CME

Ear Deformities, Otoplasty,

and Ear Reconstruction
Charles H. Thorne, M.D.
Gordon Wilkes, M.D.
Edmonton, Alberta, Canada; and
New York, N.Y.
Learning Objectives: After reviewing this article, the participant should be able to:
1. Evaluate patient’s ears for needed adjustments to size, shape, prominence, and
symmetry. 2. Identify common ear deformities and describe methods to repair
them. 3. Avoid or manage common complications associated with otoplasty and ear
reconstruction.
Summary: The essentials of otoplasty will be described/illustrated for the following
conditions: Prominent ears, underdeveloped helical rims (shell ear), macrotia,
Stahl’s ear, constricted ear, cryptotia, and question mark ear. (Plast. Reconstr. Surg.
129: 701e, 2012.)

I
n this section, the authors describe and/or illus-
trate the essentials of otoplasty for the following
conditions: (1) prominent ears, (2) underdevel-
oped helical rims (shell ear), (3) macrotia, (4)
Stahl’s ear, (5) constricted ear, (6) cryptotia, and (7)
question mark ear.
OTOPLASTY FOR PROMINENT EARS
Essentials of Preoperative Management
The overall size and shape of the ears are as-
sessed before evaluating the degree of prominence.
In other words, the surgeon makes a distinction be-
tween prominent ears that are normal in size and
contour, on the one hand, and prominent ears that
are also abnormal in size or shape, on the other.
Deformities such as macrotia, constricted ear, Stahl’s
ear, cryptotia, or underdeveloped shell-like helical
rims are noted. Once a determination has been
made regarding the size and shape, the prominence is
most easily evaluated by assessing the auricle in thirds:
upper third, middle third, and lower third (lobule).
The entire ear may be prominent, but in many cases
the prominence is more localized (e.g., upper third
only, middle third only, upper and lower thirds only).
Finally, the symmetry is addressed. Patients tend
to obsess about symmetry even though, from an
aesthetic point of view, it is frequently not the most
important issue. In most cases of asymmetry, both ears
require surgical intervention to avoid the operated ear
from being closer to the head than the unoperated ear.
Goals of Treatment
The goal in standard otoplasty is a normal ap-
pearing ear without evidence that there has been
surgical intervention. Sharp, unnatural contours,
overcorrection, and obliteration of the normal sul-
cus are not acceptable results. When the surgeon is
finishing the procedure, before suturing the inci-
sion, the result should be evaluated from three dif-
ferent angles: from the front, from the side, and
from behind. From the front, the helical rim should
protrude beyond the antihelix in the upper third of
the ear. From the side, the contours should be soft
and natural in appearance. Finally, and perhaps the
best clue that the setback is harmonious, the helical
contour should form a straight line when viewed
from behind. If, for example, the helical rim forms
a C shape, the middle third of the ear is overcor-
rected and/or the upper and lower thirds are un-
dercorrected. Any such disharmony should be cor-
rected before leaving the operating room.
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.

From the Institute for Reconstructive Sciences in Medicine,

and the Department of Plastic Surgery, New York University
School of Medicine.
Received for publication January 27, 2011; accepted October
4, 2011.
Copyright ©2012 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3182450d9f
Related Video content is available for this ar-
ticle. The videos can be found under the “Re-
lated Videos” section of the full-text article, or,
for Ovid users, using the URL citations
printed in the article.

www.PRSJournal.com 701e
 Plastic and Reconstructive Surgery • April 2012

Advantages/Disadvantages of the Treatment

Alternatives
Traditional techniques that involve scoring
the cartilage1 or full-thickness incisions/tubing of
the cartilage2 may have the advantage that recur-
rence of the deformity is less likely. We prefer to
avoid these techniques, however, with the hope of
achieving more natural appearing results and con-
fining complications to those problems that can
be more easily corrected. The approach described
below, therefore, incorporates the authors’ bias
that undercorrection, potential recurrence, and
suture complications are preferable to overcor-
rection, unnatural contours, sharp edges, and po-
tentially unrepairable deformities. The reader is
also directed to the reference describing “inci-
sionless otoplasty.”3 Video 1. Supplemental Digital Content 1, in which Dr. Thorne
demonstrates his otoplasty technique, is available in the “Related
Videos” section of the full-text article on PRSJournal.com or, for
Key Elements of the Operation Ovid users, available at http://links.lww.com/PRS/A473. (From
The steps for standard, setback otoplasty are Thorne C. Otoplasty. Plast Reconstr Surg. 2008;122:291–292.)
presented below and are depicted in Figure 1 and
demonstrated in Video 1. [See Video, Supplemental lar sulcus and to preserve at all costs the ability to
Digital Content 1, in which Dr. Thorne demon- wear an earring.
strates his otoplasty technique, available in the
“Related Videos” section of the full-text article on Dissection
PRSJournal.com or, for Ovid users, at http://links. The cartilage is exposed on its posterior (me-
lww.com/PRS/A473. (From Thorne C. Otoplasty. dial) surface, exposing the helical tail. Soft tissue
Plast Reconstr Surg. 2008;122:291–292.)] is excised from deep to the concha. The retrolobu-
lar sulcus is dissected deeply, a maneuver that is
Incision
necessary for lobule repositioning at the conclu-
An incision is made in the retroauricular sul-
sion of the procedure.
cus. The only skin removed is a small triangle from
the medial surface of the lobule, to facilitate later Correction
earlobe repositioning,4 taking care to preserve Mustardé sutures of 4-0 clear nylon are placed
enough tissue for a normal earlobe and retrolobu- to recreate the upper portion of the antihelix and

