The Postauricular Fascia: Classification, Anatomy, and Potential Surgical Applications

The posterior auricular muscle complex graft as a porous orbital implant wrap: long-term follow-up over a 31-year period

PURPOSE

Orbital implant exposures, infections, and extrusions can occur many years following enucleation or evisceration. This study analyzes complication rates following porous orbital implant wrapped with a posterior auricular muscle complex graft (PAMCG).

METHODS

This is a retrospective study of patients who underwent orbital implantation following enucleation using this technique between 1992 and 2013. Only cases with a minimum of 18 months of follow-up were included. No patients underwent peg implantation. Patient's demographics, follow-up time, type of implant, complications including wound dehiscence, exposure, postoperative infection, and extrusion were recorded.

RESULTS

This study included 36 orbits of 36 patients with a mean age of 39.3 ± 23.2 years (range, 3-84 years). Thirty patients had hydroxyapatite implants and six had porous polyethylene. The average follow-up time was 12.6 ± 5.6 years (range, 1.5-31.0 years). There were no implant extrusions, and only one exposure resulting in orbital infection that necessitated implant removal (2.8%).

CONCLUSION

Wrapping porous orbital implants with PAMCG had favorable long-term outcomes over a thirty-one-year period.

The Use of Posterior Auricular Fascia Graft (PAFG) for Slight Dorsal Augmentation and Irregular Dorsum Coverage in Primary and Revision Rhinoplasty: A Prospective Study

INTRODUCTION

Augmentation and coverage of irregularities of the nasal dorsum remain a challenge in rhinoplasty. Different techniques have been described in the current literature for this purpose. The aim of this study is to assess and illustrate the author experience and outcomes using the posterior auricular fascia graft (PAFG) for dorsal camouflage and augmentation in primary and revision rhinoplasty.

MATERIAL AND METHODS

A prospective bicentric study was conducted, including patients with slight dorsal deficiencies and/or with dorsal irregularities following hump resection, trauma or previous rhinoplasty receiving PAFG to improve the rhinoplasty outcome. To objectively assess the graft resorption rate, MRI was performed 2 weeks and 18 months after surgery. To investigate patient satisfaction, the preoperative and 1-year postoperative scores obtained using the rhinoplasty outcomes evaluation (ROE) scale were compared. The scores following a normal distribution obtained for each patient were compared using a paired t-test.

RESULTS

Forty-five patients were enroled in this study. Average follow-up duration was 35.4 months. Patients' age ranged from 17 to 57 years. No cases of infection or major graft resorption were observed. No postoperative scars were visible at the donor site. All patients were satisfied after surgery, and a statistically significant difference between pre- and postoperative scores (p<0.0001) was observed.

CONCLUSION

This study showed that PAFG is a reliable technique for dorsal camouflage and slight augmentation in primary and revision rhinoplasty. The procedure is safe, easy and quick and only requires a small learning curve.

LEVEL OF EVIDENCE II

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 .

Using Auricular Cartilage-fascia Composite Tissue Free Grafting Technique to Improve Cartilage Survival Outcomes

OBJECTIVES

Auricular cartilage graft has a wide range of applications in plastic and reconstructive surgery. However, there is still a risk of absorption of the grafts over time. Intrinsic postauricular fascia (IPF) with a rich vascular network may play an important role in the nutrition and repair of auricular cartilage. This study aimed to investigate the effect of IPF on the survival viability of free auricular cartilage grafts.

METHODS

24 auricular cartilages were obtained from 6 New Zealand white rabbits which were divided into the cartilage-fascia composite graft group (FC group, n=12) and the cartilage without fascia group (C group, n=12). Two groups of cartilage were implanted into each side of the subcutaneous pocket of the rabbit's dorsum. The rabbits were sacrificed after 3 months and all cartilage grafts were obtained. Macroscopic observation, histopathological staining, and biomechanical testing were performed on all specimens.

RESULTS

There were significant differences between the 2 groups regarding proliferating chondrocytes, apoptotic chondrocytes, vascularization, and matrix collagen. Compared to the auricular cartilage grafts without fascia, the auricular cartilage-fascia composite grafts had more neovascularization, proliferative chondrocytes, and type II collagen, with a homogeneous cartilage matrix and no obvious areas of heterogeneous staining. Young's modulus and ultimate tensile strength of cartilage were reduced in both groups compared to pretransplantation, but the composite graft group was superior to the fascia-free group.

