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Surgical treatment of congenital deformities of the ears
Surgical Treatment of Congenital Deformities of the Ears VARAZTAD H. KAZANJIAN,
C cover
ONGENITAL deformities of the externa1 ear a wide variety of conditions. They may range from a shght change in the normaI contour to a tota absence of the ear. A certain number of patients also have other faciaI defects in addition to the abnormaIity of the auricles. In many cases there is definite asymmetry of the affected side of the face due to arrested growth of the ascending ramus of the mandibIe. This may be complicated by weakness of the seventh nerve affecting the corner of the mouth and eyelid. Reconstruction of the externa1 ear is one of the most difficult procedures in pIastic surgery. In 1937 GiIlies observed that “the study of ours and other surgeons’ actua1 resuIts reveal an undisputed disappointment in the cosmetic result obtained by these methods” [I]. Since then, although much has been written on this subject and considerabIe progress has been made, the results are far from satisfactory. Up to the present no standard procedure has been deveIoped. Our present resuIts are acceptabIe onIy in that they give the patient a feeting of facia1 symmetry and baIance. FortunateIy, the two ears are on opposite sides of the face and close comparison is avoided. In this paper, the discussion is limited to the treatment of onIy one type of congenital deformity of the ear with speciaI emphasis on reconstruction of the concha, a typical exampIe of which is seen in Figure I. Here, we have a rudimentary mass of soft tissue in the auricuIar region, cIose examination of which reveals that onIy part of the IobuIe is present. The rest of the auricIe is usuaIIy an UnderdeveIoped, shapeIess mass of skin and cartilage with an absent ear cana1. X-rays show that the external auditory cana is not deveIoped and operation usuaIIy reveaIs the maIIeus and incus fused. Hearing by air is at the so-60 decibeIs IeveI.
M.D.,
Boston,
Mussachusetts
The inner ear, being of different developmental origin, is aIways normaIIy deveIoped. In the reconstruction of an auricular deformity of this type, there are three general
_i FIG. I. A vertical incision is made in front of the rudimentary ear, Through this incision, on the scalp side, the mastoid process, the periosteum of the mastoid bone as well as the surrounding tissues, are exposed to form a good sized rectangular cavity.
steps. First, and what I consider one of the most important steps in the entire series of operations, is reconstruction of the concha. Next, is the transfer of soft tissues from adjacent or distant regions in the form of a tubed ffap to supplement the inadequate soft tissues supplied by nature. A tube ffap from the neck or cIavicuIar region serves we11 for this purpose. Next, is the suppIying of frame-work to the ear, the most perfect type being autogenous auricuIar cartilage. For this purpose, we obtain concha cartiIage from the opposite norma ear suppIemented by Costa1 cartilage. Foreign bodies, such as acryIic, vitaIIium or tantaIum, and even preserved cartiIage, cannot be deAmerican Journal of Surgery, Volume 9.1. February. 1958 185
Kazanjian
FIG. 2. Diagram shows a we11 defined deep cavity to form a concha. A through and through incision, extending from the back of the rudimentary ear to the floor of the newly formed concha was made. The dotted Iines show the approximate position of a postaural skin flap to be shifted forward to cover the anterior wall as well as the Aoor of the newIy made concha.
FIG. 3. The postaural flap is advanced forward through the opening made under the rudimentary ear into the concha cavity. Usually the skin flap is Iarge enough to cover the anterior surface and the floor of the cavity. The incised anterior edge of the rudimentary ear is undermined freely and sutured to the raw edge back of the postaura1 region. This procedure hoIds the ear back and the concha open, and is not freed unti1 the reconstruction of the ear is compIete.