Fig. 1. Otoplasty technique. The combination of Mustardé scaphoconchal sutures, conchal resection with conchal reapproximation,
and a Furnas conchal-mastoid suture. (Left) Sutures placed. (Center) Sutures tightened to create the desired contour. (Right) Same
sutures as seen through the retroauricular incision.

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Volume 129, Number 4 • Otoplasty
the superior crus of the triangular fossa.5 It is
important that the surgeon appreciate that the
antihelix is not a straight line. In fact, the superior
crus (the upper termination of the antihelix)
curves far forward and becomes almost parallel to
the inferior crus. The Mustardé sutures are placed
like the spokes on a wheel (not parallel to each
other) to create a curved, natural appearing an-
tihelical fold. Approximately three to four Mus-
tardé sutures are required if the deformity is con-
fined to the upper third. If the deformity extends
into the middle third, as many as six to eight
Mustardé sutures may be required (Fig. 1).
To address the middle third, the conchal
depth is assessed. If there is excess depth, a min-
imal resection of the concha is performed at the
junction of the posterior wall and floor of the
concha. The conchal defect is closed primarily
with many more nylon sutures (Fig. 1). We prefer
to use a small conchal resection in combination
with conchal setback (see below) so that the con-
chal resection can be limited to approximately 2
mm. Two 5-0 polydioxanone sutures are used to
close the triangular skin defect on the medial sur-
face of the earlobe. The sutures also incorporate
a bite of the conchal cartilage, deep in the sulcus,
which will result in correction of the earlobe
prominence.
Finally, a 3-0 nylon conchal-mastoid Furnas
suture is placed.6 This is the suture that really sets
back the ear. The middle and upper third ma-
neuvers only create the contours and should not
be used to set back the ear. In other words, most
patients are treated with both a small conchal
resection and a conchal setback. Only rarely is a
conchal-mastoid suture alone adequate. If
placement of this suture pushes the posterior
wall of the external meatus too far forward (ob-
structing the meatus), a conchal resection is
definitely performed. The skin incision is ap-
proximated with interrupted or intracuticular
sutures of 5-0 plain gut.
Perioperative Management
Xeroform (Covidien, Mansfield, Mass.) is
placed over each ear and the patient’s head is
wrapped loosely in a bulky gauze dressing. No
attempt is made to put pressure on the ears with
the dressing. The dressing is removed in 4 to 5
days, after which no further dressing is necessary.
The patient is instructed to wear a loosely fitting
headband at night only, to prevent inadvertent
trauma to the repair.
Complications
The surgical technique determines which
complications are the most likely. The technique
described above eliminates the worst complica-
tions: overcorrection, sharp edges, unnatural con-
tours, inharmonious setback, telephone defor-
mity, and infection. Suture complications are
quite common, however. The nylon Mustardé su-
tures may eventually protrude through the poste-
rior skin. The potential risk is lessened by pushing
the knot flush with the posterior surface of the ear
cartilage. This complication may occur within the
first few weeks postoperatively but usually several
years later. Protruding sutures may be associated
with a painful, erythematous pustule. Patients
should be informed of this potential problem and
encouraged to return to the surgeon immediately.
The authors have seen patients with this problem
managed with topical antibiotics for months with
no improvement, only to be symptom free 1 day
after suture removal under local anesthesia. The
sutures can be removed without fear of recurrence
of the deformity if they have been in place for
several months.
One author (C.H.T.) has had two instances in
which the deformity recurred to a degree that
reoperation was necessary. Interestingly, a review
of the operative notes indicated that polydiox-
anone sutures were used for the Mustardé sutures
in those cases. Although this is only anecdotal
evidence, the author has returned to using nylon
sutures in all cases.
One remaining problem deserving mention is
disharmony of the result. Regardless of the oto-
plasty technique chosen, a “successful” but dishar-
monious setback may be produced; that is, the
result just does not appear right. The telephone
deformity is a good example. As mentioned above,
the helix should appear almost straight when
viewed from behind. If the helical contour resem-
bles a hockey stick or a C, the setback will just not
appear aesthetically pleasing.
OTOPLASTY FOR OTHER
EAR DEFORMITIES
Essentials of Preoperative Management
Not uncommonly, patients will present with
ears that are prominent but also abnormal in con-
tour and/or size. The first step for the surgeon is
to differentiate between deformities such as un-
derdeveloped, flat helical rims (shell ear), exces-
sively large ears (macrotia), Stahl’s ear, con-
stricted ear, cryptotia, and the question mark ear.
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 Plastic and Reconstructive Surgery • April 2012