CONCLUSIONS

Auricular cartilage-fascial composite tissue free graft could improve cartilage survival outcomes with higher viability and mechanical properties.

Surgical results of retroauricular fascia graft in frontalis suspension surgery: A case series study

Frontalis suspension surgery is commonly used for the repair of congenital ptosis and involutional blepharoptosis with poor levator function. Grafts for this procedure have been developed using a variety of different materials, each with advantages and disadvantages. The retroauricular fascia graft might be beneficial in this surgery. This article reports the surgical results of blepharoptosis, who were treated with the retroauricular fascia, which is a new autologous graft for the frontalis suspension technique. This case series study targeted patients with ptosis who underwent frontalis suspension surgery with the retroauricular fascia graft at Wakayama Medical University in Japan between May 2016 and May 2023. Patients with insufficient follow-up (<6 months) were excluded from the study. Eligible patients were categorized into one of the following three assessment groups: "good" (improvement of palpebral fissure height without laterality, Margin reflex distance-1 gap between right and left side <0.5 mm), "fair" (improvement of palpebral fissure height with laterality), or "poor" (poor improvement of palpebral fissure height). Thirty-five eyes in 25 patients were treated with the retroauricular fascia graft. The mean postoperative follow-up was 27 months. Eight patients were classified as good (32%), 15 as fair (60%), and two as poor (8%). Two patients (8%) had postoperative lagophthalmos. No patients had eyelash inversion, tarsal deformity, or recurrence of ptosis. Scars along the edge of the hairline were inconspicuous and there were no hypertrophic scars. Functional reconstruction of the eyelids using the retroauricular fascia graft technique is described here for the first time. This grafting technique may be a useful alternative for frontalis suspension surgery because it can be harvested with easy access and without leaving conspicuous scars.

Salvage of Ear Framework Exposure Following Autologous Microtia Reconstruction: Repair Strategy for Each Location of Exposure

One of the most common complications of total auricular reconstruction is exposure of the ear framework. Various reconstruction methods have been reported depending on the location and size of exposed cartilage. This report describes a safe reconstruction method for each exposed part of the grafted ear framework. From January 2019 to August 2021, 2 cases (4 areas) of framework exposure were observed following autologous microtia reconstruction. The first case developed 2 small areas of skin necrosis on the anterior helix and lower antihelix to concha. The former was reconstructed with a temporal fascia flap and the latter with a local transposition flap. The second case also developed 2 small areas of skin necrosis on the posterior helix and lower antihelix to concha. The former was sutured directly and the latter with a local transposition flap. However, both wounds recurred due to flap necrosis and the cartilage was exposed again. The 3rd operation was performed by covering both wounds with a posterior auricular turnover flap and skin graft. In both cases, the exposed framework was completely covered with the flaps, and the reconstructed ears showed well-defined convolutions. Covering exposed cartilage with a local flap with a random pattern of blood circulation is convenient because no additional skin grafts are required. However, the blood circulation of the flaps is inadequate when an elongated flap is required; consequently, flap necrosis may occur. On the other hand, a temporal fascia flap and posterior auricular flap, which have axillary pattern blood circulation, are considered to be safer. We believe that it is safe to use a temporal fascia flap for cartilage exposure in the upper half of the auricle, and a posterior auricular turnover flap for the lower half.

Repair of exposure and fracture of the porous high-density polyethylene framework after ear reconstruction

OBJECTIVE

To assess the repair method of exposure or fracture of the porous high-density polyethylene ear framework after total auricle reconstruction.

STUDY DESIGN

A prospective case study.

METHODS

From April 2018 to October 2021, 11 patients with framework exposure or fracture after total auricle reconstruction were admitted to the hospital for repair. In these 11 patients, the repair was performed using (1) a temporal muscle flap combined with free skin graft in 5 patients, (2) a mastoid fascia flap combined with free skin graft in 2 patients, (3) a simple local skin flap in 1 patient, (4) combination of a temporalis muscle flap and a mastoid fascia flap together with free skin graft in 2 patients, and (5) a Su-Por helix material combined with a temporal muscle flap and free skin graft in 1 patient.

RESULTS

After follow-up for 3-36 months, except for one patient in whom local exposure again occurred at the same site, the framework was in a good shape in the other patients, and all the skin graft survived.

CONCLUSION

The defect of the upper part of the auricle can be repaired using a temporal muscle flap combined with temporal muscle fascia and skin graft. The defect of the middle and lower part of the auricle can be repaired using a mastoid fascia flap combined with skin graft. For framework fracture, the damaged site can be first strengthened with another ear material and then combined with the adjacent fascia flap and free skin graft.

