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A method of antihelix reconstruction
A M E T H O D OF A N T I H E L I X R E C O N S T R U C T I O N By V. CHONGCHET, M.D. 1
Plastic Surgery Centre, Odstock Hospital, Salisbury, Wilts. PROMINENT or bat ears are important because of the effect of this deformity on the emotional development of the individual. Some are unconcerned about it, especially the people from the East. The indications for correction are purely psychological and cosmetic. }Etiology.--The deformity is caused by an embryological maldevetopment of the external ear in which the anfihelix is absent and the concha may be too large (Farina et al., z962). The result is that the ear protrudes from the head at an abnormal angle (Fig. i). Mothers freRIGHT EAR quently believe that the child sleeps on a folded ear. A n a t o m y . - - T h e ear develops around the first branchial groove. The tissue Skin Ext. m e o t u s comes from the first (mandibular) branchial arch and the second (hyoid) arch. The latest belief is that the entire artilage external ear, except the tragus, is of hyoid origin (Arey, 1954). It has a Cephalo - auricular angle skeleton of resilient yellow elastic cartilage LATERAL thrown into folds which give the ear its FIG. characteristic shape. The lobule is a tag Pre-operative condition. of skin containing soft fibro-fatty tissue. The two ears of the same individual are n o t always symmetrical; there are minor variations in size and shape. The average sizes are described as 6"5 cm. for length, 3"5 cm. for width, and 30 degrees for the cephalo-auricular angle (Rubin et al., x962). There are various methods of correcting bat ears. In xgxo Luckett described an operation for reconstruction of the superior crus of the antihelix by making a crescentic incision in the cartilage. Five sutures are passed through the cartilage from the cranial side from within out and back again (as a Lembert suture). Since then various modifications have been devised to avoid the sharp fold of the antihelix. Str6mbeck (I96I) reported a follow-up study of the results of this operation ; 25 per cent. were more or less disappointing because of a sharp and unnatural fold. Gibson and Davis's investigations (I958) show that in costal cartilage there exists a state of tension ; a taut outer layer controls the tendency of the main mass to expand. This is assumed to be applicable to the cartilage of the ear, which maintains its shape by a balanced force of two taut outer layers (cranial surface and lateral surface). If one taut outer layer is scored, the tension on that side is released, and therefore it will bend towards the opposite side as a bowstring.
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1 Present Address : Department of Plastic Surgery, Frenchay Hospital, Bristol. 268
A METHOD
OF
ANTIHELIX
RECONSTRUCTION
269
Cloutier (1961), using the same principle, described a method of antihelix reconstruction by widely bevelling along the cut edge of the ear cartilage. The operation described in this paper advocates anterior scoring of the ear cartilage along the line of the future autihelix (Fig. 2). Proeedure.--Either local or general anmsthesia can be used, but the latter is preferable because most patients are young children. When the helix is pushed back to its normal position with the fingers, a fold of antihelix will appear and this is marked with Bonney's blue at the height of the fold. Infiltration of the skin
EXCISION OF SKIN Undermining t o w a r d s free border
MARKING OF NEW ANTI HELIX ANTERIOR SCORING OF CARTILAGE
~"~L~'~ Fold of anti helix
N CURLING OF CARTILAGE
OVERLAPPING OF CARTILAGE
Fla. 2 Operative diagrams.
on both aspects with I : IOO,OOO adrenaline solution will first help the dissection of the skin from cartilage, and secondly will control profuse bleeding. A post-auricular ellipsed skin is removed midway between the free border of helix and cephalo-auricular angle, running almost the whole length of the ear. Undermining of the skin edge towards the free border of helix is necessary. A stabbing needle or pin is introduced through the full thickness of the ear from the lateral aspect (four to five places) ; the needle tip is inked and withdrawn to mark the site of the antihelix on the cartilage of the cranial aspect. An incision is made through the whole thickness of the cartilage, about 3 to 4 mm. distal to the markings, beginning from the superior crux to the tail of antihelix. The skin overlying the anterior surface of the cartilage on each side of the cut is then carefully dissected. No sooner has this skin been freed than a slight curl of the cartilage is apparent. With the aid of a hook holding the cartilage, a series of parallel incisions are made just through the fibrous perichondrium and taut outer layer of cartilage. This
BRITISH
270
JOURNAL OF PLASTIC
SURGERY
A
B C FIG. 3 A, Pre-operative condition. Note absence of antihelix. B, Post-operative condition. Note the natural fold of antihelix. C, Anterior scoring just through the fibrous perichondrium and taut outer layer of cartilage.
