cranioauricular angle of the reconstructed ears was similarto the opposite ears in 36 cases (Figures 5e12). There weretwo cases of asymmetry because of the contraction of thehypertrophic scar in the retroauricular sulcus. Thiscomplication was treated by excision of the hypertrophicscar and lining with a full-thickness skin graft.
Discussion
Over the past few years, the technique of elevating theburied ear framework in the stage of microtia correction hasshifted from skin grafting to the use of costal cartilage in theretroauricular sulcus. The projection of the reconstructedear was achieved by placing a wedge of costal cartilagebehind the framework. The costal cartilage was harvested inthis operation or the cartilage was banked underneath thechest incision during the stage of ear reconstruction.However, this technique would aggravate any deformity ofthe chest wall. Although Lim used a resorbable platecomposed of polylactic and polyglycolic acid as a substitutefor the costal cartilage wedge, future study is necessary todetermine its long-term effectiveness.7
A block of amorphous remnant ear cartilage is presentbeneath the concha area in lobule-type microtia. However,during conventional reconstructive surgery, this remnantcartilage was usually excised when the framework wasimplanted, freeing maximal skin to drape over the frame-work.1,2 With clinical observation and histological tests, wefound that the remnant ear cartilage could be used tofabricate and act as supporting tissue. In order to apply theremnant ear cartilage to ear reconstruction, we incorpo-rated the stage of the construction of the tragus and thestage of lifting the ear into one stage. Although theincisions were in the concha and retroauricular areas, therewas no one case of necrosis of the skin covering theframework. We preferred to transplant with the connectivetissue beneath the remnant ear cartilage which acted asthe pedicle. In most cases the remnant ear had enoughvolume to support the ear. In some cases the remnant earcartilage could be used to combine with the costal cartilageif the volume was insufficient. The remnant ear cartilagewas stable and the follow-up study of 1e2 years showed noabsorption. Future studies are required to determine thelong-term effectiveness of this procedure and how itcompares with the cartilage wedge graft technique.
References
1. Boudard P, Benassayag C, Dhillon RS, et al. Aesthetic surgery formicrotia. Arch Otorhinolaryngol 1989;246:349e52.
2. Meyer R, de Goumoens R, Derder S. Combined aesthetic andfunctional treatment of microtia. Aesthetic Plast Surg 1997;21:159e67.
3. Staffenberg DA. Microtia repair. J Craniofac Surg 2003;14:481e6.
4. Brent B. Technical advances in ear reconstruction with autog-enous rib cartilage grafts: personal experience with 1200 cases.Plast Reconstr Surg 1999;104:319e34 [discussion 335e8].
5. Yoshimura K, Asato H, Nakatsuka T, et al. Elevation of a con-structed auricle using the anteriorly based mastoid fascial flap.Br J Plast Surg 1999;52:530e3.
6. Ou LF, Yan RS, Tang YW. Firm elevation of the auricle inreconstruction of microtia with a retroauricular fascial flapwrapping an autogenous cartilage wedge. Br J Plast Surg2001;54:573e80.
7. Lim SY, Mun GH, Hyon WS, et al. The elevation of the con-structed auricle with a temporoparietal fascial flap wrappinga resorbable plate. J Plast Reconstr Aesthet Surg 2006;59:505e9.
Haiyue JiangBo PanLin Lin
Yu LiHongxing Zhuang
Plastic Surgery Hospital, Peking Union Medical college,Beijing, People’s Republic of China
E-mail address: [email protected]
ª 2008 Published by Elsevier Ltd on behalf of British Association ofPlastic, Reconstructive and Aesthetic Surgeons.
doi:10.1016/j.bjps.2008.03.058
Correspondence and communications 277
Earlobe morphology: a simpleclassification of normal earlobes
Earlobe deformities, whether congenital or acquired, havebeen described in the literature and various operationsdealing with their reconstruction have been reported. Mostof the anatomical and morphological studies of the normalear focused on the dimensions and angles of inclination ofthe ear as a whole. A few comparative studies have beenpublished focusing on the earlobe morphology in males andfemales as well as the changes in the size of the earlobewith age.1e4
Subjects and methods
This study was based on a survey of the form of 400earlobes in 200 adult volunteers (100 males and 100females) of different ages and ethnic origins in a mixedpopulation, including Arabs (70%), Asians (26%) and Euro-peans (4%) (Table 1). The patients were between 18 and 70years of age (mean 37.47, median 36). The volunteers werechosen randomly. Any volunteer with previous trauma,surgery or congenital anomaly of the earlobe or face liftwas excluded from the study.
