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Original Article |

Use of the Remnant Ear for Reconstruction in Lobule-Type Microtia FREE

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

Author Affiliations: Plastic Surgery Hospital, Peking Union Medical College (Drs Pan, Lin, Zhao, Zhuang, and Jiang), and Department of Plastic Surgery, Third Hospital of Chinese Armed Police Force Beijing Corp (Dr Lu), Beijing, China.


Arch Facial Plast Surg. 2009;11(5):338-341. doi:10.1001/archfacial.2009.66.
Text Size: A A A
Published online

Objective  To present in detail a reconstruction technique using the remnant ear in lobule-type microtia.

Methods  By comparing the location of residual ear and the contralateral normal ear, we classified 3 different types of the remnant ear. Three techniques of transposition were applied to adjust the location of the reconstructed ear.

Results  The reconstructed earlobes not only looked real but also were symmetrical with the contralateral normal ears.

Conclusion  The remnant ear is a key factor—in addition to the framework and covering skin—in ear reconstruction in microtia.

Figures in this Article

Microtic auricular deformity has been mainly categorized as the lobule type and the concha type according to the location of the remnant ear present.1,2 Lobule-type microtia, seen as small cutaneous cartilage in the mastoid area, is the most common type. The remnant ear is usually used to reconstruct the inferior part of the auricle. In most lobule-type microtia, the location of the remnant ear is the same as that of the contralateral normal ear; in some cases, however, the remnant ear is higher or lower than the contralateral normal ear. In the latter cases, it is difficult to adjust the reconstructed ear to a proper position by using the technique advocated by Tanzer3 and Brent.4 In this report, we classify the remnant ear of lobule-type microtia and define different types of transposition in ear reconstruction.

By comparing the location of residual ear and the contralateral normal ear, we use 3 different classifications for the remnant ear. In type A, the inferior location of the remnant ear is the same as that of the contralateral normal ear. In type B, the inferior location of the remnant ear is higher than the contralateral normal ear. In type C, the inferior location of the remnant ear is lower than the contralateral normal ear (Figure 1A).

Place holder to copy figure label and caption
Figure 1.

Schematic representation of our classification of remnant ears and the respective transposition techniques. A, The classification of types C, A, and B remnant ears (from left to right). The dashed lines indicate the position of the remnant ear in relation to the bottom of the earlobe on the normal ear. B, Incision design in the type A remnant ear. C, Incision design in the type B remnant ear in stage 1. A vertical skin incision was made along the lower remnant earlobe margin (A-B) and infra-aural region (A′-B′). The transposition of B to B′ is at the bottom of the remnant ear, and A′ is the position parallel to that of the contralateral normal ear. The distance of A to B is equal to that of A′ to B′. The remnant ear is pushed downward and the secondary wound surface is then closed horizontally. D, Incision design in the type C remnant ear.

Graphic Jump Location

We transpose the remnant earlobe using 1 of 3 different methods, according to the classification of the remnant ear. For type A remnant ears, the incision is made in the middle and inferior part of the remnant ear as advocated by Tanzer3 and Brent.4 The lobule flap is then mobilized posteriorly and inferiorly, using an inferior pedicle as a pivot point. The lobule flap is partially split into 2 parts. The anterior part is sutured to the skin flap, and the posterior part is sutured to the inferior border of the recipient incision (Figure 1B). For type B remnant ears, the technique involves 2 stages. In stage 1, a vertical skin incision is made along the lower remnant earlobe margin and infra-aural region. The remnant ear is pushed downward, and the secondary wound surface is then horizontally closed with 6-0 nylon sutures (Figure 1C). In stage 2, the application of the remnant ear is the same as that for type A. For type C remnant ears, the incision is made in the middle and inferior parts of the remnant ear. The pedicle of the lobule flap is in the superior part of the remnant ear. The inferior part of the lobule flap is rolled posteriorly and superiorly (Figure 1D).