pended upon as a permanent support for the ear. Foreign bodies are torerated by the tissues if thev are not subjected to trauma, but the ear being an exposed part of the body is in constant danger of trauma. The three principa1 steps in obtaining soft tissue and framework for the reconstruction of the concha do not necessarily foIIow one another and frequently are intermixed at surgery. Reconstruction of the Concha. A vertical incision is made aIong the anterior edge of the microtic ear and this incision deepened anteriorIy as we11 as posteriorIy down to the periosteum of the mastoid bone. Enough of the surrounding subcutaneous tissue is trimmed to create a cavity the size of a normaI concha. (Fig. 2.) In order to cover the floor as we11 as the sides of the new cavity with epitheIia1 tissue, a postaura skin flap, with its pedicIe inferiorly, is raised in the postaural non-hairy region. An incision is then made under the microtic ear which connects the postaura region with the concha cavity anteriorIy. The
Frc. 4. This diagram ilIustrates the postaural flap shifted forward to cover the Aoor and anterior surface of the cavity. The centra1 portion of the rudimentary ear, after undermining freely, is sutured to the raw edge at the postaural region. The exposed area of the concha as we11 as the anterior surface of the ear is covered with skin graft. A fuII-thickness skin graft is preferred because its color matches better and has less postoperative contracture.
186
Congenital
5A
5B
Deformities
of Ears
5C
5D
5E
FIG. 5. In V. C., an ad&,
eighteen year old patient, it was possibte to perform a11 surgica1 procedures under IocaI anesthesia. A, photograph shows the deformed ear, somewhat Iarger than is usuaIIy seen in children. B, after the third operation the distal end of the tube flap from the upper part of the chest is extended to the neck. Note the outIine of the newIy made concha and the antihelix sutured to the postauricuIar skin. C, The lower end of the tube ffap is sutured to the preaurictdar edge of the helix. D, the tube flap is now in position over the upper part of the ear. E, fina photograph. In the Iast procedure considerable conchal cartiIage was removed from the opposite ear and transpIanted to the upper part of the ear, after surpIus skin and fat had been trimmed.
fIap is shifted anteriorIy into the conchal cavity through this opening and is usuaIIy Iarge enough to cover the fIoor and anterior waII of the concha. (Fig. 3.) Before suturing the postaura1 flap into its new position, the incised anterior edge of the rudimentary ear is undermined, spread freeIy and sutured to the raw edge left back over the mastoid process. (Fig. 3.) This hoIds the microtic ear backwards and the concha open, and is not freed unti1 reconstruction of the ear is accompIished. The postaura fIap is then sutured into the concha cavity utiIizing it to the best advantage. It wiI1 usuaIIy cover a major portion of the cavity, and the remaining portion as we11 as any uncovered areas of the rudimentary ear are surfaced with a fuII-thickness skin graft from the norma side. A fuII-thickness graft is used here in preference to a spIit graft because of its better coIor match and Iess postoperative contracture. (Fig. 4.) At the same operation a tube ffap is formed in the left cIavicuIar region. Reconstruction of Soft Tissues. At subsequent operations, the tube ffap is shifted up to the ear to supply the needed skin and subcutaneous fat. One end is attached just above the IobuIe of the ear; the other end at the root of the helix, and the intervening section attached to the periphery of the rudimentary ear. In the meantime, at one of the rope shifting operations, the base of the postauricuIar flap is cut and transferred to cover the Iower waI1 and rim
6A
6B
FIG. 6. A, reconstruction
of the right auricle in patient P. G., who had no other facia1 defects. The first operation was performed at the age of five years. See text. B, final appearance of the right ear. Five operations were performed within a period of four years.
of the concha. When vascuIarity of the rope graft is assured, now being Iocated entireIy on the ear, the surpIus fat and skin is trimmed and the cartiIaginous framework added. Reconstruction of Framework. At this stage we shouId have an auricle with a we11 formed concha, a reconstructed Iower third, and enough soft tissue in the upper two-thirds to allow for the addition of a presentabIe framework.
