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Case Report/Case Series
Sept/Oct 2015

Periosteal Flap Technique for Elevation of the Pinna in Microtia

Author Affiliations
  • 1Head and Neck Surgery Unit, Prosper Hospital, Ruhr University, Recklinghausen, Germany
  • 2Plastic, Reconstructive, and Burn Management Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt
JAMA Facial Plast Surg. 2015;17(5):351-354. doi:10.1001/jamafacial.2015.0764

Importance  For optimal aesthetic construction of the auricle in patients with severe microtia, it is important to construct an exquisite framework and place it in the correct natural position. In addition to its accurate vertical and sagittal positioning, normal elevation is of utmost importance because this determines the auricular width from the common anterior view in interpersonal communication. Many techniques have been described to stabilize the constructed auricle in the elevated position. Some of the techniques are prone to relapse (eg, simple skin transplantation), while others are intricate (eg, using cartilage, huge pedicled flaps, and free skin grafts).

Observations  The objective of the study was to describe a simple and reliable periosteal flap technique and present our experience in 158 patients with complete unilateral or bilateral ear deformity (with possible defects of the external auditory meatus) who were operated on between February 3, 2005, and August 27, 2012. Principles of the technique include elevating the framework from the posterior aspect, stabilizing it with autogenous rib cartilage, covering this with a novel periosteal flap, and skin grafting.

Conclusions and Relevance  The periosteal flap technique proved to be straightforward and reliable. All flaps had unrestricted microcirculation. Good and stable projection of the auricle was achieved in all patients.


The ear is a defining feature of the human face. It is considered one of the most important landmarks for a harmonious and aesthetically pleasing countenance. For any facial plastic surgeon, total auricular reconstruction is a formidable challenge because of the unique architectural topography of the ear. Any reconstructive surgical procedure aims for precise duplication of the missing portion. The ability of the facial plastic surgeon to reconstruct characteristics of the normal ear, including size, location, orientation, and anatomic landmarks, is important. If 1 or more of these features are missing, the ear will appear abnormal.1 One of the goals of treatment of microtia is to create a well-defined postauricular sulcus.

Many techniques for elevation of the pinna in cases of microtia have been described. These techniques range from simple elevation of the pinna using split-thickness skin grafts to transplanting cartilage and covering it with a temporal parietal fascia flap. This study presents our experience with a novel periosteal flap for elevation of the pinna in patients with microtia.


In total, 158 patients with microtia were operated on using the retroauricular, posteriorly based periosteal flap technique between February 3, 2005, and August 27, 2012. All patients underwent total ear reconstruction using a previously described technique.2 The first stage involves creation of the pinna with cartilage from the sixth to ninth ribs, reconstruction of the chest wall, and fabrication of the tympanic membrane and meatus. The second stage entails elevating the pinna and reconstructing the middle ear3 (using the fabricated tympanic membrane and meatus in indicated cases according to the score by Siegert et al4), opening the meatus, and deepening the concha. The third stage further refines the shape of the pinna.

Report of Cases
Case 1

A 39-year-old man with right-sided grade III microtia and congenital auricular atresia had undergone more than 15 operations at other institutions for correction of the microtia and congenital auricular atresia (Figure 1). The result was unsatisfactory for the patient and his family, with multiple scars in the reconstructed auricle and the temple. Our surgical plan was to insert a tissue expander (350-mL crescent-shaped implant; Mentor) under the skin of the previously reconstructed auricle after excision of the old cartilage. Three months later, the pinna was constructed with autogenous rib cartilage, and the tympanic membrane and meatus were prefabricated.

Figure 1.
Case 1
Case 1

A, A man with right-sided grade III microtia and congenital auricular atresia had undergone more than 15 corrective operations at other institutions. B, A close-up view is shown.

Six months later, elevation of the new auricle was performed. Because of the severe scarring and multiple previous operations, no functioning temporal vessels could be detected by Doppler sonography. Relying on a random-pattern supply of the superficial temporalis fascia would have been unacceptably risky because of the numerous deep scars. Therefore, we decided to harvest a periosteal flap instead.

