R e c o n s t r u c t i o n o f t h e Ea r

Ryan M. Smith, MD*, Patrick J. Byrne, MBA, MD

KEYWORDS
 Ear reconstruction  Skin cancer  Auricular reconstruction  Mohs reconstruction of the ear

KEY POINTS
 Although the aesthetic and practical functions of the ear are often taken for granted, patients with
auricular deformities are known to suffer both physically and psychologically.
 Auricular skin cancer accounts for 6% of all cutaneous malignancies found in the head and neck.
 Repair of skin cancer defects is the most common indication for reconstructive surgery of the ear.
 The unique anatomy of the external ear makes ear reconstruction challenging.
 The goal of ear reconstruction is to restore both form and function; a careful and detailed assess-
ment of the defect will inform the best reconstructive strategy.

INTRODUCTION penalty associated with facial deformity. Further-

more, reconstructive surgery was seen to elimi-
The external ear is a complex anatomic structure nate this effect for most defects and was
with an intricate architecture and detailed topog- seen to have high societal value as an interven-
raphy. The ear is unique among facial features in tion.2 Quality of life improvements in some
that it projects away from the side of the head as domains have been measured in the use of
a free-standing structure with high visibility from prostheses for auricular reconstruction, although
many angles. Its relationship to other facial with less significance and a high rate of
landmarks helps to create the aesthetic balance noncompliance.3 The impact of auricular
of the face. The cosmetic importance of the ear deformity, therefore, creates a challenging yet
is illustrated by the practice of ear piercing, rewarding arena for the reconstructive surgeon
one of the oldest known forms of body mo- and patient.
dification dating back through ancient history. The past experience of treating traumatic and
Functionally, the external ear directs sound congenital deformities has allowed for the refine-
waves into the acoustic meatus. It also provides ment of techniques that today are useful for a
a platform for eyeglasses, allows the use of wider range of indications. Skin cancer-related de-
headphones, and accommodates hearing- fects represent one of the most common reasons
assistance devices that are crucial for social for reconstructive surgery of the ear. As the popu-
interaction, quality of life and work place lation ages, the incidence of skin cancer is ex-
productivity.1 pected to continue to increase. The development
Although the aesthetic and practical functions of Mohs micrographic surgery as an effective
of the ear are often taken for granted, patients treatment for nonmelanoma skin cancers requires
with auricular deformities are known to suffer the involvement of experienced reconstructive
both physically and psychologically. In patients surgeons familiar with options for a variety of
with facial defects in general, recent evidence defect sizes and locations. Auricular skin
using health utility and valuation metrics cancer accounts for around 6% of all cutaneous
has demonstrated a significant quality of life malignancies found in the head and neck.4 The
facialplastic.theclinics.com

Disclosure Statement: The authors have nothing to disclose.

Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery,
Johns Hopkins School of Medicine, 601 North Caroline Street, 6th Floor, Baltimore, MD 21287, USA
* Corresponding author. 1611 West Harrison Street, Suite 550, Chicago, IL 60612.
E-mail address: [email protected]

Facial Plast Surg Clin N Am 27 (2019) 95–104

https://doi.org/10.1016/j.fsc.2018.08.010
1064-7406/19/Ó 2018 Elsevier Inc. All rights reserved.
96 Smith & Byrne

exposure of the ear to chronic sun damage, a large Table 1

skin surface area-to-size ratio, and contour irregu- Anatomy of the auricle
larities that may harbor occult lesions all contribute
to the risk of malignancy in this area. Helix Outer rim that curves from the
This article discusses the relevant anatomy of helical root to the helical tail
the auricle, presents a categorization scheme above the lobule
based on defect location, and details a variety of Antihelix Parallels the helix separated by the
reconstructive options and considerations. Last, scapha
surgical timing, postoperative care, and an algo- Crua Anterior and posterior crua join to
rithm for surgical decision making are presented. form the Y-shaped antihelix
Tragus Raised point of cartilage located
anterior to the auditory meatus
ANATOMY
Antitragus Raised point of cartilage at the
The shape of the auricle is defined by the convo- base of the antihelix
luted structure of the underlying elastic cartilage, Concha Made up of the cymba and cavum
which is folded into a series of ridges that produce conchae and divided by the
both concave and convex surfaces. The very thin helical crus
and tightly adherent skin of the ear shows this Scapha Groove between the helix and the
framework in sharp relief, because the absence antihelix
of subcutaneous fat allows direct adherence to Triangular Bounded by the helix and superior
the perichondrium. The auricle is subdivided into fossa and inferior crura of the
discretely named anatomic regions based on this antihelix
surface structure (Fig. 1, Table 1). Lobule Inferior-most structure, mostly
The ear projects from its base of attachment to fibrofatty tissue instead of
make a 30 angle with the skull, and is anchored cartilage
by the superior, anterior, and posterior auricular
muscles and corresponding ligaments. The
conchal cartilage is contiguous with the cartilagi- branch of the third division of the trigeminal nerve,
nous portion of the external auditory canal, which provides some sensation superiorly, as does the
provides fixation of the auricle around the auditory lesser occipital nerve. The conchal bowl is inner-
meatus. vated by the auricular branch of the vagus nerve.
Sensation of the ear is largely provided by the The external carotid system provides the blood
great auricular nerve, which branches from the supply to the ear mainly through the posterior
third cervical nerve to innervate the anterior and auricular and superficial temporal arteries. The oc-
posterior surfaces. The auriculotemporal nerve, a cipital artery supplies the postauricular scalp and
mastoid area. The superficial temporal and poste-
rior auricular veins provide venous drainage.
Importantly, the elastic cartilage of the ear lacks
its own vascularization and is reliant on the peri-
chondrial blood supply.