FIG. 4 A, Front view, pre-operation. B, Front view, post-operation. C, Back view, pre-operation. D, Back view, postoperation. E, Lateral view, preoperation. Note absence of antihelix. F, Lateral view, post-operation. Note the natural fold of antihelix.
A METHOD
OF A N T I H E L I X
RECONSTRUCTION
271
anterior scoring made in the line of the future fold will give a smooth curl of cartilage where the new antihelix is planned to be formed. The cartilage near the tail of the antihelix is usually thick and hard ; removal or trimming of this cartilage is sometimes helpful. One chromic catgut stitch is used to transfix the fold at the tail of antihelix. The skin edges are sutured, and the ear is reformed by overlapping of the curled edges to give a normal-looking antihelix. The width of the ear is slightly reduced, but this is not noticeable. A most important step
A
B
C
D
FIG. 5
A
B FIG. 6
C
Figs. 5 and 6.--A, Front view, pre-operation. B, Front view, post-operation. C, Back view, pre-operation. D, Back view, post-operation.
D
is the dressing which maintains the contour. Wet wool is carefully moulded into the concavities of the fold, a gauze and wool overdressing is applied, and the whole is immobilised by a crepe bandage. Reinforcement of the bandage with Elastoplast as a figure-of-eight will prevent the bandage slipping forward or backward. The dressing is kept on for a week, and a night bandage only for another fortnight (Figs. 3 to 7). R e s u l t s . - - T h e operative results with this technique performed by the writer in a series of twenty-one patients since November 196o are satisfactory. One case developed an infected hmmatoma. Two cases were slightly inadequately corrected. C o m m e n t s . - - T h i s method of correction of bat ears is not suitable for the big concha and lopping of the helix. Of the two cases which were under-corrected, one was due to lopping of the helix and a protruding lobule, the other was due to a very big concha. The infected hmmatoma was caused by the child pulling
272
BRITISH JOURNAL OF PLASTIC
SURGERY
off the bandage and rubbing both ears against the pillow. The loss of width of the ear is very minimal. The colour of the ear immediately after operation is somewhat blue and this may cause unnecessary concern : it is partly due to Bonney's blue, the wide dissection and the use of adrenaline.
Fro. 7 Seventh-day post-operation bandage. Still tight and firm. A, Front view. B, Back view.
SUMMARY A method of reconstruction of the antihelix by anterior scoring in the correction of bat ears is described. The results are satisfactory with a normal-looking fold of antihelix. A firm bandage and dressing are essential to prevent ha:matoma and maintain the new ear shape. It is a pleasure to acknowledge my debt to Mr ft. N. Barron and Mr ft. E. Laing, who allowed me to operate on their patients. I am particularly indebted to Mr Barron for his helpful advice and criticism on the preparation of this paper. ! am also grateful to Mr R. Conroy and Mr L. G. Banham for the photographs, and to Mr F. E. Badrick for the diagrams. REFERENCES AREY, L. B. (I954), " Developmental Anatomy," p. 55I. Philadelphia : W . B . Saunders Co. CLOUTIER, A. MAcLEoD (1961). Plast. reconstr. Surg., 28, 412. FARINA, R., BAROUDI,R., COLEMAN,B., and DE CASTRO,O. (1962). Brit. ft. plast. Surg., xs, 194. GIBSON, T., and DAVIS, W. B. (1958). Brit. ft. plast. Surg., xo, 257. LUCKETT, W. H. (191o). Surg. Gynec. Obstet., io, 635. RUBIN, L. R., BROMBERG,]3. E., WALDEN, R. H., and ADAMS,A. (1962). Plast. reconstr. Surg., 29, 36o. STR6MBECK, J. O. (1961). Acta chit. scand., I22, 138.