The surgical procedure began by typical positioning of the patient and injection of local anesthetic and epinephrine around the reconstructed pinna in the mastoid area. A 1-cm-wide superthin skin flap surrounding the new helical rim was prepared (Figure 2A).

Figure 2.
Surgical Technique of the First Team
Surgical Technique of the First Team

A, A 1-cm-wide superthin skin flap surrounding the new helical rim is prepared. B, Wide undermining is performed without exposure of the cartilage of the framework. C, Incision of the periosteum of the mastoid plane in a C-shaped pattern with a broad posterior pedicle is shown. D, Marking for the tympanoplasty (or so-called atresia operation) is completed.

At the helical rim, the plane of preparation extended deeper around the cartilaginous framework, including elevating its surrounding connective tissue (Figure 2B). At this stage, it is of utmost importance not to expose the bare cartilage. Next, we incised the periosteum of the mastoid plane in a C-shaped pattern with a broad posterior pedicle (Figure 2C).

To achieve sufficient length of the flap, it is important to extend the incision far anteriorly. The middle part of the C-shaped flap has to be adjacent to the posterior end of the temporomandibular joint capsule.

At this point, the surgical technique changes from delicate plastic surgery performed with loupe magnification to middle ear surgery using a microscope. The tympanoplasty (or so-called atresia operation) was performed as described elsewhere2 (Figure 2D and Figure 3A).

Figure 3.
Surgical Technique of the Second Team
Surgical Technique of the Second Team

A, Drilling of the petrous portion of the temporal bone for the tympanoplasty is performed. B, Stabilization of the elevated auricle with a cartilage buttress as described by Nagata5 is shown. C, Coverage of the periosteal flap with a full-thickness skin graft is presented.

While the first team of surgeons (R.S. and R.M.) worked at the auricle, a second team (S.M.S.I. and others) removed the autogenous cartilage, which had been harvested in the first step and stored in a subcutaneous pocket of the thorax. It was carved into a crescent shape, adjusted to provide optimal protrusion of the pinna, and fixed to the baseplate of the auricular framework to stabilize the elevated position of the auricle and function like a buttress as described by Nagata5 (Figure 3B).

The flap was long enough to completely cover the cartilaginous pillar. It was fixed to the connective tissue adjacent to the baseplate with 4-0 polyglactin 910 sutures and then covered with a full-thickness skin graft from the thorax, which was harvested adjacent to the incision for removal of the rib cartilage so that no additional scar was created (Figure 3C). The flap was secured with firm tapes to avoid any movement for 1 week.

Cases 2 Through 158

The remainder of the cases were patients with grade III microtia and congenital auricular atresia without prior treatment. Because of the good result in our first case, we used the same type of periosteal flap. This procedure avoids the much more time-consuming preparation of the temporalis fascia and reserves that flap as a rescue option in case of wound healing problems, which we fortunately have not needed so far.


In total, 158 patients with grade III microtia were operated on using the retroauricular, posteriorly based periosteal flap technique and evaluated for periosteal flap and free skin graft survival in the early postoperative period. In all cases, the grafting was completely successful. Further evaluation of our technique was performed just before stage 3. We found that the aesthetic shape of the graft was excellent in all patients, with satisfactory frontal symmetry of the reconstructed ear. Figure 4 and Figure 5 show preoperative and postoperative views of a woman with right-sided grade III microtia and congenital auricular atresia.

Figure 4.
Woman With Right-Sided Grade III Microtia
Woman With Right-Sided Grade III Microtia

A, The preoperative view is presented. B, The postoperative view after stage 2 reconstruction is shown.

Figure 5.
Same Woman With Right-Sided Grade III Microtia
Same Woman With Right-Sided Grade III Microtia

A, The postoperative posterior view after stage 2 reconstruction is presented. B, A close-up view is shown.


Over the past 50 years, many surgeons have contributed greatly to improvement in the results of microtia reconstruction.514 An important step in total ear reconstruction is elevation of the buried ear framework in stage 2. This step has undergone many changes in technique, ranging from the use of skin grafting to the use of flaps and cartilage blocks in the retroauricular sulcus.

