British Journal of Plastic Surgery (2005) 58, 389 393 An alternative approach for correction of constricted ears of moderate severity M.M. Al-Qattan* Division of Plastic Surgery, King Saud University, P.O. Box 18097, Riyadh 11415, Saudi Arabia Received 6 February 2004; accepted 5 October 2004 KEYWORDS Constricted; Cup; Ear; Deformity Summary Moderately severe constricted ears are characterised by lidding, moderate reduction of the vertical height of the upper ear (reduced scapha, absent superior crus) and prominence with absent antihelix. Techniques described for the correction of moderate constricted ear deformities included an attempt to expand the upper part of the ear by various cartilage transection and/or flap techniques. In the current paper, an alternative approach is presented and is based on the recreation of an antihelix (with Mustardé sutures) and excision of the lidding without performing cartilage expansion procedures. The technique was used in four patients with satisfactory results despite the persistence of the deficient scapha and triangular fossa. No recurrence of the cupping deformity was observed (follow up ranged from 6 months to 4 years with a mean of 2 years) and this was attributed to the use of a mastoid hitch as an adjunctive technique to prevent recurrence. Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. The constricted ear (also known as the lop or cup ear) is a congenital ear deformity of variable severity characterised by four features: lidding, decreased vertical height of the ear, protrusion and low ear position. 1 The lidding deformity is found in all constricted ears and is secondary to a deficiency of the scapha and superior crus leading to a downward fold of the upper helix and helical rim. The decreased vertical height of the ear is also found in all constricted ears, but the height difference (when compared to the normal contralateral ear) varies from less than 1 cm in mild * Fax: C966 1467 9493. E-mail address: moqattan@hotmail.com. deformities to more than 2 cm in severe deformities. Protrusion with loss of the antihelix is seen in moderate and severe cases. Finally, the low ear position is pronounced in severe cases. The severity of the constricted ear deformity has been classified by Cosman 2 and Tanzer 3 as shown in Table 1. Mild constricted ear deformities are easily corrected by direct excision of the lidding, while severe deformities are generally considered as a form of microtia requiring complete autologeous reconstruction with rib cartilage grafts. Several techniques have been described for the correction of moderate constricted ear deformities and included the recreation of an antihelix (usually with Mustardé sutures) as well as a procedure to lengthen the vertical height of the upper one third S0007-1226/$ - see front matter Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2004.10.002
390 M.M. Al-Qattan Figure 1 (a) The moderately severe constricted ear deformity is characterised by lidding (with lidded cartilage) moderate reduction of the upper ear height (with reduced scapha, absent superior crus) and protrusion (with absent antihelix). The term turn-over area is given to the posterior aspect of the skin of the upper ear at the beginning of the abnormal turn-over of the ear cartilage. (b) The first step of correction is the recreation of an antihelix with Mustardé sutures. This corrects the prominence. (c) The second step is correction of the upper ear deformity by excision of skin (at the turn-over area) and excision of lidded cartilage. Note that there is no attempt to recreate a new scapha by cartilage expansion. The mastoid hitch represents the third step in which prolene sutures are sutured from the posterior aspect of the neohelix to the mastoid fascia which help to prevent recurrence of the cupping deformity. of the ear. Lengthening of the upper ear was obtained by V Y advancement of the root of the helix 4 as well as by cartilage expansion procedures such as Cosman s helical rim rotation, 2 the banner or double banner flap of Tanzer, 3 Elsahy s antihelical flip flap technique, 5 and various techniques of cartilage transection and local skin flap transposition. 1 Figure 2 Demonstration of the three steps of correction. Step I (a, b, c): Mustardé sutures to recreate the antihelix and correct the prominence. Note that the elliptical skin excision in step I is vertically oriented and is located just below the turn-over area. Step II (d, e): correction of the upper ear deformity by transverse elliptical skin excision at the turnover area and by excision of the edge of the lidded cartilage. Step III (f) is the mastoid hitch sutures between the posterior aspect of the neohelix and the mastoid fascia.
An alternative approach for correction of constricted ears of moderate severity 391 Table 1 Classifications of the severity of the constricted ear deformity Severity Description Cosman classification Tanzer classification Mild Moderate Severe Lidding and mild (!1 cm) height difference Lidding, moderate (1 2 cm) height difference, and protrusion Lidding, severe (O2 cm) height difference, protrusion and pronounced low ear position Recommended surgery A I Direct excision of the lidding B/C/D IIA/IIB Mustarde sutures, cartilage expansion procedures, and V Y advancement of the root of the helix a E III Reconstruct a new ear with rib cartilage grafts a Cartilage expansion procedures include various cartilage flap techniques (with or without the additional use of cartilage grafts and local skin flaps) to expand the upper one third of the ear. An alternative technique of correction of moderately severe constricted ear deformities is presented and is based on the recreation of an antihelix (with Mustardé sutures) and excision of the lidding without cartilage expansion procedures (which were routinely performed for moderate cases by previous authors). Patients, methods and results Over 5 years, four patients (one boy and three girls) with moderate constricted ear deformity were operated on. All patients had lidding, protrusion and moderate decrease in the vertical height of the ear (mean difference of 1.5 cm, rangez1.2 1.8 cm). Figure 3 Correction in a 12-year-old girl. (a) Pre-operative appearance. (b) Post-operative result at one year. Note the deficiency in the scapha and the absence of both the inferior crus and triangular fossa.
