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Ear Reconstruction

Anatomy –

Vascular supply –

Superficial temporal

Posterior auricular

Sensory supply –

Greater auricular – lower half

Lesser occipital – upper part posterior

Auricotemporal – upper part anterior

Vagus – conchal part

History –

1st description – Sushruta Samhita

Tagliacozzi – 1597, retroauricular flap for ear deformity

Dieffenbach – 1845, advancement flap for ear’s middle third

Gillies – 1920 – carved costal cartilage for microtia repair (kept cartilage under mastoid skin and then separated with cervical flap)

Pierce – modified Gillies – used SSG to form new sulcus and tubed flap for helix

Gillies – used maternal ear cartilage àresorbed

Radford Tanzer – 1959 – autologous rib cartilage and carving in blocks

Cronin – 1966, silicon ear frameworks – high incidence of extrusion

Young and Peer – framework fabrication

Burt Brent – 1970, four-stage repair

Nagata – 1990, two stage repair

Tanzer – father of modern auricular reconstruction.

Embryology –

Middle ear and external ear – derived from – 1st (Mandibular) & 2nd (Hyoid) branchial arches.

Auricle derived from – Six “Hillocks” of tissue.

Anterior hillock –

Upper – helix

Middle – crus of helix

Lower – tragus

Posterior hillock –

Upper – antihelix

Middle – antitragus

Lower – lobule & lower part of helix

Microtia –

Incidence – 1: 6000 live birth (ref. Grabb’s)

Etiology –

Hereditary factors –

Multifactorial inheritance –

Risk in 1st degree relatives – 3-8%

Risk in 3rd sibling with 2 siblings having microtia – 15%

Syndromes A/W microtia –

  1. Treacher Collins
  2. Craniofacial microsomia
  3. Townes-Brocks syndrome

Specific factors –

In utero tissue ischemia  <–obliterated Stapedial artery or Hemorrhage in local tissue

Other factors –

Rubella infection in mother

Ingestion during 1st trimester of pregnancy – Thalidomide, Isotretinoin,  Clomiphene citrate, Retinoic acid

Diagnosis –

Classification –

Roger classification –

  1. Microtia
  2. Lop ear – folding or deficiency of the superior helix and scapha
  3. “Cup” or constricted ear – with a deep concha and deficiency of superior helix and antihelical crura
  4. Prominent or protruding ear

Tanzer classification (classification according to signal correction approach)- [ACMS-P]

  1. Anotia
  2. Complete hypoplasia (Microtia)
    1. With atresia of EAM ( external auditory meatus)
    2. Without atresia of EAM
  3. Hypoplasia of Middle third of auricle
  4. Hypoplasia of Superior third of auricle
    1. Constricted (Cup or Lop ear)
    2. Cryptotia
    3. Hypoplasia of entire superior third
  5. Prominent ear

Nagata classification –

  1. Lobule type – ER (Ear Remnant) + ML (Malpositioned Lobule)
  2. Concha type – ER + ML + concha + Tragus & antitragus with intertragal notch
  3. Small concha type – ER + ML + small indentation
  4. Anotia – ER only
  5. Atypical


Associated deformity –

  1. Branchial arch deformities –
    1. Obvious bony or soft tissue defect
    2. Facial nerve weakness
  2. Macrostomia – 2.5%
  3. Cleft lip and/or palate – 4.3%
  4. Urogenital defect – 4.0
  5. Cardiovascular malformation

Clinical characteristics –

MC type is – Vertically oriented sausage shaped nubbin

[M: F = 2:1],        [Right: Left: B/L = 6:3:1],       [U/L: B/L = 9:1]

1/3rd to ½ patients have gross characteristics of hemifacial microsomia

Timing of surgery –

Psychological and physical consideration

Psychological – ideal before child enters school

Physical – there should be enough rib growth for fabrication of framework

Brent – @ 6yrs of age

Nagata – @ 10 yrs of age & Chest circumference >60cm @ Xiphoid level


Steps of surgery –

Brent – Four-stage [FLET]

  1. Framework placement
  2. Lobule transposition (correction)
  3. Elevation of reconstructed auricle & creation of retroauricular sulcus
  4. Tragus creation and concha deepening

Nagata – Two-stage [FLT]

  1. FLT (Brent steps 1+2+4)
  2. Elevation of reconstructed auricle & creation of retroauricular sulcus (Brent 3)


@ Age 4 – ear is 85% of adult size

@ Age 6 – ear is within 6-7 mm of its full vertical height

Reconstructed ear may grow with child.


Middle ear problem –

Hearing impairment related to – abnormal auditory canal, tympanic membrane & middle ear.

Microtia patient have hearing threshold of 40-60 dB on affected ear. (Normal – 0-20 dB)

Most patient of microtia have atresia of external auditory canal and tympanic membrane with variable deformity of middle ear ossicles.

