Associate Professor of Plastic Surgery, Karol. Institute; Plastic Department, Serafimerlasarettet, Stockholm, Sweden

Transcription

1 A NEW METHOD OF SHAPING DEFORMED EARS By A. RAGNELL, M.D. Associate Professor of Plastic Surgery, Karol. Institute; Plastic Department, Serafimerlasarettet, Stockholm, Sweden NUMEROUS methods of shaping deformed ears have been evolved during the course of the years. In this connection the writer would refer to the excellent review on the subject that was published by McEvitt in Plastic and Reconstructive Surgery, I947. McEvitt presents there a type of operation for protruding ears which embodies certain modifications of Luckett's method and which he generally uses for correction of all variations of this common deformity. The operation consists of an incision through the skin and cartilage from behind, in line with the antihelix. The incision through the cartilage is continued upward in line with the anterior and posterior crura of the antihelix, cartilage being resected in so far as it may be necessary. Following retraction of the external ear to the required position, suturing is done in layers. The writer has found this operative method to be eminently suitable in the great majority of cases of protruding ears where the fold of the antihelix has been defective, particularly as it has facilitated some reduction in size when necessary. However, we sometimes encounter patients in whom the above-mentioned method is inadequate ; for the plastic surgeon not infrequently has to contend with a deformity known as lop-ear or shell-ear (McEvitt's Group 3), of which McEvitt writes in his paper: "Type 3 ears are the most difficult with which to deal, as the shell-like auricle may be almost devoid of normal landmarks and have a continuous curving sweep from the cavum concha: to the helix." In recent years the present writer has used, in such cases, a method which has been found most helpful in some ten cases and which is therefore described below. The designation " shell-ear " is undoubtedly most appropriate, since a pronounced curvature of the fossa helicis, i.e., the upper lateral portion of the ear, often with a substantial increase in the breadth of the helix itself, imparts to the ear a most shell-like appearance. At the same time the ear is, or at least seems to be, smaller. Usually its medial lower half shows normal development. Anatomically, the actual cause of the deformity is found to lie in an abnormally folded cartilage of normal or above-normal thickness, but usually of diminished size. In the latter case the enveloping skin capsule is also smaller, though this decrease is generally either inappreciable or merely an apparent one, with a relative diminution of the concave anterior side and a relative enlargement of the convex posterior side. Reconstruction should then consist in reshaping of the cartilage support, if required with enlargement of the latter, and adaptation of the skin capsule to the new relative sizes ; i.e., retraction of the upper margin of the cartilage support inside the skin capsule. This theory has been found in practice to yield the desired, or at all events a fully satisfactory, result. OPERATIVE TECHNIQUE Under local ana:sthesia an incision 3 cm. long is made through the skin from behind toward the antihelix, i.e., roughly parallel to and I½ cm. from the free margin of the ear. From here the skin is undermined in a I cm. wide zone 202

2 - - - A NEW METHOD OF SHAPING DEFORMED EARS 203 toward the attachment of the ear, and in the other direction out to its free margin, corresponding to the upper half of the ear or two-thirds of the auricular cartilage. The skin along the free margin must be loosened from the cartilage with the utmost (;1 t t~.-, t rt F' r ~ '_. t., J ' F ~:-r ~ t ~i~il :, 'i ~,,~ :il'"~-~k\- :~ -L ~ f, FIG. Operation on the right ear showing the skin capsule retracted. The cartilage has been cut into serrations. The steel wire has been introduced through the incision in the tragus and an artery forceps applied to the free ends. care, for in that part it shows greater fibrous adhesion to the cartilage and the latter is extremely thin. It is frequently easier to cut through the cartilage parallel to the margin, leaving a millimetre of cartilage on the underside of the skin. It is then a simple matter to continue loosening the skin on the front of the ear to a I

3 204 BRITISH JOURNAL OF PLASTIC SURGERY point immediately below the line where it is desired to have the antihelix. This loosening is done throughout with small blunt-nosed undermining scissors. The skin capsule can now be pulled downward, leaving the cartilage free (Fig. i). ;.+ ;!7 (y. ~ /// /...,\ kx,\, '. :"':,i\k, ",~I ~ //,~,.. I. ~- h- j )//' FI~. 2 Operation on the right ear. The cartilage flaps have been joined to form a lattice-work, with the two outermost flaps rotated round and supported by the steel wire, the ends of which have been united. The wire has been fashioned to the required shape. Using curved scissors, the cartilage is now split zigzagwise into serrations 3 to 4 ram. wide, the first of which is based forward and upward, the next backward and downward, until the entire fossa helicis has been split as far as the antihelix line (Fig. 2). An incision I cm. long is then made through the skin of the tragus and

4 A NEW METHOD OF SHAPING DEFORMED EARS 205 the skin then undermined I cm. anteriorly and upward and downward along the ear until the undermining scissors can be seen at the upper and lower margins of the freed cartilage. A length of spring-hard stainless steel dental wire, o. 5 mm. in diameter and FIG. 3 Bilateral shell-ear deformity in 33-year-old woman. Upper row, before operation ; middle row, three months after operation according to the writer's method, before removal of the steel wires ; lower row, six months after operation or three months after removal of the wire. virtually isoelectric with the body tissues, is then drawn from the incision at the tragus, through the subcutaneous channels along the contour of the ear, back to the incision opening anterior to the ear. An artery forceps is used to hold both ends of the wire, the loop of which should be somewhat smaller than the required size of the ear (Fig. I). 3 D

5 206 BRITISH JOURNAL OF PLASTIC SURGERY The two outermost cartilage flaps are wound in slightly spiral fashion round the wire and attached to each other and to the wire with fine catgut sutures through the cartilage. They must be formed so as to ensure the best possible imitation of the fold of the antihelix, especially the anterior portion, and so that the periphery of the ear will reach the required size. The remaining two or three cartilage flaps are then sutured to the first ones and to each other, forming a lattice-work which supports the frame made up of the two marginal flaps that were first united (Fig. 2). The aim is that all gaps between the flaps will be filled out by connective tissue into a disc, which forms the new fossa helicis. The skin capsule is now drawn over and sutured behind with mattress sutures, usually without difficulty. In the event of tension, further skin is undermined on the back of the ear toward the retro-auricular sulcus. The steel wire is moved and bent to the required size and shape, and care must be taken to see that in no place does it press hard against the skin. Its ends are fashioned into small loops which are then joined in front of the ear and introduced into the skin pocket anterior to the incision in the tragus, after which the latter is closed. Cotton-wool soaked in flavin-paraffin, or some other elastic packing, is placed behind the ear in a suitable position, the aural cavity then being well packed with the same material and, if desired, covered with a rubber sponge, and an elastic bandage is applied. The patient rests on the other ear and should remain in bed for at least twenty-four hours. Ambulatory treatment can begin after a few days. The sutures behind the ear are removed on the seventh and the tenth days. The dressing is removed after two weeks and tl{e steel wire is retained for three months (corresponding to the shrinking time of connective tissue), after which the incision in the tragus is opened under local anmsthesia and the steel wire cut and withdrawn. SUMMARY The writer presents a new operative method for the reshaping of shell-ear or lop-ear; i.e., for use where the fold of the antihelix is absent and the entire fossa helicis is depressed like a scoop and often diminished in size. The method has been tried in some ten cases with fully satisfactory results. REFERENCE McEVlTT, W. G. (1947). Plast. &Recons. Surg., 2, 481.