Residency · Residency · Plastic Surgery
Ear Reconstruction After Trauma or Tumor Excision
Introduction
Ear reconstruction is one of the most technically demanding procedures in plastic surgery due to the complex three-dimensional cartilage framework of the auricle. Etiologies requiring reconstruction include congenital microtia, traumatic avulsion, burn injury, tumor excision, and auricular loss from infection. The autologous rib cartilage framework technique, pioneered by Tanzer and refined by Brent and Nagata, remains the gold standard. Alloplastic frameworks (porous polyethylene/Medpor) offer an alternative with distinct advantages and limitations.
Goals of reconstruction include restoring auricular form, symmetry, projection, and compatibility with eyeglasses and hearing aids.
Anatomy of the External Ear
Surface Anatomy
Helix: outer curved rim of the auricle; begins at the root (crus helicis) and terminates at the lobule. Antihelix: Y-shaped ridge medial to the helix; divides superiorly into the superior and inferior crura forming the triangular fossa. Scapha: depression between helix and antihelix. Concha: bowl-shaped depression adjacent to the external auditory canal; divided by the crus helicis into cymba conchae (superior) and cavum conchae (inferior).
Tragus: cartilaginous projection anterior to the external auditory meatus. Antitragus: small projection opposite the tragus, inferior to the antihelix. Lobule: non-cartilaginous, composed of fibrofatty tissue.
Dimensions and Position
Average adult ear: 5.5-6.5 cm in length, 3-3.5 cm in width. Auriculocephalic angle: 25-35 degrees; projection: 1.5-2 cm from mastoid. Long axis tilted approximately 20 degrees posterior from vertical. Superior margin at the level of the brow, inferior margin (lobule) at the level of the nasal ala. Positioned approximately 6.5-7 cm posterior to the lateral orbital rim.
Blood Supply
Superficial temporal artery and posterior auricular artery provide the dominant blood supply. Dense subdermal plexus makes the ear resilient to ischemia but susceptible to frostbite and burns due to thin skin and exposed cartilage. Anterior skin is tightly adherent to cartilage; posterior skin is loosely attached with subcutaneous tissue.
<image>Detailed anatomical diagram of the external ear labeling all major landmarks: helix, antihelix, superior and inferior crura, triangular fossa, scapha, concha (cymba and cavum), tragus, antitragus, lobule, and external auditory meatus, with auricular dimensions and position relative to facial landmarks</image>
Defect Classification
By Location and Size
| Location | Structures | Small Defect (<1.5 cm) | Medium Defect (1.5-2.5 cm) | Large/Total Defect |
|---|---|---|---|---|
| Upper third | Helix, superior antihelix | Primary closure, wedge | Antia-Buch advancement | Rib cartilage framework |
| Middle third | Concha, antihelix, central helix | Composite graft, FTSG | Postauricular flap | Rib cartilage framework |
| Lower third | Lobule, inferior helix | Local flap (bilobed) | Advancement/transposition | Local flaps |
| Total/subtotal | Entire auricle | — | — | Staged autologous or alloplastic |
Upper third: helix and superior antihelix; defects up to 1.5-2 cm can be closed primarily or with helical advancement. Middle third: concha, antihelix, and central helix; requires cartilage framework reconstruction for larger defects. Lower third: lobule and inferior helix; relatively straightforward reconstruction with local flaps. Total or subtotal loss: requires staged autologous rib cartilage reconstruction or alloplastic framework.
By Tissue Components
Skin only: amenable to grafting or local flaps. Composite (skin + cartilage): requires composite grafts (for small defects <1.5 cm) or cartilage framework with skin coverage. Full-thickness: involving anterior skin, cartilage, and posterior skin; most complex reconstruction.
Reconstructive Options for Partial Defects
Helical Rim Defects
Primary closure: defects up to 1-1.5 cm; wedge excision with layered closure maintaining helical contour. Chondrocutaneous advancement flap (Antia-Buch): mobilizes adjacent helical tissue; suitable for defects up to 2-2.5 cm. Composite graft from contralateral ear: for defects <1.5 cm; harvested from helical root or conchal bowl of opposite ear; requires well-vascularized recipient bed. Postauricular flap (banner flap): based on posterior auricular skin; provides coverage for anterior defects; divided at 2-3 weeks.
Conchal Defects
Often result from skin cancer excision (basal cell carcinoma is common in this location). Full-thickness skin graft on intact perichondrium; excellent color and contour match from preauricular or postauricular donor sites. Conchal cartilage excision with through-and-through defects: postauricular island flap or cervicofacial advancement flap. Large conchal defects may benefit from cartilage grafting to prevent contraction.
Lobule Reconstruction
Bilobed flap, advancement flap, or transposition flap from adjacent tissue. Gavello technique: paired flaps from adjacent cheek and postauricular skin. Lobule reconstruction is technically simpler but aesthetically important for earring wear and symmetry.