Hearing restoration – to be done in bilateral cases (NOT in unilateral cases).

BAHA (bone anchored hearing aid) is given.Hearing aid should be given early – within weeks of birth.

U/L BAHA is sufficient for B/L microtia with bilateral hearing loss.

BAHA can be used in U/L microtia with U/L conductive hearing loss à both audiological and subjective benefits.

Hearing impairment is – Conductive loss – due to malformed middle & external ear.

(Internal ear is derived from distinct separate ectodermal origin and hence is mostly spared)

Internal ear abnormity is seen in – 10% of microtia patients.



Canaloplasty –

In microtia –> approx half of patient have surgically correctable middle ear anatomy –> this is important in bilateral microtia (Surgery may eliminate dependence on hearing aids).

Canaloplasty NOT done in unilateral microtia.

[A before C] – Auricle reconstruction to be done Before Canaloplasty.

Auricle reconstruction after canaloplasty has compromised result due to scar (present after canaloplasty).

Cholestoma formation can cause/worsen hearing loss in adulthood.


Reconstruction –

Patient assessment –

Look for dysmorphic features.  20-60% have associated anomaly.

Microtia is a feature of –

  1. Hemifacial microsomia
  2. Treacher- Collins syndrome
  3. Nager syndrome
  4. Townes-Brocks syndrome

Facial asymmetry –

In such cases it’s better to correct bony asymmetry before ear reconstruction.


Skin envelope –

Soft, elastic skin should be available.

Limited availability can hamper ear reconstruction à will make auricle definition poor.

Check for scar around ear – can cause stretching of the supple skin envelope.

Scar along the course of STA (superficial temporal a) –> may suggest a severed STA –>  it is the pedicle for TP flap (temporoparietal)  –> A salvage flap for ear reconstruction.

Assess vestige skin –

Assess location, shape & volume of vestigial skin.

If vestige skin is located far away from auricular rectangle (RA), it need to be transposed within AR – otherwise not.

Volume/size of vestige skin –

Relatively large – a deep concha can be formed.

Small – conchal cavity will be shallow

Assess Hairline –

Low hairline – may require hair removal. If low hairline exceeds beyond upper 1/3rd of auricular framework.

Trapezium – space behind side burn –

Missing sideburn may be the initial sign of hemifacial microsomia.

The auricle is located 20mm behind sideburn.

Placing auricle in trapezium shaped space results in anterior inclination of new auricle.

Auricle rectangle (AR) –

Auricle rectangle is identified within which framework will be placed.

Identify relationship of AR with vestige skin.

Auricular template –

Tracing of normal ear.

Flipped on abnormal side and traced.


Position of tracing –

Axis – almost parallel to nasal profile

Distance – equi-distance from lateral canthus – measure distance from lateral canthus to helical root on normal side – replicate this on affected side.


Obtaining the rib cartilage –

Obtain en-bloc from contralateral side – utilizes natural rib configuration.

Helical rim from – first free floating cartilage

Framework from synchondrosis of rib 6 & 7.

Extraperichondrial dissection is preferred.

Preserve even a minimal rim of upper margin of 6th rib cartilage à maintains shape of chest.

Framework fabrication –

Aim is to exaggerate the helical rim and the details of the antihelical complex.

Basic ear silhouette is carved from cartilage block

Framework fabrication is essential in older patient, but not so much in children.

Deliberate warping is a favorable direction à allows flexion necessary to create a helix.

Framework implantation –

Cutaneous pocket created

Incision – small incision along the backside of the auricular vestige.

Native remnant cartilage is excised and discarded.

Framework is inserted.

(This framework placement displaces this skin centrifugally in advantageous postero-superior direction so as to displace the hairline just behind the rim – this principle of anterior incision and centrifugal skin relaxation – given by Tanzer).

Place a closed suction drain (this helps maintain shape).


Immediate post-op care –

Dressing – non-compressive, convulated

Remove drain – 5th day

Post-op –

Return to school – 2 weeks

Running and sports – 5 weeks

2nd stage – rotation of lobule –

Done by Z-plasty transposition of a narrow, inferiorly based triangular flap.


Tragal construction and conchal definition –

Placing a thin elliptical-shaped chondrocutaneous composite graft beneath a J-shaped incision in the conchal region.

The main limb of “J” is proposed tragal margin.

The crook of “J” represents intertragal notch.

Composite graft harvested from – Anterolateral conchal surface of opposite ear.

FTG harvested and floor of tragal region resurfaced (tragal region is excavated before placing FTG)


Tragus – created as integral strut of the main framework.

Brent – small piece of rib cartilage – first fastened to the frame à then curved around and affixed by its distal tip to frame’s crus helix.

Nagata – uses extra cartilage piece to its main framework.