Results
From this survey it was found that normal earlobes may besimply classified into three groups according to the angle ofthe junction of the earlobe with the cheek:
Type A: acute angle, where the lobe is free from thecheek (Figure 1a).Type B: right angle (Figure 1b).Type C: obtuse angle (Figure 1c).
278 Correspondence and communications
Types B and C are adherent earlobes but the adherenceis more clear in type C. Sixty-five per cent were found tohave free pendulous (acute angle) earlobes, while 35% hadan adherent (nonpendulous) earlobe. Of these, the right-
angled lobes were more common making up 23.5%, whilethe obtuse-angled lobes made up 11.5% of the total. Anal-ysis of the correlation between the dependent variable (eartype) and the independent variables (age, origin and sex)resulted in correlation coefficients of 0.01, 0.18 and 0.04,respectively. Hence, the highest correlation, at only 0.18, isbetween the ear type and origin. The ear type as a functionof origin is shown in Table 3. In this studied sample, thepercentage of the free lobe to the adherent lobe was thesame in both males and females, but the difference was inthe form of adherence. Type C lobes were less common inmales (9%) compared to type B (26%), while in females the
Table 1 Number and origin of surveyed individuals
Arabs Asians Europeans
Total number 140 52 8Percentage (%) 70 26 4
Figure 1 Classification of the earlobes according to the angle between the earlobe and the cheek. (a) Type A: acute angle.(b) Type B: right angle. (c) Type C: obtuse angle.
Correspondence and communications 279
difference was less evident, being 14 and 21%, respectively(Table 2). Statistical analysis using a single factor ANOVAtest correlating the types of earlobes to age, sex and originshowed no statistical significance (P> 0.05), with thehighest correlation (P Z 0.15) being between types B and Cand origin, either Arabs or Asians. Europeans were excludedas the sample was very small (4%) (Figure 2). None of thesurveyed individuals with the adherent earlobes consideredhis or her earlobe as abnormal, most of them were evenunaware of having an earlobe which was different thanother individuals, and none of them sought medical advicefor this. Earlobes were of the same bilateral type in all ofthe surveyed individuals. One female, who was not includedin the survey, had previously undergone a face lift severalyears earlier and was found to have a type A earlobe on theright side (Figure 3a) while the left earlobe was type C(Figure 3b). Ignoring the type of earlobe preoperatively maylead to such asymmetry postoperatively.
Discussion
In their detailed study of the morphology of the earlobeAzaria et al.1 mentioned the different forms to be pendu-lous and nonpendulous with no indication of the incidenceof each type. They recommended creating nonpendulousearlobes when reduction is indicated to avoid further ptosispostoperatively.
In contrast, the classification of the earlobes as ptosedand pseudoptosed by Mowlavi et al.2,4 considered thatearlobes attached for more than 15 mm are to be consid-ered pseudoptosed, and classified ptosis into six gradesfrom 0eV, where the adherent earlobe is classified as Grade0 ptosis. They advised reduction of earlobes only when
Table 2 Classification of the forms of the earlobesaccording to the angle of junction between the earlobe andthe face
Type A(acute angle)
Type B(right angle)
Type C(obtuse angle)
Males 65 26a 9a
Females 65 21a 14a
Total % 65 23.5 11.5a Statistical analysis using a single factor ANOVA test corre-
lating types of earlobes to sex showed no statistical significance(P> 0.05).