Total Ear Reconstruction
Autologous Rib Cartilage Framework
Brent technique (4 stages): 1. Framework fabrication and insertion into a subcutaneous pocket. 2. Lobule transposition. 3. Tragus and conchal definition with cartilage graft and skin graft.
- Elevation of the framework from the mastoid with skin graft to posterior surface. Nagata technique (2 stages): 1. Framework fabrication (base frame + helix, antihelix, scapha) with lobule transposition; single-stage insertion. 2. Elevation with costal cartilage wedge and skin graft posteriorly.
Cartilage harvest: contralateral 6th, 7th, and 8th ribs; synchondrosis of ribs 6-7 provides the base frame; floating rib (8th) provides the helical rim. Framework is carved to replicate the contralateral ear anatomy using a radiograph template or 3D-printed template. Patient age: ideally performed when the contralateral ear has reached >90% of adult size (approximately age 8-10) and rib cartilage is sufficient (chest circumference >60 cm). Temporoparietal fascia (TPF) flap may be used to provide vascularized coverage over the framework, particularly in revision cases or when skin pocket quality is poor.
Alloplastic Framework (Porous Polyethylene)
Medpor (porous polyethylene): preformed framework covered with TPF flap and skin graft. Advantages: single-stage procedure, no donor site morbidity, consistent framework shape. Disadvantages: higher rate of extrusion (5-15%), infection, framework fracture; cannot withstand trauma as well as autologous cartilage. Best suited for patients who are not candidates for rib harvest or prefer avoiding thoracic donor site.
Prosthetic Ear
Osseointegrated implant-retained prosthesis: titanium implants placed in the mastoid bone; silicone prosthesis clips onto abutments. Advantages: excellent aesthetic result; no surgical morbidity; replaceable. Disadvantages: lifelong maintenance, implant infection/loss, daily attachment/removal. Considered for patients with unfavorable local tissue, failed prior reconstruction, or significant comorbidities.
<image>Surgical illustration showing the staged autologous rib cartilage ear reconstruction: (A) harvesting costal cartilage from the contralateral chest with the synchondrosis and floating rib identified, (B) the carved cartilage framework with helix, antihelix, scapha, and conchal bowl on the back table, (C) the framework inserted into the mastoid subcutaneous pocket, (D) final result after elevation with the reconstructed ear projected from the mastoid</image>
Traumatic Ear Injuries
Auricular Avulsion
Complete avulsion: reattachment as composite graft (low success rate for large segments); banking of cartilage in a subcutaneous pocket; or microsurgical replantation if vessels are available. Partial avulsion: maintain any tissue bridge; debride minimally; repair in layers. Fenestrated technique (Baudet): de-epithelialize the avulsed segment, fenestrate the cartilage, and bury under a postauricular flap; staged elevation.
Auricular Hematoma
Untreated hematoma leads to cartilage necrosis and "cauliflower ear" deformity. Treatment: incision and drainage with through-and-through bolster sutures or dental roll compressive dressing. Must be treated within 7 days before organization of the hematoma.
Burns
Ear cartilage is highly susceptible to chondritis after burns; avoid pressure dressings on burned ears. Early topical antimicrobials (mafenide acetate penetrates cartilage); debridement of necrotic cartilage. Reconstruction after burn wound maturation using standard techniques.
Complications
Cartilage resorption: partial framework resorption can diminish definition over time; more common with rib cartilage warping. Skin flap necrosis: from excessive tension, inadequate vascularity, or pressure on the reconstruction. Framework extrusion: more common with alloplastic (Medpor) frameworks; requires removal and staged revision. Pneumothorax: rare but serious complication of rib cartilage harvest; always obtain postoperative chest radiograph.
Chest wall deformity: from rib harvest in pediatric patients; preserving perichondrium and limiting harvest minimizes this risk. Hypertrophic scarring: particularly in the postauricular region; manage with silicone and steroid injections.
Key Clinical Pearls
Autologous rib cartilage remains the gold standard for total ear reconstruction; the Nagata two-stage technique reduces the number of operations while achieving excellent results. Precise cartilage carving is the most technically demanding aspect; 3D-printed templates from the contralateral ear improve symmetry. For partial defects, always use the simplest technique that achieves the goal; the Antia-Buch advancement flap is versatile for helical defects. Auricular hematomas must be drained urgently with bolster placement to prevent cauliflower ear deformity. The temporoparietal fascia flap is an invaluable tool for providing vascularized coverage over cartilage or alloplastic frameworks.
References
- Brent B. Auricular repair with autogenous rib cartilage grafts: two decades of experience with 600 cases. Plast Reconstr Surg. 1992;90(3):355-374.
- Nagata S. A new method of total reconstruction of the auricle for microtia. Plast Reconstr Surg. 1993;92(2):187-201.
- Reinisch JF, Lewin S. Ear reconstruction using a porous polyethylene framework and temporoparietal fascia flap. Facial Plast Surg. 2009;25(3):181-189.
- Antia NH, Buch VI. Chondrocutaneous advancement flap for the marginal defect of the ear. Plast Reconstr Surg. 1967;39(5):472-477.
