The pixie ear: How to prevent and correct it-a review of the literature.

As the life expectancy of the population continues to increase, more facial-rejuvenating procedures are sought. As the number of facelift procedures increases, it is mandatory to acknowledge, and most importantly prevent, any possible associated complications. One of the complications after rhytidectomy, and a sign of facelift, is the so-called "pixie ear deformity" or "bat ear." This is regarded as a telltale sign of a facelift procedure and appears to be identified in 5% of earlobe inset cases. The ear's location is a crucial hallmark of an aesthetically pleasing face, not only by itself but also in relation with other aesthetic units. When performing a facelift procedure, tension vectors of the rhytidectomy flap could cause alterations in ear's position and appearance: the ear loses its great mobility and becomes more fixed in its acquired position, resulting in a "stuck-on" appearance. The auricle is displaced following an anteroinferior direction, with the otobasion inferius (the most caudal anterior attachment of the earlobe to the cheek) being dislocated from its original more posterior and upper position to a new more anterior and caudal location. The displacement of the auricle is usually accompanied by distortion of the earlobe rotating forward and becoming more anterior than the rest of the ear. In recent decades, many techniques and procedures have been described to prevent and correct the pixie ear; in this review, we aim to analyze and describe them comprehensively.

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.

Modified Valente Technique for Cauliflower Ear: Outcomes in Children at Two-Year Follow-Up : New Surgical Technique for Cauliflower Ear.

BACKGROUND: Cauliflower ear deformity, a common sequela of auricular trauma, presents an esthetic and reconstructive challenge. Existing surgical techniques have limitations, including complexity, donor site morbidity, and variable long-term outcomes. MATERIALS AND METHODS: In this case series, we present a novel and minimally invasive surgical approach for the correction of cauliflower ear deformity that adapts the Valente otoplasty technique; it combines cartilage debulking with helical rim release and Mustardé mattress stitches to restore ear contour and reduce the risk of recurrence. The procedural steps include bielliptic post-auricular skin and soft tissue incision, release of the cartilaginous spring, removal of excess fibrocartilaginous tissue, cartilage reshaping with suture to restore contour, and tissue redistribution to promote adherence of skin to the cartilage framework. RESULTS: Outcomes were evaluated in 7 patients (9 ears) with cauliflower ear deformity, assessing surgical duration, complications, patient satisfaction, and esthetic outcomes at two years after surgery. The mean surgical duration per patient was 52 ± 17 minutes, including 2 bilateral procedures. Follow-up at 24 months showed favorable esthetic outcome in all patients with sustained improvements in auricular contour and symmetry with neither loss of the shape nor recurrence of deformity. Patients reported high satisfaction and improved quality of life, with mean Glasgow Children Benefit Questionnaire scores of 99.3 ± 6.3. CONCLUSIONS: This technique thus demonstrated lasting correction of cauliflower ear with favorable cosmetic outcomes, low risk of complications, and high patient satisfaction. Further investigations and longer-term follow-up are warranted to validate the technique's durability and expand its application to older and more diverse patient populations. 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 .

Ear magnetic discs to prevent cauliflower ear: a case gone wrong.

We present a case of pinna pressure necrosis secondary to the use of ear magnetic discs, used in the management of auricular haematoma. A man in his 20s sustained a left auricular haematoma while wrestling. His coach aspirated the haematoma and advised the use of commercially available compression magnets on either side of the pinna to prevent haematoma reaccumulation. 5 days later, he presented to accident and emergency with left ear pain and swelling. Perichondritis was evident on examination and the compression magnets were removed to reveal significant pressure necrosis of the pinna. The skin underlying the placement of magnets (both anteriorly and posteriorly) was black and necrosed, with erosion of the underlying cartilage. In addition to this, the haematoma had reaccumulated in the surrounding pinna. The haematoma was drained via an incision, and pressure dressing applied with dental rolls. The patient was given a course of oral antibiotics to manage the perichondritis. He was reviewed regularly in the ear, nose and throat emergency clinic to monitor wound healing. 3 months later, he was reviewed in the otology clinic; there was persistent helical rim deformity, and delayed cartilage augmentation was advised.This case highlights the importance of prompt and effective management of auricular haematoma, to prevent long-term deformity. Commercially available pinna magnets for auricular haematoma should be used with caution, and patients should be counselled as such.

Auricular haematoma an avoidable cosmetic deformity: A chance or negligence.

