PEDIATRIC/CRANIOFACIAL

New Strategies for Tragus and Antitragus

Complex Fabrication in Lobule-Type
Microtia Reconstruction
Zhicheng Xu, M.D., Ph.D.
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Background: The creation of a high-defining tragus and antitragus complex

Ruhong Zhang, M.D. Ph.D.
remains a demanding challenge during staged lobule-type microtia reconstruc-
Qun Zhang, M.D., Ph.D.
tion. The success of the complex carving relies greatly on proper operation of
Feng Xu, M.D., Ph.D. the cartilage, which is commonly residual cartilage of various sizes. The authors
Datao Li, M.D., Ph.D. discuss the relevant details for sculpting the tragus and antitragus complex
Yiyuan Li, M.D., Ph.D. based on cartilage remnants in various conditions.
Shanghai, People’s Republic of China Methods: A series of 562 lobule-type microtia patients underwent autogenous
costal cartilage auricular reconstruction between 2007 and 2016. Because of
the various sizes and shapes of the remnant cartilage used for the tragus and
antitragus complex reconstruction, the authors have described possible scenar-
ios for fabrication and introduced relevant tactics for appropriate treatment.
Results: Corresponding methods for various scenarios in tragus and antitragus
complex fabrication have been shown to demonstrate a satisfactory appear-
ance. The results demonstrate the achievement of a harmonious tragus and
antitragus complex for the integrity of a constructed ear.
Conclusions: Proper use of the residual cartilage for tragus and antitragus
complex sculpture plays a vital role in acquiring a favorable contour of the
auricle in microtia reconstruction. The introduced approach enhances the
aesthetics and functionality of the complex for modern life.  (Plast. Reconstr.
Surg. 144: 913, 2019.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

T
he tragus and antitragus complex, located
in the lateral and inferior part of the auri-
cle, is a comparatively diminutive subunit in
lobule-type microtia reconstruction but plays an
important role in defining a harmonious outline
of the auricle. It gives the impression of a relatively
deep concha despite the missing acoustic meatus.
Moreover, a favorable reconstructed tragus and
antitragus complex can also accommodate ear-
phones if necessary. In previous reports, multiple
surgical techniques have been illuminated for sig-
nificant improvement of the reconstruction of the
complex.1–7 However, the complicated conditions
of the remnant cartilage of various sizes pose one
of the most demanding challenges in tragus and
antitragus complex fabrication. In this article, the
From the Department of Plastic and Reconstructive Surgery,
Shanghai Ninth People’s Hospital, Shanghai JiaoTong
­University School of Medicine.
Received for publication September 13, 2018; accepted
­February 25, 2019.­
Copyright © 2019 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000006043
authors have developed alternative solutions for
such possible scenarios and demonstrate favor-
able reconstructed auricles with harmonious tra-
gus and antitragus complexes created by these
refinements.
PATIENTS AND METHODS
A total of 562 lobule-type microtia patients,
ranging in age from 6 to 42 years, underwent recon-
struction with autogenous costal cartilage between
2007 and 2016. Overall, 523 patients underwent
unilateral reconstruction, and 39 patients under-
went bilateral reconstruction. A total of 397
patients were men, and 165 were women.
Harvesting the Rib Cartilage
We generally harvest the sixth, seventh, and
eighth costal cartilages from the contralateral
Disclosure: None of the authors has a financial
interest to declare in relation to the content of this
article.