Kazanjian ConchaI cartiIage from the opposite norma ear, with its thin and sIightIy curved contour, is idea1 for skeIeta1 support to the upper portion of the ear, from the scapha to the fossa trianguIaris. It is possibIe to remove a Iarge section of conchal cartiIage without causing any distortion of the normal ear by the foIIowing procedure: An incision is made over the post auricuIar skin, exposing the posterior surface of the concha cartiIage; the cartilage is then incised just beIow the antiheIix and the necessary amount of cartiIage is removed in one section. The soft tissues and the periosteum over the mastoid region are removed in order to preserve the contour of the concha, and the skin of the anterior surface of the concha is placed against the exposed bone andretak pIaced against the exposed bone and retained by a denta compound moId, pressed against the outer surface of the auricIe, adhering directIy to the bone. The concha cartiIage is added to the deformed ear in the folIowing fashion: A curved incision is made near the periphery of the transpIanted tube Asp along a Iine where the norma overhang of the heIix should be. The skin beIow this incision is freed up and the excess fat removed. The concha cartilage is then added in this location and secured by sutures in the most satisfactory position. The excess fat and skin are aIso trimmed from the periphery of the transpIanted tube flap, care being taken not to sacrifice too much. The incision is then sutured with mattress stitches, extending through the fuI1 thickness of the ear to accentuate the heIix. (Fig. 5A to E.) At the same operation it may be necessary to obtain strips of Costa1 cartilage to reconstruct the antihelix. A Iong thin curved strip
of Costa1 cartiIage may aIso be needed for support in the heIix. OccasionaIIy, one has a supply of costal cartilage in excess of one’s immediate needs. In such instances it is wise to store this cartiIage under the postaura skin or in the neck, as occasionahy one finds future use for this excess. When to Operate. When a child is born with a physica deformity such as a defect of the externa1 ear, it is natura1 for the parents to seek advice at an earIy date. These parents are usually advised to postpone any surgery on the ear unti1 the chiId is at least three years old. The parents are aIways anxious to have the ear reconstructed to a presentabIe appearance before the chiId starts school. ChiIdren seem to be quite sensitive regarding deformities of this type, and are cooperative and wiIIing to undergo surgery. If such operative procedure is carried out without postoperative complications we are usuaIIy abIe to create a fairIy normal Iooking ear which, ahhough being far from perfect, is acceptabIe and escapes critica comparison with the other ear on the opposite side of the head. (Fig. 6A and B.) In our series of cases, four operations were the least number of procedures required for reconstruction of the external ear. In operating upon chiIdren we are seIdom abIe to proceed without minor compIications, and IocaIized infection of the tissues wiI1 naturaIIy deIay the heaIing and perhaps create new compIications. Our most favorable cases of reconstruction were done in five stages. Reconstruction of the ear in aduIt patients has severa advantages. AI1 the operative procedures may be carried out under IocaI anesthesia; aduIt patients are more cooperative; and the incidence of postoperative infection seems to be Iess.
C cover
ONGENITAL deformities of the externa1 ear a wide variety of conditions. They may range from a shght change in the normaI contour to a tota absence of the ear. A certain number of patients also have other faciaI defects in addition to the abnormaIity of the auricles. In many cases there is definite asymmetry of the affected side of the face due to arrested growth of the ascending ramus of the mandibIe. This may be complicated by weakness of the seventh nerve affecting the corner of the mouth and eyelid. Reconstruction of the externa1 ear is one of the most difficult procedures in pIastic surgery. In 1937 GiIlies observed that “the study of ours and other surgeons’ actua1 resuIts reveal an undisputed disappointment in the cosmetic result obtained by these methods” [I]. Since then, although much has been written on this subject and considerabIe progress has been made, the results are far from satisfactory. Up to the present no standard procedure has been deveIoped. Our present resuIts are acceptabIe onIy in that they give the patient a feeting of facia1 symmetry and baIance. FortunateIy, the two ears are on opposite sides of the face and close comparison is avoided. In this paper, the discussion is limited to the treatment of onIy one type of congenital deformity of the ear with speciaI emphasis on reconstruction of the concha, a typical exampIe of which is seen in Figure I. Here, we have a rudimentary mass of soft tissue in the auricuIar region, cIose examination of which reveals that onIy part of the IobuIe is present. The rest of the auricIe is usuaIIy an UnderdeveIoped, shapeIess mass of skin and cartilage with an absent ear cana1. X-rays show that the external auditory cana is not deveIoped and operation usuaIIy reveaIs the maIIeus and incus fused. Hearing by air is at the so-60 decibeIs IeveI.