PURPOSE: This study highlights the importance of immediate intervention needed in cases of auricular trauma cases so as to prevents complications leading to cauliflower ear, loss of cartilage, necrosis. MATERIALS & METHODS: Total 10 cases of primary haematoma & recurrent cases were included in the study. A detailed history was entered in proforma. Procedure was done under local anaesthesia with all aseptic precautions. A cruciate incision was given over the most dependent part of the swelling and flaps were raised. The collection was drained and the under surface of the flap was scraped using Rosen''s knife followed by insertion of small drain tube and pressure dressing was done. Patients were followed up for three months. RESULTS: Out of the 10 cases 6 were primary cases and 4 were recurrent cases out of which males were 80% and females 20%. None of them showed recurrence. Overall cosmetic deformity was negligible with most of the patients. 1 patient developed perichondrial reaction with pain and inflammation which required long course of analgesics and antibiotics. In 3 cases a thickening of the auricle at the site of incision was noticed. CONCLUSION: Auricular haematoma most commonly is seen in male players of contact sports. These patients may land up in emergency department. Thus, by developing collaborative relationships with ENT specialists, emergency department can help ensure that patients experience possible treatment. This will help reduce the cosmetic deformities of pinna which are seen as complication of auricular haematoma.

Earfold™: A combined approach with conchal bowl reduction.

BACKGROUND: Prominent ear deformity is common amongst the human population and is partly due to underdevelopment of the antihelical fold, a prominent conchal bowl, or both. Recently, the senior author described a minimally invasive technique for changing the shape of the antihelical fold using the Earfold™ implant (Allergan plc, Dublin, Ireland). However, there is still a paucity of data regarding outcomes from combing this approach with surgical techniques to correct conchal bowl hypertrophy. OBJECTIVES AND METHODS: Questionnaire-based study evaluating outcomes in consecutive patients undergoing treatment with Earfold™ and conchal bowl reduction. Patient reported outcome measures were assessed with a validated questionnaire. Data on complications were obtained from the patient's case notes and free-text sections of the questionnaire. RESULTS: Completed questionnaires were received from 8 patients out of a total of 18 who underwent the combination treatment (44% response rate). Statistically significant differences were noted in nearly all questions (18/19) relating to changes in ear appearance as a result of the surgery, with all patients being satisfied following the combined procedure. Improvements in subjective outcomes were compared to previous studies evaluating treatment with Earfold™. CONCLUSIONS: The Earfold™ implant can be combined safely with other otoplasty techniques to achieve a good outcome in a carefully selected patient population.

Optimizing Management of Otophyma: A Case Series Highlighting the Role of Surgical and Retinoid Therapy.

Otophyma is a rare condition that can result in conductive hearing loss. Current otophyma literature does not examine validated treatment outcomes for patients. Utilizing a medical and surgical approach to maintain a patent canal can lead to significant objective improvements. The aim of this case series is to describe a combined successful approach in 3 cases from an academic, multidisciplinary center. The main outcomes analyzed were pre and post air-bone gap audiogram analysis and disimpaction frequency. The results showed that post-management, patient 1 had substantial improvement in hearing, recovering 49 dB in his right ear and 25 dB in his left ear, demonstrating near complete air-bone gap closure. Patient 2 showed a similar dermatologic and functional improvement, although objective audiometric assessment related to otophyma could not be performed due to coexisting chronic otitis media and cholesteatoma. Patient 3, in the 12 months prior to comanagement, had 8 bilateral disimpactions, and following comanagement had 2 disimpactions in 23 months. All 3 patients were pleased with the resultant functional and physical appearance following comanagement. By presenting this approach and objective measures of treatment, we hope to improve future clinical decision-making in a rare condition.

Burned Ear Reconstruction Using a Superficial Temporal Fascia Flap.

OBJECTIVES: Ear deformity caused by burns is one of the most difficult types of deformity to treat with plastic surgery, and the reconstruction of burned ears undoubtedly remains a substantial challenge. This study aims to report the therapeutic regime of using a superficial temporal fascial flap to cover the framework in burned ear reconstruction. METHODS: Autologous costal cartilage was used to form the ear framework in all of the reconstruction cases. A superficial temporal fascial flap was used as soft tissue to cover the ear scaffold. RESULTS: Five patients with 6 ears were included in our study. The external ear healed well and the location, size, and shape of both ears were generally symmetrical. No complication was observed in any of the patients. CONCLUSIONS: The superficial temporal fascial flap is a good choice for covering the autogenous cartilage framework when treating ear deformities after burns.

