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Original Article |

Tumbling Cartilage Flap and Free Auricular Composite Tissue Transplantation for Correcting Mild and Moderate Forms of Constricted Ear FREE

Bo Pan, MD; Yanyong Zhao, MD; Hongxing Zhuang, MD; Lin Lin, MD; Lei Liu, MD; Haiyue Jiang, MD
[+] Author Affiliations

Author Affiliations: Plastic Surgery Hospital, Peking Union Medical College, Beijing, People's Republic of China.


Arch Facial Plast Surg. 2010;12(4):241-244. doi:10.1001/archfacial.2010.42.
Text Size: A A A
Published online

Objective  To report a new surgical approach that results in a natural size and contour of the external malformed constricted ear.

Methods  A total of 62 consecutive patients with constricted ear underwent surgery between July 1, 2005, and December 31, 2007. Depending on the features and severity of the deformity, the methods of tumbling cartilage flap (CF), free auricular composite graft, or a combination of these 2 techniques were applied.

Results  A total of 45 patients were treated with the method of tumbling CF. Twelve were treated with an auricular composite graft from the contralateral ear, and in 5 patients a combination of the 2 methods was used. In all cases, there was an improvement in the size, shape, and symmetry of the ears, and most patients were satisfied with the outcome. Complications were rare, and there was no donor site deformity.

Conclusions  The technique of tumbling CF and free auricular composite graft provides a simple and promising treatment for constricted ears. Furthermore, this technique is easy to apply with a predictable good outcome.

Figures in this Article

Tanzer1 coined the term constricted ear, in which the rim of the ear is tightened or constricted. The constricted ear is characterized by 4 features: lidding, decreased vertical height of the ear, protrusion, and low ear position.2 It can appear in many degrees, from mild to severe. In the mild form, the helix alone is involved. The helix is folded along the upper edge, and this can cause a decrease in the height of the ear. The rolled helix may not contain cartilage or have a tightly adherent double layer. In the moderate form, the helix and scapha cartilage are constricted. In the most severe form, the ear is rolled up almost in a tube with the front part of the helix tilted forward. The entire ear and hairline may be set low.

Severe deformities are generally considered as a form of concha-type microtia requiring auricular reconstruction with costal cartilage. The mild and moderate forms of constricted ears are usually corrected by using local tissue. We applied the methods of tumbling cartilage flap (CF) and free auricular composite tissue transplantation in correcting the mild and moderate forms of constricted ear. Most of the malformed ears acquired a natural-looking contour, and the vertical height was enhanced.

OPERATIVE PROCEDURE AND TECHNIQUE FOR CREATING TUMBLING CF

Surgery was performed under general anesthesia for children, whereas local anesthesia was generally used in adults and older youths.

The lidded part of the constricted ear was folded back to recreate the superior crus, and the antihelix and an estimate of postauricular skin excision was made (Figure 1A-C). An ellipse of postauricular skin was excised, and the upper wound margin undermined in the subperichondrial plane to the eminentia scapha. A curving incision was designed in the posterior auricular cartilage 5 to 8 mm from the rim of helix, similar to the height of the helix plus the length of the scapha. The entire layer of the cartilage was cut through. The anterior skin was undermined to the external border of the antihelix. A fan-shaped CF was formed (Figure 1D), and the 2 surfaces of the CF were superficially scored. When the CF was turned over and sutured to the cartilage below, the superior crus and the antihelix were formed by the tumbling rim of the CF (Figure 1E). The compound structure of the helix and scapha was pushed backward to reach the CF (Figure 1F). A 2-layer wound closure was performed in the subcutaneous tissue and the skin. Vaseline gauze (Unilever, London, England) was applied and modeled directly on the patient's ear to give the ear the desired shape (Figure 1J).

Place holder to copy figure label and caption
Figure 1.

Moderately constricted ear. A, Preoperative view. B, The lidding part was pushed backward; then the antihelix and superior crus presented (black arrow). C, Skin excision outline (black arrow) and incision of the cartilage flap (CF) (white arrowhead). D, The elevation of the CF (black arrow). E, The CF was tumbled and sutured to the cartilage beneath. F, The horizontal section of the constricted ear. 1, Preoperative view, skin between the points labeled A and A′ was excised. The skin labeled B was incised to form the CF. The distance between points B and B′ was equal to that of helix plus scapha of the normal ear. 2, The CF was elevated and the compound structure of helix and scapha was pushed backward. 3, The CF was folded, and the skin was sutured. The antihelix came into view, and the horizontal length was decreased. G, Preoperative view of the constricted ear. H, Postauricular skin incision. I, Tumbling CF. J, Vaseline gauze (Unilever, London, England) was applied.

