goldwyn R, Cohen
M, eds. The Unfavorable Result in Plastic Surgery – Avoidance and
Treatment. 3rd ed. Boston: Little Brown; 2001.
82. Menick F, Salibian A. Primary intranasal lining injury – Cause,
deformity and treatment plan. Plast Reconstr Surg. 2014;134:1045.
Nasal mucous membranes may be injured by immune disease, infection,
trauma, or cocaine. The pathophysiology is similar – mucositis, lining
necrosis, loss of underlying cartilage and bone, followed by scar
contraction.
The mucosal damage may be isolated to the septum, creating a septal
fistula, or may extend onto the nasal vault and floor, leading to
circumferential scar contraction and severe nasal shortening and lip
retraction. External skin injury may progress to full-thickness nasal
necrosis. The clinical deformity is determined by the site, extent, and
depth of injury which dictate the technical approach to repair.
83. Menick F. An Approach to the Late Revision of a Failed Nasal
Reconstruction. Plast Reconstr Surg. 2012;129:92e. Many nasal repairs
with local and regional tissues require a late revision to improve
appearance and function. “Minor” deformities, in which the overall
dimension and position are correct, require finesse landmark recreation
and airway debulking. “Major” deformities fail to restore the basic nasal
character due to significant bulk and contour inadequacies. Revisions are
performed employing peripheral border scars, new incisions, soft tissue
sculpting excision, secondary cartilage grafts, and local lining replacement
to open the airway.

SECTION II • Head and Neck Reconstruction
7 
Auricular construction
Akira Yamada and Toshinobu Harada
SYNOPSIS
■ The commonest acquired ear deformity presenting for reconstruction
is the partial ear defect.
■ Apart from acquired ear deformities, microtia is one of the
commonest and most complex conditions that present for
reconstruction.
■ Patients with microtia may have associated anomalies.
■ Reconstruction is usually a staged procedure.
■ Creation of an adequate cartilage framework is key to the success of
reconstruction.
Introduction
What is the goal of ear reconstruction? “Creating a natural-
looking auricle”. The auricle is located at the lateral aspect of
the face and is far away from the facial triangle (eye-nose-eye),
where the attention of others is mostly focused. Therefore, the
ideal auricle is smooth, natural-looking, quiet, and does not
draw too much attention from others. Deformities (e.g., exces­
sive protrusion, cauliflower ear, unnatural curve of helix, and
dislocation), on the other hand, may draw the attention of
others. Prominent ears may need surgery because they are
likely to draw attention. If people do not notice that the
constructed auricle is man-made, the goal of the reconstruc­
tive surgeon is achieved. If your patient continues to hide the
constructed auricle longer than the wound healing period,
that is most likely due to failure to achieve the goal mentioned
above. The question is how we can construct a natural-looking
auricle with balance and harmony. The aim of this chapter is
to describe the strategy to achieve that goal.
Five characteristics of the ear
Tolleth1 states “a proper ear requires five characteristics to
have a satisfactory appearance: A posteriorly inclined axis, a
0.6 : 1 ratio of width to height, and three curved lines that
outline its shape, suggest tragus, antitragus, and concha, and
indicate a helix with its root beginning in the concha”. This
thought process may be interpreted as 1) Axis, 2) Ratio, 3) Key
line, and 4) Detail (Fig. 7.1).
Anatomy
The auricle is difficult to reproduce surgically because it is
made up of a complexly convoluted frame of delicate elastic
cartilage surrounded by a thin skin envelope (Fig. 7.2). Like
the inner ear, the external ear also has a spiral architecture
(Fig. 7.3), connecting the basal layer to the top layer. The
auricle’s rich vascular supply comes from the superficial
temporal artery (STA) anteriorly and posterior auricular
vessels posteriorly. The author observes frequently that
microtia patients with hemifacial microsomia have STA course
anomaly. The sensory supply to the auricle is mainly derived
from the inferiorly coursing greater auricular nerve. Upper
portions of the auricle are supplied by lesser occipital and
auriculotemporal nerves, whereas the concha region is sup­
plied by a branch of vagal nerve. An understanding of the
anatomy facilitates nerve block of the auricle with local anes­
thetic solution. First, the great auricular nerve is blocked by
injecting a wheal underneath the lobule. After awaiting its
effect, one continues injecting upward along the auriculoce­
phalic sulcus, around the top of the ear, and down to the
tragus. Finally, the vagal branch can be anesthetized without
discomfort by traversing the conchal cartilage, placing the
needle through the already anesthetized auriculocephalic
sulcus to raise a skin wheal just behind the canal.
Embryology of the normal ear
The middle ear and external ear are derived from the first
(mandibular) and second (hyoid) branchial arches. The auricle
itself is formed from six “hillocks” of tissue that lie along
Access video content for this chapter online at expertconsult.com

182
SECTION II
CHAPTER 7 • Auricular construction
these arches and can be seen in the five-week-old embryo
(Fig. 7.4). Many microtia patients have atresia of the auditory
meatus and tympanic membrane with variable deformities of
the middle ear ossicles. Microtia patients may present with
vestige and a patent or stenotic auditory meatus. Rarely,
especially microtia in hemifacial microsomia, patients may
present with anterior–inferior dislocated vestige and ear canal
(Fig. 7.5).
Classification of congenital
ear anomalies
Using a system that correlates with embryological develop­
ment, Tanzer2 classifies congenital ear defects according to the
approach necessary for their surgical correction (Box 7.1).
Fig. 7.1  A proper ear requires five characteristics to have a satisfactory
appearance: A posteriorly inclined axis, a 0.6 : 1 ratio of width to height, and three
curved lines that outline its shape, suggest tragus, antitragus, and concha, and
indicate a helix with its root beginning in the concha.
Axis
Ratio
Key line
Detail
Fig. 7.2  Normal anatomy of the auricle.
Helix
Superior crus
Fossa triangularis
Otobasion superioris
Inferior crus
Scapha
Cymbum conchae
Crus helicis
Antitragus
Tragus
Cavum conchae
Antitragus
Intertragal notch
Lobule
Otobasion inferioris
Fig. 7.3  Created ear framework shows that the helix connects to the bottom of the
base frame (first level), climbing like a spiral staircase to the top of the frame
(second level).
Fig. 7.5  Microtia in hemifacial microsomia; (A) vestige skin/incomplete ear canal are dislocated inferiorly. (B) Proper ear location is mostly covered with hairs. (C)
Thirteen sessions of laser treatment eliminated hairs completely from proper ear location.
A
B
C

182.e1
Classification of congenital ear anomalies
Fig. 7.4  Development of the auricle in a 5-week human embryo: 1–6, elevations
(hillocks) on the mandibular and hyoid arches; ov, otic vesicle; af, auricular fold.
(Modified from Arey LB. Developmental Anatomy, 7th edn. Philadelphia: WB
Saunders; 1974.)

