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Archive for the ‘ear reconstruction’ Category

Long-Term Outcome of ePTFE Ear Reconstruction

Sunday, August 6th, 2017

 

Ear reconstruction for partially or completely removed/lost ears in adults must take into consideration the needed soft tissue coverage. While the cartilage of the ear can be replaced by either a synthetic framework or rib cartilage, it requires vascularized tissue and a skin graft to have a reconstruction result that survives and hopefully looks good. Contrary to the understandable perception of some patients, you can’t just put a skin graft directly on cartilage or a synthetic material.

In most cases of major ear reconstruction, the key element is what is known as a TPF flap. This stands for a temporoparietal fascial flap. Fed its blood supply by the ascending superficial temporal artery passing in front of the ear, this is the fascial layers (excluding the deep fascia) overlying the temporal muscle on the side of the head. This thin tissue can be raised off the entire temporal muscle and turned down to cover a synthetic or cartilage ear framework. It is onto this tissue that a skin graft can then be placed to complete the third layer of the reconstruction.

What is important for patients to understand is that healing of these complex ear reconstruction is a process. Right after surgery and for the first month or so the ear reconstruction often looks little like an ear. The tissues are swollen and distorted and it can just look like a swollen indistinct mass one the side of the head. It takes time for the swelling to goo down and, just as importantly, the overlying soft tissue coverage to shrink down and stick into all the details of the framework. Here is an example of a partial ear amputation due to skin cancer with an immediate ePTFE framework covered by a TPF flap and skin graft. It sort of looks like an ear at the end of surgery but will get quote swollen and distorted for weeks afterward.

When seen at three months after surgery, the ear looks more defined and some of the details of the framework can finally be seen. While it will never look exactly like what was removed, it creates an acceptable looking result.

The long-term aesthetic outcome of ear reconstruction awaits the contraction of the thin overlying vascularized tissues to adapt to the framework. This ‘shrink wrap’ effect is a process that takes months after the surgery to reveal its full effects.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Constricted Ear Reconstruction

Wednesday, May 10th, 2017

 

Background: One of the most common congenital malformations of the external ear is that of the constricted ear deformity.  It goes by a number of other names such as lop ear and cup ear. But they all fall under that of an ear constriction issue. Think of the outer helical rim as a draw string and all types of constricted ears appear based on how tight the draw string is pulled. Underlying all of the presentations of the constricted ear is that some amount of tissue deficiency (skin and cartilage) exist.

The constricted ear appears in a variety of manifestations. In all types the top of the helical rim is folded over. (hence the term lop ear)  In more severe forms the cartilage of the helical rim and scapula is deficient creating a tighter roll and small ear. (thus the term cup ear) The one consistent difference between a constricted ear and microtia is that an external auditory canal is present the former but not in the latter.

Reconstruction methods of the constricted ear depend on the severity of the deformity. In more severe forms cartilage grafts are needed. This in most cases means that a rib graft framework needs to be used to  create the deficient upper east cartilage.

Case Study: This 7 year-old female was born with a severely constricted ear and multiple skin tags. As an infant her skin tags were removed.

At age 6 a first stage ear reconstruction was done using a rib graft framework under general anesthesia. The cartilage ear framework was placed underneath the unfolded ear skin as well as the surrounding post auricular skin. Several subsequent reconstructive stages were done including a postauricular release and full thickness skin graft placement.

The constricted ear is a challenging reconstruction which can be only slightly less difficult to do than a complete microtia. It does have the benefits of an existing earlobe, external auditory canal, concha and tragus which help make for a favorable result in many cases.

Highlights:

  1. Many congenital ear deformities fall into the category of a constricted ear deformity with contraction around the helical rim due to underdevelopment.
  2. Reconstruction of the underdeveloped ear framework requires an autologous rib graft method.
  1. The constricted ear deformity requires multiple stages of reconstruction to achieve its final effect.

Case Study – ePTFE Ear Implant Reconstruction

Saturday, April 15th, 2017

 

Background: Ear reconstruction is most commonly done using autologous graft materials. Whether it is microtia reconstruction using rib cartilage in children or adult ear reconstruction using cartilage grafts and pedicled skin flaps, the patient’ own tissues offer the least risk of postoperative complications and should be done when possible.