M.D.,
Boston,
Mussachusetts
The inner ear, being of different developmental origin, is aIways normaIIy deveIoped. In the reconstruction of an auricular deformity of this type, there are three general
_i FIG. I. A vertical incision is made in front of the rudimentary ear, Through this incision, on the scalp side, the mastoid process, the periosteum of the mastoid bone as well as the surrounding tissues, are exposed to form a good sized rectangular cavity.
steps. First, and what I consider one of the most important steps in the entire series of operations, is reconstruction of the concha. Next, is the transfer of soft tissues from adjacent or distant regions in the form of a tubed ffap to supplement the inadequate soft tissues supplied by nature. A tube ffap from the neck or cIavicuIar region serves we11 for this purpose. Next, is the suppIying of frame-work to the ear, the most perfect type being autogenous auricuIar cartilage. For this purpose, we obtain concha cartiIage from the opposite norma ear suppIemented by Costa1 cartilage. Foreign bodies, such as acryIic, vitaIIium or tantaIum, and even preserved cartiIage, cannot be deAmerican Journal of Surgery, Volume 9.1. February. 1958 185
Kazanjian
FIG. 2. Diagram shows a we11 defined deep cavity to form a concha. A through and through incision, extending from the back of the rudimentary ear to the floor of the newly formed concha was made. The dotted Iines show the approximate position of a postaural skin flap to be shifted forward to cover the anterior wall as well as the Aoor of the newIy made concha.
FIG. 3. The postaural flap is advanced forward through the opening made under the rudimentary ear into the concha cavity. Usually the skin flap is Iarge enough to cover the anterior surface and the floor of the cavity. The incised anterior edge of the rudimentary ear is undermined freely and sutured to the raw edge back of the postaura1 region. This procedure hoIds the ear back and the concha open, and is not freed unti1 the reconstruction of the ear is compIete.
pended upon as a permanent support for the ear. Foreign bodies are torerated by the tissues if thev are not subjected to trauma, but the ear being an exposed part of the body is in constant danger of trauma. The three principa1 steps in obtaining soft tissue and framework for the reconstruction of the concha do not necessarily foIIow one another and frequently are intermixed at surgery. Reconstruction of the Concha. A vertical incision is made aIong the anterior edge of the microtic ear and this incision deepened anteriorIy as we11 as posteriorIy down to the periosteum of the mastoid bone. Enough of the surrounding subcutaneous tissue is trimmed to create a cavity the size of a normaI concha. (Fig. 2.) In order to cover the floor as we11 as the sides of the new cavity with epitheIia1 tissue, a postaura skin flap, with its pedicIe inferiorly, is raised in the postaural non-hairy region. An incision is then made under the microtic ear which connects the postaura region with the concha cavity anteriorIy. The
Frc. 4. This diagram ilIustrates the postaural flap shifted forward to cover the Aoor and anterior surface of the cavity. The centra1 portion of the rudimentary ear, after undermining freely, is sutured to the raw edge at the postaural region. The exposed area of the concha as we11 as the anterior surface of the ear is covered with skin graft. A fuII-thickness skin graft is preferred because its color matches better and has less postoperative contracture.
186
Congenital
5A
5B
Deformities
of Ears
5C
5D
5E
FIG. 5. In V. C., an ad&,
eighteen year old patient, it was possibte to perform a11 surgica1 procedures under IocaI anesthesia. A, photograph shows the deformed ear, somewhat Iarger than is usuaIIy seen in children. B, after the third operation the distal end of the tube flap from the upper part of the chest is extended to the neck. Note the outIine of the newIy made concha and the antihelix sutured to the postauricuIar skin. C, The lower end of the tube ffap is sutured to the preaurictdar edge of the helix. D, the tube flap is now in position over the upper part of the ear. E, fina photograph. In the Iast procedure considerable conchal cartiIage was removed from the opposite ear and transpIanted to the upper part of the ear, after surpIus skin and fat had been trimmed.