183
History of autogenous ear reconstruction
mia and Treacher–Collins. Isolated microtia rarely runs in the
family. Treacher–Collins Syndrome, inherited in an autosomal
dominant fashion, often presents with bilateral microtia.
Middle ear problems
Treatments of microtia ideally involves reconstruction of the
external ear and the restoration of normal hearing.9 Hearing
impairment in microtia is related to abnormal auditory canal,
tympanic membrane, and middle ear. The problem is conduc­
tion. Typically, microtia patients have a hearing threshold of
40–60 dB on the affected side. By comparison, normal func­
tion allows us to hear sounds between 0 and 20 dB.
Regarding hearing restoration, most surgeons presently
feel that potential gains from middle ear surgery in unilateral
microtia are outweighed by the potential risks and complica­
tions, and this procedure should be reserved for bilateral
cases.6 Careful selection of the atresia surgery candidate is of
paramount importance to achieve optimal outcomes and,
more importantly, to avoid unnecessary surgery and its com­
plications. The Jahrsdoerfer criteria10 are widely accepted
guidelines to select the atresia surgery candidate. Fig. 7.6
shows a patient for whom simultaneous framework implanta­
tion and atresia surgery was performed at the first-stage
of auricular construction. V-shaped skin incision was the
employed approach both for microtia construction and atresia
surgery. Once the skin flap was prepared, subperiosteal dis­
section was performed to obtain access to the middle ear
through the microtia skin incision. While the ear, nose, and
throat (ENT) surgeon was doing atresia surgery under the
microscope, the plastic surgeon was performing auricular
framework fabrication at the back table.
The bone-anchored hearing aid (BAHA; Cochlear, Möln­
lycke, Sweden; and Ponto; Oticon, Kongebakken, Denmark)
has been used since 1977, which does not need a functioning
middle ear or patent canal.11 In microtia patients, BAHA was
initially used for bilateral microtia with bilateral conducting
hearing loss: unilateral BAHA is usually placed because a
single aid will stimulate both cochleae simultaneously.
Although traditional teaching was that hearing on a single
side is sufficient for speech development and education, the
evidence indicates both audiological and subjective benefits
when treating unilateral conductive hearing with BAHA.12–14
Indications are evolving, and reconstructive surgeons and
otologists should work together to achieve long-term success
in hearing restoration and auricular construction.
History of autogenous ear
reconstruction
Sushruta (6 BC) was probably the earliest surgeon who per­
formed auricular construction: repairing the ear lobe with a
cheek flap. Tagliacozzi described repair of ear deformities
with retroauricular flaps.15 In 1845, Dieffenbach reported the
repair of the middle third of the ear with an advancement
flap.16 This technique may have applications today (Fig. 7.7).
Early surgical attention focused mainly on traumatic deformi­
ties. However, by the end of the nineteenth century, surgeons
began to address congenital defects, in particular prominent
ears (Ely, 1881).17 The concept of microtia repair began in 1920,
when Gillies buried carved costal cartilage under masts skin,
Microtia
Clinical characteristics
Microtia varies from complete absence auricular tissue (anotia)
to a small ear with an ear canal. Nagata classifies microtia into
three types: lobule type, small concha type, and concha type.3–5
Microtia is nearly twice as frequent in males as in females,
and the right–left–bilateral ratio is roughly 6 : 3 : 1. Approxi­
mately one-third to one-half of the patients exhibit character­
istics of craniofacial microsomia. Brent found that 15% of his
1000 patients had paresis of the facial nerve.6 Dellon has
shown that the palatal muscles are rarely spared in this
syndrome.7
Timing of surgery
The timing of auricular construction is governed by both
psychological and physical considerations. From a psycho­
logical perspective, it would be ideal to begin construction
before the child enters school, but autogenous construction
should be postponed until rib growth provides substantial
cartilage to permit the fabrication of a quality framework.
Brent6 begins ear construction at age six, when the normal ear
has grown to within 6–7 mm of its full vertical height, and the
amount of cartilage is enough for Brent-type framework.
Nagata begins auricular construction at the age of 10, and
chest circumference grows over 60 cm, at the xiphoid level.3–5
These two different timings could be explained by the differ­
ence of the amount of cartilage required: Nagata-type 3D
framework needs larger amount of 6–9 rib cartilage. In other
words, surgeons are less likely to be able to fabricate Nagata-
type framework at the age of six.
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 to 17.4 per 10 000 births),8 and is higher in
Asian countries for unknown reasons. Eighty to 90% of micro­
tia is unilateral, and 10–20% is bilateral. There are more than
18 different microtia-associated syndromes with single-gene
or chromosomal aberrations; however, there is no causal
genetic mutation confirmed to date.9 Relatively common
syndromes associated with microtia are hemifacial microso­
BOX 7.1  Clinical classification of auricular defects (Tanzer)
I. Anotia
II. Complete hypoplasia (microtia)
A. With atresia of external auditory canal
B. Without atresia of external auditory canal
III. Hypoplasia of middle third of auricle
IV. Hypoplasia of superior third of auricle
A. Constricted (cup and lop) ear
B. Cryptotia
C. Hypoplasia of entire superior
V. Prominent ear

183.e1
History of autogenous ear reconstruction
Fig. 7.6  Combined microtia/atresia surgery was performed as a first stage reconstruction. Atresia surgery was performed by Dr. Shinichi Haginomori. (A) Preoperative view
of a 10-year-old male with concha type microtia. (B) Concha type skin incision was used both for microtia construction and atresia surgery. (C) Canal wall up
mastoidectomy was performed. The malleus (M) and incus (I) formed the complex. EAC, external auditory canal; Ma, mastoid cavity. (D) The malleus-incus complex was
removed. Mobility of the stapes (S) was good. MM, manubrium of the malleus; CT, chorda tympani nerve; EAC, external auditory canal; Ma, mastoid cavity. (E) The
columella (3 mm in length) was made from the cortical bone. (F) The columella (C) was inserted between the manubrium of the malleus (MM) and stapes (S). (G)
Audiological finding, one year post; the patient is able to hear whisper voice with affected side. (H) One year postoperative appearance.
A
B
C
D
E
F
-10
0
10
20
30
40
50
60
70
80
90
100
110
120
125
250
500
1000
2000
4000
3000
-20
(db)
Preoperative
Postoperative
G
H

