# Otoplasty and Auricular Reconstruction

## Introduction

Otoplasty encompasses surgical procedures to correct congenital and acquired deformities of the external ear. The most common indication is correction of **prominent ears (auricular protrusion)**, though the otolaryngologist must also be skilled in reconstruction of auricular defects resulting from trauma, tumor excision, or congenital anomalies such as **microtia**. Understanding the complex three-dimensional anatomy of the auricle is fundamental to achieving natural-appearing results.

## Auricular Anatomy

### Surface Landmarks

**Helix**: Outer rim of the ear, curving from the crus helicis to the lobule. **Antihelix**: Y-shaped ridge with superior and inferior crura that defines the fossa triangularis. **Scapha**: Groove between the helix and antihelix. **Concha**: Deep bowl divided by the crus helicis into cymba conchae (superior) and cavum conchae (inferior). **Tragus and antitragus**: Cartilaginous projections flanking the intertragic notch. **Lobule**: Fibrofatty tissue without cartilage.

### Ideal Proportions

Auricular height: **55-65 mm** in adults. Auricular width: Approximately 55% of height. **Helical rim to mastoid distance**: 10-12 mm at the superior pole, 16-18 mm at the midpoint, 20-22 mm at the lobule. The long axis is tilted posteriorly approximately **20 degrees** from vertical. The auriculocephalic angle should be **25-35 degrees**.

### Blood Supply

Primarily from the **superficial temporal artery** (anterior) and **posterior auricular artery** (posterior). Rich subdermal plexus allows for robust flap survival. Anterior skin is more adherent to cartilage than posterior skin.

## Prominent Ear Correction

### Pathoanatomy

**Underdeveloped antihelical fold**: Most common cause; loss of the normal antihelical curvature. **Conchal excess**: Deep or hypertrophied conchal bowl projecting the ear laterally. **Prominent lobule**: Often overlooked; may require separate correction. Most patients have a combination of these findings.

### Preoperative Assessment

Ideal timing: After age **5-6 years** (ear reaches ~85% of adult size; before school-related psychosocial issues). Document specific anatomic deformity contributing to prominence. Assess ear asymmetry, cartilage thickness, and skin quality. Discuss realistic expectations regarding symmetry and scar placement.

### Surgical Techniques

#### Mustarde Sutures (Antihelical Fold Recreation)

Horizontal mattress sutures of **clear permanent braided suture** placed through posterior perichondrium. Create a smooth, natural-appearing antihelical fold. Avoid overtightening, which produces a "telephone ear" deformity. Typically 3-4 sutures are placed along the desired antihelical fold.

#### Furnas Conchal Setback

Concha-mastoid sutures to reduce the conchal-mastoid distance. Anchored to the **mastoid periosteum**. Can be combined with conchal cartilage excision for severely deep conchal bowls.

#### Cartilage Scoring/Rasping

Based on the principle that **cartilage curls away from the scored surface** (Gibson principle). Anterior scoring through a posterior approach to create the antihelical fold. Risk of sharp edges and irregularities.

![Preoperative and postoperative views of bilateral otoplasty for prominent ear correction](images/otoplasty-before-after.jpg)

## Microtia Reconstruction

### Classification (Marx/Nagata)

| Grade | Description | Features |
|-------|-------------|----------|
| Grade I | Smaller ear with identifiable landmarks | Lop ear, cup ear |
| Grade II | Partial ear remnant | Some recognizable features present |
| Grade III | Classic microtia (most common) | "Peanut" remnant of skin and cartilage |
| Grade IV | Anotia | Complete absence of the auricle |

**Grade I**: Smaller ear with identifiable landmarks; lop ear, cup ear. **Grade II**: Partial ear remnant with some recognizable features. **Grade III**: Classic "peanut" remnant of skin and cartilage; most common form. **Grade IV**: Anotia (complete absence of the auricle).

### Reconstruction Options

#### Autologous Rib Cartilage Framework (Nagata/Brent Technique)

Gold standard for microtia reconstruction. Cartilage harvested from **contralateral ribs 6-9**. Performed in **2-3 stages** beginning at age 8-10 (when rib cartilage is adequate). Stage 1: Framework fabrication and insertion into a subcutaneous pocket. Stage 2: Elevation of the framework with postauricular skin graft and creation of the sulcus. Requires meticulous carving skills; long learning curve.

#### Porous Polyethylene Implant (Medpor)

Synthetic framework covered with a **temporoparietal fascia flap** and skin graft. Can be performed as early as age 3, Single-stage reconstruction possible. Higher risk of extrusion and infection compared to autologous cartilage.

#### Prosthetic Ear

Osseointegrated implants with a silicone prosthesis. Option for patients who are not candidates for surgical reconstruction. Excellent color and contour matching possible, Requires daily maintenance and periodic replacement.

![Stages of autologous rib cartilage microtia reconstruction](images/microtia-reconstruction-stages.jpg)

## Acquired Auricular Defects

### Traumatic Injuries

**Auricular hematoma**: Must be drained promptly with bolster dressing to prevent cauliflower ear. **Lacerations**: Meticulous layered closure preserving cartilage and perichondrium. **Avulsion injuries**: Replantation with microsurgical techniques when possible; otherwise staged reconstruction. **Burns**: Conservative debridement; apply topical antimicrobials; delayed reconstruction.

### Post-Oncologic Reconstruction

Small defects (<1.5 cm): Primary closure, wedge excision, or Antia-Buch helical advancement. Medium defects (1.5-3 cm): Local flaps (postauricular, preauricular), conchal cartilage grafts. Large defects (>3 cm): Staged reconstruction with rib cartilage or prosthetics. **Antia-Buch chondrocutaneous advancement flap**: Workhorse for helical rim defects.

![Antia-Buch helical advancement flap for reconstruction of a helical rim defect](images/antia-buch-flap.jpg)

## Complications

**Hematoma**: Most common early complication; can lead to cartilage necrosis and cauliflower ear. **Suture extrusion**: Especially with braided permanent sutures. **Overcorrection**: "Telephone ear" or reverse shell ear deformity. **Asymmetry**: Most common reason for revision. **Infection/chondritis**: Treat aggressively with antipseudomonal antibiotics (fluoroquinolones). **Hypertrophic scarring/keloids**: More common in patients with darker skin types.

## Key Clinical Pearls

Auricular hematoma is a surgical emergency; untreated hematoma leads to cartilage necrosis and permanent cauliflower ear deformity. Otoplasty for prominent ears is best performed after age 5-6 when the ear has reached near-adult size. The most common cause of prominent ears is an underdeveloped antihelical fold, not conchal excess. In microtia reconstruction, autologous rib cartilage remains the gold standard despite advances in alloplastic frameworks. Always evaluate hearing in microtia patients, as conductive hearing loss from canal atresia is common.

## References

1. Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. *Plast Reconstr Surg*. 2005;115(4):60e-72e.
2. Nagata S. A new method of total reconstruction of the auricle for microtia. *Plast Reconstr Surg*. 1993;92(2):187-201.
3. Brent B. Auricular repair with autogenous rib cartilage grafts: two decades of experience with 600 cases. *Plast Reconstr Surg*. 1992;90(3):355-374.
4. Antia NH, Buch VI. Chondrocutaneous advancement flap for the marginal defect of the ear. *Plast Reconstr Surg*. 1967;39(5):472-477.