From January 1, 2004, through December 31, 2006, we performed auricular reconstruction in 268 patients with unilateral lobule-type microtia, of whom 204 were male and 64 were female. One hundred sixty-three patients had microtia of the right ear and 105, of the left ear. According to our classification, 208, 40, and 20 remnant ears belonged to types A, B, and C, respectively. Among type B and C remnant ears, 21 and 16, respectively, had dysplasia of the maxilla, zygoma, and mandible. The affected hemiface of the patient often showed dystrophy (Figure 2 and Figure 3).

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Figure 2.

An 11-year-old girl with left microtia and dysplasia of the left hemiface. A, The location of the left remnant ear is higher than the contralateral normal ear (type B). B, Lateral view of the remnant ear. C, The normal right ear. D, Three-dimensional computed tomographic scan shows dysplasia of the maxilla and mandible. E, The left zygomatic arch and temporomandibular articulation are absent. F, The contralateral normal ear.

Graphic Jump Location
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Figure 3.

A 7-year-old girl with right ear malformation and dysplasia of the right side of the face. A, The location of the remnant right ear is obviously lower than the contralateral normal ear (type C). B, Lateral view of the remnant ear. C, The normal left ear. A preauricular tag is in front of the ear. D, Three-dimensional computed tomographic scan shows underdevelopment of the right zygoma, maxilla, and mandible. E, The right condylus and the coronoid process are undeveloped, and the temporomandibular articulation is absent. F, The contralateral normal ear.

Graphic Jump Location

The blood supply, contour, and location of the remnant ear constituted the main evaluation criteria after transposition to reconstruct the inferior auricle. The blood supply of the lobule flap was good, and there were no cases of necrosis of the flap. There were 12 cases of sulcus in the conjunction areas of the transposed remnant ear and the 3-dimensional framework. This complication could be manipulated by means of a Z-plasty. The reconstructed earlobe looked real, and its location coincided with the contralateral normal ear (Figures 4, 5, and 6).

Place holder to copy figure label and caption
Figure 4.

A 26-year-old man with lobule-type microtia. A, Preoperative view. The location of the remnant ear is basically the same as that of the contralateral normal ear (type A). B, Lateral view. C, Rear view. D, Postoperative view of the patient. The remnant ear was transposed using the method described for type A remnant ears in Figure 1. E, The reconstructed earlobe looks real. F, The location of the reconstructed ear is consistent with that of the contralateral normal ear.

Graphic Jump Location
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Figure 5.

A 10-year-old girl with lobule-type microtia. A, Preoperative view. The remnant ear is higher than the contralateral normal ear (type B). B, Lateral view of the remnant ear. C, Postoperative view. The location of reconstructed ear is similar to that of the contralateral normal ear. D, Lateral view of the reconstructed ear.

Graphic Jump Location
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Figure 6.

A 6-year-old boy with lobule-type microtia. A, Preoperative view of the remnant ear. B, The location of the remnant ear is lower than the contralateral normal ear (type C). C, Lateral view of the reconstructed ear. D, Postoperative rear view. The location of reconstructed ear is similar to that of the contralateral normal ear.

Graphic Jump Location

Ear reconstruction is one of the most challenging surgical procedures faced by the reconstructive surgeon.3,4 The location of the remnant ear plays a vital role in deciding the position of the reconstructed ear. In minor cases, the location of the remnant ear is obviously lower than that of the contralateral normal ear. In these cases, it is difficult to adjust the reconstructed ear to a proper position if the remnant ear is applied using the technique advocated by Tanzer3 and Brent.4 In this report, we defined a new classification and successfully applied different types of transposition according to that classification. We have proposed a new view of microtia reconstruction in which the remnant ear—in addition to the ear framework and covering skin—is the third key factor in microtia reconstruction.