184
SECTION II
CHAPTER 7 • Auricular construction
of secondary referrals after PPE framework complications:
The PPE frame may become stone-hard over time. Once extru­
sion occurred, the salvage would become difficult because the
temporoparietal fascia was already used during the primary
surgery.
Prostheses
Controversies remain regarding appropriate treatment selec­
tion for patients with major ear deformities.9 This is especially
true for severe trauma cases, such as extensive third degree
facial burns. As the author described in the secondary con­
struction section, natural-looking autogenous construction
is possible even with severe burn injuries if you follow the
principles of secondary construction.26 On the other hand,
osseointegrated auricular prosthetic reconstruction is comple­
mentary to other approaches and provides a reasonable
alternative for poor autogenous options and poor autogenous
outcomes. The disadvantages of prosthesis include intermit­
tent soft-tissue problems, long-term maintenance, prosthetic
remakes every 2–5 years, ongoing cost, possible compromise
of future autogenous options, and the need for a compliant
patient.9 Fig. 7.9 shows a patient with 95% loss of his auricle
due to third-degree burn. For this particular patient, many
surgeons may assume that prosthesis would be the primary
choice for this patient, but the author performed autog­
enous construction which is well maintained 8 years after
construction.27
Total auricular construction in microtia
Author’s method
Patient assessment
Twenty 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
syndrome) and Townes–Brocks syndrome; these conditions
and elevated it with a cervical flap.18 Gillies (1937)19 also used
maternal ear cartilage for more than 30 microtic ears; these
were found to have progressively resorbed. Peer, in 1948,20
diced autogenous rib cartilage and place 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. Steffensen, in 1955,21 attempted to use pre­
served cartilage, which resulted in progressive resorption of
the grafted cartilage.
Tanzer is considered to be the father of modern auricular
construction. Tanzer’s excellent results in 195922 determined
the dominance of autogenous construction with rib cartilage
in reconstructive surgery. Surgeons from around the world
visited Dartmouth–Hitchcock Medical Center, and autogenous
construction spread with them. In the United States, Brent
succeeded Tanzer in the early 1970s, and Brent’s artistry23 has
influenced reconstructive surgeons for over 40 years and to
this day (Fig. 7.8).6 Nagata in Japan, a student of Fukuda
(Fukuda visited Tanzer in 1963), emerged in the 1990s, and
the Nagata (two-stage) method3–5 gradually gained popularity
and became the strongest alternative to the Brent (four-stage)
method. To date, autogenous cartilage remains the most reli­
able material that produces satisfactory results with the least
complications.
Alloplastic implants
Although silicon breast implants survive until today, the
silicon ear framework is seldom used. The silicon framework,
introduced by Cronin in 1966,24 like any other types of syn­
thetic materials, extrudes, causes infection, and loses defini­
tion in the long term. PPE framework, a newer synthetic
material, was first introduced by Reinisch25 in 1991. The
advantage of PPE over autogenous construction is that it can
be applied to younger children whose costal cartilage is less
mature and not ready for autogenous reconstruction. The
disadvantage of Medpore frameworks include: use of tempo­
roparietal fascial flap, long-term risk of alloplastic implant
exposure or loss, and compromise of any future autogenous
options.9 Although Reinisch reported a low complication rate,
Firmin (European champion ear maker), Ortiz-Monasterio,
and Brent6 are strongly opposed to PPE framework because
Fig. 7.7  Dieffenbach’s technique for reconstruction of the middle third of the auricle, drawn from his description (1829–1834). (A) The defect and outline of the flap.
(B) The flap advanced over the defect. (C, D) In a second stage, the base of the flap is divided and the flap is folded around the posteromedial aspect of the auricle. A skin
graft covers the scalp donor site.
A
B
C
D
Graft

185
Total auricular construction in microtia
Skin envelope
Assessment of the available soft, elastic skin is critical, since
it will determine the volume, dimension, and size of the
3D structure of the ear framework needed. If the amount
of available elastic skin envelope is limited, you may not
be able to place the framework with the size matched to
the normal side. Imbalance between the skin envelope and
framework may make definition of the auricle poor. Surgeons
also need to check if there is any scar around the auricle
site and inside the hair. Scar interferes with the normal
stretching of the supple skin envelope, and may prevent
good definition of the auricle.28–29 Scar along the course of
the STA could be the sign of a severed STA, the pedicle of the
temporoparietal flap, which is a workhorse and important
salvage tool for auricular reconstruction.30 This is especially
important for microtia patients with craniofacial deformities,
should be considered among the differential diagnoses when
evaluating an individual with microtia.8
Facial symmetry
Asymmetry of the face will make it complicated to locate the
ear position. The location of vestige skin is sometimes mis­
leading, and it influences the decision-making of surgeons.
Even for expert surgeons, it is attempting to make the auricle
based on the current location of the vestige skin, so the surgeon
could apply their typical techniques right away. It is not
uncommon that reconstructive surgeons create the auricle in
the wrong location in hemifacial microsomia patients. The
discussion continues whether we should correct the skeleton
first or microtia first. The author prefers to address skeletal
correction first; the majority agrees, because it may make it
easier to identify the optimal auricular location (Fig. 7.10).
Fig. 7.8  Rib cartilage harvest for ear framework fabrication. Note that the upper border of the sixth cartilage is preserved; this will help prevent subsequent chest deformity
as the child grows. The entire he upting cartilagethe sixth cartilage is preserved; this will help prevent subsequent chest deformity as the child grows. t covers thberately
warped in a favorable direction by thinning it on its outer, convex surface. The thinned helix is affixed to the main sculptural block with horizontal mattress sutures of 4-0
clear nylon; the knots are placed on the framework on its undersurface.
Rim preserved
Bank

185.e1
Total auricular construction in microtia
A
B
C
D
E
F
Fig. 7.10  Microtia patient with hemifacial microsomia. First, mandibular distraction osteogenesis was performed,
and then microtia reconstruction was done. (A) Preoperative view. (B) 3D CT reconstruction demonstrates new
bone generation of the mandible between distraction pins. (C) Frontal view of the patient after mandibular
distraction osteogenesis. Tilt of the commissure is corrected. (D) Profile view of the patient prior to total auricular
construction. (E) Type A-2 template and 3D framework (F) Immediate postoperative view. (G) View of the patient
2 years after total auricular construction.
G

186
SECTION II
CHAPTER 7 • Auricular construction
A
B
C
D
E
F
Fig. 7.9  (A) 95% auricular defect from third degree burn. (B) 3D cartilage framework was placed. The lower one
third of the framework was covered with a local skin flap. (C) The upper two-thirds of the cartilage framework was
covered with a temporoparietal fascia flap. (D) Split scalp skin was grafted over temporoparietal fascia flap.
(E) Bolster sutures were placed to prevent hematoma formation. The temporary suction drain was then removed.
(F) View of the second stage (elevation). To cover the posterior aspect of the ear, after placement of the rib
cartilage block, a deep temporal fascia flap was used. (G) Eight years postoperative view of the patient.
G

