Patient factors associated with novel EAR-Q appearance, psychosocial, and social scales: A cross-sectional study and regression analysis.

INTRODUCTION: The EAR-Q is a rigorously validated patient-reported outcome measure, which evaluates ear appearance and health-related quality of life (HRQL) in patients with congenital or acquired ear conditions. The aim of this study was to conduct an exploratory analysis to examine the factors associated with EAR-Q appearance and HRQL scale scores. METHODS: In this study, 862 participants, aged 8-29 years, with congenital or acquired ear conditions, completed the EAR-Q as part of an international field-test study. Patients responded to demographic and clinical questions as well as the EAR-Q. Univariable and multivariable linear regression analyses were used to determine factors that were significant predictors for the scores on the EAR-Q Appearance, Psychological, and Social scales. RESULTS: Most participants were men (57.4%), awaiting treatment (55.0%), and had a microtia diagnosis (70.4%), with a mean age of 13 (±4) years. Worse ear appearance scores (p < 0.02) were associated with male gender, microtia, no history of treatment, ear surgery within 6 months, unilateral involvement, and greater self-reported ear asymmetry. Decreased psychological scores (p < 0.01) were associated with increasing participant age, no treatment history, recent ear surgery, and dissatisfaction with ears matching or overall dissatisfaction. Lower social scores (p ≤ 0.04) were associated with no treatment history, those awaiting surgery, ear surgery within the last 6 months, bilateral involvement, and self-reported ears matching or overall appearance. CONCLUSION: This analysis identified patient factors that may influence ear appearance and HRQL scale scores. These findings provide evidence of patient factors that should be adjusted for when undertaking future observational research designs using the EAR-Q in this patient population.

New Strategies for Remnant Ear Treatment in Microtia Reconstruction Based on Morphometric Studies.

OBJECTIVE: Given the lack of specific evaluation indices, it is difficult to determine whether to transpose or abandon remnant ears in lobule-type microtia reconstruction. The authors illuminate referable parameters beneficial for proper treatment of remnant ear in an efficient manner. METHODS: A series of 359 lobule-type microtia patients underwent autogenous costal cartilage auricular reconstruction between 2016 and 2021. Fourteen measuring points and defined distances as well as six ratios of specific distances based on position, plumpness, similarity and the width-to-length ratio of the remnant ear have been described, and relevant tactics for appropriate treatments are introduced. RESULTS: Definite morphometric results contribute to attaining satisfactory contours of reconstructed auricles with harmonious earlobes, which exhibit highly similar dimensions and appearances compared to the contralateral normal ears. CONCLUSION: With the help of the proposed locating points and measuring approaches, the procedure of remnant ear treatment is systematically clarified. This technique ensures operation safety and contributes to the aesthetic contour of the auricle. LEVEL OF EVIDENCE: IV Laryngoscope, 134:2741-2747, 2024.

Microvascular Replantation for partial auricle Amputation: Only Arterial anastomoses and Acupuncture Bloodletting.

BACKGROUND: There have been many reports on replantation of complete auricle amputation, but few reports on successful replantation of partial auricle amputation. The main reason is that the diameter of blood vessels at the end of auricle is only 0.3 mm, and it is difficult to find suitable blood vessels, especially venous vessels. The purpose of this study was to investigate the method of revascularization after partial auricle amputation. METHODS: Microvascular repairs were performed in an amputated segment with only identified artery vessels for anastomosis, and vein was unavailable for anastomosis. Postoperative acupuncture bloodletting and heparin compress treatments were planned. RESULTS: Two patients with partial ear amputation were treated at our center between 2019 and 2021. All the amputated ear were replanted successfully. No blood transfusions and no infections were observed. A week later the replanted auricles were seen, blood flow established. CONCLUSION: Microvascular repair should be considered as the best options in cases of auricular avulsion segment replantation. When no vein was available for anastomosis, only one artery repaired was feasible. Acupuncture bloodletting and heparin compress are the effective methods to treat vein congestion. 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 .

