Auricular and nasal deformities can have significant social ramifications; therefore, proper repair of these deformities is critically important to a child's well-being. Moreover, the benefits of reconstruction in the pediatric population must be weighed against added concerns about potential growth restriction on the ear and the nose with any manipulation. This article reviews various methods of auricular and nasal reconstruction and discusses some of the technical pearls for improved outcome. A complete discourse on treatment of total ear and nasal reconstruction is beyond the scope of this article. Attention is focused primarily on partial to subtotal defects.
Pediatric ear and nasal deformities, congenital and acquired, are common.
One must weigh the benefits of reconstruction on form and function versus risks of growth disturbance and donor site morbidity.
A number of local flap options are available for traumatic ear deformities depending on the location and size of injury. In larger defects, using congenital auricular reconstruction techniques may give better results.
The paramedian forehead flap is very useful for nasal reconstruction because local flap options are generally limited in this patient population. The goal of reconstruction is to preserve airway while re-establishing nasal lining, structural framework, and external skin envelop.
The ear and the nose are two prominent appendages of the face that are crucial to overall facial aesthetics. As such, auricular and nasal deformities can have significant social ramifications; therefore, proper repair of these deformities is critically important to a child’s well-being. Moreover, the benefits of reconstruction in the pediatric population must be weighed against added concerns about potential growth restriction on the ear and the nose with any manipulation. This article reviews various methods of auricular and nasal reconstruction and discusses some of the technical pearls for improved outcome. A complete discourse on treatment of total ear and nasal reconstruction is beyond the scope of this article. Attention is focused primarily on partial to subtotal defects.
The structure of the human ear is composed of three primary complexes: (1) the helix-antihelix, (2) the concha, and (3) the lobule ( Fig. 1 ). Moreover, the ear is a composite construct of skin, soft tissue, and cartilage of various shape and thickness depending on the location. A more detailed anatomic description along with embryology, neurovascular, and aesthetic considerations can be found elsewhere in literature.
Critical to any discussion about pediatric ear reconstruction is the issue of auricular growth. Although ear width continues to increase until age 10, it is well established that 85% of ear development is attained by 3 years of age. For congenital defects, this issue is compounded by a certain degree of growth arrest attributable to the underlying pathophysiology. For congenital and traumatic defects, the goal of reconstruction should be to achieve symmetry with the contralateral side. For practical purposes, the ear is fully developed at 6 years of age.
Acquired auricular deformities
There are several principles to keep in mind for traumatic injuries to the ear and the nose. First, rule out other more serious injuries, such as skull base fractures, hearing loss, and facial nerve injury. Second, thoroughly examine the area and remove traumatic debris with only minimal debridement because aggressive removal of tissue can lead to untoward distortion of structures. Third, close primarily where feasible without suturing through the cartilage. If immediate closure is not feasible, then clean, debride, and perform frequent dressing changes with topical antibiotics and nonadherent dressing to avoid desiccation before definitive reconstruction.
When evaluating the ear for reconstruction the ear is divided into five zones following the subunit principle: (1) helical rim, (2) superior third of auricle, (3) middle third of auricle, (4) lower third of auricle, and (5) lobule ( Fig. 2 ). Auricular defects can be of partial thickness or full thickness and may involve the underlying cartilaginous framework. Therefore, identifying the location in these five zones and ascertaining the depth of injury during clinical evaluation is critical in formulating the appropriate reconstructive plan.
In partial-thickness wounds, regardless of the location, the presence of perichondrium dictates the treatment so it is important to establish its presence or absence. When underlying perichondrium is present, partial skin avulsions can be reattached or a skin graft can be taken from the postauricular region to resurface the wound. When perichondrium is absent, then wedge excision should be considered to close the wound if the defect is less than 1.5 cm. Larger defects can be covered with any of the many variations of preauricular or postauricular flaps. Lastly, small avulsed ear pieces that are clean can be reattached as composite grafts within 6 hours.