Nagata15 used a galeal flap to cover a cartilage wedge graft in stage 2. Among a subsequent series of 144 patients using the technique by Nagata, Firmin16 reported 10 cases of partial failure of the graft and 1 total failure of the galeal flap.

In 8 patients with microtia, Yoshimura et al17 described a 2-stage method for reconstruction of congenital microtia using an anteriorly based mastoid fascial flap covered with a skin graft in the second operation. The skin grafts demonstrated good survival, and an appropriate auriculocephalic angle was preserved in all cases. The authors noted that their method was easy to perform and left no scar in the temporal hair-bearing area. Ou and colleagues18 used a fascial flap based on the same principle as the method by Yoshimura et al. All the fascial flaps and overlying full-thickness skin grafts survived. Ou et al stated that their technique has multiple advantages, including firm elevation, good frontal projection, and a natural appearance of the posterior aspect of the ear. Furthermore, it is a fast and practical procedure, avoids additional scars on the scalp, and preserves the superficial temporoparietal fascia and superficial temporal vessels.

In other reconstruction variations, Park and colleagues1921 described the use of a cranial-based retroauricular flap in addition to the mastoid fascia flap. Yotsuyanagi and coworkers22 used a local flap from the hairless mastoid region. They reported that the skin of the flap provides good texture and color match to the auricle. Furthermore, the flap skin has good elasticity for a subcutaneous pocket for subsequent cartilage grafting. With this technique, the suture line is placed anteriorly, resulting in a visible scar on the anterior surface of the reconstructed ear.

Alexander et al23 described a technique of elevating the buried ear framework in the second stage of microtia correction that combined a posterior temporal parietal and galeal fascial flap. The flap was robust, with a dependable blood supply based on the posterior branches of the superficial temporal artery, and all patients had satisfactory ear projection.


Based on our experience, we believe that the above-mentioned flaps in the Discussion section are unsuitable when middle ear reconstruction is indicated because they interfere with the atresia operation and might be at risk for necrosis. We also propose that the temporal parietal fascial flap should be reserved for secondary procedures and treatment of complications that may occur during or after the procedures performed for microtia reconstruction. The typical flap used for reconstruction of the retroauricular sulcus should be versatile and of sufficient length, have a wide base, lie adjacent to the ear (ie, the field of reconstruction), allow excellent exposure of the mastoid bone in cases of atresia operation without sacrificing important blood vessels (eg, the superficial temporal artery and vein), and provide a robust bed for the graft used to cover the posterior surface of the pinna after elevation. Our novel periosteal flap described herein meets all these conditions, with excellent survival of the graft and satisfactory frontal symmetry of the reconstructed ear.

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Article Information

Accepted for Publication: April 14, 2015.

Corresponding Author: Saad Mohamed Saad Ibrahiem, PhD, MRCS, EBOPRAS, Plastic, Reconstructive, and Burn Management Unit, Faculty of Medicine, Alexandria University, 1 Kolit Elteeb St, Mehatet Elramel, Alexandria 21111, Egypt (tosaadsaad@hotmail.com).

Published Online: July 16, 2015. doi:10.1001/jamafacial.2015.0764.

Author Contributions: Drs Saad Ibrahiem and Magritz had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Siegert, Magritz.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Saad Ibrahiem, Magritz.

Critical revision of the manuscript for important intellectual content: Siegert, Saad Ibrahiem.

Statistical analysis: Saad Ibrahiem.

Administrative, technical, or material support: All authors.

Study supervision: Siegert, Magritz.

Conflict of Interest Disclosures: None reported.