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FREE AURICULAR COMPOSITE TISSUE TRANSPLANTATION

A full-thickness free auricular composite graft was obtained from the normal ear in the shape of a wedge (Figure 2A and B). Once harvested, the cartilage graft was placed in saline until ready for use. A full-thickness incision vertical to the helical rim was made on the malformed ear (Figure 2C and D). The length of incision depended on the size of the free graft and was usually 1.0 to 1.5 cm. The composite graft was wedged into the cuneiform defect of the affected ear. A 2-layer wound closure was performed in the donor site and recipient site. The cartilage was sutured with 5-0 absorbable stitch, and the skin was closed with a 6-0 nylon suture.

Place holder to copy figure label and caption
Figure 2.

Donor site, with units of measure shown in millimeters. A, Preoperative view of the donor site. B, The auricular composite tissue: the black arrow shows the width of the composite tissue, and the white arrow indicates the length of the composite tissue. C, The skin incision of the constricted ear. D, The free auricular composite tissue transplantation.

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A total of 62 consecutive patients with constricted ears (31, right-sided; 19, left-sided; and 12, bilateral) underwent surgery between July 1, 2005, and December 31, 2008. Sixty cases were sporadic, and 2 patients had a familial history of ear deformities. Forty patients were male, and 22 were female; the age at presentation ranged from 6 to 40 years. Forty-five patients were treated with the method of tumbling CF (Figure 3), 12 with auricular composite graft (Figure 4), and 5 with the combination of both methods (Figure 5). The width of the free auricular graft harvested ranged from 12.0 to 18.0 mm (mean, 14.7 mm), and the length, from 17.0 to 20.0 mm (mean, 18.1 mm).

Place holder to copy figure label and caption
Figure 3.

A 6-year-old girl with constricted ear treated with the method of tumbling cartilage flap. A, Preoperative view. B, Postoperative view. The lidding of the ear was rectified, and the vertical height was enhanced.

Graphic Jump Location
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Figure 4.

A patient with right constricted ear who underwent auricular composite graft. A, Lateral view. B, One-year postoperative view after free auricular composite tissue transplantation.

Graphic Jump Location
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Figure 5.

A patient who underwent correction using both methods. A, Preoperative view. The size of the left ear was smaller than the normal ear. The structure of scapha, antihelix, and superior crus was unnoticeable. B, Left lateral view. The upper part of the ear was lidding. C, Six-month postoperative view. The constricted ear was treated by using the tumbling cartilage flap combined with free auricular composite tissue transplantation. D, The size and contour of the ear were natural looking.

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The follow-up period ranged from 1 to 12 months. Most patients were satisfied with the size and symmetry of the corrected ear. The antihelix, supra crus, and scapha were rebuilt in most patients. The lidding of the constricted ears was corrected. In 15 of the 16 cases in which a free auricular composite graft was used, the graft revascularized and healed within 12 days. There was superficial necrosis in 1 graft, which healed after 1 month. There were no cases of cartilage infection and no malformation of the donor site of the ear, except for a linear scar.

The constricted ear has a spectrum of severity and, therefore, requires a graded surgical approach. Severe deformities are generally considered to be a form of concha-type microtia, with subtotal auricular reconstruction being the main surgical option.3,4 For the mild deformity, it has been suggested that excess skin and cartilage be excised.1 However, this can result in a smaller ear than on the contralateral side. For the moderate deformity, various radical cartilage refashioning procedures have been described to produce an improvement in the shape and height of the ear.58 However, favorable results and long-term maintenance of shape and height cannot be consistently obtained by these methods.

We have developed a simple and rational approach based on some principles described by Cosman.2 The technique of tumbling CF has 3 notable merits. First, lidding is corrected by rotation of the compound structure of the helix and scapha, with concomitant improvement in the vertical height. Second, protrusion is improved by decreasing the height of the concha. Third, the detailed auricular elements, such as the antihelix and the superior crus, are reconstructed through the tumbling rim of the CF. However, the main function of this technique is to restore the contour of the malformed ear. When the size of the constricted ear is still smaller compared with the opposite, we recommend the use of auricular composite graft.

