A new operative method of correcting cryptotia using large Z-plasty

Anatomical external auricular muscle transposition with mini flap transfer for mild cryptotia: A case report

Cryptotia is a congenital ear deformity characterized by the upper helix buried under the skin of the temporal region. Recurrence and inadequate correction of ear position are major complications following auricle reconstruction. Abnormalities of the auricular muscles are closely associated with cryptotia and considered to be the main cause. However, current corrective procedures focus on provision of additional skin and abnormal auricular muscle correction is considered supplementary. We report a surgical approach focused on the anatomical repositioning of the external auricular muscle insertions and skin cover with a mini flap. Two consecutive patients aged 6 and 14 years with mild cryptotia (minimal auricular cartilage deformity) were treated using this technique with a follow-up duration of 12-25 months. The abnormal insertion of the superior auricular muscle (SAM) to the superior helix was repositioned to its correct anatomical position below the eminence of the triangular fossa, effectively moving the ear posterosuperiorly. No complications occurred postoperatively, the increase in vertical length of the superior helix to the superior ear attachment was 7.8 and 7.9 mm at 6months. Both patients could wear facemasks comfortably without them sliding off and were satisfied with the esthetic results. Total follow-up duration was 3 years in Case 1 and 4.4 years in Case 2. Primary correction of the SAM to its anatomical position may be a useful method for reducing the size of the skin flaps required with minimal donor site morbidity in reconstruction of mild cryptotia.

Correction of Cryptotia With Double Z-plasty:Modified Large Z-plasty Technique

Some cases of moderate or severe cryptotia are accompanied by a shortage of the helix. Although various operative techniques for correcting cryptotia have been reported, elongation of the helix is not considered in most of those techniques. In cases of a shortage of the helix, a drooped wide helix like a constricted ear or a cranially and posteriorly hypoplastic ear, which is characteristic of cryptotia, can appear after surgery if the helix has not been elongated. We previously reported a large Z-plasty technique that has become one of the popular techniques for correcting cryptotia. However, satisfactory results are not always achieved by using this technique in cases with a shortage of the helix. We developed a new technique (double Z-plasty) in which a small Z-plasty in the helical rim is added to the usual large Z-plasty technique. An improved helical shape and enlargement of the ear can be achieved by using this technique. Almost all types of cryptotia can be treated by appropriately using the large Z-plasty and double Z-plasty techniques.

Nonsurgical Creation of an Auriculocephalic Sulcus in Children With Congenital Auricular Deformities

Nonsurgical correction of congenital auricular deformity is known to be effective in newborns. In this study, the authors investigated factors influencing the outcome of nonsurgical or surgical correction of the auriculocephalic sulcus, an important auricular structure and one that is necessary for wearing glasses or a mask. A total of 80 ears (63 children) were splinted using a metallic paper clip and thermoplastic resin in our outpatient clinic between October 2010 and September 2019. The ears were divided into a group, in which the auriculocephalic sulcus was formed nonsurgically (n =5 6) and a group, in which surgery was needed (n = 24). The authors compared the clinical characteristics of the deformities, whether cryptotia affected the superior or inferior crus, and whether constricted ears were Tanzer group IIA or IIB between the two study groups by retrospective chart review. There was a significant correlation between the age, at which ear-molding treatment was initiated and outcome (P < 0.001). The optimal cutoff value for age, before which ear-molding treatment should be initiated was 7 months. Inferior crus-type cryptotia was corrected adequately by splinting, but all Tanzer group IIB constricted ears needed surgical treatment. Earlier initiation of ear-molding treatment is recommended, preferably before 6 months of age. Nonsurgical treatment is an effective intervention for the creation of the auriculocephalic sulcus in ears with cryptotia and Tanzer group IIA constricted ears but cannot correct for an inadequate amount of skin over the auricular margin or a defect in the antihelix.