Firm elevation of the auricle in reconstruction of microtia with a retroauricular fascial flap wrapping two titanium plate struts.

BACKGROUND: Reconstruction of the cephaloauricular sulcus in patients with microtia in ear reconstructions remains challenging. Costal cartilage and other support materials wedge were used for ear elevation. Each material has its disadvantages. To reconstruct a stable cephaloauricular sulcus and reduce costal cartilage harvesting, we used two titanium plate struts to support the costal cartilage framework. METHODS: A titanium plate strut was designed. The angle of the strut was 60°, the arm length was 0.8 cm, and the width was 0.5 cm. The thickness was 0.6 mm. Four small pores are formed on the titanium plate. The implanted framework was separated from the underlying bed. Two titanium plate struts were fixed on the raised ear framework, tendon, and periosteum, and then wrapped with a turned-over retroauricular fascia flap. The raw surface was covered with a split-thickness skin graft, harvested from the scalp. RESULTS: From 2019 to 2022, 51 patients underwent second-stage operations. All patients were followed up for a minimum of 6 months. The auricular projection was well-maintained, and the cephaloauricular sulcus of the constructed auricle was acceptable in 50 patients. There was one infection, and the titanium plate struts were removed, which resulted in shrinking cephaloauricular angles. CONCLUSIONS: Titanium plate is effective as a supportive material to obtain the proper and firm projection of the constructed auricle. It provides a new option for patients whose costal cartilage volume is insufficient or who do not want to have the costal cartilage harvested again.

Ear Reconstruction: Empirical Data of 406 Cases of Carving the Convex Structures of the Framework.

OBJECTIVE: In auricular reconstruction, the convex structures of the framework determine the esthetics, and young doctors often need sufficient training to determine the best carving techniques. This study aimed to recommend optimal carving methods and provide measured data of convex structures of the carved costal cartilage framework to prevent complications, improve esthetics, and reduce the learning curve. METHODS: From 2018 to 2021, 406 patients with microtia who underwent costal cartilage carving were enrolled. The helix is formed by the eighth costal cartilage. The complex of the antihelix was fabricated from part of the eighth costal cartilage or the ninth costal cartilage. The tragus was constructed using residual cartilage pieces from the base frame. These components were measured, and those from the new ear graded "excellent" were used for data analysis. The statistical analysis was principally processed using Excel software. RESULTS: A total of 112 ears were graded "excellent". The following are the mean and standard deviation of each group of data: antihelix thickness, 0.31 ± 0.06 cm; antihelix width, 0.40 ± 0.06 cm; superior crus thickness, 0.18 ± 0.04 cm; superior crus width, 0.38 ± 0.09 cm; inferior crus width, 0.22 ± 0.04 cm; inferior crus thickness, 0.28 ± 0.05 cm; helix thickness, 0.31 ± 0.04 cm; the four-point height of the helix, 0.52 ± 0.08 cm/0.51 ± 0.07 cm/0.46 ± 0.06 cm/0.41 ± 0.06 cm; and tragus height, 0.98 ± 0.15 cm. CONCLUSION: These data may help beginners in reducing the learning curve of ear reconstruction. Framework fabrication based on these data allows attaining a harmonious ear framework and satisfactory three-dimensional auricle outline, yielding acceptable results and few complications. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:569-575, 2023.

Strategies for ear elevation and the treatment of relevant complications in autologous cartilage microtia reconstruction.

Despite various surgical techniques for ear elevation in autogenous cartilage microtia reconstruction, it is still challenging for plastic surgeons to obtain a satisfactory depth of the cephaloauricular sulcus and stable projection of the reconstructed ear. Here, the authors demonstrate individualized options for surgical approaches and relevant details for complication management. Between January 2014 and June 2020, a series of 895 patients who underwent the second stage of microtia reconstruction were reviewed. Complications occurred in 103 patients aged between 8 and 34 years. Recommended surgical selections, as well as appropriate strategies for complication prophylaxis and treatment, were shown to minimize the negative influence on the contour of the cephaloauricular sulcus according to individual conditions. We found that 78% of the patients were satisfied with the auricle contour with harmonious integrity. Individualized strategies for ear elevation and complication treatment contribute to symmetry and satisfactory projection of the reconstructed auricle.

