Anatomy:

• Posterior auricular artery: anterior/posterior surface of auricle
• Superficial temporal artery: lateral surface of auricle
• Occipital artery: supplies posterior auricular skin
• Veins: drain into external jugular
• Nerves: great auricular nerve (lower lateral portion and inferior cranial surface); auriculotemporal (superior lateral/superior anterior surface of external acoustic meatus), Lesser occipital nerve (superior cranial surface), arnolds nerve (vagus) posterior inferior EAC and inferior conchal bowl
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• Lymphatic drainage: correlates with embryologic hillocks
• Tragus, root of helix, superior helix (from first branchial arch)- parotid nodes
• Antihelix, antitragus, lobule (second branchial arch)- cervical nodes
• Aesthetic relationships of ear: one ear length posterior to lateral orbital rim/ superior edge to superior edge; 5.5-6.5cm, 2:1 H:W; protrudes 1-2cm, incline is 25 degrees, tilts 20 degrees
• Projection 10mm S, 16mm M, 20mm 

External ear development: end of first trimester, 6 mesenchymal proliferations, hillocks form first pharyngeal cleft (from first and second arches) 4-10 weeks

• Branchial arches: 4th week of gestation 
• Auricle arises from 1-2 branchial arches –> 6 hillocks
• 1-3 hillocks: tragus, root of helix, superior helix
• 4-6: posterior helix, antihelix, antitragus, lobule (antihelix from second branchial arch)
• Meckel’s cartilage: first branchial arch
• Middle ear first pharyngeal pouch
• Failure of antihelix to form during weeks 12-16 results in protruding scapha

Ear Anomalies

• Microtia:
• absence of external ear structures due to abnormal development of 1st, mandibular, or second- hyoid arches. –>inner ear not affected
• 4-12th week intrauterine development 
• Can be associated with Goldenhar: orbital auricular vertebral syndrome or 7th brachial clefts 
• Treacher collins most associated with microtia (first and second branchial arches)
• For microtia-external hearing aids can be placed 6-12 months, reconstruction 6-7yrs, ear canal creation 13-19
• Delay ear reconstruction until 6 years
• BAHA hearing implants (behind mastoid) should be placed after autologous ear reconstruction
• Autologous reconstruction typically performed 6-7 years of age –> sufficient rib cartilage for reconstruction. Ear obtains 85% of growth at 3, fully developed by 5-7
• Difference between nagata and brent (stages 2 vs 3 or more) and the reconstruction of the tragus and lobule
• Nagata typically fewer stages
• Difference is how the lobule and tragus are reconstructed. In brent technique the lobule and tragal reconstruction are separate, but in nagata these are elevated during the same stage
• Both use autologous rib cartilage for framework
• Continuous closed suction drainage best for adherence of skin graft to cartilage construct
• Silastic frameworks not long lasting; however, alloplastic reconstruction can be successfully performed  with the temporoparietal fascial flap to cover the implant (based on the superficial temporal artery)
• Requires incisions on the hair bearing scalp, skin grafting is also required
• Stahl ear: 
• third crus, flattening of antihelix, unfurling of the helical rim, and absent superior crus of the antihelix 
• Tx: advancement of the third crus (IE local cartilage flap) to reconstruct a more antihelical fold
• Cryptotia hidden ear: congenital deformity of cartilage of the scapha and antihelix– upper pole of ear is buried beneath scalp, superior auriculocephalic sulcus is absent 
• From abnormal distribution of the intrinsic transverse and oblique auricular muscles
• treatment is surgical release when child is older –>Helical release with STSG (superior portion of auricle)
• Constricted rim: partial detachment of helix from scapha and resuturing helix at more appropriate angle
• Cup ear deformity: hooding of scapha and helix, flattening of antihelix
• Lop Ear: protrusion of the ear, folding of the superior helix
• Flag flap transfer
• Prominent ear: characterized by widening of the conchoscaphal angle, increased auriculocephalic distance  loss of antihelical fold, described as conchal valgus
• upper/middle affected –> conchoscaphal angle >90, helix positioned 12-15mm from the temporal region, cephaloauricular angle increased typically >25
• Middle ear prominence from hypertrophy of concha, depth of more than 1.5cm, middle third located more than 16-18mm away from mastoid
• Mustarde technique for prominent ear: placement of permanent sutures through cartilage and perichondrium on cranial portion of ear to bend helix posteriorly from scapha cartilage to conchal cartilage
• Scapha to concha
• Stenstrom’s: anterior surface of antihelix bent and cartilage scored to create posterior roll
• Luckett: crescent shaped portion of skin and cartilage excised from length of antihelix–> edges sutured to recreate fold
• Furnas technique: sutures placed from concha to mastoid to diminish size of concha
• Inadequate reduction of concha can protrude lobule, overtightening of mastoid sutures lead to pinned back appearance
• Webster: corrects prominent helical tail by fixation of helical tail to concha
• Resection of concha, resection of post auricular skin
• In children sutures are effective in creation of antihelical fold because cartilage is soft and pliable
• Prominent ear most likely complication is recurrence
• Telephone ear: excessive reduction of concha, inadequate correction of prominent upper/lower poles during otoplasty

Ear Molding: Estrogen responsible for growing ear cartilage in the neonatal period