Modification Kirkham method –

Anteriorly based conchal flap doubled on itself.


Detaching the posterior auricular region (framework elevation) –

  • SSG – to create retroauricular sulcus
  • Placing a wedge of rib cartilage behind the elevted ear –> greater projection of auricle achieved. Cartilage placed need to be covered with – by temporoparietal flap (Nagata) or Turnover “bookflap” of occipital fascia from behind the ear (Firmin, Weerda, Brent)


Managing the hairline –

Low hairline is MC and troublesome problems in ear reconstruction.

Options of removing hair –

1). Electrolysis, 2). Laser, 3). Replacement of follicular skin with a graft – for larger area



  1. Skin flap preparation –

Lobule splitting technique for lobule type microtia.

Nagata described in 1994 – lobule is split into two –

-Anterior lobule flap – transposed backwards to cover the anterior lobule of the framework

-Posterior lobule flap – transposed anteriorly to cover the posterior aspect of the tragugs and concha cavity.


Skin incision for small concha type microtia –

Skin incision made along small indentation –> indentation turned inside out (this will be used to cover framework)

Skin incision for concha-type microtia –

1994 – Z-plasty type incision with posterior V-shape design.

V shaped design changed to W-shaped.


  1. Removing vestige auricular cartilage –

Lobule type – all of vestige cartilage is removed.

Concha type – remnant concha is preserved as a cuff.


  1. Skin pocket dissection

2 mm thick skin flap (do not use epinephrine)

Extent of skin dissection – 1 cm beyond the hair line.


  1. Harvesting costal cartilage –

Brent harvest cartilage with perichondrium

Firmin keeps anterior portion of the perichondrium to the cartilage, leaving rest of the perichondrium at donor site.

Nagata – leaves entire perichondrium at donor site.


  1. Auricular framework creation –


Bolster suture –

Nagata uses bolster dressing for post-operative dressings

Brent uses suction.


Second stage – Auricular elevation –

Normal auricle – separated by supporting cartilage. Gives better elevation.

Raising TPF (temperoparietal fascia) flap –

Covers the cartilage block.

Augments blood supply of auricle posteriorly (which might have been lost during separation)

Alternate flap option –

1). Deep temporal fascia flap, 2). Free vascularized fascia flap


Complication –

Rate – 0 – 72.9%, Avg – 16.2 %

Most serious complication – cartilage infection. To prevent this address skin necrosis immediately.

Secondary reconstruction –

Difficult but not impossible.

Excise all scarred tissue and damaged skin envelope à replace it with well vascularized supple and thin skin envelope with well-planned framework à TPF (temperoparietal fascia) is the workhorse flap for this purpose.



Constricted ear –

Described first by Tanzer – 1975. A/k/a – “cup” or “lop” ear

Helix and scapha fossa are hooded and crura of antihelix flattened.

Inadequate helical rim circumference.

Group 1 & 2A –

Mild deformity of helix (a/k/a – “Lop” ear)

Helical cartilage with minimum skin defect.

Musgrave technique – Expands the helix. –> Multiple cuts made in curled cartilage –> fan upwards and backwards –> fixed to curved strut made of concha cartilage.

Group 2B –

Has both skin and cartilage defects – in upper third of auricle

Grotting flap – modified by Park – is used for helical skin defect – by creating both skin flap and fascial flap with the same pedicle (fascial flap provide additional coverage to skin flap which is limited in width (10-13mm)).

For helical cartilage – 8th rib cartilage is harvested.

Group 3 –

Most severe cupping. Treated as microtia – concha type microtia.


Cryptotia –

Upper pole of the ear cartilage is buried under the scalp.

Superior auricotemporal sulcus is absent.

High incidence in Japan – 1:400.

Goal of surgery – creating a retroauricular sulcus.

Methods –

1). SSG, 2). Z-plasty, 3). V-Y advancement, 4). Rotation flap

Stahl ear –

Described by Binder, 1989 (named after Dr Stahl)

Characterized by third crus extending towards helical rim.

Three types –

  1. Obtuse angle bifurcation (superior crus missing)
  2. Trifurcation
  3. Broad superior crus & broad third crus

Treatment –

Early infancy – ear remodeling.

Surgical treatment – cartilage /skin excision or cartilage alteration.


Ear remodeling –

First described by Matsuo. 

Early initiation has better result – presence of maternal estrogen makes cartilage more elastic.

Lop ear and Stahl ear – responds to ear molding only if started in neonatal period.

Cryptotia and protruding ear – responds well until approx 6m of age.

Results poor if molding started after 3m of age.

Helix-antihelix adhesion responds poorly – contraindication for ear molding.


Traumatic ear amputation –

Cartilage can be stored (under abdomen, scalp) –> but stored cartilage does not provides good definition –> best reconstructed with rib cartilage.