RECONSTRUCTIVE GOALS
Auricular defects can vary greatly in terms of their
size, depth, and location. Regardless of the defect,
the goals of ear reconstruction remain the same
and attempt to restore as many features of the
normal ear as possible. This process includes
restoration of the various subunits discussed else-
where in this article with strict attention to the
inherent concavity, convexity, and projection of
the areas involved. The overall size and shape of
Fig. 1. Anatomy of the external ear. (From Wenig BM. the ear should not be altered dramatically. Although
Embryology, anatomy, and histology of the ear. In: slight asymmetries with the contralateral ear are
Wenig BM, editors. Atlas of head and neck pathology. usually not noticed because both ears are rarely
1st edition. Philadelphia: Elsevier; 2016. p. 1076; with viewed at the same time, techniques that preserve
permission.) the size of the auricle should be preferred. Just as
 Reconstruction of the Ear 97

repair of the vermillion border is essential for lip helpful to consider all options, including the
reconstruction, perfect alignment of the gentle simplest to the most complex. Simpler procedures
curves found in the helix and antihelix are crucial may involve less operative time and patient
to avoid easily discernible notching, height morbidity, but also compromise the aesthetic
mismatch, or excessive bulk. In these areas, if the result to a degree. They can also involve longer
defect includes cartilage, then the repair must healing time and more involved wound care. Com-
restore rigid support to avoid contour irregularity plex procedures may achieve excellent cosmesis
or scar contracture. In more central defects, this but incur higher risk. Last, the use of auricular
factor is less important and soft tissue coverage prostheses for extensive defects should always
alone can often suffice. Reconstructive options be considered as an alternative to surgery. An
that maintain the postauricular and superior sulci understanding of the goals, expectations, and mo-
will avoid flattening of the ear or interference with tivations of the patient is crucial for decision mak-
the ability to wear glasses, although in many staged ing and patient satisfaction.
procedures the sulcus may be lost temporarily.
Skin defects must be addressed using appropri- Primary Closure
ately thin skin with good color and texture match Primary closure of auricular defects is possible for
with the surrounding tissue. Last, the reconstruc- very small lesions, but limited by the adherent and
tive plan should address the specific concerns, nondistensible skin of the ear. This procedure can
perceptions, and expectations of the patient. create tension at the closure, which can lead to
scarring, contracture, and distortion. Closure can
DEFECT ASSESSMENT be considered for some posterior defects where
the skin is less adherent and in the lobule, which
The chance for successful reconstruction is in lacks cartilage.
large part determined well before the first cut is
made. A thoughtful inspection of the defect Secondary Intention
with respect to its location, size, depth, subunits
involved, and tissues affected is imperative during Healing by secondary intention can be quite effec-
the preoperative assessment. As the first principle tive for defect closure, but is thought to be less
of plastic surgery dictates, “observation is the ba- cosmetic than other methods. It requires patient
sis of surgical diagnosis.”5 compliance with wound care and tolerance of
It is, therefore, useful to divide the ear into longer healing times, which may take up to
distinct zones to characterize the nature of the 10 weeks. Difficulty visualizing the wound or poor
defect and plan the appropriate reconstruction. A manual dexterity may make this impossible for
simple and intuitive categorization scheme divides some patients. Healing by secondary intention
the ear into central and peripheral zones, with the will occur even in the absence of the perichon-
central zone further divided into anterior and pos- drium and can be facilitated by creating fenestra-
terior defect locations. The peripheral zone in- tions in the cartilage to expose the opposing skin
cludes the lobule and the helix. The helix can be layer.6 Because secondary intention will result in
divided into upper, middle, and lower thirds. The a depressed scar, this method is best suited for
anterior central zone contains the concha, helical flat or concave surfaces. Defects of the anterior
root, and antihelix. central zone, particularly the conchal bowl, are
The depth of the defect can be superficial, with amenable to healing by secondary intention.
skin loss but intact underlying cartilage, or may
Skin Grafting
be deep if perichondrium and cartilage are missing
as well. In some cases, a through-and-through Skin grafting is a versatile and effective technique,
defect may include both anterior and posterior especially in the case of superficial skin defects
skin layers as well as intervening cartilage. Partial with intact underlying cartilage. Both full-
auricular defects involve multiple subunits and at thickness and split-thickness grafts can be used,
least 2 zones of the ear and can be categorized and the choice is usually governed by the native
as upper-third, middle-third, or lower-third defects. skin thickness and the presence of perichondrium.
A total auricular defect may result from total auric- Full-thickness skin grafts require the perichondrial
ulectomy or in cases of multiply recurrent cancer. layer for blood supply. They offer the advantages
of less painful harvest without the need for a
RECONSTRUCTIVE OPTIONS dermatome, direct closure of the donor site, op-
tions for facial harvest sites with closer color and
The reconstructive ladder provides a useful guide texture match, and less contracture than split
during any reconstructive procedure. It is always grafts.7 The forehead, preauricular, postauricular,
98 Smith & Byrne