187
Total auricular construction in microtia
work in this trapezium is important to prevent anterior
inclination of the auricle (Fig. 7.17). Surgeons tend to avoid
the hairline at upper lateral pole, and ear framework tends to
be placed inside the trapezium-shape space, which results in
anterior inclination of the new auricle.
Location of the normal auricle
Leonardo Da Vinci is known to have analyzed the face,
including the location of the auricle. Da Vinci analyzed the
facial proportions in similar ways as anthropologists do today.
To recognize the normal location of the auricle is critically
such as Treacher–Collins syndrome. These patients may have
a bicoronal scar due to previous skeletal reconstruction (Fig.
7.11). Surgeons should be aware of the past medical history,
such as atopic dermatitis or sensitive skin, since the barrier of
skin may be weaker with atopic dermatitis, and that would be
the potential source of perioperative infection, especially with
methicillin-resistant Staphylococcus aureus (MRSA).
Vestige skin
Since microtia has inherent skin envelope deficiency, how
surgeons utilize vestige skin strongly influences the definition
of the new auricle. The first thing surgeons need to evaluate
is 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 neces­
sary prior to framework placement procedure. The volume of
vestige skin will influence the volume and the size of cartilage
framework; if the volume/size of vestige is extremely small,
the conchal cavity will be shallow no matter how deep you
create the auricular framework. If the volume/size of vestige
is relatively large, you will have more chance to create a deep
concha by using the lobule splitting technique.3
Hairline
Surgeons need to recognize the presence of a low hairline at
the time of initial evaluation to formulate surgical strategy
(Fig. 7.12). The extent of low hairline influences the choice of
surgical procedures. If the low hairline exceeds beyond the
upper one-third of the auricular framework, either preopera­
tive laser hair removal or intra-operative fascia flap coverage
of the framework after hair-bearing skin removal may be
necessary. The author routinely uses photographic analysis
for surgical planning (Fig. 7.13); it helps locate the proper new
ear location (auricular rectangle) and its relation to the sur­
rounding anatomical structures. Photographic analysis tells
us the presence of low hairline, the location of the vestige, and
its relation to the ear, all of which will strongly influence the
choice of surgical treatment. If the extent of low hairline is
mild (Fig. 7.14) and hair covers down to scapula fossa, hair
can be removed during second-stage surgery (ear eleva­
tion).31,103 Fig. 7.5 shows an 11-year-old hemifacial microtia
patient with over 70% low hairline. Laser hair removal6 was
performed prior to cartilage framework implantation. Fig.
7.15 shows a 100% low hairline patient with Pruzansky type
2A HFM. Low hairline microtia cases in severe HFM
may develop shrinking of the new auricle after extensive
reconstruction.32
Trapezium-space behind sideburn
The sideburn is not uncommonly missing in microtia patients.
A missing sideburn may be the initial sign of hemifacial
microsomia. If the patient has normal sideburn, it is an ana­
tomical landmark useful for locating the proper new ear
position. Anthropological study shows that the auricle is
normally located approximately 20 mm behind the sideburn
(Fig. 7.16A).33 There is a trapezium-shaped, non-hair-bearing
skin space between the sideburn and the auricle in normal
anatomy (Fig. 7.16B). Avoiding placement of the ear frame­
A
Fig. 7.13  Photographic analysis and surgical planning for a child with microtia.
(A) Profile view of a child with microtia associated with hemifacial microsomia. (B)
Photographic analysis revealed that the child has a low hairline and low-set vestige.
B
Upper one-third of
the new ear will be
low hairline

187.e1
Total auricular construction in microtia
A
B
Fig. 7.11  Treacher–Collins patient with bilateral microtia. The patient had bicoronal scar, and TPF was not available. (A) Preoperative view of the left side. (B) Left side
view after two-stage auricular construction. (C) Intraoperative view of right microtia. Posterior pedicle fascia was used for ear elevation. Surgery was performed with Dr.
Satoru Nagata. (D) Immediate postoperative view of the right side.
C
D

187.e2
SECTION II
CHAPTER 7 • Auricular construction
A
Fig. 7.12  (A) A seven-year-old male with small concha type microtia. (B) 30%
low hairline was demonstrated by ear positioning template.
B

188
SECTION II
CHAPTER 7 • Auricular construction
A
B
C
D
E
F
G
H
I
J
K
Fig. 7.14  Surgical sequence of two-stage total auricular construction for concha type microtia.103 (A) Preoperative view.
(B) V-shape posterior skin incision. (C) 3D framework with Nagata-type template. (D) View prior to second stage
(elevation). Upper helix is covered with hair-bearing skin. (E) Intraoperative hair removal was performed. TPF was
sandwiched between extremely thin skin and framework. (F, G) Intraoperative impression and fabricated cartilage block for
elevation. (H) Second stage intraoperative view. (I) Temporoparietal fascia flap was raised. (J) Immediate postoperative
posterior view. (K) One year after surgery. (L) Eight years after surgery. (Reproduced with permission from Yamada A, Ueda
K, Harada T. Surgical techniques in microtia reconstruction. (PEPARS 2012; 63:77–94 (in Japanese).)
L

189
Total auricular construction in microtia
and dimension); only a few articles focus on the auricular
curve itself. Harada and Yamada developed an auricular
shape classification based on the curve ratio analysis study
(Fig. 7.20).36,37 They identified two key lines in ear shape: helix-
lobule curve and concha outline curve. There are three major
types of helix-lobule curve, types A, B, and C, and two major
types of concha outline curve, Type 1 and Type 2. 3 × 2 makes
six types of major auricular shapes. Normal ear shape may
be classified into six groups based on this analysis (Fig. 7.21).
Based on this classification, six types of auricular framework
templates were developed as a guide for creating ear frame­
works from autogenous rib cartilage (Fig. 7.20). Interestingly,
important for surgeons to avoid the misplacement of the new
auricle. A study showed that a misplaced auricle gives a less
attractive impression to others.34 The normal auricle is located
immediately behind the face mask. Surgeons should avoid
placing the new auricle inside the face mask, especially in
hemifacial macrosomia.32
Auricular rectangle
A critical step in preoperative planning is to identify the
“auricular rectangle,” within which the auricular framework
will be placed (Fig. 7.18). Placing the beautiful auricle in the
wrong place is something that surgeons should avoid. The ear
positioning template31,33,35 is a tool to identify the auricular
rectangle, which the author developed with Nagata (Fig.
7.19). Identifying the auricular rectangle is more challenging
for microtia in hemifacial microsomia patients. Once the
auricular rectangle is identified, the next step is evaluating the
relationship between the auricular rectangle and the vestige
skin. A decision has to be made on whether vestige skin can
be utilized or not. If the child has a low set vestige in severe
hemifacial microsomia, additional surgical procedures to
transpose the vestige skin to make it useable may be necessary
prior to framework placement.
Ear positioning template (EPT)
The ear positioning template (EPT) is especially helpful for
secondary auricular construction, where many landmarks are
missing and identification of the proper location of the auricle
is likely to be difficult. Harada and Yamada modified the EPT
in 2011; more anthropological references were added to the
template, and the new template is made of an acrylic plate
that facilitates surgical marking. EPT may be used to visualize
the extent of low hairline (Figs. 7.12 & 7.5).
Auricular curve analysis
There are numerous articles on auricular morphology, almost
all based on anthropological analysis (e.g., angle, proportion,
Fig. 7.15  Hemifacial microsomia with 100% low hairline and low set vestige.
A
Fig. 7.16  Topographic relationship between hairline and the auricle. (A) The
distance between sideburn and tragion (upper end of tragus) is approximately
20 mm. (B) The trapezium-shape non-hair-bearing skin exists between the sideburn
and the auricle.
B

