Question: How to achieve ideal reconstruction of severe grade IIB Tanzer constricted ear deformity?
Findings: Modified autogenous auricular reconstruction is useful in correcting severe group IIB Tanzer constricted ear deformities. Because it addresses all the anatomical features of this deformity, this technique is reproducible and reliable and has offered consistently effective results.
Meaning: The modified auricular reconstruction technique is ideal for severe grade IIB Tanzer constricted ear deformity.
Constricted ear includes deformity to the upper third of auricular cartilage.1 The deformity is characterized by lidding, reduced vertical length, ear prominence, and low-set ears in the most severe degrees.2 In 1975, Tanzer was the first to classify the deformity into four groups. Type I involves collapse of the helix, and it is treated by surgically removing this lidding.3 Type II involves the helix and scapha and is reconstructed by local tissues, while Tanzer type IIB involves a severe degree of the deformity with a sharp reduction in helical length and defective upper antihelix and scapha. This type has a marked compression of the upper third of ear, and the skin cover is insufficient to optimally cover the cartilaginous framework.
However, specific anatomical features of severe grade IIB constricted ear also include the presence of tragus, antitragus, and intertragal notch, which are noted to be preserved but narrow, even in severely constricted ears. The concha is preserved too, but constricted. Mostly, there is no actual external auditory meatus, but only a shadow of the depth of the meatus (cul de sac) was noted; the lobule is good in shape, vector, and position, and rarely to be found low-set in this degree.
To reconstruct group IIB deformity, a multitude of supplemental soft tissue coverage and/or cartilaginous framework corrective procedures have been described.2–14 Different techniques described to reconstruct Tanzer IIB constricted ears include Kislov methods,10 Cosman floating cartilaginous technique,2 Tanzer banner flap,3 El Sahy antihelical flip flap,4 Nagata costal cartilage-retroauricular flap,15 V-Y advancement of helical root,16 double pennant method,17 Z-shaped double V-Y advancement flaps,18 helical advancement with superior auricular artery chondrocutaneous flap,19 helical expansion using a free-floating costal cartilage,14 and Z-plasty.20 In 2009, Al-Qattan and Al-Omawi summarized these techniques with their advantages and disadvantages.20 Modification of auricular reconstruction techniques is necessary to adapt correction of severely constricted ear features.1 Tanzer type III deformity is considered a microtia and necessitates full costal cartilage auricular reconstruction.3
Patients with severely constricted ears are living with a social burden, which may cause a negative self-impact. Previous studies have demonstrated that surgical correction can enhance their physical and psychosocial status.1,21
AIM OF WORK
The current study described certain modifications to the known autologous auricular reconstruction to adapt specific anatomical features of severe group IIB Tanzer constricted ear deformity, and reviewed the postoperative surgical outcomes and complications. It also aimed to evaluate the postoperative patient satisfaction.
PATIENTS AND METHODS
This is a prospective study in which all patients with Tanzer type IIB constricted ear at El-Demerdash Hospital from November 2018 to November 2022 were counseled to share in the study. Twenty patients with unilateral Tanzer group IIB constricted ear who were operated on by the senior author (A.E.) were included after meeting the inclusion criteria, and their satisfaction 4 months after the second-stage surgery was assessed using a questionnaire form (Fig. 1). Inclusion criteria include both male and female patients between 6 and 15 years old, with unilateral severely constricted ears (grade IIB Tanzer classification), patients who are fit for surgery with no contraindications, and patients who are cooperative, with at least 4 months of follow-up period after second-stage surgery.
Exclusion criteria include the age groups younger than 6 years and older than 15 years; bilateral cases; mild and moderate constricted ear (grade I and IIa Tanzer) patients; patients with microtia or anotia (grade III Tanzer); patients with severe associated deformities, for example, hemifacial macrosomia; noncooperative patients; and patients with less than 4 months of postoperative follow-up.