Cartilage-Sparing Otoplasty: The Effects of Adipo-Perichondrial Flap-Assisted Posterior Auricular Muscle Complex Flap Technique on the Repair of Prominent Ear Deformities

BACKGROUND

In the repair of prominent ear deformities, the main objectives are to recreate the antihelical fold, reduce projection in patients with a large concha, and normalize the distance between the ear and the cranium. This study evaluated the efficacy of the adipo-perichondrial flap-assisted posterior auricular muscle complex (PAMC) flap technique, which involves a new approach to the repair of prominent ear deformities.

MATERIALS AND METHODS

A medially based PAMC flap and a laterally based adipo-perichondrial flap were elevated in 22 patients with prominent ear deformities. In order to shape the ear, the PAMC flap was sutured to the transition zone between the helix and antihelix, and the adipo-perichondrial flap to the periosteum of the mastoid bone. The ear-cranium distances were measured preoperatively and at postoperative first and sixth months.

RESULTS

Thirteen patients were female and 9 were male. The mean age of the patients was 19.4 years, and the mean follow-up period was 10.6 months. The ear-cranium distance significantly decreased in the postoperative first-month and sixth-month evaluations compared to the preoperative values (P < .05). No relapse, suture exposition, hematoma, keloid scar, or infection was observed.

CONCLUSION

Posterior auricular muscle complex is a strong anatomical structure that includes the trapezius muscle, occipital muscle, extrinsic ear muscles, temporal fascia, and sternocleidomastoid fascia. By elevating this structure as a flap and combining it with an adipo-perichondrial flap, successful results can be achieved in the repair of prominent ear deformities, which prevents relapses and maintains the shape of the ear in the long term.

A Modification of the Posterior Perichondrio-Adipo-Dermal Flap for Protruding Ear Correction: A Customized Technique

Prominent ear deformity is a common congenital deformity of the external ear affecting 5% of the general population. Because of the deformity's displeasing nature, corrective prominent ear surgery is widely common and performed as a prophylactic surgery. More than 200 surgical techniques for the correction of prominent ear deformity have been described to improve the cosmetic outcome and decrease complication rates. The aim of the study was to present a modified post auricular flap technique that increases the control of reshaping the ear cartilages, decreases the operation time, and provides a symmetrical long-lasting cosmetic outcome.One hundred sixty-two patients (141 male and 21 female) had ear correction surgeries performed by the same surgeon using the described technique between January 2015 and January 2018. One hundred sixty patients were gone through bilateral ear correction, whereas only 2 patients had unilateral ear correction procedures. A modified posterior perichondrio-adipo-dermal flap technique for protruding ear correction was applied to all patients.The patients' ages ranged from 18 to 40 years, with a median of 28.3 years. The mean follow-up time was 22.5 months (6-36 months). Total operation time was 35 minutes on average (25-45 minutes). As more experience was gained in flap harvesting, operation time became shorter. The mean preoperative upper third ear proportion-scalp distance was 33.1 mm and the middle third ear proportion-scalp distance was 29.8 mm. At the sixth month of the surgery, the measurements were 9.8 and 11.6 mm.Measuring and adjusting flap's width provided to achieve symmetry in initial technique. Locating the postoperative scar along the posterior surface of the helical groove also provides a natural view. Different from traditional posterior fascial flap, the width of the flap was narrowed to 8 to 10 mm. In the traditional technique, the flap was dissected along the incision margins. Narrowing the width of the flap decreased the operation time. The preserved skin between the helix and the mastoid bone has the same width with perichondrio-adipo-dermal flap. That increases the control over the helix-mastoid distance and posterior auricular fold not to mention provides permanent results. The previously mentioned method can be a simple, useful, and practical technique for protruding ear deformity.