Transposition of the remnant ear is the classic technique in microtia reconstruction. The timing of transposition is controversial. Tanzer3 advocated starting the reconstruction by transposition of the lobule. However, when the framework is inserted during stage 2, it is difficult to obtain a good match with the already transposed lobule. Brent4,5 proposed an approach for correction of the typical lobular type of microtia, which is accomplished in 4 stages: insertion of an autologous cartilaginous framework into a skin pocket, transposition of the lobule, construction of the tragus, and construction of the retroauricular sulcus. In his approach, reconstruction begins by placing the cartilaginous framework in the ideal position. The lobular flap is then correctly adapted to the already constructed contours during stage 2. This procedure is useful in most cases of lobule-type microtia. However, in dystopic microtia, it is difficult to manipulate according to Brent's method in clinical application. Park6 addressed reconstruction of dystopic microtia in which the external auditory canal is present. In his approach, the remnant ear is shifted, with attachment of the temporoparietal fascia on its cranial part. In the present study, we provide a new classification of lobule-type microtia according to the position of the remnant ear compared with the contralateral normal ear. Our ultimate goal is to mobilize the displaced lobule to the correct position at the inferior pole of the framework and then to match the long-axis dimension to that of the contralateral normal ear. We anchor the ear framework to the proper position and transpose the lobule flap simultaneously.

The transposition of the type A remnant ear is the basic technique that is widely accepted by plastic surgeons. Of our 268 patients, 77.6% underwent the type A procedure. The procedure for type B is similar to that of Park.6 Among the patients treated by Park, about 40% of lobule-type microtias had a lobule positioned higher than the contralateral normal ear. However, only 14.9% of this type were included in our study group. The converse transposition of type C remnant ears is unique, and this method was used in a small number of patients (7.5%).

In conclusion, the remnant ear is the third key factor—in addition to the framework and the covering skin—in microtia reconstruction. According to the position of the remnant ear in relation to that of the contralateral normal ear, we provide a new classification of lobule-type microtia and describe a different procedure. Our studies in 286 patients show that the reconstructed earlobes not only look real but also are symmetrical with the contralateral normal ears.

Correspondence: Haiyue Jiang, MD, Plastic Surgery Hospital, Peking Union Medical College, Badachu Road 33, Beijing, China (jianghaiyuepumc@yahoo.com.cn).

Accepted for Publication: January 26, 2009.

Author Contributions:Study concept and design: Pan, Lin, Zhao, Zhuang, Lu, and Jiang. Acquisition of data: Pan, Lin, Zhao, Zhuang, Lu, and Jiang. Analysis and interpretation of data: Pan, Lin, Zhao, Zhuang, Lu, and Jiang. Drafting of the manuscript: Pan, Lin, Zhao, Zhuang, Lu, and Jiang. Critical revision of the manuscript for important intellectual content: Pan, Lin, Zhao, Zhuang, Lu, and Jiang. Statistical analysis: Pan, Lin, Zhao, Zhuang, Lu, and Jiang.

Financial Disclosure: None reported.

Funding/Support: This study was supported by grants 2004468 from the Vital Clinical Subject Foundation of China (Dr Zhuang) and 30500290 from the Chinese National Natural Science Foundation (Dr Pan).

Additional Contributions: We thank the patients for their participation. Guo Dongjun, MD, assisted with editing the English language of this report.

Nagata  S Modification of the stages in total reconstruction of the auricle, I: grafting the three-dimensional costal cartilage framework for lobule-type microtia. Plast Reconstr Surg 1994;93 (2) 221- 230, 267-268
PubMed Link to Article
Nagata  S Modification of the stages in total reconstruction of the auricle, II: grafting the three-dimensional costal cartilage framework for concha-type microtia. Plast Reconstr Surg 1994;93 (2) 231- 242, 267-268
PubMed Link to Article
Tanzer  RC Microtia: a long-term follow-up of 44 reconstructed auricles. Plast Reconstr Surg 1978;61 (2) 161- 166
PubMed Link to Article
Brent  B The correction of microtia with autogenous cartilage grafts, I: the classic deformity. Plast Reconstr Surg 1980;66 (1) 1- 12
PubMed Link to Article
Brent  B Microtia repair with rib cartilage grafts: a review of personal experience with 1000 cases. Clin Plast Surg 2002;29 (2) 257- 271, vii
PubMed Link to Article
Park  C Balanced auricular reconstruction in dystopic microtia with the presence of the external auditory canal. Plast Reconstr Surg 2002;109 (5) 1489- 1505
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Schematic representation of our classification of remnant ears and the respective transposition techniques. A, The classification of types C, A, and B remnant ears (from left to right). The dashed lines indicate the position of the remnant ear in relation to the bottom of the earlobe on the normal ear. B, Incision design in the type A remnant ear. C, Incision design in the type B remnant ear in stage 1. A vertical skin incision was made along the lower remnant earlobe margin (A-B) and infra-aural region (A′-B′). The transposition of B to B′ is at the bottom of the remnant ear, and A′ is the position parallel to that of the contralateral normal ear. The distance of A to B is equal to that of A′ to B′. The remnant ear is pushed downward and the secondary wound surface is then closed horizontally. D, Incision design in the type C remnant ear.