A Patient With Cryptotia Corrected With Intraoperative Tissue Expansion and Superior Auricular Muscle Transfer Through a Small Hairline Incision

Cryptotia is a relatively common auricular congenital anomaly in Asia. Nonsurgical molding is easy in infancy. However, surgical correction is often necessary after infancy. The authors report a case of cryptotia in which intraoperative tissue expansion and superior auricular muscle transfer were performed through a small incision at the hairline with good results. The patient is a 7-year-old girl. Three years after the operation, successful results were obtained. This method is advantageous as the procedure is simple, risk of relapse can be reduced by also treating the auricular muscle, and scarring is relatively inconspicuous. In addition, it is possible to switch to another technique when the improvement is poor.

The Multiple V-Y Advancement Modification for the Surgical Correction of Cryptotia

Cryptotia is a rare congenital auricular deformity among Caucasians but more common in Asians. Various operative techniques have been described, such as skin graft, V-Y plasty, Z plasty, and islands skin flap. Among those techniques, V-Y plasty has many advantages and is indicated for severe cases. However, several problems remain when this method is adopted, such as conspicuous scars and lowered hairline. To overcome these problems, the authors have developed a new technique, multiple V-Y advancement modification, which stitches the skin flaps together to a tight, discrete central focal point. This technique has the advantage of hiding scars behind the earlobe, providing enough skin for the deformed areas, minimizing the condition of the hairline being lowered and auriculocephalic sulcus depth.

Nonsurgical Treatment for Congenital Auricular Deformities: A Systematic Review and Meta-analysis

BACKGROUND

The effectiveness and safety of non-surgical correction for congenital auricular deformities (CADs) remain unclear owing to a lack of high-level evidence. This systematic review and meta-analysis aimed to estimate the overall success and complication rates of the non-surgical correction for CAD.

METHODS

We searched PubMed, Medline, and Cochrane Library for eligible studies. The pooled success and complication rates of non-surgical correction were estimated using a random effects model. Subgroup analyses were performed to compare the success rates between patients treated with splints and molding systems, between those younger and older than 6-weeks, and among those with different types of CADs.

RESULTS

The review yielded 14 studies. The pooled success rate of non-surgical treatment was 93% (95% CI: 88%-97%). The success rates with splints and commercialized molding systems were 94% and 92%, respectively. The success rate was higher if non-surgical correction was initiated before age 6 weeks (96% vs. 82%). Prominent ears showed a lower success rate (85%) than other types of CADs (all > 90%). The pooled complication rate was 18% (95% CI: 10%-29%). Complications, including skin wound, irritation, and rash, were mild and easily treatable.

CONCLUSION

The non-surgical correction of CADs is highly effective and safe. Splints and molding systems offer similar effectiveness. Non-surgical correction is more beneficial if applied within 6 weeks of birth. Prominent ears have a lower, but still acceptable, success rate compared to other types of CAD. We recommend the early use of non-surgical correction to achieve favorable outcomes.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A New Method of Correcting Cryptotia by Changing Mechanical Fulcrum After Constricted Cartilage Overturned

BACKGROUND

Many techniques have been introduced to correct cryptotia. The previous methods are releasing the constricted cartilage and changing the mechanical fulcrum partly to the right position. However, some patients are still not satisfied with the treatment results, due to cryptotia recurrence and insufficient superior 1/3 width. This study aimed to develop a new method for completely changing the mechanical direction of constricted cartilage for correcting cryptotia.

METHODS

From 2007 to 2020, twenty-four cryptotia patients were treated. During surgical reconstruction, the retroauricular skin flap was elevated, the posterior aspect of the upper auricular cartilage was completely exposed, and the abnormal insertion of the auricular intrinsic muscles detached. The sharply curved antihelical cartilage was cut and overturned, and the scalp skin flap was undermined and advanced toward the postauricular sulcus. The edge of the retroauricular scalp flap is fixed on the mastoid periosteum. The incision was closed.

RESULTS

Eighteen patients had unilateral cryptotia, and six had bilateral cryptotia. Relatively favorable results were obtained in the follow-up period (range, 6-48 months). There were no cases of skin necrosis, complications, or revision surgery.

