It is more than a little ironic that most patients think of the ear in terms of the pinna, whereas many ear surgeons relegate pinna surgery to their facial plastic surgical colleagues. Nevertheless, the repair of the lop ear, microtia, atresia, auricular injuries, and neoplasia of the auricle rightly lies in the armamentarium of the otologist.
Microtia repair is a technically challenging, multistage procedure best done only by surgeons with specialized training. In microtia repair, with either autologous rib cartilage or high-density polyethylene implants, it is essential that canal atresia or stenosis repair be done in the correct sequence. In autologous rib microtia repair, the canal atresia or stenosis repair is done only after the auricular reconstruction is complete. This is essential to keep the skin flaps pliable and well vascularized. The challenge of microtia repair is maintaining the vascularity of the skin flaps that must drape over the cartilage construct. Two-staged repairs of Firmin and Nagata techniques are very demanding on the skin, and any compromise from previous incisions can be devastating to the outcome. In contrast, for high-density polyethylene implants, the canal must be done before or concurrently with the Microtia repair. The stability of polyethylene implants relies on the vascular supply of the superficial temporal artery supplying the temporal–parietal–facial flap. This flap is elevated after the canal is created. While performing atresia repair, the surgeon must exercise care in avoiding injury to this artery.
Becoming proficient with meatoplasty technique is crucial for ear surgeons who manage chronic ear disease. With proper technique, results should be predictable and reliable and the incidence of restenosis should be low. It is a common misconception that the ear canal is one-third cartilaginous and two-thirds bony. Anteriorly, the cartilage section is elongated, as it merges with the tragus, but posteriorly the conchal bowl sits directly on the mastoid meaning that the cartilaginous canal is composed only of the thickness of the conchal edge: a mere few millimeters.
Most bony ear canal surgery is done as an adjunct to chronic ear surgery. A narrow ear canal exacerbating chronic otitis media left uncorrected will hinder both surgical exposure and access for ongoing care. The most common surgery for primary ear canal disease is removal of exostoses, which tend to happen with repeated exposure to intermittent water immersion such as in surfing and kayaking. While most surgeons remove the exophytic bone with a drill, some experts use small chisels. Restoring patency to an obstructed ear canal can be dangerous as the facial nerve can be injured should the surgeon become disoriented to the alignment of the canal. The rule of thumb in both obstructing exostoses and cases of atresia is to always keep the deepest excavation superior (toward dura) and anterior (toward temporomandibular joint). Minor exposures of the temporomandibular joint capsule are of no consequence, but wide removal of this bony plate is best avoided.
When a very narrow ear canal is restored to normal size, it will not remain so unless there is adequate skin covering. This is especially important in congenital and acquired stenosis as well as in atresia. While small areas of exposed canal bone are common following chronic ear procedures, in cases of extensive osseous exposure, use of a thin split thickness skin graft is necessary. A caution is that full thickness or split thickness of excessive dermal thickness tends to undergo stenosis in ear canal repair. Also, a segment of ear canal which has been circumferentially denuded of its skin coverage is at a high risk of stenosis and should be grafted.
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Fig. 3.1 A prominent ear can be caused by lack of an antihelical fold or prominence of the conchal cartilage, or both. Otoplasty can be used to correct both of these, resulting in a less prominent pinna on frontal view.
Fig. 3.2 The posterior skin excision is done in elliptical fashion. This helps reduce posterior tethering in the midportion of the pinna, which can contribute to a “telephone ear” deformity.
Fig. 3.3 Transcutaneous black nylon sutures are placed to create the superior antihelical fold. These are typically 5-mm wide and separated by 1 cm. The width and tension of the mattress sutures will cause variation in acuity of the antihelical fold.
Fig. 3.4 The ear is reflected anteriorly, and the black sutures visualized. Clear nylon mattress sutures are then placed according to the method of Mustardé. Care is taken to avoid violation of the anterior auricular skin.
Fig. 3.5 An axial view of pinna demonstrating temporary and permanent suture placement to create the antihelical fold. Note that the permanent suture (shown here in blue) does not violate the skin anteriorly, but does penetrate the perichondrium.