Burnt ear –

Burn injury – there is non-availability of good skin.

TPF flap powerful tool for coverage of framework.


Partial ear reconstruction –

Pure helical rim defect – Antia-Buch helical rim advancement.

Major middle- third auricular defect – Converse tunnel procedure.


Prominent ear –

MC anomaly of head & neck area.

Incidence – 5% of general population.

M:F = 1:1

Normal ear – separated by less than 2 cm from and forms an angle of <25° with side of the head.

Cause of protrusion of ear –

  1. Underdevelopment or effacement of the antihelix
  2. Over-development of the deep concha
  3. Combination of 1 & 2

Timing of surgery – around 5-7 yrs of age.

Surgical techniques –

McDowell normal distance from skull to the helix.

From mastoid –

Upper third – 10-12mm

Middle third – 16-18mm

Lobule – 20-22mm

Antihelical fold alteration –

  1. Scapha-conchal suture –

Mustarde – permanent Mattress suture through cartilage without any cartilage incision (useful in soft cartilage of children). Suture from scapha to triangular fossa or concha.

  1. Anterior cartilage alteration –

Chongchet – scored the anterior scapha cartilage with multiple cartilage cut to roll it back and from an antihelix (done under direct vision).

Strenstrom – Scored antihelcial region through posterior stab incision near the cauda helicis. Principle of Gibson – cartilage bend away from abraded side.

  1. Restore helical fold by excision –

Luckett – excising a crescent of anterior skin and cartilage – conchal excision and primary closure.

Converse/wood-Smith technique – two parallel incision – parallel to desired antihelical fold –> then tubing sutures places to create defined fold.

  1. Conchal alteration –

Dieffenbach – first otoplastic attempt, 1845 –> excising skin from auricocephalic sulcus and then suturing conchal cartilage to the mastoid periosteum.

Suturing – angle b/w concha & mastoid reduced by placing sutures b/w the concha and mastoid fascia – Furnas.

[Fascia- Furnas]  [Mattress – Mustarde]


Correction of earlobe prominence-

Gosian technique –

Small amount of skin excised from medial (posterior) surface and then closed à with a bite to undersurface of concha.

Webster technique – repositioning helical tail (by suturing to concha) can reposition ear lobe (but not reliably).


Ear reconstruction – specific regional defects –

External auditory canal stenosis –

  1. FTG over acrylic mold (for several months)
  2. Multiple Z-plasty
  3. Local flap

Helical rim defect –

Up to 1.5 cm (<2cm) – Antia-Buch helical rim advancement (chondrocutaneous flap) / with V-Y advancement of helical crus (additional advancement achieved).

Thin tube of retroauricular skin – its “waltzed” into place.

Upper 1/3rd defects –

  1. Local skin flaps
  2. Helical advancement (HA)
  3. C/L conchal graft covered with a retroauricular flap (Adanis) (CG with RA)
  4. Chondrocutaneous composite flap
  5. Rib cartilage graft covered with retroauricular skin or temporoparietal flap/skin graft (RC with RA)
  6. Banner flap


Middle 1/3rd defect –

  1. Primary closure with excision of accessory triangle
  2. HA
  3. CG with RA
  4. RC with RA
  5. Diffenbach technique

Cartilage graft can be inserted through Converse tunnel procedure

Lower- third defect (Ear lobe) –

  1. Soft tissue flaps –
    1. Converse two flap technique
    2. Reverse contoured flap
    3. Zenteno-Alanis flap
  2. Cartilage graft


Pardue’s flap – for closure of split ear with maintaining tract lined with skin (for use of ear rings immediately)


Macrotia – reduction otoplasty (Crescent of scapha removed with excision of redundant helical skin)

Shell ear – wedge excision of helical rim and suturing

Question mark ear (supralobular deficiency) – deficiency treated by cartilage graft (conchal graft or rib graft)

Stahl ear (extra third crus) – excision of extra crus.

Cryptotia (buried upper pole of ear) – creation of retroauricular sulcus (SSG, Z-plasty, V-Y, Local flap)

Constricted ear (different degree of helical rim deficiency causing overhanging rim) – overhanging skin/cartilage excised & reconstructed with cartilage graft.


Differences in different techniques of ear reconstruction –


Brent Nagata Firmin
Age  of surgery 6 yrs 10 yrs 10 yrs
Steps of surgery 4 stage 2 stage 2 stage
Pieces of cartilage used 2







Conchal unit






Tragus and antitragus

Projection piece

Spare piece (to construct posterior wall of concha)

Suture used Non-absorbable (Prolene) Wire Wire
Cartilage harvest Resect entire perichondrium with cartilage Leaves entire perichondrium at donor site Leaves the posterior perichondrium at donor site
Post op dressing Uses suction to maintain shape Uses bolster dressing to maintain shape



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