CONCLUSIONS

The main advantages of this technique are the surgically reproducible results, and that it can be applied to most cases. The method described in this paper could potentially increase the width of the upper third of the auricle and reduce recurrence rate, while also leaving an inconspicuous scar and a satisfactory auricular contour. It is suggested that this technique could be an alternative method of cryptotia correction.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Preoperative Flap Surgery Simulation for a Case of Cryptotia Using a 3D Printer

Cryptotia is a congenital auricular deformity. Common methods of surgical reconstruction involve creating an auricular temporal groove using local flaps and/or a skin graft. However, it can be difficult to determine which method is most suited to the unique 3-dimensional (3D) structure of each cryptotic ear. Here, we showed that creating 3D ear models of a cryptotic ear with a 3D camera and printer and using these models to simulate surgery with two different flap methods (cat’s-ear and square) allowed selection of a reconstruction method that led to good outcomes after the actual surgery. The patient was a 7-year-old girl with left cryptotia. A 3D camera was used to acquire 3D data for the ear. After structural analysis, a home 3D printer was used to print the data into 3D ear models using an elastic material. These models exhibited good plasticity. After subjecting the models to simulated cat’s-ear and square flap surgeries, the cat’s-ear flap method was considered to better reproduce the healthy side of the ear compared with the square flap method for this particular case. Ear morphology during and after the actual surgery closely resembled the model-ear morphology during and after the simulated cat’s-ear flap surgery. We successfully created a full-scale 3D model with good plasticity using a 3D camera and 3D printer. This allowed easy, noninvasive preoperative evaluation and identification of the most suitable operation for the specific case, facilitating easier, more successful surgery.

Non-surgical correction of cryptotia

INTRODUCTION

Cryptotia is characterized by an absence of the upper part of the temporoauricular sulcus with the superior third of the auricle buried under the temporal skin. The principle of correction of cryptotia is to achieve both a functional and aesthetic ear.

METHODOLOGY

A 4-year prospective study was carried out in a single centre on infants with cryptotia. We introduce a two-staged approach for non-surgical correction of cryptotia and a treatment algorithm based on the age of the patient. In the first stage, we unbury the auricle over 2 weeks. The second stage involves 2 additional weeks of helical moulding to correct the underlying or residual deformation. In our algorithm, patients more than 6 weeks of age undergo only the first stage of cryptotia correction, whereas those less than 6 weeks of age progress to the second stage of treatment.

RESULTS

A total of 5 patients (7 ears) were treated with ages ranging from 1 day to 7 months. Two patients underwent 2-stage treatment and 3 underwent 1-stage treatment. At 1 year, all buried helices remained retracted. Four out of 7 ears treated had "Excellent" outcomes and 3 out of 7 ears had "Good" outcomes. All caregivers were extremely satisfied with the outcomes.

CONCLUSION

This simple and efficacious two-stage technique and algorithm is effective in the correction of cryptotia, even if the treatment is initiated beyond the traditional moulding window in the first six weeks of life. Using this approach, patients with cryptotia benefit by avoiding or simplifying surgical reconstruction in the future.

Management of Congenital Auricular Anomalies

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe normal ear anatomy and development, and evaluate the patient's ears for differences in shape, size, prominence, and symmetry. 2. Identify common congenital ear deformities, including prominent ear, macrotia, Stahl ear, cryptotia, constricted ear, and lobule anomalies. 3. Describe both early nonoperative management and operative techniques for correction of these ear deformities. 4. Be aware of advantages and disadvantages of common and emerging techniques for correction of pediatric ear deformities.

SUMMARY

Whereas severe ear malformations such as microtia/anotia are rare, other ear deformities, such as prominent ear, Stahl ear, and cryptotia, are common. Although these ear deformities result in minimal physiologic morbidity, their psychological and cosmetic impact can be significant. Identifying these common deformities and understanding how they differ from normal ear anatomy is critical to their management. In cases where a deformity is identified in neonatal life, ear molding may obviate the need for surgery. Although various surgical techniques have been described for correction of common ear deformities, the surgeon should follow a careful stepwise approach to address the auricular deformity or deformities present. By using such an approach, complications may be minimized and predictable aesthetic outcomes achieved.

