Reconstruction of Moderately Constricted Ears by Combining V-Y Advancement of Helical Root, Conchal Cartilage Graft, and Mastoid Hitch

PATIENTS AND METHODS

RESULTS

Peri- and postoperative periods were uneventful. Mean follow-up period was 6 months. Follow-up photographs were taken at 1 week, 1 month, and 6 months.

All V-Y flaps survived. There were no infections or hematomas, no delayed wound healing or wound dehiscence, and no skin necrosis. The scar was hidden within the helical rim and hardly visible, and no keloid or hypertrophic scars had developed. Donor site morbidity was negligent.

All patients were satisfied with the outcome of the operation because of the general form, the upright position of the upper pole of the ear, and restoration of symmetry. Revision of mastoid hitch was required in 1 patient.

The results were rated according to the level of involvement.¹⁵ There were 7 excellent, 4 good, 1 fair, and no poor results; the only patient with fair results underwent revision under local anesthesia. This patient was an adult patient who experienced collapse to the upper helix and the upper part of the ear was slightly protruding compared with the contralateral side, which was easily corrected with revision of the mastoid hitch to maintain the neohelix in the elevated position. The result after revision of the mastoid hitch was good, and the patient was satisfied with the outcome.

Analyzing the vertical height of the constricted and contralateral ears and the size difference between both ears pre- and postoperatively shows statistically significant difference between both ears preoperatively, while the difference was nonsignificant postoperatively by using the paired t test, which means that we approached symmetry between both ears in all of our patients as shown in Table 2.

The mean preoperative vertical height of the constricted ears was 5.1 ± 0.4, whereas the mean postoperative vertical height of the constricted ears was 5.8 ± 0.3. The vertical height of the constricted ear increased postoperatively, with a statistically highly significant increase in the vertical height by using the paired t test as shown in Table 3.

The mean preoperative vertical height of the contralateral ears was 5.7 ± 0.4, whereas the mean postoperative vertical height of the contralateral ears was 5.9 ± 0.4. The vertical height of the contralateral ear increased postoperatively, with a highly statistically significant increase in the vertical height by using the paired t test as shown in Table 4.

The mean change in the vertical height of the constricted ears (5.9 ± 1) was significantly higher than the mean change in the vertical height of the contralateral ears (1.9 ± 0.5) as shown in Table 5. Pre- and postoperative photographs of the 5 patients are shown in Figures 1-22.

Figure 1. Constricted right ear in a 27-year-old male patient.

Figure 2. Postoperative photograph for the same ear in Figure 1.

Figure 3. Preoperative posterior view of both ears in a 27-year-old male patient.

Figure 4. Postoperative posterior view of both ears for the same patient in Figure 3.

Figure 5. Constricted left ear in an 8-year-old male patient.

Figure 6. Postoperative photograph for the same ear in Figure 5.

Figure 7. Preoperative posterior view of both ears in an 8-year-old male patient.

Figure 8. Postoperative posterior view of both ears for the same patient in Figure 7.

Figure 9. Constricted right ear in a 7-year-old male patient.

Figure 10. Postoperative photograph for the same ear in Figure 9.

Figure 11. Preoperative anterior view of both ears in a 7-year-old male patient.

Figure 12. Postoperative anterior view of both ears for the same patient in Figure 11.

Figure 13. Preoperative posterior view of both ears in a 7-year-old male patient.

Figure 14. Postoperative posterior view of both ears for the same patient in Figure 13.

Figure 15. Constricted right ear in a 55-year-old male patient.

Figure 16. Postoperative photograph for the same ear in Figure 15.

Figure 17. Preoperative posterior view of both ears in a 55-year-old male patient.

Figure 18. Postoperative posterior view of both ears for the same patient in Figure 17.

Figure 19. Preoperative anterior view of both ears in a 9-year-old female patient.

Figure 20. Postoperative anterior view of both ears for the same patient in Figure 19.

Figure 21. Preoperative posterior view of both ears in a 9-year-old female patient.

Figure 22. Postoperative posterior view of both ears for the same patient in Figure 21.

DISCUSSION

Approaching the symmetry in cases of the unilateral constricted ear is an elusive goal, and a combination of different procedures is needed. That is why a combination of V-Y advancement of the helical root, conchal cartilage graft, and mastoid hitch procedures was performed in the current study.