Submitted for publication~ September 1962.
Plastic Surgery Centre, Odstock Hospital, Salisbury, Wilts. PROMINENT or bat ears are important because of the effect of this deformity on the emotional development of the individual. Some are unconcerned about it, especially the people from the East. The indications for correction are purely psychological and cosmetic. }Etiology.--The deformity is caused by an embryological maldevetopment of the external ear in which the anfihelix is absent and the concha may be too large (Farina et al., z962). The result is that the ear protrudes from the head at an abnormal angle (Fig. i). Mothers freRIGHT EAR quently believe that the child sleeps on a folded ear. A n a t o m y . - - T h e ear develops around the first branchial groove. The tissue Skin Ext. m e o t u s comes from the first (mandibular) branchial arch and the second (hyoid) arch. The latest belief is that the entire artilage external ear, except the tragus, is of hyoid origin (Arey, 1954). It has a Cephalo - auricular angle skeleton of resilient yellow elastic cartilage LATERAL thrown into folds which give the ear its FIG. characteristic shape. The lobule is a tag Pre-operative condition. of skin containing soft fibro-fatty tissue. The two ears of the same individual are n o t always symmetrical; there are minor variations in size and shape. The average sizes are described as 6"5 cm. for length, 3"5 cm. for width, and 30 degrees for the cephalo-auricular angle (Rubin et al., x962). There are various methods of correcting bat ears. In xgxo Luckett described an operation for reconstruction of the superior crus of the antihelix by making a crescentic incision in the cartilage. Five sutures are passed through the cartilage from the cranial side from within out and back again (as a Lembert suture). Since then various modifications have been devised to avoid the sharp fold of the antihelix. Str6mbeck (I96I) reported a follow-up study of the results of this operation ; 25 per cent. were more or less disappointing because of a sharp and unnatural fold. Gibson and Davis's investigations (I958) show that in costal cartilage there exists a state of tension ; a taut outer layer controls the tendency of the main mass to expand. This is assumed to be applicable to the cartilage of the ear, which maintains its shape by a balanced force of two taut outer layers (cranial surface and lateral surface). If one taut outer layer is scored, the tension on that side is released, and therefore it will bend towards the opposite side as a bowstring.
~
~
1 Present Address : Department of Plastic Surgery, Frenchay Hospital, Bristol. 268
A METHOD
OF
ANTIHELIX
RECONSTRUCTION
269
Cloutier (1961), using the same principle, described a method of antihelix reconstruction by widely bevelling along the cut edge of the ear cartilage. The operation described in this paper advocates anterior scoring of the ear cartilage along the line of the future autihelix (Fig. 2). Proeedure.--Either local or general anmsthesia can be used, but the latter is preferable because most patients are young children. When the helix is pushed back to its normal position with the fingers, a fold of antihelix will appear and this is marked with Bonney's blue at the height of the fold. Infiltration of the skin
EXCISION OF SKIN Undermining t o w a r d s free border
MARKING OF NEW ANTI HELIX ANTERIOR SCORING OF CARTILAGE
~"~L~'~ Fold of anti helix
N CURLING OF CARTILAGE
OVERLAPPING OF CARTILAGE
Fla. 2 Operative diagrams.
on both aspects with I : IOO,OOO adrenaline solution will first help the dissection of the skin from cartilage, and secondly will control profuse bleeding. A post-auricular ellipsed skin is removed midway between the free border of helix and cephalo-auricular angle, running almost the whole length of the ear. Undermining of the skin edge towards the free border of helix is necessary. A stabbing needle or pin is introduced through the full thickness of the ear from the lateral aspect (four to five places) ; the needle tip is inked and withdrawn to mark the site of the antihelix on the cartilage of the cranial aspect. An incision is made through the whole thickness of the cartilage, about 3 to 4 mm. distal to the markings, beginning from the superior crux to the tail of antihelix. The skin overlying the anterior surface of the cartilage on each side of the cut is then carefully dissected. No sooner has this skin been freed than a slight curl of the cartilage is apparent. With the aid of a hook holding the cartilage, a series of parallel incisions are made just through the fibrous perichondrium and taut outer layer of cartilage. This
BRITISH
270
JOURNAL OF PLASTIC
SURGERY
A
B C FIG. 3 A, Pre-operative condition. Note absence of antihelix. B, Post-operative condition. Note the natural fold of antihelix. C, Anterior scoring just through the fibrous perichondrium and taut outer layer of cartilage.