A Prospective Study on Changes in Auricular Protrusion after Chronic Otitis Media Surgery with the Postauricular Approach.

OBJECTIVES: Some patients complain of apparent auricle protrusion after chronic otitis media (COM) surgery with the postauricular approach. This study investigates whether auricular protrusion could be restored to the preoperative state after COM surgery; if so, the time needed after surgery and whether the degree of auricular of protrusion differed according to the surgical procedure. MATERIALS AND METHODS: Forty-seven patients who underwent tympanoplasty and canal wall up and canal wall down mastoidectomy between July 2016 and July 2017 were prospectively studied. To examine the degree of auricular protrusion, the longest distance from the head to the helical rim and the distance from the mastoid process to the helical rim in the plane along the level of the upper margin of the tragus were measured 1 day before surgery and 1 day; 2 weeks; and 1, 2, 4, and 6 months, postoperatively. RESULTS: The superior aspect of the auricle returned to the preoperative state within 2 months of surgery, irrespective of the surgical procedure. The middle aspect was restored to the preoperative state within 4 months of tympanoplasty or canal wall up mastoidectomy, and within 2 months of canal wall down mastoidectomy. CONCLUSION: Postoperative auricular protrusion is a transient phenomenon.

Neck Deformities in Plastic Surgery.

This article provides facial plastic surgeons with the insight to avoid and address common pitfalls in neck procedures. Many aesthetic issues are created from overtreatment or undertreatment of components of the neck. Using the platysma muscle as the divide, ease of access to superficial anatomy leads to overtreatment problems, whereas difficulty of access to deeper structures leads to undertreatment problems and to overall imbalances. Strategies to accurately assess and treat all structures of the neck proportionally can be used to both avoid and treat any neck aesthetic issues. The advent of minimally invasive techniques has resulted in new complications.

Common Complications in Rhytidectomy.

Complications of rhytidectomy are well known, yet often preventable. A thorough preoperative history and physical along with realistic patient expectations provide the surgeon and patient with insight into potential complications and postoperative management. Understanding of surgical pitfalls and avoidance are crucial in beginning to manage facelift complications. Possible complications of facelift techniques should not discourage surgeons from pursuing a particular technique as the majority of complications are temporary. Though, a strong patient-physician relationship is critical when complications occur. Complications may be frustrating for both the patient and surgeon, yet are overwhelmingly temporary and manageable without surgical intervention.

Criptotia em paciente ocidental adulto: relato de caso / Cryptotia in a Western adult patient: a case report

Criptotia é uma deformidade auricular congênita comum em orientais e rara em ocidentais, sendo a grande maioria dos estudos de técnicas cirúrgicas orientais e aplicados em crianças. Nesta patologia, a cartilagem do polo superior da orelha encontra-se alojada embaixo da pele na região temporal, o que impossibilita o uso de óculos, devido à falta de apoio e torna o polo superior sem definição estética. O presente estudo tem por objetivo relatar o caso de um paciente adulto com criptotia, submetido ao tratamento cirúrgico com retalho de pedículo subcutâneo mastóideo, revisando as principais técnicas descritas para o tratamento deste acometimento. O retalho de pedículo subcutâneo descrito por Yoshimura, mostrou-se adequado para a correção da criptotia em paciente ocidental e adulto.

Cryptotia is a congenital ear deformity common in Easterners and rare in Westerners, with most studies addressing Eastern surgical techniques applied to children. In this pathology, the cartilage of the upper pole of the ear is lodged subcutaneously in the temporal region, which prevents individuals from using glasses due to lack of support and prevents esthetic definition of the upper pole. The present study aimed to report the case of an adult patient with cryptotia undergoing surgical treatment using a mastoid subcutaneous pedicle flap and review the main techniques described for the treatment of this involvement. The subcutaneous pedicle flap described by Yoshimura proved to be adequate for correcting cryptotia in a Western adult patient.

Retalho retroauricular ilhado para reconstrução parcial de orelha: relato de casos / Retroauricular island flap for partial ear reconstruction: case reports

Defeitos parciais de orelha podem ser tratados de diversas formas, dentre elas o fechamento primário, cicatrização por segunda intenção ou retalhos. Diversas opções técnicas foram descritas para a sua reconstrução de modo a manter o contorno natural da orelha, sem sacrificar tecido sadio ou alterar sua estética e função. Apresentamos neste artigo dois casos atendidos no Instituto do Câncer do Hospital de Base de São José do Rio Preto de reconstrução de defeitos condrocutâneos de orelha após ressecção de carcinoma basocelular em região central da orelha, com a confecção de retalho retroauricular ilhado transposto através de uma janela cartilaginosa e com o pedículo desepidermizado. Área doadora com fechamento primário. Tal procedimento constitui técnica segura, pois a região retroauricular é ricamente vascularizada, é de fácil execução, em único estágio e com resultado estético e funcional satisfatório.