Fig. 2. Ear reduction and setback for macrotia with prominence. (Above, left) Cartilage is excised from the scapha followed by
placement of Mustardé sutures. (Above, right) A small conchal reduction has been performed and the concha is reapproxi-
mated. (Below, left) A single Furnas suture is placed. (Below, right) The postoperative result is shown. This patient was a young
child, and the amount of reduction was small. In the vast majority of ear reduction cases, it is necessary to remove a wedge
from the helical rim. If the helical rim is not shortened, it will be too long for the reduced scaphal circumference, resulting in
buckling and irregularities.

Goals of Treatment pearance of the deformities discussed in this ar-

The goals of treatment are the same as for
standard otoplasty except that, depending on the
degree of deformity, the results may fall short of
normal. All ear deformities exist along a spectrum
ranging from mild, almost imperceptible abnor-
malities to severely affected, underdeveloped
structures that bear little resemblance to normal
auricles. If the latter is the case, otoplasty may be
inappropriate and the patient may be best treated
by discarding the cartilage and placing a cartilage
framework as discussed below under “Total and
Subtotal Ear Reconstruction.”
Advantages and Disadvantages of Treatment
Alternatives
As with standard otoplasty, numerous tech-
niques have been described to improve the ap-
ticle. Each has its own pros and cons. Rather than
describe the myriad procedures that exist in the
literature, the authors’ preferred methods, along
with the rationale for choosing them, are dis-
cussed below.
Key Elements of the Surgical Procedure
Incision
There are only so many acceptable incisions
through which to perform otoplasty. The ret-
roauricular incision was described above and is
used for standard otoplasty. The correction of
shell ear, macrotia, constricted, ear and Stahl’s
ear all require an incision on the lateral (visible)
surface of the ear, just inside the helical rim
either alone or in combination with the auric-
ular sulcus incision. When placed appropriately,

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Volume 129, Number 4 • Otoplasty

these anterior incisions usually heal with an ac- Stahl’s Ear

ceptable scar. Cryptotia and the question mark
ear require different approaches.
Shell Ear
In the case of shell ear (absence of the helical
overhang), the mere performance of the incision
through the skin and cartilage, followed by skin
closure at the end of the procedure, will create
some helical definition. If a wedge of helical rim
skin and cartilage is removed so that there is slight
tension on the closure, the helical rim will curl
into a desirable contour.
Macrotia
Once the above incision is made, a crescent of
skin and cartilage (much less skin than cartilage)
is excised from the scapha7,8 (Fig. 2). The result is
a helical rim that is excessively long for the newly
reduced scaphal circumference. A wedge excision
of the helical rim, as described under “Shell Ear,”
is almost always required to avoid irregularities in
the redundant helix.
In Stahl’s ear, there is an abnormal bar of
cartilage (sometimes called the third crus), ex-
tending from the antihelix to the helix at approx-
imately the junction between the upper and mid-
dle thirds of the ear. If that abnormal cartilage is
obvious, it must be excised (Fig. 3). The cartilage
defect is closed primarily. In addition, there may
be excess scapha in the region of the third crus
and absence of the normal superior crus of the
triangular fossa. Any excess scapha is trimmed as
described above for macrotia. These authors pre-
fer the technique described by Kaplan and
Hudson,9 in which the excised piece of cartilage is
used to augment the deficient superior crus.
Constricted Ear
In a constricted ear, the fundamental abnor-
mality is that the helical rim is deficient in cir-
cumference for the scapha to which it is attached.
The inadequate length of the helix “constricts” the
ear and forces it into a cupped shape that pro-

Fig. 3. Repair of Stahl’s ear. (Above, left) Preoperative appearance. (Above, right) Exposure of the lateral surface of the ear
cartilage and plan for resection of extra crus. (Below, left) Appearance after resection of abnormal crus and reconstruction of
the superior crus using the resected cartilage. (Below, right) Postoperative result.