Auricular composite grafts have been a useful technique in the reconstruction of deformities of the ear.911 A wedge-shaped composite graft from the opposite ear provides additional tissue to restore the height and size of the affected ear. In all our cases, the sizes of the 2 ears were unequal preoperatively. The size differences following surgery, however, were corrected adequately, and the size asymmetry was regarded as slight and inconspicuous. The composite grafts were usually harvested from the upper third of the ear in our method and had no impact on the general profile of the normal ear, except for a fine linear scar. The vascularization of the auricular composite graft depends on the bilateral edge of the graft, so the size of the composite graft was limited. Generally speaking, a 5-mm maximum distance from the point of vascular contact is preferred.12 In our practice, the maximum width of the wedge-shaped composite graft is 18 mm, and the maximum length is 20 mm. The length of the composite graft should not be shorter than 15 mm; otherwise, the donor defect would be difficult to close.

In conclusion, the technique of tumbling CF and free auricular composite graft provides a simple and promising treatment for constricted ears. Furthermore, this technique is easy to apply and has consistently good results and minimal complications.

Correspondence: Haiyue Jiang, MD, Plastic Surgery Hospital, Peking Union Medical College, Badachu Rd 33, Beijing, People's Republic of China (jianghaiyuepumc@yahoo.com.cn).

Accepted for Publication: December 27, 2009.

Author Contributions:Study concept and design: Pan, Zhao, Zhuang, Lin, Liu, and Jiang. Acquisition of data: Pan, Zhuang, Lin, and Jiang. Analysis and interpretation of data: Pan. Drafting of the manuscript: Pan, Zhao, Zhuang, Liu, and Jiang. Critical revision of the manuscript for important intellectual content: Pan, Zhao, and Lin. Statistical analysis: Pan, Zhao, Zhuang, Lin, and Jiang. Obtained funding: Pan, Zhao, Zhuang, Lin, Liu, and Jiang. Administrative, technical, and material support: Pan, Zhao, Zhuang, Liu, and Jiang. Study supervision: Pan and Zhao.

Financial Disclosure: None reported.

Funding/Support: This work was supported by the Vital Clinical Subject Foundation of China under grant No. 2004468 and the Chinese National Natural Science Foundation under grant 30500290.

Additional Contributions: We thank the patients for their participation. Dongjun Guo, MD, and Walid Sabbagh, MD, provided assistance with editing the English language of this article.

Tanzer  RC The constricted (cup and lop) ear. Plast Reconstr Surg 1975;55 (4) 406- 415
PubMed Link to Article
Cosman  B The constricted ear. Clin Plast Surg 1978;5 (3) 389- 400
PubMed
Xiaogeng  HHongxing  ZQinghua  YHaiyue  JYanyong  Z Subtotal ear reconstruction for correction of type 3 constricted ears. Aesthetic Plast Surg 2006;30 (4) 455- 459
PubMed Link to Article
Spira  M Subtotal ear reconstruction for correction of type 3 constricted ear. Aesthetic Plast Surg 2007;31 (6) 752- 753
PubMed Link to Article
Millard  DRMcCafferty  LRPrado  A A simple, direct correction of the constricted ear. Br J Plast Surg 1988;41 (6) 619- 623
PubMed Link to Article
Horlock  NGrobbelaar  AOGault  DT 5-year series of constricted (lop and cup) ear corrections: development of the mastoid hitch as an adjunctive technique. Plast Reconstr Surg 1998;102 (7) 2325- 2335
PubMed Link to Article
Demir  Y Correction of constricted ear deformity with combined V-Y advancement of the crus helicis and perichondrioplasty technique. Plast Reconstr Surg 2005;116 (7) 2044- 2046
PubMed Link to Article
Al-Qattan  MM An alternative approach for correction of constricted ears of moderate severity. Br J Plast Surg 2005;58 (3) 389- 393
PubMed Link to Article
Argamaso  RV An ideal donor site for the auricular composite graft. Br J Plast Surg 1975;28 (3) 219- 221
PubMed Link to Article
Clairmont  AAConley  JJ The uses and limitations of auricular composite grafts. J Otolaryngol 1978;7 (3) 249- 255
PubMed
Avelar  JMPsillakis  JMViterbo  F Use of large composite grafts in the reconstruction of deformities of the nose and ear. Br J Plast Surg 1984;37 (1) 55- 60
PubMed Link to Article
Rees  TD The transfer of free composite grafts of skin and fat: a clinical study. Plast Reconstr Surg 1960;25556- 564
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Moderately constricted ear. A, Preoperative view. B, The lidding part was pushed backward; then the antihelix and superior crus presented (black arrow). C, Skin excision outline (black arrow) and incision of the cartilage flap (CF) (white arrowhead). D, The elevation of the CF (black arrow). E, The CF was tumbled and sutured to the cartilage beneath. F, The horizontal section of the constricted ear. 1, Preoperative view, skin between the points labeled A and A′ was excised. The skin labeled B was incised to form the CF. The distance between points B and B′ was equal to that of helix plus scapha of the normal ear. 2, The CF was elevated and the compound structure of helix and scapha was pushed backward. 3, The CF was folded, and the skin was sutured. The antihelix came into view, and the horizontal length was decreased. G, Preoperative view of the constricted ear. H, Postauricular skin incision. I, Tumbling CF. J, Vaseline gauze (Unilever, London, England) was applied.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Donor site, with units of measure shown in millimeters. A, Preoperative view of the donor site. B, The auricular composite tissue: the black arrow shows the width of the composite tissue, and the white arrow indicates the length of the composite tissue. C, The skin incision of the constricted ear. D, The free auricular composite tissue transplantation.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

