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Demystifying Congenital Deformities of the Upper Ear: How better understanding the commonality of defects has led to a uniform approach to treatment
Bruce S. Bauer, MD.
NorthShore University HealthSystem, Northbrook, IL, USA.
PURPOSE - The goal of this presentation is to demonstrate the commonality of upper pole deformities (previously termed constricted ear, Stahl's ear, cryptotia, etc), and present a systematic approach to reshaping the skin envelope (whether deficient or excessive) and both cartilage deficiencies and deflections, based on a thirty year experience in treating non-microtia ear deformities.
METHODS - Whether the deformity of the upper pole of the ear is the result of skin shortage alone, or in combination with varied degrees of crimping of the helical rim, and missing or malposition of the normal antihelical crura , the key to optimal reshaping of the deformed cartilage is the direct anterior approach to the deformed cartilage through an incision along the proposed new helical rim (where constriction is present) or at the helical rim for Stahl’s ear, and cases where the skin envelope is not significantly deficient. With an anterior approach to the deformities, the full extent of the cartilage deformity can be visualized and corrected. The release of fibrous adhesions and the “splinting” of the reshaped cartilage with ipsilateral or contralateral conchal grafts varies depending on the surgical findings. With the anterior incision along the line of the future helical rim the skin redraping is not limited by the geometry of the original deformity. As the skin is re-draped, the use of multiple fine quilting sutures of 6-0 chromic assure that the skin is correctly redistributed.
RESULTS - The five common features of upper ear deformities include: an adherent helical rim, deformity of scapha (typically acute folding), fibrous adhesions between cartilage folds, varied deficiency of the skin envelope, occasional increased radius of curve of the upper pole, and the deformity may or may not be associated with ear prominence. Following the previously “accepted” posterior approach to the constricted ear, the re-draped skin envelope cannot enlarge beyond the limits of the decreased radius of curve of the original defect. A posterior approach also risks damage to the delicate helical rim cartilage and may potentially lead to compromise of portions of the anterior or helical rim skin. A direct anterior approach to the upper ear combined with release of cartilage adhesions and “reshaping” of the cartilage, performed alone, or in concert with combined otoplasty techniques, predictably corrected the full spectrum of upper pole ear deformities. Rather than classic banner flaps, the usable cartilage is restructured using the parts of the ear most like normal, and filling the defects with the cartilage graft (from helical rim lid, contralateral and smaller ipsilateral cartilage grafting.
CONCLUSIONS - Understanding the common anatomic deformities, regardless of whether they fall under the classic description of constricted ear, cryptotia, or Stahl’s ear, is more pertinent to the successful correction of the deformity than is the name used to describe the defect. Modifying the approach to placing the primary incision anteriorly provides both unparalleled visualization of the deformity, and a greater measure of safety for both surgeon and patient.
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