189.e1
Total auricular construction in microtia
Fig. 7.19  The ear positioning template is a tool to identify the tauricular rectangle,
within which the auricular framework will be placed.

190
SECTION II
CHAPTER 7 • Auricular construction
the normal auricle with transparent film.38 The author found
that manual tracing looks easy, but it may not be easy to
capture the delicate curves of the auricle unless surgeons have
background skills in art. The manual tracing tends to be too
big and too wide; such an ear frame template may result in
poor definition due to skin deficiency. The other disadvantage
of manual tracing is that the normal side is not always normal.
Minor deformities, such as helix–antihelix adhesion, can
disrupt the smooth curve of the helix; in such a case, the
contralateral side is not the ideal template for the new auricle.
Nagata2,3,4,31 developed a single ideal ear template for all types
of auricular construction. It is based on both anthropometric
analysis39 and Nagata’s clinical experiences. Nagata slightly
changed his single template twice (Fig. 7.23).31 From curve
analysis point, Nagata changed from uncategorized to Type
B-1, and finally Type A-1. The author previously used the
Nagata template (Type B-1) for the first 10 years of practice,
then switched to the six types of templates which Harada and
Yamada developed in 2009.36,37 These templates are based on
the analysis of normal auricular curves (Fig. 7.20). The aim of
the six templates is to express the subtle, individual difference
of the auricular shape as opposed to applying a single ideal
template for auricular construction. The author applies the
new templates to various ethnic groups, and believes these
templates allow us to cope with individual normal ear shape
differences.
A.  First-stage of total auricular construction
(Video 7.1 )
Markings
After the induction of general anesthesia, the author performs
preoperative marking with permanent marker before the
surgical preparation. The author uses the ear positioning
template as a guide for markings (Fig. 7.19).
Patient position
The author uses semi-lateral position to facilitate simultane­
ous auricle site and cartilage harvesting. Since the duration of
surgery will be 5−7 h, preventive measures of pressure sores
are mandatory. Keeping the neck in neutral position is crucial
to prevent C1, C2 rotary subluxation.40
1.  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. 7.24). The skin
flap is more likely to create a deeper concha bowl than skin
grafting or a composite skin/cartilage graft. Nagata described
lobule splitting techniques in 1994,3 and the techniques
remain misunderstood by many surgeons. Contrary to
Tanzer/Brent (full-thickness)2,6 lobule rotation, splitting the
lobule creates two flaps: anterior and posterior flaps. Lobule
splitting technique is considered to be a modified z-plasty
or application of Masson principle.41 The author uses a #15
scalpel, with blade facing upward, and splits the lobule with
a stabbing scalpel motion. Splitting continues down to the
fascia level. After completion of the lobule split, the anterior
lobule flap will be transposed backward to cover the anterior
lobule portion of the framework. The posterior flap will be
Fig. 7.17  Anteriorly inclined auricle that touches the sideburn.
Harada found that both the Brent framework and the latest
Nagata template are similar to Type A-1 framework, based on
the curve analysis (Fig. 7.22).36,37
Auricular template
When surgeons plan for auricular reconstruction, most sur­
geons use some kind of template as a guide for fabricating ear
framework. The most widely used method has been tracing
Fig. 7.18  Critical step in preoperative planning is to identify the auricular
rectangle, within which the auricular framework will be placed.

190.e1
Total auricular construction in microtia
Fig. 7.22  Type A-1 auricular construction was performed for lobule type microtia. (A) Preoperative view. (B) Type A-1 rib cartilage framework. (C) Postoperative view.
A
B
C
A
B
C
Fig. 7.24  First stage surgery for lobule type microtia. (A) Skin incision outline for
anterior surface of the lobule. (B) W-shaped skin incision outline on the posterior
surface of the lobule and the mastoid surface. (C) Undermining the mastoid area to
create 2-mm thick skin flap, using straight blunt scissors. Skin pocket extends 1 cm
beyond the ear outline. (D) 3D frame is inserted from tarsal portion by rotating
around the subcutaneous pedicle. (E) Under temporary suction, skin flap is coapted
to 3D frame, and excessive skin is trimmed.
D
E

