382

Trauma Management of the Auricle

Armin Steffen, MD1 Henning Frenzel, MD1

1 Department of Otorhinolaryngology, UKSH, University of Lübeck, Address for correspondence Armin Steffen, MD, Department of
Luebeck, Germany Otorhinolaryngology, UKSH, University of Lübeck; Ratzeburger Allee
160, Luebeck 23538, Germany (e-mail: armin.steffen@uksh.de).
Facial Plast Surg 2015;31:382–385.

Abstract Smaller injuries of the auricle, such as lacerations without tissue loss, have more or less
standardized treatment protocols that require thorough wound closure of each affected
layer. Even extended lacerations of larger parts of the ear quite often heal with only
minor irregularities. New in vivo diagnostic tools have aided the understanding of this
outstanding “skin flap behavior.” At the other end of the trauma severity spectrum are
partial or complete amputations of the ear. Here, the debate has become more intense
over the last decade. There were numerous reports of successful microvascular
reattachments in the 1990s. Consequently, pocket methods and their variations have

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received increasing attention because the results seem to be convincing. Nevertheless,
the pressure damage due to banking larger parts of the elastic cartilage in the mastoid
Keywords region is tremendous, and the tissue for secondary reconstruction is severely injured.
► auricle Particularly in cases of acute trauma with relevant concomitant injuries to the patient
► ear and in cases in which the amputated area is in a critical state, direct wound closure is a
► trauma straightforward and safe option. Subsequent thoughtfully planned secondary recon-
► injury struction using ear or rib cartilage, or even allogenous material as an ear framework, can
► reconstruction achieve excellent aesthetic results.

The history of auricular trauma and its treatment are long and
well documented.1 There are principles of surgical therapy for
acute situations of smaller injuries and auricular hematoma,
which are no longer debated because they have provided
patients with reliable and consistently good results.2,3 In
contrast, the discussion regarding reattachment methods
has oscillated in waves that have favored direct replantation,
microvascular repair, pocket methods, or secondary recon-
struction, and the roles of additional medical agents have
remained unclear. Therefore, this article aims to specifically
highlight the reattachment debate that has occurred over the
last decades.
Vascular Supply of the Auricle
The vascular supply of the anterior part of the human ear
arises from several branches of the superficial temporal
artery, and the rest of the ear is supplied by the posterior
auricular artery. These patterns can be explained by the
embryology of the formation of the ear from the six ear
hillocks.4,5 Both sources span a network of large interindivid-
ual variability. Meticulous anatomical preparation has led to
this knowledge, but dynamic examinations were missing
until recently. In 2008, Frenzel and his team published a laser
fluorescence angiography study of normal and malformed
ears.6 With this technique, these authors first revealed a
functionally segmented perfusion from the main supplying
trunk, then revealed the filling of the neighboring segments
by smaller arteries, and finally elucidated the capillary supply
of the whole ear. In most cases, the dominating vessel arises
from the cavum conchae and the fossa triangularis. These new
insights helped surgeons understand why even large lacer-
ations with narrow pedicles can survive direct reattachment
because some of these lacerations are better described as
axial than random pattern flaps.
Epidemiology of Ear Trauma
In a meta-analysis of 326 injured ears,7 the most frequent
causes were found to be traffic accidents (35.9%), injuries at

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 Trauma Management of the Auricle Steffen, Frenzel 383

home (27.6%), and fights (24.5%). However, the rankings of
these three causes vary substantially with the database being
considered, that is, institutional or literature reviews versus
case series. Furthermore, the distribution is strongly influ-
enced by age and sex. Injuries at home are particularly preva-
lent among children and seniors, and traffic accidents are more
frequent among the middle-aged. Ear injuries caused by fights
predominantly occur in men (as victims). Among the cases in
the literature, those caused by bites, primarily from humans
and dogs, are relatively common (40%), whereas an institu-
tional review reported a much lower rate of bites (12%). With
these data and differences in mind, better-grounded judg-
ments of reported reattachment methods are possible in terms
of potential comorbidities and concomitant injuries.
two, or all three layers. Most situations can be managed
sufficiently by beginning with cartilage repair using No. 8
shaped sutures. In cases of larger lacerations of the outer
circumference, bolster sutures that are left in place for at least
4 days can provide further stabilization and reduce the risk of
hematoma. Cases involving cartilage exposure with skin loss
of the anterior side of the ear frequently require a shortening
of the ear by wedge excisions,1 whereas the posterior side of
the ear offers more suitable options for direct closure or
smaller local flaps (►Fig. 1). After thorough cleaning, in most
cases of trauma, even a single antibiotic injection will support
uneventful healing. The application of a wound bandage with
iodine ointment for several days additionally protects the
repaired ear.