www.PRSJournal.com 913
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 Plastic and Reconstructive Surgery • October 2019
chest; if necessary, the ninth is also prepared for
use. The synchondrosis of the sixth and seventh
costal cartilages is used for the base frame recon-
struction. The helical element is normally formed
by the eighth costal cartilage. The ninth costal
cartilage is only used to lengthen or heighten a
slender eighth cartilage if necessary. Nonbiode-
gradable hydroxyapatite bone cement with epox-
ide acrylate maleic resin is used as the support
material during ear elevation; thus, extra costal
cartilage harvesting and banking are unnecessary.
Tragus and Antitragus Complex Fabrication
After completion of the main part of the
framework, the residual cartilage, mostly from
the sixth or seventh costal cartilages, is used for
fabrication of the tragus and antitragus complex.
Because of the various sizes of the cartilage rem-
nants, various approaches to carving the tragus
and antitragus complex have gradually evolved
through our experience (Fig. 1).
Scenario 1: Integrated Tragus and Antitragus
Complex
Referring to the morphometric study of the
normal human auricle,8–10 we find that the tragus
and antitragus complex can be well constructed
with a comparatively large residual block if it is no
smaller than 2 or 3 × 2 or 3 cm. In our experience,
the tragus, antitragus, and intertragic notch can
be well defined in an integral whole with a perfect
curve fluctuating up and down. This condition usu-
ally occurs in adult and adolescent patients with
strong and adequate cartilage remaining for use.
In addition, one cartilage strut is routinely
added under the tragus during the fabrica-
tion with the purpose of allowing the tragus’s
Fig. 1. Summary of different scenarios of tragus and antitragus complex fabrication in lobule-type microtia reconstruction.
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Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
protrusion and stabilization and the deepening of
the conchal bowl (Fig. 2).
Scenario 2: Separated Tragus and Antitragus
Complex
If the residual cartilage is not as large as that
in scenario 1 but should be more than approxi-
mately 1 to 1.5 × 2 to 3 cm, the tragus and antitra-
gus can be fabricated separately and fixed on the
base frame to form the final complex.
Part A: Antitragus Fabrication
If the cartilage ready for the antihelix is long
and wide enough, the antihelix and antitragus can
be constructed integrally. Otherwise, the antitra-
gus can be made individually with a smaller piece
of cartilage. In addition, more attention should be
paid to the lower part of the base frame, primarily
the seventh rib cartilage. If it is not wide enough
based on the template from the normal side, a
block of cartilage with the same thickness as the
base frame can be added laterally to broaden its
width. Then, the prepared antitragus can be fixed
in the appropriate position on the widened base
frame (Fig. 3).
Part B: Tragus Fabrication
We normally adopt two methods for tragus
fabrication for this type.
Type A. The residual cartilage is routinely
placed horizontally. It is in situ configuration such
that the height of the tragus is the thickness of
the rib cartilage. Referring to the normal side as
a template, the contour of the tragus is sketched
and then carved. In addition, another cartilagi-
nous cube is added under the original tragus to
augment the tragus’s protrusion, enhance the
conchal depth, and secure the reconstructed
 Volume 144, Number 4 • Lobule-Type Microtia Reconstruction

Fig. 2. Schematic representation of scenario 1. (Above) The tragus and anti-

tragus complex is constructed in an integral whole, and one cartilage strut
is routinely added under the tragus. (Below) Completed framework ready
for reconstruction.

tragus in a stable projection, similar to that in sce-
nario 1 (Fig. 4).
Type B. Different from type A, the cartilage
piece is placed upright. That is, the piece is reori-
ented 90 degrees from the in situ configuration
such that the height of the tragus is the width of
the rib cartilage. In this way, the outline of the tra-
gus is high enough, and no additional cartilage
strut must be appended. More importantly, a gen-
tle slope of the groove is carved into the medial
side of the tragus to smoothly integrate the con-
tracted skin flap after the operation. Therefore,
an almost C shape of the erected tragus from the
lateral view ensures the appropriate height and
stability in the structure (Fig. 5).
Afterward, as reported previously,11,12 a piece
of residual cartilage fixed by wire is added between
the tragus and the base frame of the inferior crus
to reinforce the two end points of the C-shaped
framework. The lower end of the strut is not
fixed to the base frame until the framework has
encircled the subcutaneous pedicle and has been
accommodated in the proper place within the
skin pocket. In addition, we immobilize the tra-
gus at the base of the soft tissue with a 4-0 braided
suture to lessen the projecting pressure upward
to the skin flap, which can reduce the occurrence
of necrosis of the skin flap and exposure of the
cartilage.
RESULTS
We performed 601 ear reconstructions in 562
consecutive patients with lobular-type microtia
using the described method. The follow-up period
for all patients ranged from 6 to 36 months. Two
patients in scenario 1 (n = 205) complained about
the shallow and narrow incisura intertragica at the
connection between the tragus and antitragus.
Sloughing on the tip of the local flap occurred
in four cases in scenario 2 (n = 357). Meticulous
ointment coverage was a reliable solution, and no
further treatments were needed. The complaints
of another three patients in this scenario focused
on the overly prominent appearance of the indi-
vidually reconstructed tragus. Nevertheless, they
appeared inconspicuous after the second stage.