191
Total auricular construction in microtia
Skin incision design for concha-type microtia
Nagata originally (in 1994) described the skin incision as a
z-plasty type incision with posterior V-shape design (Fig.
7.14).3 Recently Nagata changed from V-shape to W-shape
incisions (Figs. 7.28 & 7.29)31 at the posterior aspect of the
lobule. There was no explanation why Nagata changed the
shape of the incision from V-shape to W-shape for concha type
microtia. However, the author found that concha type pre­
sents with a higher location of vestige than normal lobule
location. A W-shape incision has better freedom to transpose
the lobule in the optimal location.
2.  Removing vestige auricular cartilage
Lobule type and concha type is slightly different in the way
to remove vestige cartilage. The author removes all of the
remnant auricular cartilage in lobule type microtia for two
reasons: vestige cartilage will not contribute to the auricular
framework, and the vestige cartilage obstructs the smooth
expansion of the skin envelope. Further, removing the vestige
transposed anteriorly to cover the posterior aspect of the
tragus and concha cavity. Subcutaneous pedicle is preserved
for the posterior skin flap to secure the vascular supply.2
Firmin argued with Nagata that this subcutaneous pedicle is
unnecessary.42 Studies showed that the subcutaneous pedicle
in Nagata’s W flaps does increase the vascularity and decrease
skin flap necrosis.43,44 The author prefers to keep the subcu­
taneous pedicle because the pedicle will keep the posterior
flap sticking down to the concha cavity; thus a deep concha
bowl is more likely to be achieved with subcutaneous pedicle
preservation (Figs. 7.25 & 7.26).
Skin incision for small concha type microtia
Nagata defines small concha type as the presence of a small
indentation in the concha region (Fig. 7.12).4 The skin incision
is made along the margin of the small indentation, which is
the difference from lobule type microtia skin incision (Fig.
7.27). The indentation is turned inside out to form an inverted
cone pocket to cover the framework. The rest of the surgical
procedure is similar to lobule type microtia.31
Fig. 7.20  Auricular curve analysis. (A) There are three
types of helix-lobule outline curves: types A, B, and C. (B)
There are two types of concha outlines: Type 1 and Type 2.
(C) Six types of auricular frame templates based on curve
analysis. (D) For each of the six types of templates,
various sizes were developed, ranging from 44 mm to
72 mm in vertical height. (Reproduced with permission
from Yamada A, Ueda K, Harada T. Surgical techniques in
microtia reconstruction. PEPARS 2012;63:77–94 (in
Japanese).)
Type A
Type B
Type C
A
Type 1
Type 2
B
C
A-1
A-2
B-1
C-1
B-2
C-2
44mm
46mm 48mm 50mm
52mm
54mm
56mm
58mm
60mm
62mm
64mm
66mm 68mm
70mm
72mm
D

191.e1
Total auricular construction in microtia
Fig. 7.25  Lobule type microtia. (A) Preoperative profile. (B) One year after surgery. (C) Eight years after surgery.
A
B
C
A
B
Fig. 7.26  Lobule type microtia. (A) Preoperative profile of an 11-year-old female. (B) Topographic marking and skin incision outline (red). (C) 3D framework and Nagata
type template. (D) Intra-operative view; anterior lobule flap and posterior W-shaped flap are seen.
C
D

191.e2
SECTION II
CHAPTER 7 • Auricular construction
Fig. 7.28  Concha type microtia for which W-shaped posterior incision was used. (A) Preoperative profile. (B) Type A-1 52-mm template is overlapped onto the normal ear
to confirm the needed size and shape of template needed. (C) W-shaped posterior lobule skin incision (red). (D) Type A-1 52-mm template and 3D framework. (E) One
year after surgery.
A
B
C
D
E

192
SECTION II
CHAPTER 7 • Auricular construction
injection of fluids makes dissection less accurate, and it may
cause vascular compromise of the delicate skin flaps. The
extent of skin pocket dissection usually goes beyond the
hairline border, up to 1 cm beyond the hair line. The author
usually dissects hair-bearing skin again with 2-mm thickness.
Because hair-bearing skin has more dense fibrous tissue than
non-hair-bearing skin, dissection underneath hairs needs
more effort. But, at the same time, surgeons must be careful
not to dissect too much, and not to make the skin flap too thin,
otherwise you may have vascular compromise of the skin
flap. The author does not violate trapezium-shaped space in
front of the new auricle (Fig. 7.16B) to prevent anterior
inclination.
4.  Instrumentation
Framework fabrication requires specific types of instruments:
a carving knife and 38G double-armed stainless wires are
cartilage will create a space to accommodate a new frame­
work. In contrast, in concha type microtia, the remnant concha
cartilage should be preserved as a cuff to facilitate the smooth
transition of the concha cavity. The other important technical
tip is that when you remove vestige cartilages, especially from
anterior aspect of the auricle, you must preserve as much soft
tissue as possible: anterior skin is extremely thin, therefore
dissection of the vestige cartilage must be very delicate, and
sharp dissection to remove only cartilage is essential, other­
wise the chance of skin flap congestion/necrosis may be high.
The author’s preferred instrument for removal of the vestige
cartilage is converse scissors.
3.  Skin pocket dissection
The author uses small straight blunt scissors, aiming to create
a 2-mm-thick skin flap (Fig. 7.30). The author does not use
epinephrine injection for hemostasis purposes because
A
B
C
Fig. 7.21  Normal ears can be classified into six types based on two key lines. (A) Type A-1, (B) Type A-2, (C) Type B-1, (D) Type B-2, (E) Type C-1, (F) Type C-2.
D
E
F

193
Total auricular construction in microtia
ing rib cartilage without perichondrium attached is a safer
technique than harvesting cartilage with perichondrium, in
terms of pneumothorax risk. Preserving perichondrium at the
donor site and adding leftover diced cartilage into the peri­
chondrium sleeve is proven to boost regeneration of the
cartilage/bone matrix (Fig. 7.31). This technique may cause
less chest deformity.46,47 The author uses a transverse 4–5 cm
skin incision that usually has better scar quality than an
oblique skin incision. After completion of rib cartilage harvest,
the author routinely asks the anesthesiologist for manual
inflation up to 25–30 cm H2O to determine if any bubbles
come up. Small tears can be repaired by direct closure. If there
is any clinical suspicion of pneumothorax, a portable chest
X-ray, while under general anesthesia, should be taken for
possible chest tube placement.
6.  Auricular framework
Creating the auricular framework is a fascinating, fun proce­
dure, if you are properly trained. There are several simulation-
type training modules available (Figs. 7.32–7.34),48–52 which
may be helpful prior to starting clinical cases. The architec­
ture of the auricular framework is a critical component to
create the complex and delicate definition of the auricle (Fig.
7.35). It is important to remember that the skin envelope to
cover the framework is as critical as auricular framework
itself: the balance between 3D framework and skin envelope
is the key to achieving optimal definition of the auricle.
Nagata-type 3D framework is distinct from previous 2D
framework: the helix connects to the bottom of the base
frame (first level), climbing as a spiral staircase, to the top of
the frame (second level) (Fig. 7.3). The tragus component is
also unique to the Nagata-type 3D framework, which is
covered by the posterior W-shaped skin flap, created by
lobule split technique.
Bolster sutures
Nagata uses classic bolster sutures for postoperative dressings
that were popularized by Tanzer.2 Brent uses suction drain
postoperatively. At the first stage of total auricular construc­
tion, the author uses suction only temporarily during the
special instrumentation for Nagata-type framework fabrica­
tion. The author uses round, curved 2-mm, 3-mm, 4.5-mm,
and 6-mm width wood carving knives (Mikisho Company,
Hyogo, Japan). Because of a recent trend of restriction against
wood-handle surgical instrumentation, carving knives with
disposable blades (2-mm, 3-mm, 4.5-mm, and 6-mm) were
developed (KLS Martin, USA). A 38G double-armed microtia
wire (Medicon, Tuttlingen, Germany; Bear Medic Co., Tokyo,
Japan) allows surgeons more delicate fixation of each cartilage
parts compared with conventional 32 or 34G wire.
5.  Harvesting costal cartilage
Simultaneous harvesting of costal cartilage and skin dissec­
tion in the auricle site is beneficial to shorten the length of
surgery as well as lessen the fatigue of the surgeons. Brent
harvests costal cartilage himself by attaching perichondrium
to the cartilage. Firmin keeps the anterior portion of perichon­
drium to the rib cartilage and leaves the rest of perichondrium
to the donor site, stating that the “deformation at the donor
site is minimal”.45
Nagata let the second surgeon harvest rib cartilage, leaving
the entire perichondrium to the donor site (Fig. 7.31). Harvest­
A
Fig. 7.23  Evolution of Nagata ear template; from curve analysis point, Nagata
changed from uncategorized to Type B-1A, and finally to Type A-1B.
14mm
3mm
1.5mm
2mm
3mm
3mm
4mm
2mm
1.5mm
3mm
3mm
3mm
3mm
3mm
3mm
3mm
14mm
14mm
7mm
8mm
28mm
28mm
56mm
F
F
T
T
B
Fig. 7.27  (A) The skin incision is made along the margin of small indentation that
is the difference from lobule type microtia skin incision. (B) The indentation is
turned inside out to form an inverted cone pocket to cover the framework. The rest
of the surgical procedure is similar to lobule type microtia.
A
B