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 Plastic and Reconstructive Surgery • April 2012

trudes from the head. In the mildest deformities,

the overhang can be trimmed. The result is an ear
that is slightly small; however, the contour is im-
proved. Any attempt at otoplasty must be accom-
panied by lengthening of the helix. The usual
procedure is to extend the lateral incision de-
scribed above into the concha, around the crus of
the helix. In this manner, the crus of the helix can
be recruited into the helix, thereby lengthening it
and allowing standard otoplasty maneuvers to set
back the ear. The defect in the concha is closed
primarily. As described above, severe deformities
(Tanzer 3a and 3b) may be better treated as a
microtia case with a rib cartilage framework rather
than by attempting salvage of the native cartilage.
Cryptotia
In cryptotia, the superior aspect of the ear is
hidden beneath the temporal scalp. In some cases,
the auricular cartilage is normal and requires only
to be extracted from its hiding place. Lateral trac-
tion on the ear will reveal a normal auricle. In
other cases, the cartilage is malformed and re-
quires additional modification. The ear is grasped
and pulled away from the scalp, and an incision is
made around the superior aspect. Various tech-
niques have been described on how to resurface
the defect, from skin grafts to ingenious local
flaps.10 These authors have found that full-thick-
ness skin grafts from the groin provide the least
visible donor site for such extra tissue (Fig. 4).
Question Mark Ear
In the question mark ear, there is excess sca-
pha in the upper portion of the ear and a defi-
ciency at the junction of the middle and lower
thirds, resulting in a “question mark” shape. The
superior excess can be treated as described above
under “Macrotia.” In mild cases, the deficient
lower third can be treated using the combination
of a V-Y advancement from behind the ear plus a
cartilage graft.11 The cartilage graft can usually be
taken from the scaphal reduction or from the con-
cha. In severe deformities, however, it is preferable
to discard most of the ear cartilage and create a rib
cartilage framework as described below under “Total
and Subtotal Ear Reconstruction.”

NONOPERATIVE CORRECTION OF
EAR DEFORMITIES
During early infancy, the auricular cartilage
retains its fetal plasticity, allowing some of the
deformities described above to be corrected by
nonsurgical stenting.12,13 The ears are folded over
acrylic and taped into the correct position. The
splints and tape are changed regularly, and the
skin is checked compulsively for erosion. The pro-
Fig. 4. Cryptotia. (Above) Preoperative deformity showing su-
perior aspect of ear cartilage buried beneath scalp skin. (Cen-
ter) Design of the flap. (Below) Postoperative result. (Used with
permission from Gordon Wilkes, M.D.)
cess is continued for several months or until there
is no further improvement in auricular contour.
Remarkable results from Japan have been pub-

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Volume 129, Number 4 • Otoplasty
Fig. 5. Neonatal ear molding. (Left) Appearance at birth and (right) after ear molding. (Used
with permission from Gordon Wilkes, M.D.)
lished. Dr. Barry Grayson, an orthodontist at New
York University, has produced similar superb re-
sults. What remains unclear is how many weeks or
months this moldability lasts. An illustrative ex-
ample is shown in Figure 5. It is our impression
that the new cartilage will not be formed in those
cases where cartilage is deficient, but the shape of
the existing cartilage can definitely be altered.
TOTAL AND SUBTOTAL
EAR RECONSTRUCTION
In this section, the authors describe and illus-
trate the essentials of ear reconstruction for total
and subtotal defects.
Patients with microtia, patients with traumatic
or extirpative loss of the auricle, and some patients
with the extreme manifestations of the deformities
described above are best treated with total or sub-
total reconstruction of the ear. In addition to au-
togenous methods of reconstruction, prosthetic
reconstruction and Dr. Reinisch’s technique of
reconstruction14 using polyethylene frameworks is
described and illustrated. Excellent results have
also been reported by Park using expansion and a
two-flap technique.15
Autogenous Reconstruction
Essentials of Preoperative Assessment
Preoperative assessment consists of an evalu-
ation of the skin quality/laxity, presence or ab-
sence of an external auditory canal, presence or
absence of scars, location of the hairline, the ex-
tent to which any remnant corresponds to the
ideal position of the eventual reconstructed ear,
and the underlying skeleton. Although most pa-
tients in this category have isolated microtia and
have never had previous surgery, there are many
patients who have microtia in the setting of severe
skeletal and soft-tissue hypoplasia (hemifacial mi-
crosomia), microtia that has been operated on
previously, posttraumatic deformities, and postex-
tirpative deformities. The microtia classification in
the literature with the most practical implications
for surgical technique is that of Nagata16 –18: lob-
ular type, small conchal type, and large conchal
type. In the latter type, a tragus and concha are
present, at least to some extent, and this allows
placement of a less complex cartilage framework
and generally yields superior aesthetic results. Mi-
crotia patients who have undergone previous sur-
gical intervention will have scars and cartilage or
artificial frameworks, all of which may not be in
the ideal position.
Even a perfect ear that is located too low or
too anterior is frequently worse than no ear at
all. Finally, patients with posttraumatic defor-
mities or postablative deformities frequently
have the advantage of a tragus and concha but
the disadvantage of nondistensible, scarred, some-
times irradiated soft tissue. A more detailed and
extremely helpful classification awaits publication
by Firmin19 and takes into consideration the type
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 Plastic and Reconstructive Surgery • April 2012