Partial ear defects can be treated in several ways, including primary closure, healing by secondary intention, or flaps. Several surgical options have been described for reconstruction in order to maintain the natural contour of the ear, without sacrificing healthy tissues or changing the aesthetics and function. In this article, we present two cases of reconstruction of chondrocutaneous defects of the ear after resection of basal cell carcinoma in the central region of the ear, with the production of a retroauricular island flap transposed through a cartilaginous window with the de-epidermized pedicle. The donor area healed following a primary closure. This procedure can be performed in a single stage, yields satisfactory aesthetic and functional results, and is safe because the retroauricular region is richly vascularized.

Auricular prostheses attached to osseointegrated implants: multidisciplinary work-up and clinical evaluation.

PURPOSE: Not long after the introduction of osseointegrated implants outside the oral cavity, auricular prostheses are retrained on osseointegrated implants. New insights have been gained with the next-generation percutaneous osseointegrated titanium implants for bone conduction hearing since its introduction in 2010. As a result, the same technology was introduced in the Vistafix® system (VXI implant) to retain auricular prostheses. The aim of this study is to evaluate the surgical procedure, clinical outcome, and satisfaction of the patient of osseointegration-retained auricular prosthesis using VXI implants. MATERIALS AND METHODS: 11 patients who received an auricular prosthesis using VXI implants between December 2012 and November 2017 were evaluated retrospectively. The patient's medical files were reviewed to assess clinical complications and the necessity for revision surgery. The subjective outcome was measured using the Glasgow benefit inventory (GBI). RESULTS: In total, 31 implants were placed in 11 patients. None of these implants were lost nor revision surgery needed. An adverse skin reaction was observed in 13.0% of the implants and in 27.2% of the patients, adequately treated with an antibiotic ointment. The average follow-up time was 2 years and 7 months. The GBI displayed a positive score in every patient. CONCLUSIONS: The VXI implants used are a safe and reliable treatment option for retaining auricular prostheses in patients with an absent auricle. Patients were satisfied with their auricular prosthesis and showed benefit in quality of life. Studies with larger numbers and preferably a prospective character are needed to draw statistically significant conclusions.

[Experimental studies on the repair and restitution of cartilage by cartilage acellular extracellular matrix and adipose tissue-derived stem cells].

Objective: To investigate the effects of the repair and restitution of ear-shaped cartilage by adipose tissue-derived stem cells(ADSC) and cartilage acellular extracellular matrix. Methods: ADSC were extracted by digesting with collagenase type II from the adipose tissue from 32 patients with adiposity whose fats were drawn, and were cultured and subcultured in vitro. The natural biological scaffolds were prepared by acellular method using porcine ear cartilage, and then the second generation ADSC(5.0×10(7)/ml) were inoculated on the preformed natural bio-scaffold scaffold by culturing in vitro for 3 days to form a cell scaffold complex. 32 New Zealand white rabbits were randomly divided into the experimental groups, the control group A, the control group B and the control group C. All New Zealand white rabbits were modeled by ear cartilage defects. The cell scaffolds composite was implanted into the experimental group of the ear cartilage defects of rabbits, the ADSC were implanted into the control group A, the cartilage acellular extracellular matrix scaffold was implanted into the control group B and the control group C was modeled only by ear cartilage defects. After 16 weeks, the animals were sacrificed and the repair effect was observed by gross appearance and histological examinations including HE, Toluidine blue staining, Safranin O and typeⅡ collagen staining. Its were quantitatively analyzed by positive staining results of type Ⅱ collagen. Ear cartilage tissue elasticity was detected. SPSS 17.0 software was used to analyze the data. Results: The cartilage defects in the experimental group were repaired well by general shape observation and those in the control group was filled in with granulation tissue. There were significant differences between the experimental group and the control group in the wet weight(P<0.05). HE staining showed that cartilage cavities formed in articular cartilage defects, and only the fibrous tissue was filled with the ear cartilage defect in the control groups. In the repair area, Toluidine blue staining, Safranin O and type Ⅱ collagen staining were positive in the experimental group, and negative in the control groups. There was no significant difference between the experimental group and the normal ear cartilage in the ear cartilage elastic constant detection(P>0.05). Conclusions: The mechanics and histology of rabbit ear neonatal cartilage constructed by ADSC combined with cartilage acellular matrix are close to normal ear cartilage. Cartilage acellular matrix material combined with adipose-derived stem cells has good repair and reconstruction ability for ear cartilage defects, which possesses potential clinical application value.