193.e1
Total auricular construction in microtia
A
B
Fig. 7.32  The author’s training method of creating 3D framework: Step 1; practice by using potato. (A) Type C-2 template was placed on a potato. (B) Type C-2 template
was printed on a flat potato surface. (C) Relief of 3D framework carved out from potato. (D) Completed potato 3D frame.
C
D

193.e2
SECTION II
CHAPTER 7 • Auricular construction
Fig. 7.33  Step 2: practice on a carrot 3D framework (A) Type A-1 template was printed on flat surface of carrot. (B) Five parts of 3D framework are created from carrots.
(C) Five parts are assembled to create a carrot Type A-1 3D framework.
A
B
C

193.e3
Total auricular construction in microtia
A
B
Fig. 7.34  Step 3: practice to create a 3D framework from a precise rib cartilage copy. (A) Type A-2 template is placed on 6–7 rib cartilage model. (B) Five parts of 3D
framework are created from a rib cartilage model. (C) Completed 3D framework from a rib cartilage model; anterior surface. (D) Posterior surface of 3D framework.
C
D

194
SECTION II
CHAPTER 7 • Auricular construction
A
B
C
D
E
F
Fig. 7.29  First stage of concha type microtia reconstruction. (A) Skin incision outline. (B) Skin incision outline for anterior
surface. (C) W-shaped skin incision outline on the posterior surface of the lobule and the mastoid surface. (D, E) Vestige cartilage
is excised carefully, except the concha bowl portion which will serve as a cuff to fix the 3D framework. (F) 3D frame without tarsal
portion. (G) Temporary suction is used to coapt the framework to the skin to visualize the reconstructed auricle.
G
surgery to visualize optimal skin adaptation to the frame­
work. After completion of bolster sutures, the author removes
the temporary suction. Based on the author’s experiences,
bolster sutures cause minimum hematoma formation. The
author uses Xeroform with plenty of Vaseline-based ointment
to make a roll of bolster, and uses 4-0 Prolene (SH-2 needle,
double-armed, Ethicon) for fixation. Dense roll and too-tight
fixation may be the cause of pressure sores underneath the
bolster. If you see tightness or discoloration of skin in the
postoperative period, especially POD #2–3, surgeons may cut
one or two sutures and keep the bolster in place, usually for
10–14 days.

195
Total auricular construction in microtia
B.  Second-stage of total auricular construction
(Auricular elevation)
The difficulty of auricular elevation is often underestimated.
Normal auricle is separated from mastoid area by supporting
cartilage. The simplest way to divide the auricle from the head
is to place a skin graft in between the head and auricle without
skeletal support. Since the resultant defect after division of the
auricle from the head is relatively large, a popular choice of a
skin donor site has been the groin area. The disadvantage of
auricular division with groin skin grafting includes less
optimal elevation, persistent edema of the auricle, pubic hair
growth, mismatched skin color, and difficult skin cleaning. To
overcome the disadvantages described above, Nagata pro­
posed a more complex auricular elevation that the author
routinely performs (Figs. 7.36 & 7.14).31,53
1.  Raising temporoparietal fascia flap (TPF)
The author uses a TPF to cover the entire posterior aspect of
the auricle, not just the cartilage block for elevation. Nagata
states that placing TPF has two benefits: to cover the cartilage
Fig. 7.30  View of skin pocket dissection. Small, straight, blunt scissors are used
to create a 2-mm-thick skin flap. The contour of scissors can be seen from outside.
A
B
C
Fig. 7.31  Harvesting rib cartilage technique (usually from ipsilateral side) without
perichondrium. (A) Incision outline (yellow) to preserve entire perichondrium for sixth
and seventh rib cartilage. (B) Intraoperative view showing the seventh rib cartilage
exposed after peeling off the perichondrium. (C) Sixth to ninth rib cartilage without
perichondrium. Entire cartilage is white in color which is the sign that they are without
perichondrium. (D) At the donor site, a perichondrium sleeve was created, and leftover
cartilage was diced and injected into the space inside perichondrium sleeve.
D

195.e1
Total auricular construction in microtia
A
Temporal parietal fascia
B
Fig. 7.36  Second stage of surgery (ear elevation). (A, B) Framework is separated from head. (C, D) Fabricated cartilage is wedged, and then the entire posterior surface is
covered with temporoparietal fascia flap. (E) Split scalp is harvested and grafted over TPF.
Cartilage
C
D
Temporal parietal fascia
E
Full thickness skin graft