Non-surgical correction of cryptotia and the analysis of treatment time and other influence factors

OBJECTIVE

To explore correlations between post-treatment outcomes of non-surgical correction for cryptotia and treatment time and other influence factors.

METHODS

Forty-seven consecutive patients with 64 cryptotias were treated with the adjusted external stretching device and followed up over 12 months. A subjective evaluation scale was designed for patients to collect clinical data. Pretreatment and posttreatment evaluation were conducted by two blinded investigators. The correlations between influence factors and outcomes were explored through fractional polynomial method, multiple logistic regression, and robust linear regression methods.

RESULTS

Thirty-five patients with 49 cryptotias were included. Twenty-nine cryptotias (23 patients) have been successfully managed. Two of 17 unilateral cryptotias achieved nearly complete symmetry. The final optimal cutoff value for initiating treatment time is 6 months and for the duration of treatment per day is 5 h per day. Positive relationships between initiating treatment time >6 months and onset time, type II and onset time, initiating treatment time >6 months and effect stabilization time were observed.

CONCLUSIONS

Initiating treatment time <6 months and duration of treatment per day >5 h benefit for the posttreatment outcomes. Patients wearing the device under 6 months old would have earlier onset time and effect stabilization time. It is hard to achieve complete bilateral symmetry in unilateral patients. The adjustable devices can used for the auricles with different sizes and removed and equipped conveniently.

A New Surgical Method of Correcting Abnormal Cartilage in Mild or Moderate Cryptotia

OBJECTIVE

This study aimed to introduce a new technique for the correction of mild or moderate types of cryptotia.

METHODS

During January 2010 to March 2015, patients with cryptotia deformities came to our hospital and were enrolled in this study. A new surgical method of correction of abnormal cartilage by combining irregular incisions in auricle malformation and directional transplantation of auricular cartilage was designed. The irregular Z shaped flap was designed to correct the skin defects. In the ipsilateral cavum conchae, the auricular cartilage strut was harvested, followed with irregular cartilage incisions and cartilage transplantation.

RESULTS

After correction, the corrected auricles in 3 cases showed natural contour with deep auriculotemporal sulcus and no conspicuous scars. The antihelix folding and backward rotation deformities of the auricular cartilage were corrected, and the morphology of superior and inferior crus of the antihelix was not destroyed. One case appeared necrotic. During 1 year of follow-up, there was no incidence of recurrence or revision.

CONCLUSIONS

The combined techniques for correction of abnormal cartilage are simple and easy to operate, and the reconstructed auricles show natural contour without conspicuous scars. The new technique is suitable for correction of mild and moderate cryptotia.

Cryptotia recurrence lowering technique with additional acellular dermal matrix graft

BACKGROUND

Cryptotia is a congenital anomaly in which the upper part of the retroauricular sulcus is absent and buried underneath the temporal skin. Various surgical techniques have been reported for the correction of cryptotia following Kubo's V-Y plasty in 1933. Conventional methods using a local skin flap, skin grafting, tissue expansion, Z-plasty, and any of these combined approaches can result in skin deficiency of the upper auricle. The aim of this study was to develop a new method that improves cosmetic results and has fewer complications.

METHODS

This study involved four patients in whom five cryptotia deformities were corrected using V-Y plasty and Z-plasty. After elevation of the flap, acellular dermal matrix (ADM; MegaDerm) that was over 5 mm in thickness was applied to the cephalo-auricular angle and positioned to enhance the projection of the ear. Lastly, the flap was transposed to complete the repair.

RESULTS

Between January 2014 and February 2018, cryptotia correction with ADM graft was performed in four patients. None of the patients developed a recurrence of cryptotia, and there were no postoperative complications such as wound infection, seroma formation, and dehiscence. In addition, the procedures resulted in a favorable cosmetic appearance.

CONCLUSION

Based on these findings, i.e., no recurrence and a favorable cosmetic result, when using an ADM graft, it is suggested that this technique could be an alternative method of cryptotia correction. It could also lessen donor-site morbidity when compared to autologous cartilage grafting and be more cost-effective than using cartilage from a cadaver.

A New Modified Method of Correcting Cryptotia with a Subcutaneous Pedicled Flap

Supplemental Digital Content is available in the text.