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 Plastic and Reconstructive Surgery • October 2019
Fig. 3. Schematic representation of base frame fabrication in
scenario 2. (Above) If the lower part of the base frame is not wide
enough based on the template from the normal side, a block of
cartilage is added laterally to increase its width. Then, the pre-
pared antitragus is fixed in the appropriate position on the wid-
ened base frame. (Center) A block of cartilage is ready to increase
the width of base frame. (Below) Completed three-dimensional
framework of a broadened base frame before tragus fixation.
There were no episodes of pneumothorax, hema-
toma, keloid, or infection in this series. The follow-
ing three patients are summarized as examples.
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CASE REPORTS
Case 1
A 19-year-old man presented with lobule-type microtia
(Fig. 6). The tragus and antitragus complex were fabricated as
an integral whole using our method in scenario 1. Postoperative
results 2 years after elevating the framework were satisfactory. The
tragus and antitragus complex appeared natural and smooth,
which approximated the shape of the normal ear at follow-up.
Case 2
The patient in case 2 was a 12-year-old boy whose tragus was
made using the type A technique in scenario 2 with a cartilage
strut added at the bottom and fixed on a broadened base frame
(Fig. 7). The width and depth of the incisura intertragica were
appropriate at follow-up. The well-contoured tragus and antitragus
appeared vividly detailed, with harmonious and natural features.
Case 3
This case was a 13-year-old boy whose tragus was recon-
structed upright, as described in scenario 2, type B (Fig. 8).
Postoperative results after 7 months were favorable. The tragus
and antitragus complex showed clearly defined morphologic fea-
tures, with no sign of cartilage resorption, deformation, or wire
exposure.
DISCUSSION
Reproducing the tragus and antitragus com-
plex is one of the most important procedures
in auricular reconstruction. First, the complex
determines the depth and form of the concha.
A successfully reproduced complex ameliorates
the aesthetic outcome of the concha and per-
fectly conceals the missing acoustic meatus in
lobule-type microtia reconstruction.13 Moreover,
a fluctuant curve and appropriate dimensions of
the complex define an appropriate width of the
lower half of the reconstructed auricle, which con-
tributes substantially to the cosmetically refined
ear with harmonious integrity. Furthermore, it
ensures the functionality in accommodating mod-
ern technology to wear earphones or hearing
aids.14 Therefore, successful structural and func-
tional reconstruction of the complex greatly ben-
efits the patients in regaining confidence in life
and integrating into society.15
In addition, we may encounter different pre-
dicaments to achieve a satisfactory complex. It is
important to present a perfect V-shaped curve and
decent interval space of the tragus and antitragus
complex. Otherwise, a U-shaped complex is apt
to appear if the interval space is too large. Con-
sidering the hard-tissue deficiency region beneath
the complex, it could not provide adequate pro-
jection. Thus, a substantial challenge for us is to
develop the proper extent of the complex protru-
sion, especially to the subunit of the tragus. An
 Volume 144, Number 4 • Lobule-Type Microtia Reconstruction
Fig. 4. Schematic representation of tragus fabrication in sce-
nario 2 (type A). (Above) The separated tragus is fabricated by
horizontally placed residual cartilage, and another cartilaginous
cube is added under it, similar to that in scenario 1. (Center)
Completed three-dimensional framework. Note that the antihe-
lix, antihelix, and antitragus are constructed integrally. (Below)
Completed three-dimensional framework. Note that the antihe-
lix and antitragus are constructed separately.
overly prominent structure would easily lead to
necrosis of the skin flap. In contrast, the structure
would appear to be insufficiently prominent if the
tragus were not sufficiently high. Moreover, the
tragus would be liable to collapse because of unsta-
ble fixation or improper cartilage fabrication. In
our experience, the strategies to solve the above
problems depend mostly on proper application of
the residual cartilage for the complex sculpture.
If the cartilage has an ideal size and volume, it will
demonstrate a harmonious reconstructed subunit
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Fig. 5. Schematic representation of tragus fabrication in sce-
nario 2 (type B). (Above) The tragus is fabricated by residual carti-
lage placed upright, and no additional cartilage strut is required.
A gentle slope of the groove is carved into the medial side of
tragus to smoothly integrate the contracted skin flap after the
operation. (Center) Completed three-dimensional framework.
Note that the antihelix and antitragus are constructed integrally.
(Below) Completed three-dimensional framework. Note that the
antihelix and antitragus are constructed separately.
with appropriate interspaces and a perfect curve
through elaborate fabrication and fixation. How-
ever, we have encountered remaining cartilage
that varies in size. It is indeed a great challenge for
us to determine whether and how to use the car-
tilage. In this report, we systematically introduce
and classify corresponding solutions for such pos-
sible scenarios.
If the dimensions of the residual cartilage are
sufficient for the tragus and antitragus complex
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 Plastic and Reconstructive Surgery • October 2019