Fig. 6. Drawings demonstrate the Brent technique for fabrication of ear frame-
work from rib cartilage. The Brent framework consists of two pieces. The base
is obtained from the synchondrosis of two rib cartilages and the helical rim is
obtained from a “floating” rib cartilage. The details are carved into the base
using a gouge. The helical rim piece is thinned and attached to the base using
nylon sutures.

of incision required, the type of framework re-
quired, and the type of additional cartilage that is
used for projection.
Goals of Treatment
The goal in these patients is to create an ear
that appears normal from conversational distance
and will have little effect on the patient’s hairstyle
and earrings. No reconstructed ear will avoid de-
tection under intimate scrutiny. The framework,
whether cartilage or polyethylene, is bulkier and
less flexible than a normal ear. A prosthesis, al-
though inconspicuous from a distance, will be ob-
viously artificial in any intimate setting. If the pros-
thesis is removed, which it has to be for at least 8
hours per day, the metallic suprastructure to
which it is attached will be visible, palpable, and
potentially embarrassing.20
Advantages and Disadvantages of the
Treatment Alternatives
The advocates of cartilage reconstruction, in-
cluding the authors of this article, tout the advan-
tages of autogenous tissue. The advocates of arti-
ficial frameworks attempt to “sell” the avoidance of
a chest incision and the biocompatibility of porous
polyethylene. Those who prefer prosthetic recon-
struction claim superior aesthetics, less invasive
procedures, and a lower cost. The authors’ ratio-
nale for autogenous reconstruction is addressed
in more detail under “Complications” below.
Within the category of autogenous reconstruc-
tion, the two most popular techniques are those
described by Brent21 and Nagata.16 –18 The Brent
technique is a modification of that originally de-
scribed by Tanzer22 and involves four stages (de-
scribed below). Nagata analyzed the results of the
Brent technique and designed a two-stage tech-
nique (described below) to address its perceived
imperfections. The Brent technique is easier to learn
and has fewer complications. The Nagata technique
condenses the reconstruction into two stages and
uses a more detailed, complicated framework. The
Nagata technique has the potential to yield a better
aesthetic result by providing a more natural tragus,
antitragal notch, and conchal bowl region and better
antihelical definition.23 The Nagata technique is like
“swinging for the fences”; there are more home runs
and more strikeouts.
Key Elements of the Surgical Procedure
Brent technique. The patient is examined in the
upright position and the lowest point of the ear-

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Fig. 7. Drawings depict Nagata stage 1 incision, dissection of pocket, and insertion
of framework. (Above, left) The W-shaped incision is made, taking the skin from the
medial surface of the earlobe to resurface the concha. (Above, right) The pocket is
dissected, leaving an intact “pedicle” at the caudal end of the flap. (Below, left) The
framework is inserted. (Below, right) After stage 1, suction drains are in place to
encourage coaptation of the skin to the underlying framework.

Video 2. Supplemental Digital Content 2, in which Dr. Wilkes

Fig. 8. Drawings showing the Nagata framework. (Left) In a man-
ner similar to Brent, the base and its details are carved from the
synchondrosis of two adjacent rib cartilages. (Right) The four
pieces of cartilage that make up the framework are shown and
numbered. The base and helical rim are present, as they are in the
Brent technique. There is an additional antihelix triangular fossa
piece and an additional tragus-antitragus piece that are unique
to the Nagata procedure.
demonstrates the carving of ear framework using autogenous
rib cartilage, is available in the “Related Videos” section of the
full-text article on PRSJournal.com or, for Ovid users, at
http://links.lww.com/PRS/A474.
lobe on the unaffected side is transferred to the
affected side. The attempt is to place the lowest
point of the reconstruction so that it, and the
patient’s earring, are at the same level as the nor-
mal side. The normal ear is traced on clear x-ray

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 Plastic and Reconstructive Surgery • April 2012