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

An 11-year-old girl with left microtia and dysplasia of the left hemiface. A, The location of the left remnant ear is higher than the contralateral normal ear (type B). B, Lateral view of the remnant ear. C, The normal right ear. D, Three-dimensional computed tomographic scan shows dysplasia of the maxilla and mandible. E, The left zygomatic arch and temporomandibular articulation are absent. F, The contralateral normal ear.

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

A 7-year-old girl with right ear malformation and dysplasia of the right side of the face. A, The location of the remnant right ear is obviously lower than the contralateral normal ear (type C). B, Lateral view of the remnant ear. C, The normal left ear. A preauricular tag is in front of the ear. D, Three-dimensional computed tomographic scan shows underdevelopment of the right zygoma, maxilla, and mandible. E, The right condylus and the coronoid process are undeveloped, and the temporomandibular articulation is absent. F, The contralateral normal ear.

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

A 26-year-old man with lobule-type microtia. A, Preoperative view. The location of the remnant ear is basically the same as that of the contralateral normal ear (type A). B, Lateral view. C, Rear view. D, Postoperative view of the patient. The remnant ear was transposed using the method described for type A remnant ears in Figure 1. E, The reconstructed earlobe looks real. F, The location of the reconstructed ear is consistent with that of the contralateral normal ear.

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

A 10-year-old girl with lobule-type microtia. A, Preoperative view. The remnant ear is higher than the contralateral normal ear (type B). B, Lateral view of the remnant ear. C, Postoperative view. The location of reconstructed ear is similar to that of the contralateral normal ear. D, Lateral view of the reconstructed ear.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.

A 6-year-old boy with lobule-type microtia. A, Preoperative view of the remnant ear. B, The location of the remnant ear is lower than the contralateral normal ear (type C). C, Lateral view of the reconstructed ear. D, Postoperative rear view. The location of reconstructed ear is similar to that of the contralateral normal ear.

Graphic Jump Location

Tables

References

Nagata  S Modification of the stages in total reconstruction of the auricle, I: grafting the three-dimensional costal cartilage framework for lobule-type microtia. Plast Reconstr Surg 1994;93 (2) 221- 230, 267-268
PubMed Link to Article
Nagata  S Modification of the stages in total reconstruction of the auricle, II: grafting the three-dimensional costal cartilage framework for concha-type microtia. Plast Reconstr Surg 1994;93 (2) 231- 242, 267-268
PubMed Link to Article
Tanzer  RC Microtia: a long-term follow-up of 44 reconstructed auricles. Plast Reconstr Surg 1978;61 (2) 161- 166
PubMed Link to Article
Brent  B The correction of microtia with autogenous cartilage grafts, I: the classic deformity. Plast Reconstr Surg 1980;66 (1) 1- 12
PubMed Link to Article
Brent  B Microtia repair with rib cartilage grafts: a review of personal experience with 1000 cases. Clin Plast Surg 2002;29 (2) 257- 271, vii
PubMed Link to Article
Park  C Balanced auricular reconstruction in dystopic microtia with the presence of the external auditory canal. Plast Reconstr Surg 2002;109 (5) 1489- 1505
PubMed Link to Article

Correspondence

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