Modified Auricular Reconstruction Technique
All patients were operated on using a prefabricated 3D model (Planmeca 3D Mid CBCT Scanner, Planmeca Oy; Helsinki, Finland), and all patients underwent preoperative markings for the planned pocket at the mastoid skin area according to measurement of the size and position of the contralateral normal ear (Fig. 2). All procedures were performed under general anesthesia, while the patient was supine with the head tilted to the deformed side. All patients underwent two-stage reconstructive surgery using the modified Firmin technique,22–24 with some special modifications to adapt the anatomical features of grade IIB Tanzer constricted ear.
Surgical incision was a transfection incision in the area just above the tragal area, between the upper two-thirds (the deficient segment) and the lower third (anatomically preserved segment). Dissection of a subcutaneous pocket under the mastoid skin of the affected ear according to the preoperative markings was done. The constricted concha was preserved and released by full-thickness radial incisions to expand the conchal area, which help release the constriction deformity and widen the intertragal notch. The crumbled remnant cartilage was preserved and used for elevation of the auricle in the same stage as described in a previous publication by the senior author.25 In those patients, the tragus, antitragus, and intertragal notch (lower third) are usually present and preserved, so there was no need to fabricate the full-cartilaginous framework as described by Firmin22–24; instead, some modifications were added, in which creation of a cartilaginous framework in the first stage was done, but not the full-cartilaginous framework; only a question mark–shaped frame was needed to reconstruct the helix and antihelix (upper two-thirds) (Fig. 3). Costal cartilage for the framework was harvested from the seventh, eighth, and ninth costal cartilages. Extending the cartilaginous framework downward to be inserted in a pocket created inside the lobule area was done to give it support, by making the cartilaginous frame continued in the lobule area as one unit (Fig. 3). Application of the cartilaginous framework was done inside the subcutaneous pocket. The skin of the original concha was anchored by sutures to a point on the inferior crus of the antihelix of the prefabricated cartilaginous framework, and it helps maintain a proper position and vector of the framework and prevent telescoping of the framework after its application in the subcutaneous pocket (Fig. 4). Suction drain was applied in all cases, which helped adaptation of the mastoid skin to the cartilaginous framework (Fig. 5), and was maintained for 7–10 days. The skin was redraped, and then closed with 6/0 Prolene sutures after application of the framework in the correct position and vector. Closure of chest donor site was done in layers with application of a tube drain, which was removed on the third postoperative day.
Four patients needed set-back of their contralateral ear to achieve symmetry. A postauricular approach was used to create the antihelix and to set back the ears using the concho-scaphal (Mustarde suture) and concho-mastoid sutures. Scoring the cartilage anteriorly was done in all patients. Elevation of the auricular framework with skin graft was done in the second stage after 3–6 months. Lobule transposition was also done in the second stage, but it was needed in selected cases, because many cases already have normal position and vector of their ear lobule (Fig. 6).
A band of excess skin at the junction between the antihelix and the conchae was often noted and required Z-plasty to release it in the third stage. Mostly, no actual external auditory meatus was found, but only a cul de sac appearance reflecting the depth of the meatus without an actual opening (Fig. 7).
The follow-up duration was at least 4 months after the second stage. Photographs were taken at 3 months and 6 months after the second-stage surgery (Figs. 8–17).
Grading for the postoperative assessment of the aesthetic outcomes was done by the senior surgeon according to a four-point Likert scale (1 = poor, 2 = fair, 3 = good, and 4 = excellent), comprising general form, symmetry, size, and the details of the subunits. A known scoring system for aesthetic outcomes after auricular reconstruction was applied.26
A conducted questionnaire assessed patient’s satisfaction.27 The questionnaire comprised three parts. Part one includes assessment of patients' satisfaction with their ear’s general appearance. The second part includes assessment of the four ear subunits (helix, antihelix, concha, and lobule). The third part evaluated the auricle’s elevation from the scalp.28
Patient age ranged from 6 to 15 years. The mean age of patients was 9.1 ± 1.5 years. There were six female patients and 14 male patients. The contralateral ears were prominent in only four patients and were normal in 16 patients. Follow-up period after the second stage ranged between 4 months and 12 months, with mean follow-up period of 6 months.