The incision is made and the cartilage rem-

Video 3. Supplemental Digital Content 3, in which Sean
Boutros, M.D., demonstrates first-stage autogenous recon-
struction, is available in the “Related Videos” section of the
full-text article on PRSJournal.com or, for Ovid users, at
http://links.lww.com/PRS/A475.
film and sterilized. Using this tracing, a template
is fashioned of the desired framework, approxi-
mately 3 mm shorter and 2 mm narrower than the
desired ear. The template is used to mark the exact
location and orientation of the desired auricle. An
incision is designed to provide access for removal
of the superior cartilage remnant and large
enough to place the eventual framework. In ad-
dition, it is placed such that it can be used at stage
2 for lobule rotation and at stage 4 for construc-
tion of the tragus.
nant is removed from the superior portion of the
malformed ear. The pocket is dissected so that it
extends slightly beyond the markings, especially
posteriorly, where skin without hair can be re-
cruited over the framework. Hemostasis is ob-
tained, a moist gauze is placed over the area, and
attention is directed to the chest.
A transverse incision is made over the caudal
aspect of the rib cage. The rectus abdominis mus-
cle is divided and the cartilages are exposed and
examined. Two cartilage pieces are required, one
that includes the synchondrosis of two rib carti-
lages to form the base and a second, preferably 10
cm in length, to create the helical rim. The details
are applied to the cartilages on the back table
using sterilized gouges and scalpels, and the car-
tilages are attached using nylon sutures (Fig. 6).
Once the framework is complete, it is inserted into
the pocket, two closed suction drains are placed,
and the incision is sutured. A soft bulky dressing
is applied.
At stage 2, the lobule is rotated, the caudal
aspect of the cartilage framework is inserted into
the bivalved lobule, and the lobule is inset in the
precise position to yield an auricle of the desired
length. At stage 3, the auricle is elevated, the ret-
roauricular scalp is undermined and advanced
into the sulcus, and the defect on the backside of
the elevated ear is resurfaced using a full-thickness
graft from the groin. At the final stage, the tragus

Fig. 9. Drawings show Nagata stage 2, elevation of the framework. (Left) The auricle is elevated, the cartilage
graft is wedged into the sulcus, the scalp is advanced, and the cartilage graft is covered with a temporo-
parietal flap and skin graft. (Center) The skin graft is inset. Nagata prefers a split-thickness skin graft, but
these authors have noted significant shrinkage of the split grafts and recommend full-thickness grafts.
(Right) Cross-section shows the cartilage graft in place providing projection and the temporoparietal flap
covering the cartilage graft.

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is constructed. An incision is made around the
posterior border of the ideal tragus. The skin of
the concha is elevated and the concha is deepened
by excising subcutaneous tissue. A composite graft
from the contralateral concha is placed upside
down to resurface the underside of the tragus, and
a small full-thickness graft is used to resurface the
conchal floor.
Nagata technique. The patient is examined in
the same fashion, and the lowest point of the de-
sired new ear is marked as described above. A
similar tracing is made, but it is helpful to make
additional tracings of the antihelix piece and the
tragus-antitragus anatomy so that decisions can be
made intraoperatively and those pieces carved ac-
cordingly. The W-shaped incision is designed to
provide the same exposure as in the Brent pro-
cedure, but also to rotate the lobule at the first
stage (Fig. 7). As mentioned above, Firmin has
developed a simplified approach to the incisions/
skin approach.19
The superior remnant is removed and the
pocket is dissected. A soft-tissue pedicle is left at-
tached near the apex of the central limb of the W
to help with vascularity of the large skin flap. Note
that the Nagata technique robs the skin from the
back of the earlobe to resurface the concha. This
results in a large flap with more potential for
ischemia than in the Brent technique but has
the advantage of potentially superior conchal-
tragal definition. The lobule is rotated into po-
sition and inset.

Fig. 10. Autogenous reconstruction for microtia with the Nagata technique. (Above, left)
Preoperative appearance. (Above, right) Postoperative result. (Below) Rib cartilage frame-
work. (Used with permission from Gordon Wilkes, M.D.)

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 Plastic and Reconstructive Surgery • April 2012