Fig. 6. Case 1. A 19-year-old man presented with congenital microtia. The tragus and antitragus com-
plex are constructed as an integral whole using our method in scenario 1. (Left) Preoperative oblique
view of lobule-type microtia. (Right) Postoperative oblique view, 2 years after ear elevation.

Fig. 7. Case 2. A 12-year-old boy presented with congenital microtia. The tragus was made using the
type A technique from scenario 2 with a cartilage strut added at the bottom and fixed on a broadened
base frame. (Left) Preoperative lateral view of lobule-type microtia. (Right) Postoperative oblique view,
12 months after ear elevation.

fabrication as described in scenario 1, it is more
convenient to properly duplicate the contour and
size of the complex. The smooth and fluctuant
curve can be defined entirely as a whole. In addi-
tion, the mutual distance between the tragus and
antitragus is decent regardless of the visual effect
or application function. Specifically, the V-shaped
structure of the tragus and antitragus is well
duplicated. The intertragic notch is presented in
a smooth and graceful curve. Moreover, it could
even accommodate earphones, similar to the nor-
mal side.
We commonly encounter undesirable cartilage
left for fabrication. Therefore, we have developed
alternative solutions for such possible conditions
in scenario 2. We emphasize that proper width of
the lower part of the base frame, a footstone of
the tragus and antitragus, is of great importance
to accurately position and obtain structural har-
mony of the complex. If the complex is fixed to

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 Volume 144, Number 4 • Lobule-Type Microtia Reconstruction

Fig. 8. Case 3. A 13-year-old boy presented with congenital microtia. The tragus was reconstructed
upright as described in scenario 2, type B. (Left) Preoperative oblique view of lobule-type microtia.
(Right) Postoperative oblique view, 7 months after ear elevation.

the narrow base frame without being broadened
based on the template from the normal side, it
would be off-center to the left or right, top-heavy,
and discordant in structure. To solve such prob-
lems, we recommend that a piece of cartilage
should be added to broaden the narrow base
frame and further accommodate the complex in
an appropriate position, especially in scenario 2.
As the seventh cartilage is commonly wide and suf-
ficient enough in scenario 1, no additional carti-
lage is needed to broaden the base frame.
The procedure of fabricating the antitragus is
flexible according to various cartilage conditions.
If possible, the tragus and antitragus or antihelix
and antitragus can be rebuilt as a whole if the car-
tilage is of proper width and length. Otherwise,
the antitragus has to be sculpted separately from
a smaller piece of cartilage. In our experience,
the tragus and antitragus complex is preferred
as described above. The antihelix and antitragus
complex is the second option. In other words, we
would rather build an integral complex than use
separate parts because a more fluent curve and
less unnecessary incisure are more likely to be
demonstrated in a whole structure than in com-
bined portions.
Regardless of whether the tragus and anti-
tragus complex is constructed integrally or sepa-
rately, determining the appropriate height and
stability are central elements, especially in the tra-
gus fabrication, which is an important and com-
paratively difficult procedure. As we know, the
antitragus is commonly treated as the extensive
part of the antihelix and sits on the normal or
broadened base frame. Thus, it is convenient to
make it in a stable situation. However, most of the
tragus is extended outside the frame and fixed at
the relatively soft base tissue; thus, it is essential to
keep it in a stable condition with proper height.
Therefore, an additional cartilage strut is usually
added beneath the tragus and fixed laterally to the
base frame. In this way, the necessary height and
stability of the tragus are ensured. In our experi-
ence, the final tragus is almost at the same level
as the highest point of the antihelix. If it is lower
than that point, the tragus would not be protrud-
ing enough when placed into the skin pocket. In
contrast, when it is placed much higher, the skin
flap would not sustain the pressure from the tra-
gus. As a result, the occurrence of skin flap necro-
sis and cartilage exposure would increase. To
prevent such complications and ensure the safety
of the skin flap, we recommend that the edge of
the tragus be sculpted smoothly and that unnec-
essary stimulation of the skin flap be limited.
More importantly, the tragus is routinely fixed at
the base of the soft tissue with a suture to further
reduce the projecting pressure upward to the skin
flap. Specifically, we avoid any additional pressure
from the tragus to the skin flap, and only allow
the normal contraction pressure of the skin flap
to the tragus at follow-up.
In scenario 2, two techniques of tragus fabrica-
tion were illustrated, including a horizontally placed
tragus with additional cartilage at the bottom or
placed upright with no extra cartilage. Theoretically,