Microtia Part II: Post-Operation and Complications Management Lessons from 1012 Ear Reconstruction Operations.

BACKGROUND: Ear reconstruction presents challenges for surgeons, not only during the pre-operation and in-operation stages, but also post-operation. The post-operation stage and the treatment of complications are critical to the overall success of ear reconstruction surgery. METHODS: This article, the second of two articles setting out details and precautions for each step of the ear reconstruction process for microtia patients, covers post-operative care: negative pressure drainage, bandaging and fixing, nursing, treatment of complications and satisfaction survey. RESULTS: Over the period Jan 2015-July 2021, our surgical team treated 77 complications in 1012 microtia ear reconstructions. This article presents the key learnings from this high volume of operations. All complications were treated promptly and the shape of the auricle was preserved as much as possible. Patients were surveyed after the operation and expressed satisfaction with the shape of the reconstructed external auricle. Three typical cases involving different types of complications are described. CONCLUSIONS: This article deals in detail with the post-operation stage. We share our cumulative surgical experience gained over 20 years, especially the latest practical lessons gleaned over the last six and a half years. 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 .

Prussian Blue Nanozyme Promotes the Survival Rate of Skin Flaps by Maintaining a Normal Microenvironment.

Ischemia-reperfusion (I/R) injury leads to a low success rate of skin flap transplantation in reconstruction surgery, thus requiring development of new treatments. Necroptosis and apoptosis pathways, along with overexpression of reactive oxygen species and pro-inflammatory factors in skin flap transplantation, are deemed as potential therapeutic targets. This study provides a paradigm for nanozyme-mediated microenvironment maintenance to improve the survival rate of the transplanted skin flap. Prussian blue nanozyme (PBzyme) with multiple intrinsic biological activities was constructed and selected for this proof-of-concept study. The prepared PBzyme shows anti-inflammatory, antiapoptotic, antinecroptotic, and antioxidant activities in both in vitro and in vivo models of I/R injured skin flaps. The multiple inhibitory effects of PBzyme maintained a normal microenvironment and thus significantly promoted the survival rate of the I/R injured skin flap (from 37.21 ± 8.205% to 79.61 ± 7.5%). Of note, PBzyme regulated the expression of the characteristic signal molecules of necroptosis, including Rip 1, Rip 3, and pMLKL, indicating that PBzyme may be a therapeutic agent for necroptosis-related diseases. This study shows great prospects for clinical application of PBzyme in the treatment of skin flaps via local administration.

Strategies for the Treatment of Auricular Complications after the First Stage of Autologous Cartilage Microtia Reconstruction.

BACKGROUND: Effective handling of auricular complications after the first stage of autologous cartilage microtia reconstruction remains one of the most demanding challenges for plastic surgeons. Here, the authors discuss relevant details for treatment of such complications in various conditions. METHODS: A total of 1739 microtia patients underwent the first stage of auricular reconstruction with autogenous costal cartilage between 2007 and 2019. Different complications occurred in 136 cases. The details of complications are described, and relevant tactics for appropriate prevention and treatment are introduced. RESULTS: Selective methods for the management of different complications in a prompt and effective manner after the first stage of ear reconstruction have been shown to salvage and maintain the contour of the reconstructed auricle to the maximum extent. CONCLUSION: Auricular complications can be well treated and prevented through careful preoperative preparation, meticulous intraoperative manipulation, and proper postoperative management. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Microtia Part I: Preoperation and In-operation Lessons from 1012 Ear Reconstruction Operations.