The number of patients in the current study was reasonable statistically and comparable with that of the previous study by Horlock et al,⁸ whose study was conducted on 19 constricted ears in 17 patients, and was greater than that in another study by Kon and Van Wijk,¹³ who used 9 ears in 8 patients and only 4 patients in another study by Al-Qattan.¹⁷

Patient age in the current study was variable. The study included 9 children, whose age ranged from 6 to 10 years (mean age = 8.1 ± 1.5 years), and 3 adults, whose age ranged from 27 to 55 years (mean age = 42.3 ± 14 years), in comparison with the previous study, which included only young age group patients (age range from 5 to 13 years; mean age = 7.4 years) by Horlock et al⁸ and from 6 to 12 years in another study by Al-Qattan.¹⁷ On the contrary in the study conducted by Kon and Van Wijk,¹³ the mean age of patients was much older; it ranged from 12 to 36 years (mean age = 19.5 years).

V-Y advancement of the root of helix was used to reconstruct the constricted ear deformity in studies conducted by Cosman³ and Stenstrom,⁹ whereas conchal cartilage grafting was used in other studies by Tanzer,² Park,⁶ and Paredes et al.¹² There were no recorded studies that combined both techniques together. On the contrary, Horlock et al⁸ added the mastoid hitch as an adjunctive to other techniques as V-Y advancement in some cases. The current study standardized the use of all these modalities (V-Y helical root advancement, conchal cartilage grafting, and mastoid hitch) together in all cases.

The present study depended on the ear measurements by comparing the vertical height of both ears pre- and postoperatively and the clinical assessment as described by Chana et al.¹⁵ The same assessment tools were used in previous study by Horlock et al.⁸ Other studies depended on the general form, the upright position of the upper pole of the ear, and restoration of symmetry.^13,17 Therefore, this current study is more objective.

A limited postauricular incision rather than a lateral incision¹¹ described in many cup ear reconstructions was used in this study to reduce scar visibility. Lateral incision was not used in this study because the final scar after unfolding of the constricted helix may end up very anteriorly. Another reason was that the pocket created by V-Y advancement would optimally cover the conchal cartilage graft. A third cause was that V-Y advancement together with the limited postauricular incision was enough to release the constricted helix without the need for any additional incisions.

Anterior scoring of the cartilage was used to refashion the angulated cartilage leaf and create the antihelical folds. V-Y advancement of the anterior helical root similar to the procedure described by Stenstrom⁹ provided good cartilage access and a very acceptable scaring. It was more useful in release of the upper helix constriction and allowed more pocket for the cartilage graft. This procedure released the tight anterior structures, which might have contributed to recurrence of the deformity. V-Y advancement in addition contributed to the elevation of the helical rim.

Stephenson¹⁸ and Kon and Van Wijk¹³ used costal cartilage grafts with a small donor scar and minimal postoperative inconvenience. But, still, there was a donor site scarring. Therefore, Musgrave¹⁹ modified this technique by using conchal cartilage rather than costal cartilage. The same was advocated in the current study to avoid donor site morbidity of the costal cartilage graft.

To obtain greater expansion (for more severe deformities), the double banner flaps have been used.² But it weakens the cartilage framework of the upper helix and leads to recurrence of the deformity.⁸ Therefore, in the current study, V-Y advancement of the root of helix was used to expand the angulated cartilage of the upper helix, and conchal cartilage graft was used to maintain this expansion.

Importation of the additional skin is needed for type II deformities by a variety of techniques.^14,20,21 In the current study, importation of the additional skin was not a requirement for type IIA constricted ears: first, because of V-Y advancement of the root of helix released the tightness of the skin anteriorly, and, second, because of the dissection of the postauricular pocket over the mastoid fascia released the skin posteriorly and facilitated tension-free closure as a result of the elastic properties of the undermined skin.

The described technique in the present study was suitable for only type IIA deformities. Because type IIB and III Tanzer deformities need to be placed in a different context and regarded as concha-type microtia and corrected accordingly.

CONCLUSION

This study adopted a simple procedure to correct 12 cases of constricted ears classified as moderate deformities (type IIA) according to the criteria of Tanzer. We concluded that these deformities are best corrected by a V-Y advancement of the helical root, cartilage scoring, conchal cartilage grafts from the contralateral ear, and a mastoid hitch to maintain helical shape, height, and position and to prevent recurrence. This combined technique was reproducible and reliable in reconstruction of moderate-degree constricted ear deformities.