Helical Rim Defects
For full-thickness helical rim defects, the size of the defect drives the treatment approach. Where the defect is less than 2 cm, a contralateral composite graft or an ipsilateral chondrocutaneous rotation flap can be used. The chondrocutaneous flap, as described by Antia and Buch, is a versatile flap that can be advanced superiorly, inferiorly, or in both directions and requires only one stage without damaging the donor site ( Fig. 3 ). Where the defect is larger than 2 cm, superiorly based preauricular or postauricular flaps with or without cartilage grafts can be used. For larger defects, the Davis conchal transposition flap, which transposes the chondrocutaneous conchal surface on a skin pedicle to fill a marginal defect, is also an option, but a skin graft is needed to close the donor site.
Another useful flap, first described by Dieffenbach, is the posterior auricular skin flap ( Fig. 4 ), which is elevated the same width as the defect up to the hairline. Cartilage, if needed, can be taken from the ipsilateral or contralateral ear. It is important to reduce tension on the closure by temporarily suturing the conchal cartilage down to the mastoid. The flap pedicle can be divided at 3 weeks and donor defect skin grafted.
Many other reconstructive options, including tubed-pedicle flaps and tunneled techniques, have also been described but these techniques, by and large, are difficult to perform and to obtain consistent results.
In the superior third of the ear, like helical rim defects, the size of the defect also drives the reconstructive technique. Defects less than 2 cm can be reconstructed with various methods of auricular reduction. To this end, Tanzer excision patterns are useful to optimize wound closure while maximizing the amount of soft tissue available ( Fig. 5 ). Defects larger than 2 cm in this region without cartilaginous involvement can be resurfaced with preauricular flaps alone. Large composite defects may require a costal cartilage graft along with either a skin flap or graft for coverage. Chondrocutaneous composite flaps, such as the Ortichochea conchal rotational flap ( Fig. 6 ), provide another option for full-thickness defects.
Middle and Lower Defects
Auricular reduction is useful for small defects in the middle and lower third of the ear. However, defects larger than 2 cm require a more complex reconstructive option, such as a contralateral composite graft with posterior auricular skin flap or chondrocutaneous flap.
Lobular defects are generally closed primarily because there is ample amount of soft tissue without need for cartilaginous support. However, cleft earlobe from traumatic earring avulsion requires special attention. A wedge excision can be performed but the wound edges must be everted or z-plasty performed to prevent notching. If the patient plans on wearing earrings, then a local flap can be rolled to create a tract with epidermal lining or the defect can be closed around a suture as a stent for future earring use.
Total and Subtotal Defects
With larger defects, local options become limited. Moreover, many surgeons believe that reconstruction with local tissue rearrangement gives rise to imperfect outcomes. Consequently, many have abandoned the use of local tissue in favor of using principles of congenital auricular reconstruction to repair partial and total acquired deformities. Some centers are performing two-stage Nagata technique ( Fig. 7 ) for traumatic partial ear amputations. Ali and colleagues modified the Nagata technique into a single-stage procedure to treat patients with acquired segmental auricular defects. They report a low complication rate and high satisfaction rate in 20 patients with the use of costal cartilage, temporoparietal fascial flap, and split-thickness skin graft.
For total auricular avulsion, an attempt at replantation can be made; however, the lack of reliable veins, need for lengthy procedure with long hospital stays, frequent complications, and need for leeching for venous congestion with subsequent blood transfusion handicaps the efficacy of this technique. Some argue that the results of ear replantation are seldom rewarding and that it is better to discard the amputated segment, allow rapid primary healing, and perform formal elective ear reconstruction with costal cartilage.
In the case of a total traumatic defect where immediate reconstruction is not a viable strategy, banking the auricular cartilage for future reconstruction has been described. The banking of cartilage is based on the "pocket principle" and several modifications have been used to improve outcomes, including dermabrading and fenestrating the amputated segment. However, banking remains an unreliable, ineffective method because it often causes cartilage to go through significant warping. Furthermore, a salvage procedure with costal cartilage is often needed in auricular amputations of this degree. Also, because the skin flap has already been elevated in creating the retroauricular pocket, the soft tissue coverage and reconstruction becomes more difficult.