196
SECTION II
CHAPTER 7 • Auricular construction
follicles are located very close to TPF, monopolar electrodis­
section may cause alopecia (Fig. 7.38).
2.  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 a color match with auricular skin. Nagata
harvests split-thickness scalp manually with a #15 scalpel. The
author uses either a #15 scalpel or electronic dermatome with
thickness of 0.4 mm (Aesculap, Germany).
3.  Cartilage block for elevation
Many agree that without placing a block underneath the ear
framework, the ear is not practically elevated from the head
block and to augment the posterior vascular supply to the
auricle that was lost at the time of separation of the auricle
from the head.53 If low hairline is mild (hairs cover helix and
scapha fossa), TPF enables surgeons to perform intra-operative
hair removal (Fig. 7.14). Since superficial temporal artery
(pedicle of TPF) may run an atypical course in hemifacial
microsomia, the author routinely uses Doppler ultrasound to
plot the course of STA on the temporal skin. If TPF is not
available, either deep temporal fascia flap (Figs. 7.37 & 7.9F),
or fascia flap based on posterior vasculature (Fig. 7.11) is the
second option. If a local fascia flap is not available, the third
option may be a free vascularized fascia flap.23,54–56
Alopecia has been reported as a complication of TPF
harvest. The author uses a zig-zag temporal skin incision,
raising the skin flap via sharp dissection with a #15 scalpel to
dissect between fat tissue and TPF. Since the majority of hair
Fig. 7.35  Fabrication of 3D framework. C6-C9, Harvested rib cartilage from sixth to ninth rib. C, conchal bowl unit. This can be fabricated either as one unit or as two
separate units. B, Base frame from sixth and seventh. T, tarsal portion; H, helix unit; AH, antihelix unit. 4, Helix is attached to the posterior surface of the base frame. 11
Helix and antihelix are attached to the base frame, prior to tragus and concealed in bowl unit. 13,14,15, Anterior view of completed 3D framework. 16, Posterior view of
completed 3D framework.
C6
C7
C8
T
B
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
H
AH
B
C
C9

196.e1
Total auricular construction in microtia
Fig. 7.37  The nutrient vessel for deep temporal fascia can be seen one layer
below temporoparietal fascia flap. The course of the branch of the middle temporal
artery (yellow arrows) is similar to the temporal branch of STA.
Fig. 7.38  Unsatisfactory auricular construction; poor definition, exposed auditory
canal, hairs on helix, and pubic hairs grow from groin skin graft.

197
Secondary construction
parietal fascia flap and scalp skin graft to provide coverage in
challenging cases of anotia, failed autogenous reconstructions,
and post-traumatic cases.60 The potential for complications
including skin necrosis and the added surgical stage are the
major concerns with the use of soft-tissue expanders in ear
reconstruction.61,62 Since the skin of the auricular site is thin,
the amount of expanded skin may not be enough to eliminate
the hairs in the auricle. Even after skin expansion, the con­
structed auricle still may include hair-bearing skin at the
helical rim (Fig. 7.42).
Unsatisfactory outcome
The cause of unsatisfactory outcomes are multifactorial:26
improper evaluation of the deformities, improper selection of
the surgical procedures, non-recognition of the facial asym­
metry, improper assessment of low hairline, improper selec­
tion of the new auricular location, improper inclination of the
auricle, improper timing of the surgery, insufficient amount
of costal cartilage, improper cartilage harvesting techniques,
improper thickness of skin pocket dissection, failure to utilize
lobule spiriting techniques, improper shape, volume, size,
and width of framework, and finally improper postoperative
care. Thus, secondary construction is a challenge, and must
reverse all of the above-mentioned setbacks (see secondary
construction section).
Complications
The overall complication incidence in ear reconstruction is
reported to be 16.2% in average with a range of 0–72.9%. 63
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 a local skin flap,
but skin necrosis in a medial portion, such as concha bowl,
usually requires a local fascia flap to salvage it.57 Long-term
complications include the collapse of the ear framework and
extrusion of wires. Total auricular construction in HFM has
higher frequency of complications, such as malposition of the
new auricle and shrinkage of the auricle.32
Secondary construction
Secondary construction is challenging, but it is not impossible.
In many unsatisfactory outcomes, patients have lost supple
skin, and have developed many scars and disintegrated
frameworks. To create a smooth, natural-looking auricle in
such situations, surgeons should take an aggressive approach:
discard all scar tissue, deformed framework, and the damaged
skin envelope, then replace it with a well-vascularized, supple,
and thin skin envelope and a well-planned framework.23,26,31
In secondary cases, the temporoparietal fascia flap is a power­
ful workhorse to provide a thin envelope to cover the frame­
work (Figs. 7.9 & 7.42).30 If the local fascia flap is not available,
a distant free fascia flap may be the option. Brent described
the use of contralateral TPF plus hair-bearing skin to restore
the temporal hair line plus auricular construct.6 If the recipient
vessels are not available near the auricle, a vascularized free
(Fig. 7.39). Placing a cartilage block behind the framework has
two purposes: elevating the auricle and creating the auriculo­
cephalic sulcus. Nagata and Yamada studied the normal
shape of the auriculocephalic sulcus, and based on that study,
a 2D template was developed. The author routinely makes an
intra-operative impression to make a 3D template for fabrica­
tion of a cartilage block for sulcus construction (Fig. 7.14).
Hemifacial microsomia
(craniofacial microsomia)
Auricular construction in hemifacial microsomia (HFM) is
complex and challenging.32 Even in mild forms in terms of
mandibular underdevelopment (e.g., Pruzansky Type 1),
vestige skin tends to be located in the anterior and lower face,
and may accompany low hair line, low set ear canal, and
vascular anomalies (Fig. 7.5). If surgeons simply apply the
standard formula of auricular construction (place the auricle
where vestige is located), the new auricle tends to be located
in the face mask, which may be aesthetically unacceptable.
Surgeons should avoid placing the new auricle inside the face
mask. It is not uncommon to place the new auricle in an
anterior–inferior location, trying to avoid the low hairline in
HFM. Compromising the location of the auricle to some extent
may be necessary; otherwise, the location of the new auricle
will be too far back in the occipital area.
In HFM, skeletal correction prior to ear construction may
help to place the auricle in proper location (Fig. 7.10).102 It is
notable that laser hair removal works best for black hairs, with
multiple sessions (could be more than 10 sessions to com­
plete), but it is currently not effective against blond hairs (Fig.
7.7). The author found that in the microtia patient with severe
HFM there is a higher risk of ear shrinkage after complex total
auricular construction.32
Treacher–Collins syndrome
The patient with Treacher–Collins syndrome has distinctive
facial features: high nose, deficient lateral orbit/zygoma,
small chin, and overall facial size is small. Placing a large
auricle in such a face 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 45–50 mm
in length, to balance with the rest of the face (Figs. 7.11, 7.40
& 7.41). It is not uncommon that microtia in Treacher–Collins
syndrome accompanies a low hairline. To eliminate hairs from
the auricle, laser hair removal is one option, and the other is
that the local fascia flap such as the temporoparietal fascia or
fascia flap based on posterior vascular pedicle may be applied
to cover the upper third of the framework, after surgical hair
removal.57
Tissue expander
The idea to expand the skin to create extra soft, elastic, thin
skin to cover the ear framework is a tempting one, and
boomed in the 1990s, but the popularity of tissue expander
use in microtia reconstruction58,59 has decreased. Soft-tissue
expanders also have been used to expand under a temporo-