The use of synthetic frameworks or implants for ear reconstruction has its origin and current use with Medpor material. Most commonly done as an alternative to the use of rib cartilage in congenital microtia deformities in children, it offers a premade and well shaped ear implant. As a substitute for a hand-carved rib cartilage ear framework, it requires vasculrized tissue cover using the temporalis fascial flap (TPF flap) covered with a split-thickness skin graft. Its benefits is that it usually creates a much better shaped ear in the end and does so in less operative time with no need for a rib graft donor site.

While Medpor ear frameworks are effective, the material itself does not replicate very well the physical characteristics of natural ear cartilage. It is much more stiff (in fact rigid) and lacks any substantial flexibility. While creating a nice ear shape it does not create a good feeling ear. This stiffness can make the Medpor framework ear prone to occasional discomfort and skin breakdown due to pressure or trauma.

Case Study: This 78 year-old male has multiple basal cell skin cancers on his left ear on both front and back ear surfaces. It was decided that the best treatment for his ear cancer was near amputation. He was interested in a synthetic ear implant as opposed to a rib graft. Under general anesthesia he had a subtotal ear resection preserving the superior helical root, concha and earlobe.

Using an ePTFE coated composite ear implant, it was carved into a shape replicating the portion of the ear cartilage removed. This was then sutured to the remaining ear cartilage.

A TPF flap was raised through a vertical incision above the ear. It was folded down over the ear framework, preserving its temporal vascular pedicle, and sewn into the tissue edges around the remaining ear. A split-thickness skin graft was harvested from the thigh and laid over the TPF flap and sewn into place.

With healing time and tissue contraction, the details of the ear framework will eventually become more apparent through the applied vascular cover. In the long run the reconstructed ear will have a more natural feel due to the inherent softness of the ePTFE material.

Highlights:

  1. Synthetic ear reconstruction relies on the use of a Medpor ear framework covered by a fascial flap and skin graft.
  2. A new synthetic ear implant made of a composite silicone and ePTFE coating offers a softer and more flexible design.
  3. Composite ePTFE ear frameworks offer a carving feel that is identical to that of natural rib.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Microtia Rib Graft Ear Reconstruction

Friday, December 23rd, 2016

 

The ear is composed of two basic structures, cartilage and skin. The cartilage component of the ear is considerable as only the earlobe is not supported by it. The cartilage is solely responsible for the very complex shape of the ear with its many hills, valleys, ridges and curves that are seen externally. How it gets this shape is an embryological marvel as six hillocks fuse in utero to ultimately create what we see as the external ear.

While cartilage supports all the convexities and concavities of the ear, its most important contribution is to its elevations or convexities. (helical rim, superior and inferior crus, antihelix, tragus and antitragus) Cartilage can be removed from any of the concave areas and the shape of the ear would not change. This is well known from the common harvesting of ear cartilage in rhinoplasty from the concha, the largest ear concavity which looks the same both before and after graft harvest.

rib-graft-microtia-ear-reconstruction-dr-barry-eppley-indianapoliosThe greatest illustration of the role of cartilage in the shape of the ear is in microtia reconstruction. For children born with parts or all of the external ear missing, the traditional ear reconstruction method is done with rib cartilage. Portions of ribs 6, 7, and 8 are used to create a cartilage ear framework for insertion under the skin. In making his ear framework the complete concept of the ‘hills and valleys’ of the ear must be artistically created by carving and assembling the pieces of rib cartilage. The eventual shape of the ear is seen many months after surgery as the overlying skin shrinks into and around its cartilage shape.

Of all the shaping procedures that are done in plastic surgery throughout the body, making an ear out of rib cartilage in microtia reconstruction certainly qualifies as a sculpting surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Fat Grafting for the Stiff Medpor Ear Recconstruction

Wednesday, September 28th, 2016

 

Microtia is a congenital condition where all or major parts of the ear are missing. Two methods of microtia reconstruction have evolved using either one’s own ribs or through the use of a synthetic framework. Autologous microtia reconstruction is done to using portions of the cartilaginous #7, 8 and 9 ribs to create the base framework of the ear. Alloplastic microtia reconstruction uses a synthetic performed ear framework made of a Medpor material that is simultaneously covered by a vascularized temporal fascial flap. Such ear reconstructions are usually done around ages 6 to 8 years old.