Perioperative and postoperative periods were uneventful, except for one patient, who presented with postoperative collection and underwent evacuation in the same operative night through the same operative incision. This patient reported excellent results after that. No revisions were done in any of our patients.
All skin flaps survived well. There were no skin loss, no infections, and no wound healing complications. The scars were accepted in all patients. Donor site morbidity was negligible, and graft donor sites healed well. No absorption or change of the shape of the cartilage of the reconstructed auricle was noted in any of our patients.
According to the scoring system for aesthetic outcome assessment, all patients have nice shape, good symmetry as regard both size and position, nice helix, nice antihelix, nicely positioned lobule, and natural shape. Results were scored as excellent in 12 patients and good in eight patients. No fair or poor scores were reported.
Assessment of postoperative photographs shows symmetry in size, shape, and position in 16 of 20 (80%) patients. Asymmetrical cases were present in four patients who otherwise reported good satisfaction rates.
Regarding the questionnaire, in its first part, all patients were satisfied with the surgical outcome because of the overall shape, the correct vector of the upper part of the ear, symmetry, and ear fitting with face. There were 13 excellent, seven good, and zero fair or poor results. Regarding the second part, the helix, concha, and lobule were the most satisfying parts to patients. The subunit with the least patient satisfaction was the antihelix. Regarding the third part, patients were satisfied with the elevation of their auricle from scalp and reported symmetry in size, shape, and position in 14 of 20 (70%) patients. Patients provided assessments on a five-point Likert-type scale ranging from 4 to 5 (Figs. 8–17).
Cosman2 described the constricted ear deformity as lidding, reduced ear length, prominence, and low-set ears in the most severe cases. It was reported that if the difference in height is less than 1 cm, it is considered a mild deformity, but if it is more than 2 cm, it is considered a severe deformity.19 The aim in reconstructing Tanzer IIB constricted ears is extending both the tight skin cover and cartilage available to reconstruct the upper pole of ear.18
The reconstructive techniques for group IIB deformity include (1) refashioning the original cartilage and/or grafting, (2) extending the skin cover with flaps, and (3) procedures that correct prominence.19
Stephenson7 performed radial incisions to the existing cartilage to extend the cartilage in a fanlike manner. This is similar to what was done in the current study, as radial incisions were done to release the constricted concha to release the narrow intertragal notch, which have a positive impact on the patient’s satisfaction with the conchal subunit. Musgrave9 enhances the technique by anchoring these radially incised cartilages to a conchal cartilage graft, as was done in the current study, as the radially incised concha was anchored to the antihelix part of the costochondral framework.
A recent study by Huang et al in 2022 reported that costal cartilage is not favored for patients who are younger than 5 years and in old patients who have calcification of their costal cartilage. However, because costal cartilage has a good thickness, it was favored by some surgeons and patients.29
Costal cartilage was used in all of our patients; however, full discussion with patients and their guardians was done, reporting that the costal cartilage framework will be a little bit thicker than the normal ear, but it gives better strength to the frame and better support, which will give the reconstructed ear an adequate length and better elevation from their heads.
The current study included a relatively large number of patients (N = 20) in comparison to previous studies. A study by Duan and Liu in 2019 included only 15 patients.18 They were reconstructed by the double V-Y advancement flap technique. Conchal graft was performed to reconstruct the defect inferior to the flaps. They reported that reconstruction with costal cartilage grafts gives stronger support, as was done in all patients of the current study. Complications included one patient with partial necrosis of the inferior flap, possibly because of the suction drain applied under the flaps. In the current study, a cartilaginous frame was inserted in a pocket dissected under the mastoid skin. After suction, none of the patients showed any vascular compromise to the skin.
