(A) Advancement of the third crus of the antihelix
(B) Partial detachment of the folded segment of helical cartilage from the scapha and repositioning of the helix with sutures
(C) Placement of sutures from the conchal bowl to the mastoid fascia
(D) Rasping of the anterior surface of the antihelical cartilage to create the antihelix
(E) Separation of the superior auricle from the temporal skin with placement of a retroauricular skin graft

The correct response is Option E.

In patients with cryptotia, the superior portion of the auricle adheres to the temporal skin in varying degrees of severity. Management involves release of the adherent portion of the auricle; skin grafting is frequently required. Advancement of the third crus of the antihelix is the treatment of Stahl's ear, a deformity that involves the presence of a third antihelical crus.

Partial detachment of the helix from the scapha and resuturing of the helix at a more appropriate angle are recommended for patients who have the constricted ear deformity. In this deformity, which varies in severity, the helical rim is constricted, and the superior portion of the helix typically folds over the scapha.

Placement of sutures from the conchal bowl to the mastoid fascia and rasping of the anterior surface of the antihelical cartilage have been described for correction of prominent ears, which are characterized by widening of the conchoscaphal angle and flattening of the antihelical fold. Other methods of correction include resection of the conchal bowl and placement of retention sutures, which are used to recreate the antihelical fold.

References
1. Furnas D. The correction of prominent ears by concha-mastoid sutures. Plast Reconstr Surg. 1968;42:189.
2. Leber D. Ear reconstruction. In: Georgiade GS, Riefkohl R, Levin LS, eds. Textbook of Plastic, Maxillofacial and Reconstructive Surgery. Baltimore, Md: Williams & Wilkins; 1997:497.
3. Mustarde J. The correction of prominent ears using mattress sutures. Br J Plast Surg. 1963;16:170.
4. Sugino H. Surgical correction of Stahl's ear using the cartilage turnover and rotation method. Plast Reconstr Surg. 1989;83:160.
5. Tanzer R. The constricted ear. Plast Reconstr Surg. 1975;55:406.

A 24-year-old man undergoes total auricular reconstruction using a porous polyethylene implant covered with a temporoparietal fascia flap and a skin graft after sustaining burns to the face and ear. On follow-up examination one month later, there is a 1 * 1-cm area of necrosis of the flap; a small area of implant is exposed beneath the eschar.

Which of the following is the most appropriate next step in management?

(A) Initiation of frequent dressing changes and allowing the wound to heal secondarily
(B) Removal of the implant and allowing the wound to heal secondarily
(C) Removal of the implant and immediate replacement with a smaller porous polyethylene implant
(D) Removal of the implant and immediate replacement with a rib cartilage graft
(E) Removal of the implant and immediate replacement with a Silastic implant

The correct response is Option A.

Excellent results have been reported with the use of porous polyethylene implants covered with temporoparietal fascial flaps for ear reconstruction in patients with burns. In the past, Silastic implantation was associated with an unacceptably high complication rate, frequently resulting in removal of the implant. Adequate soft-tissue coverage of any type of alloplastic implant, whether porous polyethylene or Silastic, is essential.

Because porous polyethylene allows for ingrowth of tissue, small areas of implant exposure can be managed with frequent dressing changes and either allowing the wound to heal secondarily or covering the wound with a skin graft after granulation tissue has formed over the implant. Although removal is an option, the surgeon should wait for a minimum of six months before inserting another implant or a cartilage graft.

References
1. Leber D. Ear reconstruction. In: Georgiade GS, Riefkohl R, Levin LS, eds. Textbook of Plastic, Maxillofacial and Reconstructive Surgery. Baltimore, Md: Williams & Wilkins; 1997:497.
2. Wellisz T. Reconstruction of the burned external ear using a Medpor porous polyethylene pivoting helix framework. Plast Reconstr Surg. 1993;91:811.

Which of the following best describes the Mustarde otoplasty technique?

(A) Bending of the antihelix using mattress sutures
(B) Endoscopic scoring and suturing of the cartilage
(C) Excision of a crescent-shaped piece of skin and cartilage
(D) Placement of sutures from the concha to the mastoid
(E) Scoring of the anterior surface of the antihelix

The correct response is Option A.

The Mustarde technique, which was first described in 1963, involves the placement of permanent sutures through the cartilage and perichondrium on the cranial portion of the ear to bend the antihelix posteriorly. Although this technique is still preferred, many surgeons use a combination of procedures based on the deformity and the needs of each patient.

Stenstrom's technique is used to correct prominent ears. With this technique, the anterior surface of the antihelix is bent and scored to create a posterior roll. This can be accomplished using an otoabrader instrument.

Graham and Gault conceived an endoscopic technique that involves scoring and suturing of the posterior cartilage. Scars are minimized with this procedure.

With the Luckett procedure, a crescent-shaped portion of skin and cartilage is excised from the length of the antihelix. The edges of the cartilage are sutured to create an antihelical fold.

In the Furnas technique, sutures are placed from the concha to the mastoid to diminish the size of the concha. Excision of conchal cartilage may also be required.

References
1. Caouette-Laberge L, Guay N, Bortoluzzi P, et al. Otoplasty: anterior scoring technique and results in 500 cases. Plast Reconstr Surg. 2000;105:504.
2. Furnas DW. External ear. In: Jurkiewicz MJ, Krizek TJ, Mathes SJ, et al, eds. Plastic Surgery: Principles and Practice. Saint Louis, Mo: CV Mosby Co; 1990:191-194.

In a child with microtia, growth of the reconstructed ear is primarily dependent on which of the following factors?

(A) Age of the child
(B) Presence of the perichondrium
(C) Preservation of intercostal muscle
(D) Type of fixation
(E) Type of rib graft

The correct response is Option B.

An intact perichondrium is most crucial for growth of the reconstructed ear. If the perichondrium is present, the reconstructed auricular framework will grow at a rate similar to that of the normal ear. The age of the child and timing of reconstruction are secondary considerations because the auricle reaches near normal size at approximately 6 years of age. Preservation of the intercostal muscle attached to the graft does not influence future growth of the reconstructed ear, nor does the type of fixation used. Only rib cartilage should be used for grafting, and bone should not be included.

References
1. Tanzer RC. Microtia: a long-term follow-up of 44 reconstructed auricles. Plast Reconstr Surg. 1978;61:161.
2. Thomson HG, Winslow J. Microtia reconstruction: does the cartilage framework grow? Plast Reconstr Surg. 1989;84:908.