fIap is shifted anteriorIy into the conchal cavity through this opening and is usuaIIy Iarge enough to cover the fIoor and anterior waII of the concha. (Fig. 3.) Before suturing the postaura1 flap into its new position, the incised anterior edge of the rudimentary ear is undermined, spread freeIy and sutured to the raw edge left back over the mastoid process. (Fig. 3.) This hoIds the microtic ear backwards and the concha open, and is not freed unti1 reconstruction of the ear is accompIished. The postaura fIap is then sutured into the concha cavity utiIizing it to the best advantage. It wiI1 usuaIIy cover a major portion of the cavity, and the remaining portion as we11 as any uncovered areas of the rudimentary ear are surfaced with a fuII-thickness skin graft from the norma side. A fuII-thickness graft is used here in preference to a spIit graft because of its better coIor match and Iess postoperative contracture. (Fig. 4.) At the same operation a tube ffap is formed in the left cIavicuIar region. Reconstruction of Soft Tissues. At subsequent operations, the tube ffap is shifted up to the ear to supply the needed skin and subcutaneous fat. One end is attached just above the IobuIe of the ear; the other end at the root of the helix, and the intervening section attached to the periphery of the rudimentary ear. In the meantime, at one of the rope shifting operations, the base of the postauricuIar flap is cut and transferred to cover the Iower waI1 and rim
6A
6B
FIG. 6. A, reconstruction
of the right auricle in patient P. G., who had no other facia1 defects. The first operation was performed at the age of five years. See text. B, final appearance of the right ear. Five operations were performed within a period of four years.
of the concha. When vascuIarity of the rope graft is assured, now being Iocated entireIy on the ear, the surpIus fat and skin is trimmed and the cartiIaginous framework added. Reconstruction of Framework. At this stage we shouId have an auricle with a we11 formed concha, a reconstructed Iower third, and enough soft tissue in the upper two-thirds to allow for the addition of a presentabIe framework.
Kazanjian ConchaI cartiIage from the opposite norma ear, with its thin and sIightIy curved contour, is idea1 for skeIeta1 support to the upper portion of the ear, from the scapha to the fossa trianguIaris. It is possibIe to remove a Iarge section of conchal cartiIage without causing any distortion of the normal ear by the foIIowing procedure: An incision is made over the post auricuIar skin, exposing the posterior surface of the concha cartiIage; the cartilage is then incised just beIow the antiheIix and the necessary amount of cartiIage is removed in one section. The soft tissues and the periosteum over the mastoid region are removed in order to preserve the contour of the concha, and the skin of the anterior surface of the concha is placed against the exposed bone andretak pIaced against the exposed bone and retained by a denta compound moId, pressed against the outer surface of the auricIe, adhering directIy to the bone. The concha cartiIage is added to the deformed ear in the folIowing fashion: A curved incision is made near the periphery of the transpIanted tube Asp along a Iine where the norma overhang of the heIix should be. The skin beIow this incision is freed up and the excess fat removed. The concha cartilage is then added in this location and secured by sutures in the most satisfactory position. The excess fat and skin are aIso trimmed from the periphery of the transpIanted tube flap, care being taken not to sacrifice too much. The incision is then sutured with mattress stitches, extending through the fuI1 thickness of the ear to accentuate the heIix. (Fig. 5A to E.) At the same operation it may be necessary to obtain strips of Costa1 cartilage to reconstruct the antihelix. A Iong thin curved strip
of Costa1 cartiIage may aIso be needed for support in the heIix. OccasionaIIy, one has a supply of costal cartilage in excess of one’s immediate needs. In such instances it is wise to store this cartiIage under the postaura skin or in the neck, as occasionahy one finds future use for this excess. When to Operate. When a child is born with a physica deformity such as a defect of the externa1 ear, it is natura1 for the parents to seek advice at an earIy date. These parents are usually advised to postpone any surgery on the ear unti1 the chiId is at least three years old. The parents are aIways anxious to have the ear reconstructed to a presentabIe appearance before the chiId starts school. ChiIdren seem to be quite sensitive regarding deformities of this type, and are cooperative and wiIIing to undergo surgery. If such operative procedure is carried out without postoperative complications we are usuaIIy abIe to create a fairIy normal Iooking ear which, ahhough being far from perfect, is acceptabIe and escapes critica comparison with the other ear on the opposite side of the head. (Fig. 6A and B.) In our series of cases, four operations were the least number of procedures required for reconstruction of the external ear. In operating upon chiIdren we are seIdom abIe to proceed without minor compIications, and IocaIized infection of the tissues wiI1 naturaIIy deIay the heaIing and perhaps create new compIications. Our most favorable cases of reconstruction were done in five stages. Reconstruction of the ear in aduIt patients has severa advantages. AI1 the operative procedures may be carried out under IocaI anesthesia; aduIt patients are more cooperative; and the incidence of postoperative infection seems to be Iess.