Although a transverse chest incision usually

results in less tendency for hypertrophic scar, an
oblique incision is more versatile and can be ex-
tended if the surgeon needs to search for better
cartilage pieces. A total of five pieces are needed
as opposed to the two for the Brent technique: the
base, the helical rim, the antihelix piece, the tra-
gus-antitragus piece, and a piece to bank in the
chest for the second stage. Once the cartilages are
harvested, it is helpful to leave a catheter in the
chest for the continuous administration of bupiv-
acaine postoperatively. The cartilage remnants
that remain after the framework is carved can be
diced and placed in the perichondrial sleeves to
maximize rib cartilage regeneration. Alterna-
tively, neo–rib cartilages can be constructed by
wrapping the diced remnants in an absorbable
gauze (e.g., Surgicel; Ethicon, Inc., Somerville,
N.J.) gauze and sewing them into the cartilaginous
defects. The surgeon then sits at the back table and
Fig. 11. Close-up view of the patient shown in Figure 10, post-
the cartilages are carved and spliced together as
operative result. (Used with permission from Gordon Wilkes,
shown in Figure 8. Although Nagata, Firmin, and
M.D.)
Wilkes prefer to use double-armed wire sutures on
straight needles, Thorne uses sutures of the same
design but in nylon. The double-armed short,
straight needles allow two pieces of cartilage to be Complications
Ischemic wound healing problems are rare
sutured from the anterior surface, rather than
when using the Brent technique. There is a defi-
from the posterior surface. (See Video, Supple-
nite learning curve with the Nagata procedure,
mental Digital Content 2, in which Dr. Wilkes
however, and ischemic necrosis of the skin flap at
demonstrates the carving of ear framework us-
the tip, in the region of the intertragal notch, is
ing autogenous rib cartilage, available in the not uncommon in inexperienced hands.
“Related Videos” section of the full-text article Even when the surgeon is experienced and there
on PRSJournal.com or, for Ovid users, at http:// is no “complication,” the vagaries of wound healing
links.lww.com/PRS/A474.) When the framework and variations in skin thickness, and variations in the
is complete, it is inserted into the pocket. Most surgeon’s ability to create a perfect framework, yield
surgeons use closed suction drains, but Nagata a spectrum of postoperative results—not uniformly
sews bolsters in place to encourage the skin to excellent results. This is true for both Brent-type and
drape into the interstices of the framework. (See Nagata-type reconstructions.
Video, Supplemental Digital Content 3, in which If exposure of the cartilage framework occurs,
Sean Boutros, M.D., demonstrates first-stage au- it must be dealt with promptly. Small areas of
togenous reconstruction, available in the “Related exposure (0.5 cm) that are not over a prominent
Videos” section of the full-text article on PRSJour- area of the framework may heal secondarily but
nal.com or, for Ovid users, at http://links.lww.com/ require close follow-up. If there is the slightest
PRS/A475.) evidence of infection, local flap coverage is nec-
At the second stage, the ear is elevated, the essary. For larger areas of cartilage exposure or
banked cartilage is removed from the chest and where the exposure is over the helical rim, cov-
used to augment projection of the framework, a erage should be provided on an urgent basis. The
temporoparietal flap is used to cover that cartilage type of local flap varies with the size and location
graft, and the sulcus is resurfaced with a skin graft. of the cartilage exposure. If there is any doubt
Nagata prefers a split-thickness graft from the scalp, about the viability of a local flap, a temporopari-
but others have found those grafts excessively prone etal flap and skin graft are the most reliable op-
to contraction and prefer a full-thickness graft from tions. Although use of the temporoparietal flap
the groin (Fig. 9). An example of a postoperative precludes its use at the second stage, it is vastly
result is shown in Figures 10 and 11. preferable to have stable coverage over the frame-

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Volume 129, Number 4 • Otoplasty
Video 4. Supplemental Digital Content 4, in which John
Reinisch, M.D., and Joseph Roberson, M.D., demonstrate ear re-
construction using a Medpor framework and canaloplasty in a
single stage, is available in the “Related Videos” section of the
full-text article on PRSJournal.com or, for Ovid users, at http://
links.lww.com/PRS/A476.
work than to “cheat” on the coverage and save the
temporoparietal flap for the second stage. Nylon
or wire sutures may become visible or palpable
months or years later and are easily removed.
Reconstruction Using a Medpor Framework
Because of space constraints, the steps of this
procedure are not discussed in detail but are
Fig. 12. Prosthetic reconstruction of the ear after burn deformity. (Left) Deformity. (Right) After
fabrication of implant retained prosthesis. (Used with permission from Gordon Wilkes, M.D.)
shown in Video 4, produced by Reinisch. (See
Video, Supplemental Digital Content 4, in which
John Reinisch, M.D., and Joseph Roberson, M.D.,
demonstrate ear reconstruction using a Medpor
framework and canaloplasty in a single stage, avail-
able in the “Related Videos” section of the full-text
article on PRSJournal.com or, for Ovid users, at
http://links.lww.com/PRS/A476.) Reinisch has the
most experience with this technique. His complica-
tion rate was high (42 percent) when he first began
to use Medpor (Porex Surgical, Inc., Newnan, Ga.)
frameworks, but the routine addition of temporo-
parietal flaps has resulted in a very low complication
rate at the present time.14 The video also shows con-
comitant canaloplasty to restore hearing. The au-
thors of this article have seen a number of patients
who underwent this procedure performed by sur-
geons other than Reinisch, who had persistent and
difficult problems with exposed Medpor frame-
works.
Prosthetic Reconstruction
Prosthetic reconstruction has a role in ear re-
construction, especially in older individuals who
are not interested in or who are not candidates for
a multiple stage reconstruction. The best indica-
tions are adult patients who have undergone ma-
jor extirpative surgery, patients with major trauma
or burns, and elderly patients with medical
comorbidities20,24 (Fig. 12). Prostheses are gener-
ally not the best choices in children, however,
unless there is no other option. Children tend not
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 Plastic and Reconstructive Surgery • April 2012