We developed a surgical technique to correct cryptotia using a subcutaneous pedicled flap raised from the retroauricular region. A skin paddle over the caudal part of the auricular sulcus is designed and transferred to the skin defect of the upper posterior surface of the auricle. This procedure has been performed on 17 ears in 14 patients with cryptotia since 1992. There were no postoperative complications, such as necrosis of the flaps or deformities, and cryptotia did not recur in any patient. A satisfactory auricular contour with a sufficiently deep auriculotemporal sulcus was preserved in all cases. The intraoperative procedure to correct cryptotia and outcomes obtained are presented herein and compared with other procedures.

Otoplasty for Congenital Auricular Malformations

Among the less common congenital auricular anomalies are cryptotia, Stahl ear, constricted ear, and macrotia. The vast majority of these occur spontaneously without accompanying syndromes or other deformities. This article provides a comprehensive overview of these anomalies, as well as common techniques to correct these anomalies.

Mastoid fascia kite flap for cryptotia correction

OBJECTIVE

Cryptotia is one of the most common malformations of the upper auricle with aesthetic and functional consequences, however there is no standard treatment. We present the surgical technique and results of a kite flap procedure which can be used in the different cryptotia subtypes.

METHODS

We reviewed all patients treated in our department from 2010 to 2015, using a mastoid fascia kite flap technique. The incision of this local flap follows the retro-auricular sulcus along the rim of the helix superiorly and drawing a skin paddle inferiorly. The mastoid fascia is exposed and a superiorly and posteriorly based flap is drawn and detached from the skull. Finally, the skin paddle is rotated and sutured between the superior helix and temporal skin creating the superior sulcus. The retro-auricular incision is closed directly inferiorly.

RESULTS

Six patients (mean age 12) and seven ears were studied. One patient had bilateral cryptotia and only two had a normal contralateral ear. Mean follow-up was of 45 months. There was no skin necrosis, no complications reported and no revision surgery.

CONCLUSIONS

We describe a reliable flap with a simple design and improved aesthetic result, as the thickness of the flap projects the helix well, the scar is entirely hidden in the retro-auricular sulcus and the direct suture induces a harmonious medialization of the inferior part of the ear and earlobe.

Prevention of Recurrence in the Surgical Correction of Cryptotia Using Local Flaps With a Cartilage Wedge Graft

Cryptotia attributable to deficient posterior skin coverage frequently recurs. Because local flaps cover only the posterior aspects of the defective upper auricular cartilage and lack functional support to resist collapse of the helix, especially if severe helical cartilage anomalies are present, additional support is required to prevent the postoperative recurrence of this anomaly. The authors present cases of cryptotia treated using local flaps including a Z-plasty or formation of a trefoil flap with an additional cartilage wedge graft on the cephaloauricular sulcus to enhance projection of the helix. The combination of a graft with a local flap using a large Z-plasty or trefoil flap efficiently corrects the cryptotia, and is associated with minimal visible scarring and few complications, including recurrence.

Comparison between Z-plasty and V-Y Advancement for the Surgical Correction of Cryptotia

Background

Cryptotia correction by V-Y advancement of a temporal triangular flap was introduced in 2005. However, despite the several advantages of V-Y advancement, visible scars at the donor site are problematic. As a result, a Z-plasty technique was considered for skin deficiency in mild cases. Therefore, we introduce a new surgical scheme for cryptotia correction based on considerations of techniques and complications that arose in our clinic.

Methods

Between 2000 and 2013, 26 patients (35 cases) of cryptotia were treated. Seventeen patients had unilateral cryptotia and nine had bilateral cryptotia. Two corrective methods were used, Z-plasty or V-Y advancement, based on the severity. In mild cases, Z-plasty was used for correction and in severe cases, V-Y flap advancement was used for more skin supplement.

Results

Follow-up periods ranged from 6 months to 1.5 years. The results obtained were relatively favorable. Nine cases of mild deformity were corrected by Z-plasty, and the other 26 cases with mild or severe deformities were corrected by V-Y advancement. In Z-plasty cases, there was one hypertrophic scar and in V-Y advancement cases, seven resulted in visible scarring and three in skin sloughing.