Table 3 Correlation between ear type and origin
Origin Type A(acute angle)
Type B(right angle)
Type C(obtuse angle)
Arabs 94 35a 11a
Asians 33 11a 8a
Europeans 3 1 4a Statistical analysis using a single factor ANOVA test corre-
lating types B and C to origin (Arabs and Asians) showed nostatistical significance (P> 0.05).
ptosed more than 5 mm and discouraged Azaria et al.’s1
recommendation of creating adherent earlobes withreduction as, according to their survey, the adherentearlobe was not the preferred ideal aesthetic earlobe inNorth American Caucasians.5
The high incidence of adherent earlobes in the normalpopulation (about 1:3) obliges us to consider it as a variantof the normal, and so we should avoid giving it names whichindicate an abnormality like pendulous, pseudoptosis orGrade 0 ptosis. It should rather be classified as a ‘type’according to the angle it forms with the cheek and it shouldbe respected when planning any form of reduction orreconstruction. Any change from one type to anothershould be discussed with patient preoperatively. In thereconstruction of a unilateral congenital split earlobe, the‘type’ of the normal earlobe is of utmost importance inchoosing the technique to avoid asymmetry. Earlobes wereof the same type bilaterally in all of the surveyedindividuals.
This simple classification may be noted at a glance withno need for any measurements and may be very useful inachieving aesthetically pleasing results for any surgery onthe earlobe and face lift incisions.
0
20
40
60
80
100
120
140
160
Arab Asian EuropeanOrigin
Samples
C
B
A
b
a
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Arab Asian EuropeanOrigin
Percent
C
B
A
Figure 2 Earlobe types and origin in the studied sample.
Southeast Asia, Northern and central Australia, and Centraland South America. Sporadic cases are seen in temperateregions, e.g. the UK. It is the most common cause of fatalcommunity-acquired bacterial pneumonia in endemicareas.1,2 We report an unusual case of a recurrent ulcersubsequently diagnosed as melioidosis.
A 24-year-old Taiwanese male with a non-healing woundover the left knee was evaluated. Examination revealeda 4� 5 cm ulcer containing plaques and clusters. Therewere no palpable lymph nodes. Laboratory studies andchest and knee X-rays were normal. A debridement andsplit-thickness skin graft were performed, and cephazolin,i.v., followed by ceflexin, po, were administered.
Purulent drainage was noted 14 days postoperatively.Ceflexin and topical neomycin were given. The woundworsened and biopsy-like holes with yellowish dischargewere noted (Figure 1). We performed a complete excisionof the lesion site and a split-thickness skin graft. Cephazolinand gentamicin i.v. for 3 days followed by ceflexin po were
pe A. (b) Left ear post facelift, type C.
280 Correspondence and communications
References
1. Azaria R, Adler N, Silfen R, et al. Morphometry of the adulthuman earlobe: study of 547 subjects and clinical application.Plast Reconstr Surg 2003;111:2398.
2. Mowlavi A, Meldrum DG, Wilhelmi BJ, et al. The aestheticearlobe: classification of lobule ptosis on survey of northAmerican caucasians. Plast Reconstr Surg 2003;112:266.
3. Brucker MJ, Patel J, Sullivan PK. A morphometric study of theexternal ear: age-and-sex related differences. Plast ReconstrSurg 2003;112:647.
4. Mowlavi A, Meldrum DG, Wilhelmi BJ, et al. Incidence of earlobeptosis and pseudoptosis in patients seeking facial rejuvenationsurgery and effects of aging. Plast Reconstr Surg 2004;113:712.
5. Mowlavi A, Meldrum DG, Wilhelmi BJ. Earlobe Morphology delin-eated by two components: the attached cephalic segment andthe free caudal segment. Plast Reconstr Surg 2004;113:1075.
Raeaf El Kollali51, Mohammed Mazhar Street,
Apt. 4, Zamalek e 11211,Cairo, Egypt
E-mail address: [email protected]
ª 2008 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2008.01.046
Figure 3 (a) Right ear post facelift, ty
Recurrent cutaneous melioidosistreated with surgery andantibiotics
Melioidosis (Whitmore’s disease) is an infectious diseasecaused by Burkholderia pseudomallei, endemic in
Figure 1 Chronic ulcer 1 month after split-thickness skingraft.