medpor-ear-framework-dr-barry-eppley-indianapolismedpor-ear-framework-back-side-dr-barry-eppley-indianapolisBoth microtia ear reconstruction methods have their own unique advantages and disadvantages. The Medpor ear reconstruction framework offers the advantages of a well-shaped preformed ear framework and the avoidance of a donor rib scar and harvest site. Because it is a stiff material, however, it can feel fairly rigid. The rigidity of the wedge on the back part of a Medpor ear framework, which allows it to have good projection from the side of the head, can be a source of ear stiffness and rigidity.

medpor-ear-framework-reduction-dr-barry-eppley-indianapolismedpor-ear-reconstruction-fat-grafrt-dr-barry-eppley-indianapolisTo reduce the rigidness of a Medpor ear reconstruction, the wedge on the back part of the ear framework can be shaved down from an incision on the back of the ear. This is then filled with a dermal-fat graft placed into the space where the wedge of Medpor material was removed. Some slight projection of the ear reconstruction may be lost but the ear will have some flexibility when pressed on.

While many rib graft microtia reconstructions need projection and a more rigid graft placed behind it, a synthetic framework often needs the opposite. The preformed framework provides good projection but at the expense of ear stiffness. The ear is made of flexible cartilage that springs in and out and that is a feature that a plastic material can not do.

Dr. Barry Eppley

Indianapolis, Indiana

Surgical Correction of the Constricted Ear Deformity

Monday, May 30th, 2016

 

One of the major types of congenital ear deformities is that of the constricted ear. It is estimated that it represents about 10% of all congenital ear deformities. It is a variable ear deformity that has been described by multiple classification systems (e.g. Tanzer, Cosman, Ngata) with associated surgical strategies based on its classification. The numerous classification systems can be confusing and it is not easy to always define what type of surgery is best for the variable presentations in which the constricted ear is seen.

Constricted Ear Reconstruction with Rib Graft Insertion Dr Barry Eppley Indianapolis Constricted Ear Reconstruction with Rib Grarft Dr Barry Eppley IndianapolisIn the May 2016 issue of Plastic and Reconstructive Surgery, a paper was published entitled ‘Classification and Algorithmic Management of Constricted Ear: A 22-Year Experience’. Over 160 ears that had a lidded helix, compressed scapha and triangular fossa and an overall cuplike appearance were used as the clinical material for the study. The authors classification system uses a antihelical tubing test and a scapha-helix push test. By these two methods four types of contricted ear are identified. Type 1 constricted ears can be treated by an antihelical tubing procedure using horizontal mattress sutures placed on the backside of the ear. A type 2 constricted ear was treated by  tumbling concha-cartilage flap combined with a mastoid hitch suture. In type 3 constricted ears an antihelical wrapping technique using a free floating rib cartilage graft was used. In type 4 constricted ears where a shortage of helix exists, a helical expansion technique using a rib graft and preauricular and scapha skin flaps was used.

Based on their experience the authors have evolved to the following concepts for the constricted ear. First, waiting to age 12 or older allows for better results. Second, the existing cartilage framework was not sectioned but rolled and grafted to prevent unnatural shapes. Third, rib grafts are better than ear cartilage grafts for helical expansion. Lastly, the protruding part of the constricted ear is often overlooked and needs to be corrected by mattress sutures and/or mastoid hitch sutures.

The constricted ear and microtia have some overlap in their features. What separates them surgically is that in the constricted ear the existing cartilage framework is maintained and cartilage and soft tissue flaps are added to it. In microtia, the existing framework is unusable and has to be replaced. This paper provides an effective surgical strategy for the constricted ear that allows for a single stage correction without removal of any of the existing ear framework

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Macrotia Ear Reduction

Sunday, December 6th, 2015

 

Background: The embryology and development of the human ear is a marvel in not only its complexity but how well it works most of the time. It is created by the merging of six separate tissue segments (hillocks) in utero that create the recognizable ear that is a collection of various ridges and valleys. But due to its complex shape the ear is prone to a wide variety of congenital anomalies of which microtia is the most severe.

macrotiaThe opposite of microtia is macrotia where the ear is abnormally large. Unlike microtia where various parts of the ear are either missing or deformed, in macrotia the ear components are normal but bigger than desired. The ear is usually felt to be large primarily because it is vertically long. Various parts of the ear may be bigger than normal but usually the upper and lower thirds of the ear are what is too long.

