Preoperative Planning

The successful grafting of a well-sculpted cartilage framework is the foundation for a sound ear repair. By accomplishing this as the first surgical stage, one takes advantage of the optimal circulation and elasticity of inviolated virgin skin. With this in mind, I avoid initial repositioning of vestige remnants, as resulting scars can inhibit circulation and restrict the skin's elasticity and ability to accommodate a three-dimensional framework [13]. Secondary procedures, such as earlobe rotation, tragus construction, and elevating the ear, take place upon sound healing of the "foundation." Shortcuts with so-called "one-stage repairs" [15] are risky and produce ears that inevitably require further detailing to achieve a quality result [91].

Figure 12. Planning the auricular framework from a reversed film pattern traced from the opposite, normal ear.

Figure 12 - Rreversed film pattern traced from the opposite, normal ear.
From Brent, B.: Total auricular construction with sculpted costal cartilage. In B. Brent (Ed.), The Artistry of Reconstructive Surgery, St. Louis, 1987, The C.V. Mosby Co., pp. 113-127.

I initiate the planning by first tracing a film pattern from the opposite normal ear, which is reversed and used to plan the new framework (see Fig. 12). I then make a new pattern several millimeters smaller in all dimensions to allow for the extra thickness which occurs when the cartilaginous framework is inserted under the skin. The framework's inferior pole is greatly reduced to accommodate the earlobe upon its transposition. As mentioned before, if the patient has no usable earlobe tissue, I carve the framework's lower end to resemble an earlobe (see Fig. 11). This is further defined when I separate the ear from the head with a skin graft.

I predetermine the ear's location in the office by studying the opposite side and making facial measurements that help to achieve symmetry with the opposite normal ear. I note the ear's axial relation to the nose, its distance from the corner of the eye, and its lobule's position, which is usually displaced upward (see Fig. 13). The ear's new position is straightforward and relatively easy for me to plan in a pure microtia, but much more difficult when severe bony and soft tissue deficiency exists. Not only are the heights of the facial halves asymmetrical, but the anterior-posterior dimensions of the affected side are foreshortened as well. In these patients, one best plans the new ear's height by lining it up with the normal ear's upper pole (it's distance from the eye is somewhat arbitrary).

Figure 13. Preoperative determination of auricular location.



Figure 13 - Preoperative determination of auricular location.
The ear's slant is positioned to match the opposites side, roughly parallel to the profile of the nose; the distance is matched from the corner of the eye; and the microtic lobe's position is noted (usually displaced upward) when tracing the reverse film pattern, so that the lobe will eventually be positioned correctly when it is transposed into position and "spliced" onto
the new ear during the second stage of the surgical repair.

In pure microtia, the vestige-to-eye distance mirrors the ear-to-eye distance of the opposite, normal side. However, in severe hemifacial microsomia patients, the vestige is much closer to the eye. If one places the new ear's anterior margin at the vestige site, then the ear appears too close to the eye; if one uses the measured distance of the normal side as a guide, then the ear looks too far back on the head. In these patients, I find it best to compromise by selecting a point halfway between these two positions.

When both auricular construction and bony repairs are planned, careful, integrated timing is essential. Most often the family pushes for the ear repair to begin first, which helpfully assures the auricular surgeon virginal, unscarred skin. The craniomaxillofacial surgeon argues that by going first he will correct the facial symmetry, thus making ear placement easier. I find this unnecessary when the above described guidelines are followed [23].

If the bony work is done first, it is imperative that scars are peripheral to the proposed auricular site, and that they do not lie precariously over the future region of the ear.