Burn Injuries and Keloids
Auricular burns and frostbite occur with relative frequency in the pediatric population. Typically, auricular burns are managed topically with mafenide acetate cream to prevent desiccation and infection. Compressive dressings should not be used because they may compromise vascularity to the injured tissues. Conservative debridement of eschar after demarcation should be performed and the defect reconstructed according to the depth and location of defect. A patient commonly needs prophylactic antibiotic coverage because Pseudomonas infection regularly causes suppurative eschar in this type of injury. Frostbite wounds are managed with rapid rewarming using warm, saline-soaked dressings. Tetanus prophylaxis is recommended and the use of systemic prostaglandin inhibitors (ie, ibuprofen) or topical thromboxane inhibitors (ie, aloe vera) has been advocated to limit thrombosis and tissue loss.
The earlobe is the most common site of keloid formation because of an association with ear piercing, which occurs with relative frequency in the pediatric population. Treatment modalities for keloid scars in this region run the gamut from simple excision to corticosteroid injection, radiation therapy, and silicone dressings. Proper treatment usually requires serial treatment using multiple modalities. Unfortunately, regardless of the treatment technique, there is a very high recurrence rate ranging from 19% to 100%.
Postoperative care is equally as important as the reconstruction itself with auricular injuries. A postoperative hematoma or seroma can cause permanent warping of cartilage, known as “cauliflower deformity,” which is difficult to repair. The use of bolster dressings and a careful follow-up in these patients is helpful in preventing unwanted complications ( Fig. 8 ).
Congenital auricular deformities
Congenital ear deformities can be divided into three broad categories: (1) complete absence, (2) hypoplasia, and (3) hyperplasia. Complete auricular reconstruction for total and subtotal auricular deformities and otoplasty for prominent ears are beyond the scope of this article. Instead, addressed next are varying degrees of microtia and auricular malformations.
Clinical variations of microtia materialize from stunted development during 6 to 8 weeks of gestation. The severity of the deformity diminishes the later in gestational age the malformation occurs. A detailed history and physical examination is important because auricular malformations are associated with many syndromic abnormalities, including Goldenhar syndrome, Treacher Collins syndrome, and cleft lip and palate. Isolated microtia is considered the mildest form of hemifacial microsomia.
The degree of the external auricular defect does not correlate with the functionality of the middle ear; therefore, a complete radiographic and audiologic evaluation is needed to fully assess any damage to the middle ear. The need for otologic surgery must be taken into consideration when planning for ear reconstruction, because most surgeons recommend auricular reconstruction before middle ear surgery.
The age of the child is important in determining the timing of reconstruction. For example, in larger defects requiring cartilaginous support, the costal cartilage is rarely of sufficient size until 5 to 6 years of age. Because most children start school at this age, any physical abnormality has obvious psychosocial implications. Therefore, most surgeons recommend reconstruction to be performed during this time. Other factors that also affect the timing of surgery include the maturity of a child, recognition of the deformity of the child, the rate of the ear growth, and the elasticity of the cartilage.
Some minor to moderate microtia deformities are amenable to the use of local tissue, including local flaps, composite grafts, and skin and cartilage grafts. The subunit principle described for trauma reconstruction can also be applied as a tool in determining the surgical method to be used in the reconstruction of these types of deformities. Furthermore, incisions must be carefully placed to maintain perfusion to surrounding tissue in the event that total ear reconstruction is needed as a salvage procedure. Often, a malformed cartilaginous remnant must be removed and replaced with cartilage grafts for optimal results.
Lastly, osseointegrated implants are a valuable reconstructive option that can be used to support a prosthetic ear in extreme microtia or anotia. In certain patients, these implants have shown positive long-term results with high patient satisfaction and can be easily combined with hearing aids ( Fig. 9 ). However, the prosthesis is costly and they generally need to be replaced every 5 years from wear and tear and from the child’s growth. Moreover, upkeep and maintenance of the implants is necessary and tedious to prevent peri-implantitis, infection, and loss of the implants.