BACKGROUND: Organ reconstruction is one of the most challenging tasks in plastic and reconstructive surgery. This is particularly true of ear reconstruction, which requires enormous attention to detail. METHODS: In the first of two articles, we set out details and precautions for each step of the preoperative and intraoperative stages of the ear reconstruction process for microtia patients. We cover preoperative screening and assessment of surgical conditions, the design of intraoperative incisions, flap separations, costal cartilage extraction, framework carving and cranial ear angle surgery. RESULTS: Over the period Jan 2015-July 2021, our surgical team carried out 1012 microtia ear reconstructions, at the rate of 3-4 per week. This article presents the key learnings from this high volume of operations. Two typical cases involving different types of microtia are presented in order to illustrate the process of total ear reconstruction. CONCLUSIONS: This article describes in detail the preoperative and intraoperative stages of the ear reconstruction process. We share our cumulative surgical experience gained over 20 years, especially the latest practical lessons gleaned over the last six and a half years. 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 .

The efficacy and safety of low-energy carbon dioxide fractional laser use in the treatment of early-stage pediatric hypertrophic scars: A prospective, randomized, split-scar study.

BACKGROUND: Various laser therapies have been introduced in scar management. However, pain during treatment has limited the application of laser therapy in pediatrics. OBJECTIVES: To evaluate whether the use of the low-energy mode of a carbon dioxide (CO2 ) laser improves hypertrophic scars in a pediatric population. METHODS: This prospective, randomized, split-scar trial was designed to assess the safety and efficacy of low-energy CO2 laser use. Patients aged <12 years with hypertrophic scars were enrolled. Each hypertrophic scar was equally divided into three parts: the two ends of each scar were randomly assigned to control and experimental groups, and the center portion was considered a transition zone and was not included in the analysis. A total of three laser treatments were performed at 1-month intervals. Scar scale scores 6 months after the final treatment was the primary outcome. Additionally, the Visual Analog Scale (VAS) was used to evaluate pain after each treatment. RESULTS: Of the 23 patients enrolled, 20 completed the study. The total Patient and Observer Scar Assessment Scale (POSAS) score at the 6-month follow-up was significantly lower for the treated site (44.95 for the treated group vs. 64.85 for the control group, p < 0.0001). Both the patient and observer POSAS scores showed an obvious difference between the treated and control groups (19.95 vs. 29.95 for patient scores, respectively, p < 0.0001, and 26.00 vs. 34.90 for observer scores, respectively, p < 0.0001). All observer and patient scores describing pain, pruritus, color, stiffness, and thickness were statistically different and favored the treated site. No significant difference was found in patient score of irregularity. The average VAS therapeutic pain score was 3.5 ± 1.43 out of 10. CONCLUSIONS: Low-energy CO2 fractional laser therapy improved hypertrophic scars in a pediatric population. Therefore, for children with hypertrophic scar, low-energy CO2 laser with less procedure pain may be more appropriate.

Auricular reconstruction in microtia for soft tissue coverage: Flap pocket method versus expansion method.

BACKGROUND: Auricular reconstruction is the sole therapy for external ear deformities. The flap pocket method and the expansion method are currently the two principal auricular reconstruction methods in microtia. The efficacy and safety of these two surgical techniques has long been a subject of controversy, bedeviled by a lack of objective comparative evidence. METHODS: The authors searched the PubMed, Embase, Web of Science and Cochrane Library databases for clinical studies on auricular reconstruction in microtia updated to Jan 1, 2021. A meta-analysis was conducted to estimate the major outcomes for patient convenience, incidence of complications and postoperative patient satisfaction. RESULTS: A total of twenty-two articles involving 7963 patients were included in this study. Nine studies involving 2475 patients concerned the flap pocket method and thirteen studies involving 5488 patients concerned the expansion method. The pooled patient satisfaction rate was higher using the flap pocket method than the expansion method (90.5% versus 83.3%, p = 0.000). Total complication incidence was lower using the flap pocket method than with the expansion method (6.8% versus 9.5%, p = 0.000). There were zero expander-related complications using the flap pocket method, but a 4% complication incidence using the expansion method. The total treatment period for the flap pocket method was 5.57 ± 1.13 months, much shorter than the 10.75 ± 3.54 months (p < 0.05) of the expansion method. CONCLUSIONS: In microtia, the flap pocket method scores higher on patient satisfaction, while having lower post-operative complications and a shorter treatment period compared with the expansion method.

