Stenosis is best treated by a full-thickness graft applied over an acrylic mold, provided a reasonable recipient vascular bed can be prepared. Occasionally, multiple Z-plasties are used to relieve webbing of the orifice, or a local flap is employed to line the canal and break up the contracture. An acrylic stent is recommended for several months to counteract the inexorable tendency toward contracture.

Acquired losses of the helical rim vary from small defects to major portions of the helix. The former defects, which usually result from tumor excisions or minor traumatic injuries, are best closed by advancing the helix in both directions, as described by Antia and Buch1 (Figure 27.1). The success of this excellent technique depends first on freeing the helix from the scapha via an incision in the helical sulcus that extends through the cartilage but not through the posterior skin. The posterior auricular skin is undermined, until the entire helix is hanging as a chondrocutaneous flap on the posterior skin. Extra length can be gained by a V-Y advancement of the helical crus, as described in the correction of the constricted ear. Defects up to 1.5 cm can be closed without tension. Defects larger than 2 cm are too large for this technique. In order to facilitate closure, it is necessary to “cheat” by removing some of the scaphal cartilage, taking tension off the reapproximated helical rim. Reducing the scapha reduces the size of the ear and the patient should be alerted to this fact in advance. Although originally described for upper-third auricular defects, this technique is also effective for middle-third defects, as well as for defects at the junction of the middle and lower thirds.

If the helical rim alone is missing, as may occur in burn injuries, a thin tube of retroauricular skin can be applied to the residual scapha with acceptable results (Figure 27.2). This is one example where cartilage may not be necessary. The disadvantage of this technique is that it requires three stages to “waltz” the tube into place: (a) formation of the tube in the sulcus, (b) transfer and insetting of one end of the tube, and (c) transfer and insetting of the other end of the tube.

Techniques available for upper-third defects in increasing order of size and complexity are as follows (Figure 27.3):

Techniques available for middle-third defects are as follows:

Cartilage grafts can be inserted via the Converse tunnel procedure in which the skin is not detached at the junction of the residual ear and the retroauricular skin. The problem is that precise placement of the graft with exact coaptation
to remaining cartilage is difficult using this approach, and a detached retroauricular flap (Figure 27.5) is preferable. Middle-third auricular tumors are excised and closed by either a wedge resection with accessory triangles (Figure 27.4) or a helical advancement, as previously described.

Various techniques have been described to reconstruct earlobe defects using soft-tissue flaps. These techniques are not as effective as those that employ cartilaginous support. Like the alar rim, the normal earlobe does not contain cartilage. A reconstructed earlobe, however, will only maintain its contour if cartilage is included, analogous to nonanatomic alar rim grafts. The author prefers to use thin, flat cartilage obtained from the nasal septum.2 The cartilage is placed beneath the cheek/retroauricular skin in the first stage. A hole can be made in the cartilage at this initial stage for later ear piercing. In the second stage, an incision is made around the cartilage graft and the flap is advanced beneath the earlobe as in a facelift (Figure 27.6).