The average height of the ear, as measured from the bottom of the lobule to the top of the upper helix, is in the range of 60 to 65mms. (average of 63mms) While they are some slight differences in these measurements between men and women, they are not all that different. (around 5% or less) The average length of the earlobe is around 18mms or about 1/3 of the total ear height.The average height of the pinna or cartilaginous portion of the ear, calculated by subtracting the earlobe height from the total ear height, was around 45mms.

Case Study: This 27 year male had ears that he felt were too big (long) as well as stuck out. He had seen other plastic surgeons but they only wanted to fix the protruding aspect of them. His total ear height was 76mms with an earlobe length of 24mms.

Vertical Ear Reduction result intraop Dr Barry Eppley IndianapolisUnder local anesthesia with infiltration around the base of his ear, three specific ear reshaping procedures were done. The earlobe was vertically reduced by 6mms with a helical rim excision technique. The upper third of the ear was reduced by 7mms using  scaphal excision of cartilage and outer skin with a helical rim reduction. (scapha-helical rim flap) Lastly ear was set back with concha-mastoid sutures from a postauricular incision. At the end of the procedure the total ear height was 65mms.

Macrotia ear reduction is done by reducing the height of the ear from the top (scapha-helical reduction) and bottom (earlobe reduction) simultaneously. Correction of any ear protrusion can be safely done during macrotia reduction surgery.

Highlights:

  1. Macrotia is an aesthetically abnormal enlargement of the ear that is most manifest in the vertical dimension.
  2. Macrotia ears usually have a combined increased height of the upper ear and longer earlobe.

3) Macrotia ear reduction surgery is done by an upper ear scapha-helical reduction flap and a helical rim earlobe reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Burn Ear Reconstruction Options

Saturday, August 29th, 2015

 

Ear reconstruction is challenging and is put to the test when portions of the ear are lost from a burn injury. Burned ears present with a unique situation due to the pattern of ear loss. Almost always the external auditory canal and the cartilaginous tragus and portions of the antihelix may remain. But the outer helix and earlobe are often lost due to the greater exposure of the outer framework of the ear to the heat source.

Maintenance of the external auditory canal and the surrounding cartilage is always beneficial in ear reconstruction as these ear areas can be the hardest structures to surgically recreate. But the burnt tissue around the remaining stump of the ear, which has usually been skin grafted, poses a dilemma for outer ear framework reconstruction. The skin is not pliable and can not be used/elevated to provide any skin coverage over a helical cartilage reconstruction.

Burned Ear Reconstruction with Rib Graft result Dr Barry Eppley IndianapolisThere are two methods to create the necessary skin coverage for burn ear reconstruction. The most common is the use of a tissue expander as a first stage procedure. The surrounding skin grafted/burned skin can be slowly expanded directly over where the recreated helix will be. Once adequately expanded a cartilage graft can be used to make the helix and placed under the expanded. The key here is slow tissue expansion to prevent breakdown of the scarred skin.

Burn Ear Reconstruction 2  result Dr Barry Eppley IndianapolisThe second approach is to use the scarred skin around the ear stump as a pedicled skin flap. The raised skin is rolled onto itself and cartilage grafted underneath it. This will require that a skin graft be done to cover the area left raw from where the skin flap was raised.

There is also a third approach where an ear cartilage framework is covered by a pedicled temporal fascial flap. This requires of course an intact temporal artery pedicle which may or may not be present. The fascial flap covers the framework and is then skin grafted.

The burn ear deformity presents a different reconstructive challenge than that of congenital microtia for example. It suffers from poor quality surrounding skin cover and thus requires a different strategy for providing soft tissue coverage over a cartilage framework reconstruction.