and supraclavicular skin can be used. Split-

thickness skin grafts can be used for cartilage
coverage in the absence of perichondrium. Split
grafts can provide very thin coverage useful in
the conchal bowl, meatus, and ear canal and
may help to prevent stenosis. They may also
be better compressed to the wound bed by
bolstering, which can increase survival.

Local Flaps
Local flaps are versatile and offer tissue that can
closely match native structures. They are useful
for larger defects and rely on a random pattern
blood supply. The geometry and design of local
tissue flaps is important for successful healing
because necrosis related to folding, narrowing of
the pedicle, or constriction during inset may
compromise the result. Specific local flap tech-
niques are discussed in greater detail elsewhere
in this article.

Regional Flaps and Free Tissue

Regional flap reconstruction and free tissue trans-
fer can be used for the most severe defects or in
the case of total auriculectomy. These techniques Fig. 2. Measurement of the defect and creation of a
are useful when most of the ear framework is lost template.
and extensive costal cartilage grafting is required
to rebuild form. This vascularized tissue can cover
cartilage constructs and decrease warping, ab-
sorption, and infection. Both fascia and skin can
be incorporated into the flap design to provide
thin covering and external lining. The radial fore-
arm free flap and regional temporoparietal fascia
flap have been used for this purpose. These tech-
niques require a multistage approach and repre-
sent the most extensive means of auricular
reconstruction.

STRATEGIES BASED ON LOCATION

Peripheral
Helix
The most important consideration in the recon-
struction of helical defects is perfect approxima-
tion of the wound edges to avoid notching and
contour irregularities that are highly visible in this
area. Meticulous closure in multiple layers to
achieve a tension-free repair will avoid these is-
sues. The use of vertical mattress sutures to create
eversion of skin edges is also helpful.
Small skin defects in the upper third of the helix
may heal well by secondary intention or full-
thickness skin grafting if no cartilage needs to be
replaced. A composite graft including cartilage
and skin can be harvested from the posterior ear
and conchal bowl if cartilage must be replaced Fig. 3. Transposition of the template onto the poste-
(Figs. 2–6). Another option is the helical cutaneous rior ear for composite graft harvest.
 Reconstruction of the Ear 99

Fig. 4. Planned incisions for graft harvest.

Fig. 6. Postoperative result.

advancement flap, which is an anterior based skin

flap created with incisions made parallel to the he-
lix that is, advanced posteriorly. Preauricular cuta-
neous advancement or rotation flaps can provide
skin coverage for upper third defects as well.
Larger defects of the upper third that involve carti-
lage can be closed using helical chondrocutane-
ous flaps.8 In this technique, a crescent-shaped
incision is made in the scapha through the anterior
skin and cartilage. The helix is mobilized on its
posterior auricular skin and advanced for closure
(Fig. 7). A modification of this technique converts
the wound into 2 wedge-shaped defects and
closure is performed with siding chondrocutane-
ous flaps (Figs. 8–12).
Full-thickness defects of the upper third require
adequate tissue to restore the contour of the heli-
cal rim. A 3-staged postauricular tube flap can pro-
vide sufficient height to the helix. In the first stage,
the mastoid skin is tubed and remains pedicled su-
periorly and inferiorly. During the second stage,
the tube is lifted and remains pedicled inferiorly
to be inset along the superior defect margin. The
last stage completes the transfer.
Fig. 5. Preparation for inset of the graft into the Middle third defects may be closed using a
defect. wedge excision if small. Extension of the defect
100 Smith & Byrne