New strategies for base frame fabrication in microtia reconstruction.

The base frame provides a stable support for the helix, antihelix, and tragus-antitragus complex in microtia reconstruction, and this support is vital to attain a highly defined outline for a reconstructed auricle. The success of base frame sculpting depends on appropriate treatment of the cartilage, mainly the sixth and seventh costal cartilages, which may have different characteristics. The aim of this study was to demonstrate the relevant details for base frame fabrication under various scenarios. Between 2016 and 2019, a total of 352 patients with microtia underwent autologous auricular reconstruction. Concerning the different sizes and characteristics of the costal cartilage used for the base frame reconstruction, we describe the related methods for fabrication and introduce corresponding strategies for proper management. We found that 90% of the patients responded at follow-up, and 76% of them were satisfied with the cosmetically refined auricle with harmonious integrity. The elaborate design and appropriate utilization of costal cartilage for base frame sculpting is one of the most significant and fundamental processes in microtia reconstruction. It contributes to achieving a clearly defined outline of the auricle with harmonious integrity, which is as important as the other projected subunits.

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 .

[Effects of different orthodontic treatments on sputum chemokines CX3CL1, RANKL/OPG levels in patients with malocclusion].

PURPOSE: To investigate the effects of different orthodontic treatments on gingival crevicular fluid chemokine CX3CL1, nuclear factor κB receptor activating factor ligand/osteoprotegerin(RANKL/OPG) levels in patients with malocclusion. METHODS: Ninety-six patients with malocclusion who were scheduled to undergo orthodontic treatment were randomly divided into four groups. All patients were treated with square wire appliance, and 0, 50, 150, 250 g of far-distal orthodontic force were given respectively. The levels of CX3CL1 and RANKL/OPG in gingival crevicular fluid were detected in four groups after 1, 2, 3, and 4 weeks of treatment. SPSS 25.0 software package was used for statistical analysis of the date. RESULTS: The levels of CX3CL1, RANKL and RANKL/OPG in the gingival crevicular fluid of the four groups were continuously increased after treatment for 1-3 weeks, and decreased after 4 weeks of treatment (P<0.05). The OPG in the gingival crevicular fluid was at a low level after 1-3 weeks of treatment. There was an increase after 4 weeks of treatment (P<0.05). The levels of CX3CL1, RANKL, OPG and RANKL/OPG in gingival crevicular fluid increased gradually in group A, B, C and D (P<0.05), and the differences between the groups were statistically significant (P<0.05). CONCLUSIONS: The levels of CX3CL1 and RANKL/OPG in gingival crevicular fluid are closely related to orthodontic force and treatment time, and can be used as an index to evaluate orthodontic treatment of alveolar bone remodeling.

An international study to develop the EAR-Q patient-reported outcome measure for children and young adults with ear conditions.

BACKGROUND: There is currently a lack of patient-reported outcome measures for ear reconstruction. We developed the EAR-Q to measure ear appearance and post-operative adverse effects from the patient perspective. METHODS: Field-test data were collected from children and young adults in eight countries between 13 May 2016 and 12 December 2019. Rasch measurement theory (RMT) analysis was used to refine the scales and to examine their psychometric properties. RESULTS: Participants had microtia (n = 607), prominent ears (n = 145) or another ear condition (n = 111), and provided 960 assessments for the Appearance scale (e.g., size, shape, photos), and 137 assessments for the Adverse Effects scale (e.g., itchy, painful, numb). RMT analysis led to the reduction of each scale to 10-items. Data fit the Rasch model for the Appearance (X2(80) = 90.9, p = 0.19) and Adverse Effects (X2(20) = 24.5, p = 0.22) scales. All items in each scale had ordered thresholds and good item fit. There was no evidence of differential item function for the Appearance scale by age, gender, language, or type of ear condition. Reliability was high for the Appearance scale, with person separation index (PSI) and Cronbach alpha values with and without extremes ≥0.92. Reliability for the Adverse Effects scale was adequate (i.e., PSI and Cronbach alpha values ≥0.71). Higher scores (liked appearance more) correlated with higher scores (better) on Psychological, Social and School scales. INTERPRETATION: The EAR-Q can be used in those 8-29 years of age to understand the patient perspective in clinical practice and research, and in addition, can be used to benchmark outcomes for ear reconstruction internationally.