Dr. Barry Eppley

Indianapolis, Indiana

Simultaneous Stahl’s Ear and Constricted Ear Corrections

Thursday, July 30th, 2015

There are numerous types of congenital ear deformities. The constricted ear represents a tightness of the ear like a cinch around the outer helix of the ear which makes it smaller and often folded somewhat onto itself. The Stahl’s ear deformity, also known as a Vulcan or Spock ear, has a cartilage fold that can cause a pointed malformation in the upper part of the ear. Both types of ear deformities are uncommon but are even more rare when they occur together.

In the July 2015 issue of the International Journal of Plastic Reconstructive and Aesthetic Surgery, an article appeared in print entitled ‘ Surgical Correction of Constricted Ear combined with Stahl’s Ear’. Over a seven year period, the authors had 19 patients with constricted ear with Stahl’s ear, most of whom had it on just one side. They were surgically treated by a technique that consisted of an initial double Z-shaped skin incision made on the back side of the ear with the entire layer of cartilage cut parallel to the helix traversing the third crus to form a fan-shaped cartilage flap. The superior crus of the antihelix were shaped by folding the cartilage rim. The cartilage of the abnormal third crus was made part of the new superior crus of the antihelix and the third crus was eliminated.

Postoperative assessment of the ear reconstructions based on symmetry, helical stretch, successful elimination of the third crus, the auriculo-cephalic angle, and the substructure of the reshaped ears. All reconstructions were rated as excellent to good without any complications seen. This study shows that even the rarest of congenital ear deformities can be successfully treated with the proper surgical technique.

In the human ear the bifurcated Y-shaped superior and inferior crus is a major component of its upper half. In Stahl’s ear deformity an aberrant crus usually replaces the superior crus, crossing the scaphoid fossa from the site of the normal bifurcation of the antihelix posteriorly towards the helix which gives it an abnormal J-shape. A surgical technique to correct Stahl’s ear deformity can be done by a Z-plasty to the incision to lengthen the skin on the posterior surface, together with making use of the aberrant crus to reconstruct the superior crus without reducing the ear size using horizontal mattress sutures. This is achieved by posterior scoring and suturing without any cartilage excisions which converts the J antihelix into a Y antihelix.

Adding the constricted ear problem to the Stahl’s ear raises the stakes in terms of reconstructive difficulty. The tightness of the skin and shortage of cartilage necessitates the need to release the constricted cartilage into a fan shape and use Z patterned incisions on the back of the ear.

Dr. Barry Eppley

Indianapolis, Indiana

Lop Ear Deformity Reconstruction with Rib Graft

Sunday, June 7th, 2015

 

The shape of the ear is incredibly complex and it is a miracle that the ear is properly formed as often as it does. But when it does not become adequately shaped there are many possibilities for its deformity. One such category of congenital ear deformity is that of the constricted ear. This is where the outer rim of the ear is smaller than it should be or tightened…much like that of a cinch around a waistband.

lop eqar beforeOne form of a constricted ear deformity is that of the lop ear or lidding deformity. Like the well known lop eared rabbit, this is where the top half of the ear folds over onto itself. This is due to a deficiency of natural cartilage or normal cartilage stiffness in the upper third of the ear involving the scapha, superior crus and triangularis fossa. Without this support the superior helix folds over causing a marked decrease in vertical ear height as well.

While the lop ear can be easily folded back up into an upright position manually, it will not so easily stay that way for it lacks structural support to remain so. Thus simple cartilage suturing, like that in a setback otoplasty (ear pinning), will not usually work or will only have short term shape retention. Cartilage grafting is usually need to provide the support or ‘framework’ for ear shape retention.

Lop Ear Reconstruction with Rib Graft Insertion Dr Barry Eppley IndianapolisLop Ear Reconstruction with Rib Grarft Dr Barry Eppley IndianapolisThe cartilage graft can be easily harvested from the tail end of the one of free floating ribs. (numbers 9 or 10) Only a 2 to 2.5 cm length of rib graft is needed that is carved to a curved shape with the perichondrium removed from the convex side. The rib graft is inserted behind the ear through a postauricular incision after a pocket has been made and the entire folded cartilage exposed. The ear is then folded back and the rib graft placed between the folded sides and sutured into place. This provides a stable construct for the ear to heal in its new shape.

The severe lop ear deformity is best reconstructed with a small rib graft. This ensures the ear will heal in an upright position without risk of a recurrent fold over due to inadequate cartilage support.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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