Two Laterally Based Flap Otoplasty for Protruding Ear Correction

: The postauricular fascial flap as supportive or stand-alone technique provides natural, symmetrical-looking ears with minimal complications and recurrence. However, the posterior fascial flap otoplasty is not applicable for all protruding ear deformity types. It is particularly advantageous in terms of anti-helix creation yet does not have a satisfactory effect for correction of conchal hypertrophy. In this paper, it was aimed to describe a new technique, solely focuses on overcoming the conchal hypertrophy problem during protruding ear repair.A total of 12 patients (8 male and 4 female) underwent otoplasty with the same surgeon between May 2017 and May 2018. All otoplasties were performed bilaterally. Patients with conchal hypertrophy and anti-helical effacement were included into this study to evaluate the efficiency of the new technique.A total of 12 patients (8 male and 4 female) underwent otoplasty with described technique. Patients ages ranged from 18 to 30 years, with a median of 27.6 years. None of the patients suffered from early postoperative complications, such as skin necrosis, suture extrusion, hematoma, or wound infection. There was only 1 patient with the complaint of asymmetry at the late postoperative period and unilateral revision otoplasty was performed.In this study it was aimed to demonstrate a new technique which contains one posterior perichondrio-adipo-dermal flap and 1 perichondreal flap. The technique is highly advantageous if the patient suffers from both conchal hypertrophy and anti-helical effacement. It was seen that the described technique is practical and efficient for patients who both has conchal hypertrophy and anti-helical effacement. LEVEL OF EVIDENCE:: III, therapeutic study.

Two-Flap Otoplasty: A New Technique for Protruding Ear Correction

Prominent ear deformity is a common congenital deformity of the external ear affecting 5% of the general population. Although this is a harmless deformity, several publications demonstrate the psychological distress, emotional trauma, and behavioral problems that this deformity can inflict on children. As a result of these concerns, corrective prominent ear surgery is now widely performed as a prophylactic surgery.A laterally based perichondrioadipodermal flap and a medially based adipoperichondrial flap were elevated. A subdermal pocket was prepared over mastoid bone. Medially based adipoperichondrial flap was fixed to the posterior helical skin; laterally based perichondrioadipodermal flap was fixed to the mastoid bone periosteum. The helix-mastoid distances and concha-mastoid angles of the patients were measured preoperatively and at the sixth month of the surgery as the late postoperative assessment. Patients were also evaluated for suture extrusion, granuloma formation, deformity recurrence, and postauricular area sensitivity.Twenty-two patients with bilateral prominent ear deformities were treated between January 2017 and January 2018. None of the patients suffered from skin necrosis, suture extrusion, hematoma, or wound infection at the early or late postoperative period. Unilateral recurrence was noted in 1 patient, and revision was performed.Preparation of a medially based adipoperichondrial flap and a laterally based perichondrioadipodermal flap and the reposition of these flaps with opposite vectors not only decrease postoperative complication rates but also provide a primary otoplasty technique. The posterior fascia flap is already a well-documented and reliable protruding ear correction method.

The surgical anatomy of soft tissue layers in the mastoid region

Background

An understanding of the soft tissue layers in the mastoid region has become important for otologic reconstructive surgery. The objective of this study was to clarify the surgical anatomy of the soft tissue layers in the mastoid region and reveal its clinical significance.

Methods

Cadaveric study.

Results

Our dissections showed the soft tissue layers consisting of skin, subcutaneous layer, superficial and deep mastoid fasciae, and periosteum. The superficial mastoid fascia was continuous with the temporoparietal fascia cranially and the superficial cervical fascia caudally. The deep mastoid fascia could be clearly separated from the superficial mastoid fascia and has continuity to the loose alveolar layer in the temporoparietal region. However, it caudally fused with the fascia and ligament of the sternocleidomastoid.

Conclusions

A comprehensive understanding of soft tissue layers would improve otologic reconstructive surgery.

Level of Evidence

NA

[Repair of skin and soft tissue defects of auricle and donor site with relay flap]

Objective

To investigate the effectiveness of relay flap on repairing skin and soft tissue defect of auricle and donor site.

Methods

Between May 2014 and January 2016, 10 patients with auricular tumor were repaired by relay flap. There were 4 males and 6 females with an average age of 35 years (range, 21-69 years). There were basal cell carcinoma in 2 cases, pigmented nevus in 3 cases, papilloma in 4 cases, and Bowen's disease in 1 case. The size of the residual wound after tumor resection ranged from 1.1 cm×1.0 cm to 2.3 cm×1.7 cm. The superficial temporal artery posterior auricular perforator flap was used to repair the auricle defect wound. The size of flap ranged from 1.5 cm×1.4 cm to 2.8 cm×2.0 cm. The first donor site was repaired with the posterior auricular artery perforator propulsive flap. The size of flap ranged from 4.0 cm×2.0 cm to 7.5 cm×3.0 cm. The wound of the second donor site was sutured directly at the first stage.