Correction and Prevention of the Pixie Ear Deformity: A Combined Technique.

Background: Ear and earlobe deformities after surgical rhytidectomy are common and can significantly diminish the aesthetic outcome. The main causes of ear/earlobe distortion are skin overresection, an imbalance between vertical/horizontal skin-lift vectors, and tractional distortions through superficial muscularaponeurotic system (SMAS) tension. Objectives: To demonstrate a new method for earlobe suturing and ear fixation that would prevent aesthetics-related complications after facelift surgery. Methods: A total of 105 primary SMAS facelift surgeries were performed between 2015 and 2016 by the first author. A combination technique consisting of a posterior earlobe rotation flap (PERF) and a concha-mastoid suspension suture (CMSS) was executed bilaterally within each facelift procedure (n = 210). A retrospective data analysis was conducted (preoperatively and one year postoperatively) using our hospital information system and a photometric data analysis to assess auricular displacement, earlobe distortion, and hypertrophic scarring. Results: Pseudoptosis of the earlobe was noted in two cases, and auricular displacement was observed in four cases. Bilateral mild hypertrophic scarring was seen in one patient. The postoperative photometric analysis showed a natural ptosis grade I/II in all the patients, with a statistically significantly reduced postoperative earlobe size (P < 0.05). The total rate of aesthetics-related complications was 4% in our cohort (earlobe distortion with pseudoptosis: 1%; auricular displacement: 2%; hypertrophic scarring: 1%). Conclusions: Our modification of the facial flap anchoring at the ear base in combination with a CMSS stabilizes the natural position of the ear and prevents distortion while allowing better control over the earlobe's aesthetic shaping. This novel method reduces the incidence of ear/earlobe deformities and hypertrophic scarring at the ear base after rhytidectomy and, therefore, promises to be a valuable advancement.

Otoplastia Combinada / Combined Otoplasty

Introdução: Orelha em abano é a deformidade congênita mais comum de cabeça e pescoço, cuja transmissão se dá por herança autossômica dominante, sem predileção por gênero. A orelha proeminente ou "em abano" ocorre quando há um excesso ou hipertrofia da concha auricular, apagamento da antélice, um ângulo escafoconchal maior que 90º ou uma combinação destes, ocorrendo uni ou bilateralmente. O objetivo é apresentar uma abordagem conservadora para correção de orelha em abano, com a associação de técnicas. Métodos: Foi utilizada uma variação cirúrgica para realização de otoplastia com o auxílio de uma abordagem anterior para ressecção da concha auricular associada ao enfraquecimento da antélice com incisões parciais na cartilagem também por via anterior e a realização de pontos de Mustardé por via posterior para melhor definição da antélice, sem a fixação da concha à mastoide. Foram operados 200 pacientes com idade média de 17 anos, entre janeiro de 1987 e janeiro de 2015, sendo 60% do gênero feminino. Resultados: Dos 200 pacientes, apenas 24 necessitaram revisões cirúrgicas discretas. Conclusão: O procedimento cirúrgico é simples, facilmente reprodutível, proporcionando bons resultados, com alto grau de satisfação e baixo índice de complicações/morbidade.

Introduction: Protruding ear is the most common congenital deformity of the head and neck, with an autosomal dominant inheritance and no predilection for sex. Protruding ear or prominent ear occurs when there is concha excess or hypertrophy, erasure of the antihelix, a scapho-conchal angle greater than 90°, or a combination of these factors, occurring unior bilaterally. The objective is to present a conservative approach to correct protruding ear, with a combination of techniques. Methods: The otoplasty surgical technique involved an anterior approach for resection of the auricular concha, which was associated with weakening of the antihelix, and partial incisions of the cartilage were performed through anterior access and of Mustardé sutures, through posterior access for better definition of the antihelix without fixation of the concha to the mastoid. Two hundred patients with a mean age of 17 years underwent operations between January 1987 and January 2015, 60% of whom were female. Results: Of the 200 patients, only 24 patients needed discrete surgical revisions. Conclusion: The surgical procedure is simple, easily reproducible, provides good results, and is associated with a high degree of satisfaction and a low rate of complications/morbidities.