Cryptotia, known as “hidden ear,” occurs as a result of abnormal adherence of the ear to temporal skin resulting in absent superior auriculocephalic sulcus. This condition is associated with various degrees of cartilage malformation. Splinting to slowly mold and elevate the cryptotic ear away from the postauricular surface may be attempted initially but definitive treatment involves division of the adherent skin and placement of a split-thickness skin graft to create a sulcus ( Fig. 10 ).
The defining features of Stahl ear, also known as Spock ear, are the presence of a third crus, flat helix, and malformed scaphoid fossa ( Fig. 11 ). The deformity can be corrected by splinting in neonates while the cartilage is still soft and malleable. There are several surgical options that have been described, including z-plasty, cartilage reversal, and wedge excision of the third crus with helical advancement.
Constricted ear is a continuum of deformities involving the upper third of auricular cartilage that ranges from slight lidding to virtual microtia ( Fig. 12 ). Although there are several colloquial terms for this deformity, including lop, canoe, and cup ear, lidded helix, and cockle shell, all involve some permutation of the following four features: (1) lidding caused by deficient fossa triangularis, scapha, and superior crus; (2) protrusion caused by a flattened antihelix and helical rim with a deepened conchal fossa; (3) low ear position with or without hooding; and (4) decreased ear size.
Constricture can be divided into mild, moderate, and severe deformities. Most mild deformities resolve spontaneously. Splinting can be useful for milder cases early on but most deformities require surgical correction. In mild cases, surgical efforts are concentrated on improving helical definition and height because native cartilage frequently maintains near-normal auricular infrastructure. Local skin and subcutaneous tissue reshaping produces excellent results. The surgical approach to moderate ear constricture is varied and debatable. The literature describes many different techniques but most surgeons conclude that regardless of the technique, successful reconstruction hinges on proper expansion of the skin envelope, reshaping the cartilage, and prevention of helical collapse. Moderate to more severe deformities often require complete autologous reconstruction with costal cartilage ( Fig. 13 ). Adequate soft tissue coverage must be available when planning for extensive cartilage fabrication. As such, the combination of an autologous cartilaginous framework in conjunction with an expanded skin graft is a reliable, effective means of recreating auricular form. In addition, a mastoid hitch may be useful to tether the easily malleable neohelix to a more structurally sound mastoid fascia after substantial cartilage manipulation.
The nose is perhaps the single most prominent aesthetic feature of the face. The same structured anatomic characteristics that give it such importance in appearance also contribute to its corporeal vulnerability. Moreover, external deformities, congenital or acquired, can cause significant nasal airway obstruction, which is a challenge for infants who are obligate nasal breathers. Therefore, any attempt at nasal reconstruction must simultaneously account for the functional and aesthetic component of nasal deformity with the caveat that it is possible to exacerbate the problem with any surgical manipulation.
During embryologic development, the face is formed by five facial prominences: frontonasal prominence, two maxillary prominences, and two mandibular prominences. The nose forms from the frontonasal prominence through neural crest migration during the third to tenth weeks of gestation. These cells ultimately differentiate into the medial and lateral nasal processes. The two lateral nasal processes develop into the external walls of the nose: the nasal bones, upper lateral cartilages, ala, and the lateral crus of the lower lateral cartilage. The two medial nasal processes fuse to form the nasal septum and the medial crus of the lower lateral cartilage. The medial processes also interact with the maxillary prominence to create the midface. Facial clefts result from disruptions to the fusion of these processes.
The growth of the midface is contingent on the normal growth of the cartilaginous nasal septum. The sphenodorsal zone of the septum coordinates the development of the nasal dorsum, and the sagittal growth of the basal rim guides the forward outgrowth of the premaxilla. Complete loss of the septum arrests the growth of the nose and the maxilla. Therefore, surgeons should always avoid harvesting grafts from a developing septum.
In a growing child, the nose follows a particular growth pattern. Nasal bridge length increases the fastest between 4 and 5 years of age for boys and 6 and 7 years of age for girls. Girls finish nasal growth at the age of 12, whereas boys continue to grow in length.