A 6-year-old girl with constricted ear treated with the method of tumbling cartilage flap. A, Preoperative view. B, Postoperative view. The lidding of the ear was rectified, and the vertical height was enhanced.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

A patient with right constricted ear who underwent auricular composite graft. A, Lateral view. B, One-year postoperative view after free auricular composite tissue transplantation.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

A patient who underwent correction using both methods. A, Preoperative view. The size of the left ear was smaller than the normal ear. The structure of scapha, antihelix, and superior crus was unnoticeable. B, Left lateral view. The upper part of the ear was lidding. C, Six-month postoperative view. The constricted ear was treated by using the tumbling cartilage flap combined with free auricular composite tissue transplantation. D, The size and contour of the ear were natural looking.

Graphic Jump Location

Tables

References

Tanzer  RC The constricted (cup and lop) ear. Plast Reconstr Surg 1975;55 (4) 406- 415
PubMed Link to Article
Cosman  B The constricted ear. Clin Plast Surg 1978;5 (3) 389- 400
PubMed
Xiaogeng  HHongxing  ZQinghua  YHaiyue  JYanyong  Z Subtotal ear reconstruction for correction of type 3 constricted ears. Aesthetic Plast Surg 2006;30 (4) 455- 459
PubMed Link to Article
Spira  M Subtotal ear reconstruction for correction of type 3 constricted ear. Aesthetic Plast Surg 2007;31 (6) 752- 753
PubMed Link to Article
Millard  DRMcCafferty  LRPrado  A A simple, direct correction of the constricted ear. Br J Plast Surg 1988;41 (6) 619- 623
PubMed Link to Article
Horlock  NGrobbelaar  AOGault  DT 5-year series of constricted (lop and cup) ear corrections: development of the mastoid hitch as an adjunctive technique. Plast Reconstr Surg 1998;102 (7) 2325- 2335
PubMed Link to Article
Demir  Y Correction of constricted ear deformity with combined V-Y advancement of the crus helicis and perichondrioplasty technique. Plast Reconstr Surg 2005;116 (7) 2044- 2046
PubMed Link to Article
Al-Qattan  MM An alternative approach for correction of constricted ears of moderate severity. Br J Plast Surg 2005;58 (3) 389- 393
PubMed Link to Article
Argamaso  RV An ideal donor site for the auricular composite graft. Br J Plast Surg 1975;28 (3) 219- 221
PubMed Link to Article
Clairmont  AAConley  JJ The uses and limitations of auricular composite grafts. J Otolaryngol 1978;7 (3) 249- 255
PubMed
Avelar  JMPsillakis  JMViterbo  F Use of large composite grafts in the reconstruction of deformities of the nose and ear. Br J Plast Surg 1984;37 (1) 55- 60
PubMed Link to Article
Rees  TD The transfer of free composite grafts of skin and fat: a clinical study. Plast Reconstr Surg 1960;25556- 564
PubMed Link to Article

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