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 Plastic and Reconstructive Surgery • October 2019
the tragus is more stable when fabricated by the for-
mer method that provides more contact area with
the base tissue. However, we could also take advan-
tage of the latter method to save cartilage, especially
if there is no more suitable cartilage to add beneath.
In addition, the second method allows us to carve
and make the bottom plane flatter to increase the
contact area. It is immobilized at the base of the soft
tissue with a suture to further reduce the possibility
of moving or overturning.
Occasionally, the tragus, antitragus, helix, and
antihelix could be made completely as a whole on
the base frame if the cartilage is broad and wide
enough to entirely define all these structures. This
scenario can occur in adults or adolescent patients
with strong cartilage but a comparatively smaller
auricle, especially in Western patients. Therefore,
in Asian patients, we prefer to construct these sub-
units using additional cartilage and to combine
them on the base frame. Overall, the tragus and
antitragus complex can be rebuilt with the appro-
priate protrusion and stability by the techniques
introduced in the article.
So far, Nagata’s and Firmin’s techniques have
been broadly accepted as standard procedures
in microtia reconstruction. To ensure a reliable
blood supply to the skin flap, Nagata emphasizes
the importance of preserving a subcutaneous
pedicle,3 which has been well documented by ana-
tomical preparations.16–18 Firmin does not think
that the pedicle is vital to increase flap blood sup-
ply.5 Moreover, the framework, accompanied by a
projection block for stabilization of the root of the
helix to the tragus, which also serves for deepen-
ing of the conchal bowl, could be easily accommo-
dated in the proper place within the skin pocket.
The maneuver can well be performed without the
subcutaneous pedicle, as the lack thereof releases
much more flexibility for additions of projection
and stabilization pieces between the roots of the
helix to the tragus. It really takes us more time
to accommodate the framework under the influ-
ence of the pedicle. The lower end of the strut is
not fixed to the base frame until the framework
has rotated, wrapping around the subcutaneous
pedicle, and is seated in its appropriate position.
Nevertheless, we prefer to keep the subcutaneous
pedicle, especially in Asian patients. As we know,
the characteristic of skin varies according to race.
For example, the skin is thinner and more flex-
ible in Caucasians than in Mongolian patients. It
provides numerous advantages, as a much sharper
and more clearly defined auricular contour can
be attained.19 However, to ensure a reliable blood
supply to the tip of the flap, we think it necessary
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Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
for us to reserve the pedicle in most of our cases.
Meanwhile, care must be taken to dissect the skin
flap at a moderate layer to avoid injuring the sub-
dermal vascular plexus. In some cases, where skin
seems to be thin and elastic, we attempt to follow
Firmin’s approach. It occurs more frequently in
patients from the western part of our country,
where patient race is much closer to Caucasian.
CONCLUSIONS
Proper use of the residual cartilage for tra-
gus and antitragus complex fabrication is critical
to attain a satisfactory contour of the auricle in
lobule-type microtia reconstruction. The intro-
duced approach enhances tragus and antitragus
complex aesthetics with harmonious integrity that
has proven to be realistic and aesthetically pleas-
ing at follow-up.
Ruhong Zhang, M.D., Ph.D.
Department of Plastic and Reconstructive Surgery
Shanghai Ninth People’s Hospital
Shanghai JiaoTong University School of Medicine
No. 639, Zhi Zao Ju Road
Shanghai 200011, People’s Republic of China
zhangruhong@163.com
PATIENT CONSENT
Patients or the parents or guardians provided writ-
ten consent for the use of patients’ images.
ACKNOWLEDGMENTS
The authors thank Françoise Firmin, M.D., Ph.D.,
Chunxiao Cui, M.D., Ph.D., Tianya Li, M.D., Ph.D.,
Xia Chen, M.D., and Wei Chen, M.D., Ph.D., for con-
tributing to the work.
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