Fig. 3.6 Two permanent mattress sutures are placed through the auricular cartilage and anterior perichondrium, with care taken to avoid violation of the skin, using the method of Furnas. These are then secured to the mastoid periosteum. Anterior displacement of the conchal cartilage is avoided by placing these sutures posteriorly on the mastoid.
3.3 Microtia Repair
Fig. 3.7 The classes of microtia according to pinna size and subunits affected. For the purpose of this classification, the subunits of the pinna are helix, antihelix, scapha, tragus, antitragus, concha, and lobule. Class 1: a small ear with all of the subunits present, although some may be abnormally shaped; Class 2: a small ear with missing subunits; Class 3: a classic peanut ear with no recognizable subunits except for the lobule; Class 4: anotia (the complete absence of a pinna). Microtia surgery involves multiple stages. Some surgeons employ two stages, others employ three or more. Stages are usually spaced by 3 to 4 months at a minimum. In this chapter, we illustrate a two-staged technique as described by Dr. Francoise Firmin. Foundations from Dr. Burt Brent’s four-staged technique and Dr. Satoru Nagata’s two-staged technique can be appreciated.
Fig. 3.8 Stage 1 initiates with planning the placement of the reconstructed ear. Standing at the head of the bed, a ruler is used to mark the inferior point of the lobule in symmetry with the nonmicrotia ear. In bilateral microtia, the commissures of the eye and mouth are used as reference points, with the new pinna placed as high as permitted by the demarcation of non–hair-bearing retroauricular skin.
Fig. 3.9 The distances from the lateral canthus of the eye to the root of the helix (X), and the lateral commissure of the mouth and the anterior point of the lobule (Y), are measured on the unaffected side. These measurements are used for placement of the reconstructed ear. The superficial temporal artery is identified with Doppler and marked.
Fig. 3.10 The rotation of the ear. The pinna has a polarity, or an axis of rotation. First, on the nonmicrotia side, the slope of the nose is drawn on the face, and the angle of the pinna is drawn, as determined by the longest measurement of the pinna. The angle between these is measured. On the microtia side, the slope of the nose is repeated, the angle is measured, and the axis of the reconstructed ear is drawn on the face. This becomes a guide for the planned rotation of the reconstructed ear.
Fig. 3.11 Markings for the planned placement of the reconstructed ear are kept in view throughout the procedure.
Fig. 3.12 Harvest of rib cartilage is planned from the sixth to ninth cartilage. The ninth cartilage is obtained when prominent. In this technique, cartilage is harvested from the ipsilateral side of the microtia ear.
Fig. 3.13 The typical plan for the harvested cartilage for microtia reconstruction of the left ear: The floating eighth rib often serves as the helical rim and, when robust, can also be used for the antihelix. The synchondrosis of the sixth and seventh ribs often provides the base plate. Extra pieces of cartilage serve to become the P1 (Projection 1) piece as described by Dr. Firmin, and banked pieces for the elevation of the ear in the second stage. Banked cartilage pieces are placed in a pocket of the subcutaneous skin of the chest closure secured to the dermis.
Fig. 3.14 The helix is often carved from the eighth rib cartilage, and is shaped to sit flat on the base plate. The center is gouged to create a curved surface and allow for ease of curvature.
Fig. 3.15 The base plate is prepared by removing the perichondrium on the anterior surface. It is kept intact on the posterior surface. Often, marks are made on the cartilage to delineate the placement of the antihelix and the scapha in the correct orientation. This can be done by inking the cartilage based on a drawing of the opposite ear drawn on X-ray film. The X-ray film is then flipped to show the mirror image, and drawn on paper. The paper is then dipped in water-soluble ink, and stamped on the cartilage. Carving begins with reducing the lobule and gouging the scapha. Then, the triangular fossa can be deepened. Posteriorly, the edge of the cartilage is beveled so that the back surface of the ear is sloped.