Critical to any discussion about nasal reconstruction in the pediatric population are issues regarding nasal growth and timing of surgery. Because the septum is a major growth center of the face, any significant septal trauma, including iatrogenic, can adversely affect midfacial development. In addition, any manipulation of the nasal anatomy and resultant scarring of the nasal structures can have significant adverse consequences to nasal form and function. Furthermore, the smaller surface area of the nose and lack of potential donor sites of adequate size in children means local flap options are limited. Although most surgeons agree that the optimal time for extensive nasal reconstruction is during adolescence when most nasal growth has occurred, reconstruction may be performed earlier because of psychosocial factors and despite possible reoperation at a later age. Moreover, satisfactory results can be obtained with careful planning and execution.
First, it is important to understand the complex nasal anatomy, which can be simplified to the “Rule of 3s.” The nose can be divided into three layers: (1) the external skin envelope, (2) skeletal-cartilaginous framework, and (3) internal nasal lining. The nose can be divided into three vaults based on the underlying skeletal structure (proximal, middle, and distal). Lastly, the external nose can be divided into aesthetic subunits. Modified from Burget and Menick’s subunit principle, the adult nose is divided into nine subunits: unpaired dorsum, tip, and columella and paired sidewall, ala, and soft triangle ( Fig. 14 ). However, unlike the ear, which has fully developed subunits from birth, the nose goes through significant development and change throughout life. Some of the subunits, depending on the age of the child, can hardly be observed in early childhood. The pediatric nose has a bulbous tip and no distinctive side walls. The nasal apertures are typically rounder. As such, Giugliano and colleagues advocate using a modified approach to the subunit principle in the pediatric population to include just 3 subunits: (1) tip, (2) dorsum, and (3) ala ( Fig. 15 ).
Principles of Nasal Reconstruction
Whether managing a traumatic or congenital deformity, a proper defect analysis is critical to optimize outcomes. The “Rule of 3′s” can be used to simplify defect analysis because any assessment of the defect must address the location (upper, middle, or lower third), the depth (skin and soft tissue, skeletal framework or lining), and the dimensions of defect (aesthetic subunits and absolute size). The goal of reconstruction is to preserve airway patency while optimizing nasal aesthetics through replacement of like tissues and re-establishment of distinct nasal layers.
Patients can be divided into three broad categories: (1) young children who have indistinct nasal subunits, (2) mid-aged children who have developing subunits, and (3) older children who have completed nasal growth and have fully developed subunits. In infants and toddlers, it may be prudent to attempt primary closure if at all possible to minimize further distortion of adjacent structures. Revision is inevitable in this population as the child grows, but the importance of minimizing distortion of adjacent structures and significant scarring cannot be overemphasized. Older children who have completed growth should be treated as adults from a reconstructive standpoint. The difficulty lies in treating those patients in the intermediate category and the decision to treat and the modality of treatment should be determined on a case-by-case basis. The following discussion is more pertinent to treatment of nasal deformities in older children but the principles discussed can be applied to the entire pediatric population.
Regardless of the age of the patient, significant contraction or distortion of the external nose can cause external valve collapse and stenosis, which are troublesome functional problems. Whether it be congenital or acquired, it is imperative to release all deforming forces on the nose and recreate the defect. In doing so, it is likely that the defect will require replacement of the nasal lining, structural framework, and skin.
Defects that involve the nasal lining are often overlooked. In the experience of the authors and others, a proper re-establishment of the nasal lining is critical to maintain long-term durability of any repair. Several options exist for lining replacement but septal mucoperichondrium ( Fig. 16 ) remains the workhorse flap for small to moderate sized defects at any age. As a rule, septal procedures should be minimized until 12 to 13 years old to prevent growth arrest of the midface. Turnover flaps or skin grafts can also be used in smaller defects. Larger defects often require a free tissue transfer for lining replacement in a staged manner, most often with free radial forearm fasciocutaneous flap.
As for reconstruction of the structural framework, the use of septal cartilage should be avoided in the pediatric population. Instead, auricular cartilage should be used for small defects and those involving the ala, whereas costal cartilage can be used for larger defects. Costal cartilage is generally taken from the sixth or seventh rib.