FIG. 4 A, Front view, pre-operation. B, Front view, post-operation. C, Back view, pre-operation. D, Back view, postoperation. E, Lateral view, preoperation. Note absence of antihelix. F, Lateral view, post-operation. Note the natural fold of antihelix.
A METHOD
OF A N T I H E L I X
RECONSTRUCTION
271
anterior scoring made in the line of the future fold will give a smooth curl of cartilage where the new antihelix is planned to be formed. The cartilage near the tail of the antihelix is usually thick and hard ; removal or trimming of this cartilage is sometimes helpful. One chromic catgut stitch is used to transfix the fold at the tail of antihelix. The skin edges are sutured, and the ear is reformed by overlapping of the curled edges to give a normal-looking antihelix. The width of the ear is slightly reduced, but this is not noticeable. A most important step
A
B
C
D
FIG. 5
A
B FIG. 6
C
Figs. 5 and 6.--A, Front view, pre-operation. B, Front view, post-operation. C, Back view, pre-operation. D, Back view, post-operation.
D
is the dressing which maintains the contour. Wet wool is carefully moulded into the concavities of the fold, a gauze and wool overdressing is applied, and the whole is immobilised by a crepe bandage. Reinforcement of the bandage with Elastoplast as a figure-of-eight will prevent the bandage slipping forward or backward. The dressing is kept on for a week, and a night bandage only for another fortnight (Figs. 3 to 7). R e s u l t s . - - T h e operative results with this technique performed by the writer in a series of twenty-one patients since November 196o are satisfactory. One case developed an infected hmmatoma. Two cases were slightly inadequately corrected. C o m m e n t s . - - T h i s method of correction of bat ears is not suitable for the big concha and lopping of the helix. Of the two cases which were under-corrected, one was due to lopping of the helix and a protruding lobule, the other was due to a very big concha. The infected hmmatoma was caused by the child pulling
272
BRITISH JOURNAL OF PLASTIC
SURGERY
off the bandage and rubbing both ears against the pillow. The loss of width of the ear is very minimal. The colour of the ear immediately after operation is somewhat blue and this may cause unnecessary concern : it is partly due to Bonney's blue, the wide dissection and the use of adrenaline.
Fro. 7 Seventh-day post-operation bandage. Still tight and firm. A, Front view. B, Back view.
SUMMARY A method of reconstruction of the antihelix by anterior scoring in the correction of bat ears is described. The results are satisfactory with a normal-looking fold of antihelix. A firm bandage and dressing are essential to prevent ha:matoma and maintain the new ear shape. It is a pleasure to acknowledge my debt to Mr ft. N. Barron and Mr ft. E. Laing, who allowed me to operate on their patients. I am particularly indebted to Mr Barron for his helpful advice and criticism on the preparation of this paper. ! am also grateful to Mr R. Conroy and Mr L. G. Banham for the photographs, and to Mr F. E. Badrick for the diagrams. REFERENCES AREY, L. B. (I954), " Developmental Anatomy," p. 55I. Philadelphia : W . B . Saunders Co. CLOUTIER, A. MAcLEoD (1961). Plast. reconstr. Surg., 28, 412. FARINA, R., BAROUDI,R., COLEMAN,B., and DE CASTRO,O. (1962). Brit. ft. plast. Surg., xs, 194. GIBSON, T., and DAVIS, W. B. (1958). Brit. ft. plast. Surg., xo, 257. LUCKETT, W. H. (191o). Surg. Gynec. Obstet., io, 635. RUBIN, L. R., BROMBERG,]3. E., WALDEN, R. H., and ADAMS,A. (1962). Plast. reconstr. Surg., 29, 36o. STR6MBECK, J. O. (1961). Acta chit. scand., I22, 138.
Submitted for publication~ September 1962.