Partial and (Sub-) Total Amputations of the Ear

Trauma Classification
The wording related to avulsion and the meaning of partial
amputation of the ear are misleading. Here, avulsion and
amputation are reserved exclusively for separation from the
Several aspects influence decision making regarding severe
auricular injuries, including the state of the avulsed ear, the
remaining ear remnant, the temporal circumstances, con-
comitant injuries, the patient’s medications and comorbid-

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body. Even cases of narrow pedicles are termed deep lacer-
ations. A partial amputation of the ear describes an avulsion
of a smaller part of the auricle and not a deep laceration as the
term has previously been used.
Acute Treatment of (Deep) Lacerations of the Ear
In everyday clinical situations, the greatest proportion of
auricular injuries involves blunt injuries that affect one,
ities (e.g., diabetes), and the surgeon’s experience. Direct
reattachment appears to be successful only for small ampu-
tations. With pocket methods and modifications,8 the injured
ear is dermabraded and fixed to the stump. Next, the remnant
is banked in the mastoid area, and a second reconstruction
step is used to restore the retroauricular fold. In cases of clear
cuts with short trauma-to-door-times, microvascular repairs
are appropriate if the patient is sufficiently healthy for a

Fig. 1 An 89-year old man stumbled in his bedroom and acquired a deep three-layer laceration between the upper and middle third of the auricle
(A). Thorough closing of each layer without tension was possible only with cartilage reduction due to the missing skin in the anterior part. At the
end of surgery, the upper part was compromised due to venous congestion (B and C). After 4 weeks, healing was uneventful, and the patient was
aesthetically and functionally satisfied because he was still able to use his hearing aids and glasses without problems (D and E).

Facial Plastic Surgery Vol. 31 No. 4/2015

384 Trauma Management of the Auricle Steffen, Frenzel
Fig. 2 A 13-year-old girl with a dog bite injury to her left ear. A partial autologous ear reconstruction was performed 6 month later: preoperative
view (A), first stage of reconstruction with attached three-dimensional rib cartilage framework (B), at the end of first stage procedure with bolster
sutures in place (C), lateral view 12 months after second stage of reconstruction (D), and postauricular sulcus 12 months after second stage of
reconstruction (E).
multiple hour procedure. Especially when only the arterial
supply can be restored, blood transfusion can be necessary
because the venous drainage (e.g., drainage elicited with
leeches) can be substantial. If the patient is unstable or if
the avulsed ear is badly damaged, defect closure with a
secondary reconstruction is a favorable option (►Fig. 2).
After the first successful microvascular reattachment by
Pennington et al, 9 numerous reports with excellent results
were published. A subsequent review of 25 years of the
relevant literature10 indicated that this technique seems to
be favorable. It is a very rare situation in the medical
literature that an initial case report and a review published
decades later result in a subsequent case report of a patient
after 30 years. In 2010, Pennington published an examina-
tion of his initial patient. He achieved long-term stable,
aesthetic, and functional ear restoration, and even the
recovery of two-point sensitivity.11 The 25-year review10
closes with a quite skeptical judgment of pocket methods
due to the published results in the literature regarding
microvascular techniques and the experiences of our center
with direct wound closure with secondary reconstructions
using rib cartilage as the framework.1,12 The publication
bias in the reviews of the ear reattachment literature is
relevant and requires thorough consideration. Indeed, it
should be highlighted that several case series involving the
pocket method and modifications over the last decade 13–17
Facial Plastic Surgery Vol. 31 No. 4/2015
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have reported sufficient and excellent results with this
method. Ihrai et al 13 recommended pocket methods espe-
cially for smaller amputations of less than 15 mm and those
that do not involve the lobule. Reports of direct reattach-
ments of larger parts of the ear are still currently being
published.18 To support this simple and straightforward
procedure, the authors of these papers argue that this
technique at least offers the possibility of auricle salvage
and that in contrast to pocket techniques, in cases of failure,
there is no additional trauma to the ear remnant or the
surrounding tissue. If the skin and lower fascia layers are
saved, broader spectrum of secondary reconstruction
methods that use rib cartilage,1,12,19 auricular cartilage,20
or even porous ethylene21 as the ear framework remain
available. Because aesthetic results are not the only con-
sideration and quality-of-life aspects have received in-
creasing attention in ear reconstruction,22 it should be
noted that Braun and coworkers21 observed smaller im-
provements in quality of life in cases of acquired auricular
defects than in cases of congenital ear deformities.
Conclusion
The debate regarding the best treatment for acute ear trauma
with amputation is more open than ever. Nonetheless, with
the broad spectrum of modifications in mind, surgeons can

choose the best option for each patient based on the specific
situation, and this choice is influenced by many factors.
Pennington and Pennington stated11, “You only have one
good shot at an ear replantation, so it is essential to make
the conditions as advantageous as possible.”
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