are time consuming and prone to failure, espe-

Video 5. Supplemental Digital Content 5, in which Dr. Wilkes
and anaplastologist Akhila Regunathan demonstrate the fabri-
cation of an ear prosthesis, is available in the “Related Videos”
section of the full-text article on PRSJournal.com or, for Ovid us-
ers, at http://links.lww.com/PRS/A477.
to wear prostheses, if they can help it, and the
devices serve as daily reminders of their deformity.
The authors feel that an appropriate autogenous
reconstruction for congenital deformities is supe-
rior and more stable, requires less maintenance,
and is cheaper in the long run. Prosthetic ears can
be retained by adhesives or by using osseointe-
grated titanium fixtures attached to transcutane-
ous abutments. The adhesives still have a role but
cially in important social situations. The method
of retention using osseointegrated implants is
more convenient and more secure.
Advocates of prostheses say they are cheaper
than surgical reconstruction. These authors doubt
that is true if cost is calculated over the life of the
patient. Prostheses last only approximately 5 years
and have to be replaced continually, at significant
expense. In addition, soft-tissue problems around
the abutments can result in long periods when the
prosthesis cannot be worn. In contrast, a talented
and experienced anaplastologist can produce an ear
prosthesis that is remarkable in its color, texture, and
life-like quality. (See Video, Supplemental Digital
Content 5, in which Dr. Wilkes and anaplastologist
Akhila Regunathan demonstrate the fabrication of
an ear prosthesis, available in the “Related Videos”
section of the full-text article on PRSJournal.com or,
for Ovid users, at http://links.lww.com/PRS/A477.) In
fact, without such an individual available to make the
prosthesis, prosthetic reconstruction should not be
contemplated.
RECONSTRUCTION OF PARTIAL
EAR DEFECTS
The surgical options for a given partial ear
defect depend on the location of the defect.
There are fewer options as the defect ap-
proaches the lobule. Interestingly, the lower the

Fig. 13. Drawings of Antia-Buch helical advancement. (Left) An incision is designed inside the helical rim and
around the crus of the helix. (Center) The incision is made through the skin and the cartilage, but not through
the posterior skin. The helical rim is advanced to allow closure and a dog-ear of skin is removed on the posterior
surface of the ear. (Right) Closure showing the crus of the helix advanced into the helical rim.

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Volume 129, Number 4 • Otoplasty
defect, the more important it is aesthetically and
the more difficult it is for the patient to conceal.
Upper Third Defects
The choices for defects of the upper third are
as follows:
1. Local skin flaps.
2. Helical advancement (Antia-Buch procedure)25
(Fig. 13).
3. Chondrocutaneous composite flap.
4. Conchal cartilage graft and retroauricular
skin flap (two stages).
5. Rib cartilage graft and retroauricular skin
flap (two stages).
6. Rib cartilage graft, temporoparietal flap,
and skin graft (two stages).
Middle Third Defects
The choices for defects of the middle third are
as follows:
1. Primary closure with excision of accessory
triangles (Fig. 14).
2. Retroauricular skin tube for helical rim de-
fects only (three stages).
3. Helical advancement.
4. Conchal cartilage graft and retroauricular
skin flap (two stages) (Fig. 15).
5. Rib cartilage graft and retroauricular skin
flap (two stages).
Lower Third Defects
Various techniques have been described to re-
construct earlobe defects using soft-tissue flaps.
These techniques are not as effective as those that
include cartilage support. The nasal septum pro-
vides thin cartilage that is extremely useful in de-
fects of the earlobe. A pocket is dissected corre-
Fig. 14. Wedge resection and primary closure with excision of
accessory triangles. (Left) Wedge excision performed and acces-
sory triangles designed. (Right) Closure of the defect.
Fig. 15. Two-stage reconstruction of a middle third defect using
rib cartilage graft and skin flap. (Left) The incision and retroau-
ricular flap are designed. (Right) The cartilage has been inserted
and the flap closed over it.
sponding precisely to the defect, and a piece of
septal cartilage is inserted. At a second stage, an
incision is made around the earlobe, and the
cheek and neck skin is advanced beneath the ear-
lobe as in a face lift.
Charles H. Thorne, M.D.
Department of Plastic Surgery
New York University School of Medicine
812 Park Avenue
New York, N.Y. 10021-2759
ct322@aol.com
PATIENT CONSENT
Patients or parents or guardians provided written
consent for the use of patients’ images.
ACKNOWLEDGMENTS
The authors thank John Reinisch, M.D., and Sean
Boutros, M.D., who submitted videos for this article.
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