PRELIMINARY REPORT ON TWENTY-FIVE CASES OF EXTERNAL EAR CONSTRUCTION IN CHILDREN

By DAVID MATTHEWS, M.D., M.Ch. F.R.C.S., IVOR BROOMHEAD, M.Chir., F.R.C.S. and CARLOS ROXO, M.D.

The Hospital for Sick Children, Great Ormond Street, London

THIS is a preliminary report on the total external ear construction in congenitally de- formed children by the Tanzer technique (1959) at the Plastic Surgery Department of The Hospital for Sick Children, London.

Twenty-five patients have been treated between July 1959 and March I966.

Distribution

Sex Bilateral

Males 2i

Females 4

Total 25

Right Side Left Side

I2 8

I 2

13 I0

Associated Features (a) External auditory meatus.--Absent in I6 patients ; deformed in 2 patients. (b) Facial asymmetry.--Mandibular hypoplasia, 4 ; maxillaryhy poplasia, 2 ;

zygomatic hypoplasia, 2 ; I case of Treacher-Collins syndrome. (c) Accessory auricles.--4 patients. (d) Contra-lateral bat ear.-- 3 patients. (e) Branchial fistula.--I patient. ( f ) Macrostoma.-- 4 patients.

The Stages o f Surgery Stage I . - -The transposition of the ear lobe as a flap to a position symmetrical to

the other ear lobe. All unwanted residual ear cartilage is usually excised during this stage.

Stage 2.--Dissection of the costal cartilage from the seventh, eighth and ninth ribs on the side opposite to the side of the deformed ear. Modelling and inserting it super- ficially under the auricular skin through an anterior incision, maintaining the helix ridge with through-and-through sutures tied over capillary rubber tubing. When necessary a Wolfe graft obtained from the costal incision is used to make good any defect in the skin cover in the region of the concha.

Stage 3.--Creation of the bucket handle, using a split skin graft if necessary. (Note : Tanzer (I963a, b) more recently suggested the insertion of a crescentic piece of cartilage into the retro-auricular region prior to the closure of the bucket handle in order to improve the auriculo-cephalic angle.)

Stage 4.--Closure of the bucket handle with a semicircular flap from the side of the head roiled outwards and sutured to a shallow flap from the back of the anti-helix. The posterior denuded area is covered with a Wolfe graft i f necessary.

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46 BRITISH JOURNAL OF PLASTIC SURGERY

Stage 5.raThe formation of a tragus by means of a flap from the conchal wall based anteriorly and rolled on itself, skin grafting the defect.

The results are illustrated in Figures I and 2.

FIG. I

Average result in unilateral case. A, Pre-operative. B and C, Post-operative result.

C o m m e n t a r y on the Opera t ive Procedures

Stage I.--Eighty per cent. of the cases had this stage executed at the age of 3 to 4 years. Only three had a relatively well positioned ear lobe ; all of them needed to have rudimentary ear cartilage removed.

Stage 2.--Usually performed four months after the previous stage, but in some instances combined with Stage I.

Stages 3, 4 and 5.--Performed usually at intervals of four to five months. Some patients exhibited a hairy skin area over the upper pole of the reconstructed

auricle because of insufficient non-hirsute skin under which to bury the cartilage. At first this was treated by excision of the hair-bearing area and skin grafting the defect ; more recently by lifting the area and excising the follicles from beneath it.

The formation of an external auditory meatus by grafting a channel, drilled into the mastoid bone, with a skin graft was done in those cases where there was impaired hearing on both sides, and usually after the fourth stage.

EXTERNAL EAR CONSTRUCTION IN CHILDREN 47

E

FIG. 2 Condition complicated by facial hyo- plasia, downward displacement of auricular tags and macrostoma. A and B, Pre-operative. C~ After Stage 2 operation. D and E, Post-operative

result.

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More than 5o per cent. of the patients submitted to the above sequence of operation have been re-admitted at least once for further surgery to improve the cosmetic appear- ance.

Complications (a) Infection.--This occurred at some stage of the repair in 6 of the 25 cases. Only one can be attributed to an operative infection in a total of 128 operations.

In this case total loss of the cartilage implant resulted. One patient developed infection a few days after leaving hospital following the

cartilage implant. The portal of infection was almost certainly an unhealed suture hole over the cartilage. Slight marginal loss of the helix cartilage followed.

In three cases infection was secondary to exposure of cartilage, trauma at home being the precipitating factor in two of these patients. Cartilage loss was only slight.

In the final case the middle ear had previously been explored and had resulted in a persistently moist and slightly infected cavity.

(b) Necrosis.rain two cases there was some loss of the lobule after setting it back in Stage I ; in one the loss was extensive.

(c) Hcematoma.--This occurred once after the Stage 2 procedure. (d) Wire.--Wire used to fashion the cartilage came through the skin in three cases

and was removed without causing further trouble. (e) Injury.--Injury after completion of the repair in the wear and tear of school life

caused cartilage exposure in two cases and ulceration of the skin graft in two. ( f ) Pleura.--This was opened three times in t~king the 25 grafts. No complication

followed immediate closure.

Evaluation of Resu l t s . - - I t has been stated by Peet and Patterson (1963) that an ear reconstructed surgically, even though imperfect, is preferable to a prosthesis in, young patients. With this we entirely agree.

In general, the results have been in our opinion cosmetically acceptable, but in almost every case the depth and definition of eventual contour has been less satisfactory than the initial result. This has appeared to be due both to absorption of cartilage and to contraction of the skin cover, drawing it out of the concavities.

The ears were almost all too flat against the head. It is intended to try to rectify this by the retro-auricular insertion of the angled piece of cartilage as recommended by Tanzer.

REFERENCES

PEET, E. W., and PATTERSON, T. J. S. (1963). " The Essentials of Plastic Surgery." Oxford : Blackwell.

TANZER, R. C. (1959). Plastic reconstr. Surg., 23, I. - - (i963a). Plastic reconstr. Surg., 31, 16. - - ( i 9 6 3 b ) . Trans. int. Soc. plast. Surg., 3rd Congress, Washington. Amsterdam:

Excerpta Medica.