Results

All the flaps survived. The donor and recipient sites healed by first intention. The patients were followed up 10-28 months, with an average of 14.2 months. The appearance of reconstructed auricle was satisfactory, and the tumor had no recurrence. The appearance, color, texture, and thickness of the flaps were basically consistent with the recipient site, without obvious scar, traction deformity, or obvious abnormal sensation.

Conclusion

The relay flap has advantages of reliable blood supply, the simple operation method, the concealed donor site, which is a good choice to repair the skin and soft tissue defect of auricle and donor site.

Salvage of a cartilage framework exposure in total ear reconstruction using a retro-auricular fascia flap with double axial irrigation

Cartilage framework exposure during total ear reconstruction requires an early salvage procedure and a secure coverage. We present a case that has been successfully covered by a retro-auricular fascia flap and a skin graft. Because we were dealing with a post-traumatic ear amputation with extensive scarring, the flap was designed to include both the retro-auricular artery and the occipital artery for an enhanced vascular security. This flap design may play a more important role especially in post-traumatic ear reconstruction.

Interpositional Flap Reconstruction of Temporomandibular Joint Using a Novel Anterior-Based Mastoid Flap Technique

In this report, it was aimed to use the anterior-based mastoid fascia flap as an interpositional graft in TMJ surgery. This technical report, along with this characteristic, is the first in the literature.

Prominent Ear Correction: A Comprehensive Review of Fascial Flaps in Otoplasty

Over the last 100 years, more than 200 different methods have been described to correct prominent ear deformity. These techniques revolved around various combinations of postauricular incision, cartilage scoring, and strategic suture placement to reapproximate the antihelical fold and correct angular deformity. In the last two decades, fascial flap techniques have become prominent in otoplasty. This article gives a comprehensive review of the different surgical techniques employed to construct fascial flaps and their contributions to otoplasty.

Investigation of Microsurgical Technique Combined With Skin Flap Expansion for Ear Reconstruction in Treating Hunter Type III Congenital Microtia

OBJECTIVE

This study aims to observe the efficacies of microsurgical technique combined with the Zhuang's skin soft tissue expander in treating Hunter type III congenital microtia.

METHODS

Fifty-eight patients (61 ears) were enrolled from 2003 to 2012; the skin tissue expander was embedded subepidermally in the first stage via the intrahairline longitudinal incision in the postauricular mastoid area, the diseased-side rib cartilage was then taken for preparing the ear bracket in the second stage, and the tragus was surgically reconstructed in the third stage.

RESULTS

The mean follow-up lasted 6 months to 10 years, the results were satisfactory for 54 ears and acceptable for 5 ears, and 2 ears (in two patients) appeared with complications, including 1 case of ear flap expansion rupture and 1 case of postoperative lateral helix flap necrosis.

CONCLUSIONS

The combination of microsurgical technique, Zhuang's skin soft tissue expander, and autogenous rib cartilage graft could achieve satisfactory results in treating Hunter type III congenital microtia, and the complications were less, so it was worthy of clinical applications.

Vascular Nature and Existence of Anastomoses of Extrinsic Postauricular Fascia: Application for Staged Auricular Reconstruction

A staged auricular reconstruction in microtia patients was developed by using superficial mastoid fascia (as part of extrinsic postauricular fascia) to cover the cartilagenous framework due to its highly vascularized nature. Three branches of external carotid artery (superficial temporal artery, posterior auricular artery and occipital artery) were found to supply this fascia, this study was therefore aimed to investigate the dimension of blood supply from each vessel and also to demonstrate the existence of anastomoses among these arteries. Thirty-eight pinnas and postauricular fascias from Thai fresh adult cadavers were included to document the anastomoses by showing both perfused dye connection (10 dissections) and visible anastomotic branches (8 dissections) among them. Distribution of each vessel trunk and its branches were demonstrated using superimposed illustration in the other 20 dissections with dye injection into each artery to designate 3 zones of anastomotic area between each arterial pair. Maximal size of viable postauricular fascial flap for staged reconstruction according to this vascular study was thus estimated to be at least 5 cm above and 3 cm below the Frankfurt horizontal plane and about 6 cm posterior to external acoustic meatus owing to the course of posterior auricular artery and its anastomoses. In addition, greater size of flap with dual blood supply from both superficial temporal and posterior auricular arteries can be raised by harvesting beyond 5 cm above external acoustic meatus.