Evaluation of effectiveness of three-dimensional printed ear splint therapy following ear elevation surgery in microtia patients: A randomized controlled trial.

AIM: This study aimed to compare the effectiveness of a 3D-printed ear splint with that of a conventional thermoplastic ear splint after microtia reconstruction. METHODS: Patients who underwent ear elevation surgery with postauricular fascia coverage between October 2017 and October 2018 were included. They were randomly divided into the experimental group (3D-printed ear splint) and the control group (thermoplastic ear splint) and underwent routine postoperative rehabilitation and antiscar therapy. Splint therapy was initiated 4 weeks postoperatively and continued until 24 weeks postoperatively. The evaluated indices were the Vancouver scar scale score (VSS score), cranioauricular distance, patient compliance, complications (dermatitis, skin ulcers, skin necrosis), and patient satisfaction. A two-group t-test was carried out to compare all variables except patient satisfaction, which was compared using the Mann-Whitney U-test; p < 0.05 was considered significant. RESULTS: Twenty patients were included in each group. At 4 weeks postoperatively, the VSS score (p = 0.748) and cranioauricular distance (p = 0.647) showed no significant differences between the groups. At 24 weeks postoperatively, the mean VSS scores were 4.85 ± 1.46 and 6.25 ± 1.74 (p = 0.009), the mean cranioauricular distances were 15.80 ± 1.82 mm and 13.95 ± 1.93 mm (p = 0.004), and the patient satisfaction scores were 4.5 ± 0.51 and 3.7 ± 0.47 (p < 0.001) in the experimental group and the control group, respectively, all showing significant differences. Two patients in each group exhibited skin irritation or skin ulcers, which resolved after 6 months of follow-up. CONCLUSION: The application of 3D-printed ear splints provides better inhibition of scar contracture, better maintenance of ear projection and higher patient satisfaction than conventional ear splints following ear elevation surgery in microtia patients. Therefore, 3D-printed ear splints should be preferred over conventional ear splints whenever possible.

Clinical Results of Ear Elevations in Patients with Microtia Using Skin Grafts from Three Donor Sites: A Retrospective Study.

BACKGROUND: Skin grafts, frequently used for ear elevation in ear reconstructions, may suffer from color mismatches, scar hypertrophy, secondary contraction, and auricular sulcus depth differences. To determine the most suitable donor area, we compared the contralateral postauricular area, groin, and scalp as potential donor sites. METHODS: Since 2008, we have used three donor sites for obtaining skin grafts used in ear reconstructions. Full-thickness groin skin, split-thickness grafts from the scalp, and contralateral postauricular and groin composite full-thickness skin grafts were used in 202, 231, and 195 patients, respectively. Photographic assessments were used to assess color matching, sulcus depth, cranioauricular angle symmetry, and flatness of the skin grafts; surgical complications were also documented. RESULTS: Among the three donor sites, there were no significant differences in the color matching scores (p = 0.456). The scalp donor scores had significantly lower mean scores for sulcus depth and symmetry and for graft flatness scores than the other donor sites. The assessment scores between the groin and postauricular donor groups were similar. Each donor site was associated with some surgical complications. However, postauricular skin, when combined with groin skin, demonstrated the best cosmetic results and the fewest complications. CONCLUSION: All three donor sites are viable options for skin graft donor sites in ear elevation surgeries. Although the advantages and disadvantages of each site should be explained to the patient, the ultimate donor site selection may be determined according to patient and surgeon preferences. 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 .