Fig. 7. The sliding chondrocutaneous flap for helical reconstruction. (From Sivam SK, Taylor CB, Stallworth CL.
Reconstruction of upper third auricular defects. Op Tech Oto 2017;28(2):108; with permission.)

into a wedge shape allows closure without stand- reserved for small lesions. Modification of the
ing cutaneous deformities if the apex angle is 30 chondrocutaneous advancement flap used for up-
or less. In larger excisions, this angle is more per third defects into a bidirectional advancement
obtuse and excision of Burow’s triangles may be flap can be used for the middle third of the helix.
needed to convert the wedge into a stellate A composite graft obtained from the helix of the
pattern. Wedge excision will make the ear smaller contralateral ear has been used for wedge-shaped
and can result in a cup ear deformity. It should be

Fig. 9. Conversion of the wound into 2 wedge-shaped

Fig. 8. Large defect of the upper third of the helix. defects.
 Reconstruction of the Ear 101

Fig. 10. Primary closure of the first wedge. Fig. 12. Postoperative result.

defects of the middle third. A full-thickness com-

posite graft is harvested that is one-half the size
of the defect. This graft is turned 180 for inset
into the ipsilateral ear and both defects are closed
in layers. Use of this technique risks deforming the
contralateral ear in the case of poor healing or if
loss of the graft occurs.
Staged repair of middle third defects using pos-
teriorly based advancement or rotation flaps are
common. Retroauricular flaps are lifted from the
posterior ear whereas postauricular flaps are lifted
from the scalp and cross the sulcus (Figs. 13–15).

Fig. 11. Sliding chondrocutaneous flap closure of the

second wedge. Fig. 13. Middle third defect involving skin only.
102 Smith & Byrne

postauricular sulcus or mastoid skin. These areas

provide adequate thickness and can be closed pri-
marily. A well-placed bolster is crucial for graft sur-
vival given the concave nature of the conchal bowl.
Quilting stitches can also be used to seat the graft
in the wound bed.
Transposition flaps using a pull-through tech-
nique can be useful for defects of the concha
that extend superiorly into the antihelix or into
the auditory canal. Based superiorly or inferiorly,
the flap is lifted from the retroauricular skin and
tunneled through the defect for inset anteriorly.
The tunneled portion of the pedicle can be deepi-
thelialized. The retroauricular defect is closed pri-
Fig. 14. Postauricular cutaneous advancement flap is marily and a second stage allows division of the
lifted and prepared for inset. pedicle.
Island flaps are also used and are supplied by
The lower third of the helix is where the cartilage the posterior auricular artery. Both myocutaneous
terminates at the helical tail just above the lobule. and cutaneous designs have been described. The
This area has greater skin mobility than the superior flap is brought out through the defect anteriorly
helix. Two-stage superior or inferior based trans- and inset. One advantage of this technique is
position flaps can achieve coverage of larger lower that a large skin paddle can be used allowing a
third defects. Either conchal or rib cartilage can be 2-layered closure of both the anterior primary
included to prevent significant contracture of the and posterior secondary defects. This procedure
flap if needed. Small defects are best treated with can result in a significant reduction of the sulcus.
secondary intention or full-thickness skin grafting. The method described by Park in 1998 identifies
the middle branch of the posterior auricular artery
Lobule using Doppler ultrasound examination to base an
The mobility of the lobular skin owing to the island flap for anterior conchal defects.
absence of cartilage in this region allows direct
linear closure and wedge excision to be effective Helical root Defects of the helical root can be
with less risk of notching seen in other areas. Ver- repaired using the chondrocutaneous advance-
tical mattress sutures can further decrease this ment flap method also used for the helical rim.
risk. Total lobular defects can be reconstructed Mobilization of the ascending helix and advance-
with the Gavello technique, in which a bilobed ment inferiorly and posteriorly can reestablish the
flap with an anterior base is folded on itself. horizontal orientation of helical root.