The Versatile Posterior Auricular Fascia in Secondary Rhinoplasty Procedures

BACKGROUND

Secondary rhinoplasty often involves the addition of autogenous graft material to add volume, structure, support and to camouflage cartilage and bone grafts. A variety of fascias have been used to camouflage, wrap and give "fill" in secondary rhinoplasty. The posterior auricular fascia is a source of material ideal for such purposes, and its quantity, anatomical structure and ease of harvest with minimal donor site morbidity make it a versatile and attractive autogenous graft.

METHODS

The clinical records of patients receiving autogenous posterior auricular fascial grafts were reviewed. There were two main uses of this graft material, one was to cover the tip reconstruction in secondary rhinoplasties under thin tip skin. This is a camouflage graft. The second use is for fill and augmentation, especially for the nasal dorsum and as an interpostitional graft between the dorsum and the tip.

CONCLUSION

The posterior auricular fascial graft has many potential uses in secondary rhinoplasties and is readily harvested as a generous graft concurrent to conchal cartilage harvest and with a concealed scar behind the ear.

LEVEL OF EVIDENCE V

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 .

Reconstruction of the postauricular defects using retroauricular artery perforator-based island flaps: Anatomical study and clinical report

The objectives of the study were to introduce and investigate the reliability of a new flap for postauricular defects using the retroauricular artery perforator.Twenty auricles from 10 Asian human cadavers were dissected to examine the retroauricular perforator distribution and diameter. Fourteen patients with postauricular defects underwent reconstruction using the retroauricular artery perforator from 2013 to 2015. After locating the position of the perforator by ultrasound Doppler blood flow detection, a suitable flap was designed according to the defect's size, condition, and distance from the pedicle. The flap was meticulously elevated, rotated appropriately, and sutured to the defect. The donor site was then closed.Cadaver dissection showed that the posterior auricular artery produces at least 2 constant branches with an external diameter of 0.84 ± 0.25 mm at the origin. These branches proceed toward the mastoid process at the height of the auriculocephalic angle to nourish the skin and fascia. A total of 14 clinical cases were available for 3 to 12 months postoperative follow-up. All flaps survived completely, maintaining good skin color, perfect outer contour, and complete patient satisfaction with the aesthetic results after initial treatment.Retroauricular artery perforator-based island flaps appear to be ideal for 1-stage reconstruction of postauricular skin defects.

Davis flap: the glory still present

BACKGROUND

Upper third defects of the ear are too large to be closed primarily without distorting the auricle. Full thickness defects can be reconstructed with local flaps. In this article, Davis flap was used to fill the upper third defects of the ear with some modifications.

PATIENTS AND METHODS

Eight patients underwent reconstruction of full thickness auricular defects with Davis flaps from July 2012 to December 2014. The posterior surface of the flap and the raw area of conchal area were covered by full thickness graft taken from posterior surface of ear.

RESULTS

All flaps survived. No congestion was noted. The donor sites and skin grafts healed uneventfully.

CONCLUSION

Davis flap is a simple and reproducible tool for reconstruction of upper third of ear.

The discrete scar in prominent ear correction: a digital 3-dimensional analysis to determine the ideal incision for otoplasty

INTRODUCTION

Various postauricular incision sites can be used for prominent ear correction depending on technique and surgeon preference. No study has previously looked at the most aesthetic (least visible) location for the postauricular scar. We investigated the visibility of various scar locations on the posterior ear from a third person perspective through a "Visibility Arc"-a formal assessment of the range of degrees where a particular scar is visible. The objective was to determine the least visible incision-that is, the scar with the shortest visibility arc.

METHODS

Normal ears were marked with 3 different color markers to simulate postoperative scar position, namely, (1) black in auriculocephalic sulcus, (2) blue in the sulcus of the antihelical fold/groove, and (3) green between black and blue. Starting laterally from the right ear toward the left ear, each head was photographed across 180 degrees posteriorly, at 10-degree intervals to determine which colored line (corresponding to a particular scar location) was visible over what "visibility arc."

RESULTS

Forty individual ears were analyzed. Scars located in the sulcus of the antihelical fold had the shortest average visible arc, which was a 70-degree arc. The auriculocephalic sulcus had the largest visibility arc, and was most obvious of all of the scar locations-a 100-degree arc. The scar location in between these 2 locations had an 80-degree arc.

CONCLUSIONS

The least visible scar for pinnaplasty rests in the groove of the antihelix posteriorly, with scars slightly medial to this almost as discrete. The most visible scars when viewed from behind will be those in the "traditional" location of the auriculocephalic sulcus.