392 M.M. Al-Qattan Figure 4 Correction in a 6-year-old boy. (a) Pre-operative appearance. (b) Post-operative result at 6 months. Note the deficiency in both the scapha and triangular fossa. The procedure is done under general anaesthesia and is completed in three steps (Figs. 1 and 2). The first step of correction is the creation of an antihelix with Mustardé buried mattress sutures which were originally described by Mustardé for the correction of prominent ears. 6 Following closure of the vertical posterior skin incision, correction of the upper ear deformity (Step II) is performed by excision of skin and cartilage. Skin excision is done in a transverse fashion at the posterior aspect of the skin of the upper ear at the beginning of the abnormal turn-over of the ear cartilage. Cartilage excision is done at the edge of the lidded cartilage. The final and third step is the mastoid hitch described by Horlock et al. 7 Two 4/0 polypropylene sutures are sutured from the posterior aspect of the neohelix to the mastoid fascia to prevent recurrence of the cupping deformity. A bulky dressing is applied and is removed after 3 weeks. No postoperative complications were noted and the result was satisfactory in all patients (Figs. 3 and 4). However, the procedure did not correct the deficient vertical height of the ear and the preoperative scaphal and triangular fossa deficiency persisted after surgery. However, the procedure was able to recreate a new superior crus which was in continuity with the neo-antihelix by the Mustardé sutures. Finally, no recurrence of the cupping deformity was observed (follow up ranged from 6 months to 4 years with a mean of 2 years). Discussion Previous techniques that were described for the correction of moderately severe constricted ears included an attempt to expand the upper part of the ear. 2 5 This expansion was done using various cartilage transection/flap techniques which were generally complicated, frequently required anterior skin incisions, and sometimes required additional cartilage grafts and the use of local skin flaps to cover the expanded upper ear cartilage. The technique described in the current paper does not attempt to expand the cartilage of the upper ear and hence it is much simpler to execute, avoids anterior skin incisions, and does not require
An alternative approach for correction of constricted ears of moderate severity 393 additional cartilage grafts or local skin flaps. The main disadvantage of the current technique is the persistence of scaphal and triangular fossa deficiency. Despite that, all patients were satisfied with the final result. This is probably because the deficiency in the vertical height of the ear was only moderate. Furthermore, the previously absent superior crus was recreated in continuity with the new antihelix by the Mustardé sutures (Figs. 3 and 4). Not much is written in the literature about the inferior crus in moderately severe constricted ears. The author noted that the inferior crus may also be absent in these patients (pre-operatively the patient in Fig. 3 had no inferior crus while the patient in Fig. 4 had an inferior crus). The current technique does not recreate an inferior crus (if absent). The post-operative appearance of the ear in these patients was also considered satisfactory despite the absence of the inferior crus (see Fig. 3(b)). A major problem of surgical correction of moderately severe constricted ears is recurrence of cupping of the upper ear. 7,8 Horlock et al. 7 recommended using a mastoid hitch as an adjunctive technique to prevent this recurrence. We have included the mastoid hitch in our approach and experienced no recurrence of the cupping deformity in our patients after a mean follow up of two years. References 1. Paredes AA, Williams JK, El Sahy NI. The constricted ear. Clin Plast Surg 2002;29:289 99. 2. Cosmon B. The constricted ear. Clin Plast Surg 1978;5: 389 400. 3. Tanzer RC. The constricted (cup and lop) ear. Plast Reconstr Surg 1975;55:406 15. 4. Millard DR, McCafferty LR, Prado A. A simple, direct correction of the constricted ear. Br J Plast Surg 1988;41: 619 23. 5. El Sahy NI. Technique for correction of lop ear. Plast Reconstr Surg 1990;85:615 20. 6. Mustardé JC. The treatment of prominent ears by buried mattress sutures: a ten-year survey. Plast Reconstr Surg 1967;382 6. 7. Horlock N, Grobbelaar AO, Gault DT. 5-year series of constricted (lop and cup) ear corrections: development of the mastoid hitch as an adjunctive technique. Plast Reconstr Surg 1998;102:2325 32. 8. Furnas DW. Discussion: 5-year series of constricted (lop and cup) ear corrections: development of the mastoid hitch as an adjunctive technique. Plast Reconstr Surg 1998;102:2333 5.