Central Defects Antihelix Posterior transposition flaps and island

flaps based on the posterior auricular artery can
Anterior be used for defects of the antihelix as previously
Concha Full-thickness skin grafting can be used described.
for conchal defects with harvest from the
Posterior
The posterior auricular skin is slightly less adherent
to the underlying perichondrium than the anterior
skin. This property allows the use of bilobed trans-
position flaps to reconstruct defects 2 cm or less in
size. The primary lobe of the flap is designed with
equal size to the defect, whereas the secondary
lobe is smaller than the defect. However, owing
to the relative obscurity of the posterior ear, less
involved methods of reconstruction, such as direct
closure, skin grafting, and secondary intention,
may be selected with little aesthetic cost. In de-
fects that span the postauricular sulcus, direct
closure can be used as it is when postauricular
skin grafts are harvested. This strategy may nar-
Fig. 15. Flap inset before final skin closure. row the sulcus and pin the ear back in an angle
 Reconstruction of the Ear 103

Fig. 18. Cartilage graft after harvest and carved to

create specifically shaped construct.

Fig. 16. Large defect involving the helix, antihelix,

and crura.

less than the 30 of normal divergence from the

skull. If this feature is noticed postoperatively at
the time of suture removal, it can be corrected
by pulling the wound edges apart and allowing
healing by secondary intention.
If the donor skin is insufficient for use of a
bilobed flap, an O-to-T flap may be used. This
flap is especially effective for posterior defects
that approximate the helical rim. This technique
avoids a decrease in the size of the ear, unlike
the wedge excision that is used for helical rim re-
pairs. A longitudinal incision is created along the
posterior auricle and the posterior skin is elevated, Fig. 19. Creation of subcutaneous pocket and place-
which is then advanced superiorly and incorpo- ment of graft.
rated into the T-shaped closure.

Fig. 17. Incision and exposure of costal cartilage for

graft harvest. Fig. 20. Immediate postoperative result.
104 Smith & Byrne

The eighth rib provides 8 to 10 cm of cartilage

that is well-suited for the helix. The contralateral
concha can be harvested if very thin cartilage is
needed. A variety of carving instruments and
fixation materials have been used to tailor the
graft and fit the specific need of the defect
(Figs. 16–21).

Total Reconstruction
Total auricular reconstruction is beyond the focus
of this article. Reconstruction of the entire auricle
requires an extensively carved cartilage construct
and full soft tissue coverage. A temporoparietal
fascial flap or radial forearm free flap can be
used. Alternatively, in some patients, use of a
prosthesis may be the best option. Prosthetics
that include osteointegrated implants can be
more durable and reliable than traditional
adhesive-based prostheses.

REFERENCES

Fig. 21. Final postoperative result. 1. Kozlowski L, Ribas A, Almeida G, et al. Satisfaction of
elderly hearing aid users. Int Arch Otorhinolaryngol
2017;21(01):92–6.
Partial Reconstruction 2. Dey JK, Ishii LE, Joseph AW, et al. The cost of facial
Reductive closures such as wedge excision, heli- deformitya health utility and valuation study. JAMA
cal chondrocutaneous sliding flaps, or composite Facial Plast Surg 2016;18(4):241–9.
grafting from the contralateral ear can all be used 3. Tam CK, McGrath CP, Ho SMY, et al. Psychosocial
for partial auriculectomy defects and have already and quality of life outcomes of prosthetic auricular
been described. These procedures, however, will rehabilitation with CAD/CAM technology. Int J Dent
produce a smaller ear and incur a cosmetic cost 2014;2014:393571.
in doing so. They should be reserved for patients 4. Arons MS, Savin RC. Auricular cancer: some surgical
with poor overall health, advanced age, or for and pathologic considerations. Am J Surg 1971;
those patients already bothered by large ears. 122(6):770–6.
In 1920, Gillies was the first to use a carved 5. Gillies H, Millard DR. The principles and art of plastic
autologous costal cartilage framework for partial surgery. Boston: Little, Brown and Company; 1957. p.
ear reconstruction. This method has been refined 48–54.
over the last century and now represents a power- 6. Levin BC, Adams LA, Becker GD. Healing by second-
ful tool for partial and total auricular reconstruc- ary intention of auricular defects after Mohs surgery.
tion. Cartilage grafting supplies the framework Arch Otolaryngol Head Neck Surg 1996;122(1):
needed to recreate multiple missing subunits, 59–66.
can be combined with soft tissue techniques for 7. Brenner MJ, Moyer JS. Skin and composite grafting
coverage, and is able to resist scar contracture techniques in facial reconstruction for skin cancer.
that leads to distortion. Facial Plast Surg Clin North Am 2017;25(1):347–63.
The synchondrosis of the sixth and seventh ribs 8. Shonka DC Jr, Park SS. Ear defects. Facial Plast Surg
is commonly harvested to have sufficient material. Clin North Am 2009;17(3):429–43.