Conclusion

The main advantage of Z-plasty is a lower likelihood of visible scarring at the donor site. In mild cases, Z-plasty may be a good alternative, but in severe cases, V-Y advancement is probably the best option for more skin supplement.

Considerations for the management of cryptotia based on the experience of 34 patients

Background

Cryptotia is a congenital ear deformity in which the upper pole appears buried beneath the mastoid skin. Cryptotia is a common auricular malformation among Asians. The aim of this paper is to examine the surgical techniques for and complications of 34 cryptotic patients.

Methods

Surgery was performed for 34 cryptotic deformities (January 2005 to January 2012). Twenty-two patients (64.7%) were classified as having type I cryptotia, and 12 patients (37.5%) type II cryptotia. Among the type I cryptotia patients, 8 patients had mild deformity and 14 severe deformity. Among the type II cryptotia patients, 10 patients had mild deformity and 2 severe deformity.

Results

The mild deformities were corrected via Z-plasty, V-Y plasty, full-thickness skin graft, and transposition flap, while the severe deformities were corrected via cartilage graft or Medporfor the spread of cartilage adhesion of antihelix. There were two cases of reinvagination in the autologous cartilage graft group. Implant exposure occurred with Medpor (two cases). There were two cases of hypertrophic scar on the previous surgical wound with Medpor. There were no complications in the 18 patients who had mild deformities.

Conclusions

The type I cryptotia patients had more severe deformities than the type II cryptotia patients. As most of the type II cryptotia patients had only mild deformities, their deformities were corrected without using autologous conchal cartilage graft or Medpor, except for two patients. Through more case analyses, researchers should make an effort to identify methods for recurrence and prevention of complication.

A new technique for correcting cryptotia: bolster external fixation method

INTRODUCTION

Cryptotia is a congenital auricular deformity in which the upper third of the auricle is buried under the temporal skin. There is no standard surgical method to correct cryptotia.

OBJECTIVES

This study is aimed at devising a new surgical method to correct cryptotia with good auricular contour and inconspicuous scar.

PATIENTS AND METHODS

We retrospectively reviewed 8 patients diagnosed with cryptotia in West China Hospital between 2006 and 2009. All of them received this new surgical method to correct cryptotia. The follow-up period ranged from 6 months to 1 year.

RESULTS

All patients possessed good auricular contour and sufficient skin for release of the upper part of the auricle without the need for a skin graft or local skin flap transferred. All patients possessed deep auriculotemporal sulci and inconspicuous scars. There were no complications, and cryptotia did not recur in any patient.

A tie-over with "untied" parallel stitches: a useful technique for fixation of a bolster after treatment of cryptotia

We describe a new technique for the treatment of cryptotia by which stitches for bolster fixation are inserted parallel to the auriculartemporal sulcus and temporarily left untied. After the bolster has been inserted into the temporal sulcus, the corresponding ends of the threads are tied to each other. Our technique is easy to use and secures a firm bolster fixation, and we recommend it for the treatment of cryptotia.

Surgical correction of cryptotia combined with intraoperative distention using isotonic saline injection and rotation flap method

The following report describes the combination of surgical correction with intraoperative distention using isotonic saline injection and the rotation flap method for correction of cryptotia. This technique provided extensive skin coverage of the upper portion of the auricle and was an easy and quick method of dissecting the cartilage of the posterior auricle. The main advantages of this technique include achievement of skin expansion without the need for expander material, simple design of the skin incision, and easy dissection of the cartilage. Although one patient experienced partial congestion in the upper tip of the rotation flap, no other complications occurred. Further, cryptotia did not recur.

Nonsurgical treatment of various auricular deformities

Nonsurgical treatment does not always correct all auricular deformities. However, we believe that all types of deformities can be treated if the gradual and continuous correction is made. Therefore, it is recommended that nonsurgical treatment should be tried first, even in older children. Even if the correction with the splint is not satisfactory, the improved form with the splint will make it easier to obtain a good, delicate form by surgery at a later stage.