A study by Egemen et al19 in 2012 included only six patients who underwent helical advancement and superior auricular artery chondrocutaneous flap.30,31 This flap included a conchal cartilage graft to support the soft tissues. These patients rejected the harvest of a costal cartilage graft. Disadvantages of this technique include that although the technique maintains good height of the auricle, it cannot reconstruct the inferior crus of the antihelix and root of the helix. Proper reconstruction of such structures necessitates a stronger cartilage than the concha.19
The Park study in 2009 included only eight patients, and correction was done using helical extension with a free-floating costal cartilage. Split cartilage was inserted into a helix.14 For extending the skin cover, a fasciocutaneous grotting flap and/or advancement of the marginally based scapha skin flap were used. Complications included bullae around the helices postoperatively, without further vascular compromise. Skin tension caused by inserting cartilage may cause the formation of bullae. This was not experienced in the current study.
Other techniques that used a fabricated costal framework include that reported by Nagata, who described a method that incorporates into a gap of upper auricle for reconstruction of constriction deformity.15 Fisher and Kasrai also reported that the original cartilage was discarded and replaced totally with a costal cartilage in reconstruction of a constriction deformity.32
One of the challenges of autogenous cartilage reconstruction is absorption or change in the shape of the reconstructed auricle similar to other nonvascularized grafts.33–35 Resorption of the cartilage framework is associated with patients who experienced exposure of their reconstructed cartilage, and it did not happen in any of the patients included in the current study. In a previous publication by Han and Oh in 2016, cartilage graft absorption occurred in eight patients 5 years after the first stage.35 Additional costal cartilage graft was performed before auricular elevation for treatment.35
Limitations of the current study include a small sample size, which should be extended to include a larger number of patients. Extending the follow-up period up to 5 or 10 years is also needed to detect any resorption or change in the shape of the reconstructed auricle.
The following summarizes how the current technique differs from previously described techniques:
- We used a prefabricated 3D model.
- Surgical incision was a transfection incision in the area just above the tragal area, between the upper two-thirds (the deficient segment) and the lower third (anatomically preserved segment).
- The constricted concha was preserved and released by full-thickness radial incisions to expand the conchal area.
- The crumbled remnant cartilage was preserved and used for elevation of the auricle in the first stage.
- In grade IIB Tanzer constricted ears, the tragus, antitragus, and intertragal notch (lower third) are usually present and preserved, so there was no need to fabricate the full-cartilaginous framework as described by Firmin. Instead, only a question mark-shaped frame was needed to reconstruct the helix and antihelix (upper two-thirds).
- Extending the cartilaginous framework downward to be inserted in a pocket created inside the lobule area was done to give it support, by making the cartilaginous frame continued in the lobule area as one unit.
- The skin of the original concha was anchored by sutures to a point on the inferior crus of the antihelix of the prefabricated cartilaginous framework, and it helps maintain a proper position and vector of the framework and prevent telescoping of the framework.
- Lobule transposition was done in the second stage, but it was needed in selected cases, because many patients already had normal position and vector of their ear lobule.
- The band of excess skin at the junction between the antihelix and conchae needs Z-plasty to release it in the third stage.
- Mostly, no actual external auditory meatus was found, but a cul de sac appearance reflecting the depth of the meatus without an actual opening was noted.
Tanzer group IIB constricted ears showed a variety of external features. The technique mentioned in the current study was reproducible and reliable and offered consistently effective results in reconstruction of severe degree constricted ear deformities. The helix, conchae, and lobule of the reconstructed auricle get the highest level of satisfaction, while the antihelix still needs more continuous work and follow-up to enhance the aesthetic outcome.
The authors have no financial interest to declare in relation to the content of this article.
Written informed consent was obtained from all individual participants included in the study or their legal guardians. Patients or their legal guardians signed an informed consent regarding publishing their data and photographs. Additional informed consent was obtained from all participants or their legal guardians for whom identifying information is included in this article.
The study was authorized by our institution’s ethics committee and followed the World Medical Association Declaration of Helsinki.
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