Fig. 3.16 The tragus–antitragus complex is a challenging three-dimensional entity that has convexities and concavities. The intertragal notch is the thinnest portion.
Fig. 3.17 The antihelix is first to be placed on the baseplate.
Fig. 3.18 A silicone block is used to secure the cartilage as the individual pieces are constructed together. Double-ended 5.0-steel sutures are used to suture the cartilage. Steel suture is preferred to prevent future migration of cartilage pieces when exposed the tensile strength of the skin. Double-ended steel sutures can be made by hand threading 5.0-steel wire through the eyelet of small, straight cutting needles.
Fig. 3.19 View of the undersurface: the cartilage construct is lifted away from the silicone block, the needles cut, and the wire sutures are twisted together, trimmed, and ends turned down onto the undersurface of the cartilage. As each cartilage piece is added to the construct, the silicone block provides the stability needed for suturing.
Fig. 3.20 Once the antihelix is placed, the P1 piece is secured to the baseplate in preparation for the helix. The P1 piece allows for the crus of the helix to drop to a lower plane while providing stabilization to the curve of the helix.
Fig. 3.21 The helix is then secured with steel sutures.
Fig. 3.22 The tragus–antitragus complex is placed and secured to the baseplate and the P1 elevation piece.
Fig. 3.23 An anterior view allows appreciation of the appropriate contours of the ear construct.
Fig. 3.24 Preparation of the skin for a type 2 skin approach as described by Dr. Firmin. This approach is often chosen for class 3 microtia when the inferior portion of the microtia remnant will be used to make the lobule of the new pinna. With the planned outline for the ear reconstruction drawn relative to the microtia ear, the ear is pulled until a natural point is found where the lobule meets the planned incision with the least amount of tension on the remnant. This is where the lobule will be transposed. The X marks the point where the lobular skin meets the planned point of transposition.
Fig. 3.25 The skin is then divided and a pocket is dissected in the lobule to allow insertion of the cartilage framework. Best results are obtained when the cartilage inserts well into the lobule, near the tip.
Fig. 3.26 As the lobule is turned to its new location, an X-ray template of the base plate can be used to check the insertion of the lobule.
Fig. 3.27 The posterior skin is incised to allow the transposition of the lobule to the new location.
Fig. 3.28 The retroauricular skin is then dissected, and the cartilage remnant is removed from the microtia ear. This skin will drape over the cartilage construct, so care must be used to maintain the skin vascularity and the same thickness throughout.
Fig. 3.29 The cartilage remnant is removed. In many cases, dissection of the cartilage remnant is not a trivial dissection and requires a meticulous degloving of the cartilage while maintaining skin flap integrity and vascularity.
Fig. 3.30 Skin dissection must go beyond the planed placement of the ear to allow for the skin to drape over the contours of the construct, and allow for placement of a posterior drain.
Fig. 3.31 The transposed lobule is then sutured in place posteriorly, known as the “adhesion of the lobule,” with a 4-0 absorbable suture.
Fig. 3.32 The cartilage construct is inserted into the lobule and placed under the skin. Drains are placed anteriorly and posteriorly to allow suction of the skin to aid resection of excess skin. Typically, 10F Blake drains are used, under low suction, classically maintaining suction with test tubes.
Fig. 3.33 Excess skin is excised. Incisions are hidden in the natural junction of subunits, and trifurcations of the closure are avoided if possible.
Fig. 3.34 The skin is closed with 6.0 nylon sutures, and the drains are kept to suction for 3 to 5 days. Postoperatively, test tubes are changed every 3 to 4 hours to maintain suction while the construct heals.
Fig. 3.35 Stage 2: elevation of the ear. The initial step of stage 2 involves planning the retroauricular incision. Care must be taken to be off the edge of the cartilage framework. A releasing incision is designed to allow advancement of the retroauricular skin.
Fig. 3.36 Elevation of the superior flap. It is essential to elevate only skin and leave the fascia and periosteum overlying the cortex intact.
Fig. 3.37 Elevation of the inferior flap. At this step, the areolar tissue overlying the mastoid can be thinned to deepen the sulcus.