• Complications: most common is skin ulceration
• Auricular molding at 3 days for increased maternal estrogens. Can initiate as far out as 3 months of age
• 2 month treatment with molds for ear deformities
• When treatment is delayed several weeks success rate drops to 50% (90% in some studies)
• Can treat prominent ear, cryptotia, lop ear, stahls ear

Trauma

• Blunt trauma: hematoma most common complication–> evacuate with bolster dressing –> complication cauliflower ear (subperichondrial hematoma over devascularized cartilage)
• Burns: mafenie acetate, noncompressive dressings (pseudomonas most common cause suppurative eschar)
• Chondrodermatitis nodularis chronica helicis: painful, chronic nodular or cystic ulcerative lesions seen in superior pole of helix –> mistaken as malignancy –> complete excision, biopsy and underlying cartilage, and closure

Defect Reconstruction

• Squamous CC most common on ear
• Partial thickness defects: (perichondrium intact) –> SG taken from c/l post auricular region 
• Perichondrium missing –> wedge excision <1.5cm defection  –> pre and post auricular defects rotated and advanced; or two bipedicle flap technique
• Traumatic ear: variable partial thickness without stating if perichondrium is intact –> debride with local wound care and let it demarcate
• Full thickness: Helical Rim
• Small defects <2cm: contralateral composite graft (less 1.5cm), antia-buch procedure, chondrocutaneous rotation flaps 
• Helical defects
• Antia Buch: incision through helical sulcus through skin and cartilage –> helix advanced into defect –> creates v-y advancement of crus helicis
• Superior third defect 1.2cm –> Antia- Buch flap –> local flap that uses tissue from helical rim based on post-auricular skin to reconstruct helical margin
• Chondrocutaneous rotation flaps: inferiorly based on antihelix, antitragus, or lobule –> used for defects of middle and lower helix up to 5cm can be closed with lobule advancement
• Superior third <2cm, middle third <2cm
• Tanzer’s excision patterns and primary closure
• Large Defects: >2cm
• Superior helical defects
• auricular cartilage grafts (contralateral ear),
• Conchal transposition flap: composite flap based on crux of helix –> assists in reconstruction deformities of the superior helix
• Middle third defects
• Post auricular flap: supplied by posterior auricular artery and vein –> wrap the flap in conchal graft –> flap pins the ear back and requires division of the base of the flap in a second stage
• Rotated post auricular island flap (many for concha): design of the flap is on the posterior ear and partially on the mastoid area, based off of posterior auricular artery
• Conchal defects
• retroauricular flap
• Postauricular island flap (revolving door) good for conchal defects and can replace entire concha
• Upper 2/3 loss, use rib cartilage graft with TP fascia flap and STSG
• This accounts also for multiple anatomical components missing. Perform a staged reconstruction with a cartilage framework 
• Older patients, partial middle ear defect can be treated by wedge resection and primary closure (2-2.5) –> younger can cause cupping and needs flap 
• Partial middle third: post auricular transposition flap –> divide after 10 days
• Rim defects: triangular kite flap, rim advancement flaps
• Conchal area: postauricular revolving door flap
• Ear reconstruction in elderly difficult due to harvested costal cartilage is brittle and calcified, younger have difficulty with skin grafts
• Microsurgical replantation of ear: tissue debridement –> dissection –> large arteries to ear enter posterior aspect of pinna (external carotid, anterior auricular branch of STA, branch of occipital artery)
• If no venous outflow can be found, ear should still be reattached with microvascular techniques, followed by leach therapy for venous congeswtion
• In children with large loss of ear, may perform composite graft when microsurgical reattachment is not an option
• Auricular composite grafts used for alar reconstruction –> should be no larger than 1.5cm –> continue to observe if cyanotic with eschar (treat like skin graft)
• Porous polyethylene implants: great for burn reconstruction –> cover with TP fascia –> if graft exposed (small area) can be allowed to granulate in with dressing changes, do not remove until 6 month post op
• Rib cartilage preferable to porous polyethylene due to extrusion rates
• Most aesthetic outcomes for ear recon when entire ear absent- placement of osteointegrated screws and prosthetic device when TP flap unavailable
• Indications of ear prosthesis: traumatic/ablative defects

Complications

• Chrondritis: pain, swelling tenderness –> IV abx (surgical if suppurative!); Suppurative infection of reconstruction: ID with drains first prior to removal cartilage
• Ear hematoma: if aspiration not successful, surgical drainage required with placement of through and through sutures and gauze bolsters to prevent cauliflower ear
• Severe u/l ear pain after otoplasty typically hematoma –> if not evacuated, complications such as pressure necrosis and fibrosis may develop
• Duskiness of graft  s/p composite graft –> needs HBO (stimulates angiogenesis) –> composite graft should be left in place for 2 weeks 
• Hematoma requires ID of skin, perichondrium, and application of a pressure dressing 
• Venous congestion for ear replantation can be managed non-operatively- use leeches; arterial insufficiency requires surgery
• Banked ear cartilage: in sq pocket of abdomen, cartilage can lose its strength and architectural detail –> can become warped or contracted

Miscellaneous: 

• Local control rates for radiation of the head and neck region for SCC are predicted by size of the lesion (<1cm 91% curative for primary sCC)
• Mohs has the highest reported cure rate for SCC