Wang  T. Auricular reconstruction. In: Papel ID, ed. Facial Plastic and Reconstructive Surgery. 2nd ed. New York, NY: Thieme; 2002:615-633.
Siegert  R.  Combined reconstruction of congenital auricular atresia and severe microtia. Laryngoscope. 2003;113(11):2021-2027.PubMedArticle
Siegert  R, Weerda  H.  Two-step external ear canal construction in atresia as part of auricular reconstruction. Laryngoscope. 2001;111(4, pt 1):708-714.PubMedArticle
Siegert  R, Weerda  H, Mayer  T, Brückmann  H. High resolution computerized tomography of middle ear abnormalities [in German]. Laryngorhinootologie. 1996;75(4):187-194.PubMedArticle
Nagata  S.  Modification of the stages in total reconstruction of the auricle, part IV: ear elevation for the constructed auricle. Plast Reconstr Surg. 1994;93(2):254-266.PubMedArticle
Brent  B.  The correction of microtia with autogenous cartilage grafts, I: the classic deformity? Plast Reconstr Surg. 1980;66(1):1-12.PubMedArticle
Brent  B.  The correction of microtia with autogenous cartilage grafts, II: atypical and complex deformities. Plast Reconstr Surg. 1980;66(1):13-21.PubMedArticle
Nagata  S.  A new method of total reconstruction of the auricle for microtia. Plast Reconstr Surg. 1993;92(2):187-201.PubMedArticle
Nagata  S.  Modification of the stages in total reconstruction of the auricle, part I: grafting the three-dimensional costal cartilage framework for lobule-type microtia. Plast Reconstr Surg. 1994;93(2):221-230.PubMedArticle
Nagata  S.  Modification of the stages in total reconstruction of the auricle, part II: grafting the three-dimensional costal cartilage framework for concha-type microtia. Plast Reconstr Surg. 1994;93(2):231-242.PubMedArticle
Nagata  S.  Modification of the stages in total reconstruction of the auricle, part III: grafting the three-dimensional costal cartilage framework for small concha-type microtia. Plast Reconstr Surg. 1994;93(2):243-253.PubMedArticle
Tanzer  RC.  Total reconstruction of the external ear. Plast Reconstr Surg Transplant Bull. 1959;23(1):1-15.PubMedArticle
Tanzer  RC, Rueckert  F. Reconstruction of the ear. In: Grabb WC, Smith JW, eds. Plastic Surgery: A Concise Guide to Clinical Practice. Boston, MA: Little Brown; 1968:424-425.
Nagata  S.  Total auricular reconstruction with a three-dimensional costal cartilage framework. Ann Chir Plast Esthet. 1995;40(4):371-399.PubMed
Nagata  S.  Secondary reconstruction for unfavorable microtia results utilizing temporoparietal and innominate fascia flaps. Plast Reconstr Surg. 1994;94(2):254-265.PubMedArticle
Firmin  F.  Ear reconstruction in cases of typical microtia: personal experience based on 352 microtic ear corrections. Scand J Plast Reconstr Surg Hand Surg. 1998;32(1):35-47.PubMedArticle
Yoshimura  K, Asato  H, Nakatsuka  T, Sugawara  Y, Park  S.  Elevation of a constructed auricle using the anteriorly based mastoid fascial flap. Br J Plast Surg. 1999;52(7):530-533.PubMedArticle
Ou  LF, Yan  RS, Tang  YW.  Firm elevation of the auricle in reconstruction of microtia with a retroauricular fascial flap wrapping an autogenous cartilage wedge. Br J Plast Surg. 2001;54(7):573-580.PubMedArticle
Park  C, Lee  TJ, Shin  KS, Kim  YW.  A single-stage two-flap method of total ear reconstruction. Plast Reconstr Surg. 1991;88(3):404-412.PubMedArticle
Park  C, Lew  DH, Yoo  WM.  An analysis of 123 temporoparietal fascial flaps: anatomic and clinical considerations in total auricular reconstruction. Plast Reconstr Surg. 1999;104(5):1295-1306.PubMedArticle
Park  C.  Modification of two-flap method and framework construction for reconstruction of atypical congenital auricular deformities. Plast Reconstr Surg. 1997;99(7):1846-1857.PubMedArticle
Yotsuyanagi  T, Yokoi  K, Nihei  Y, Sawada  Y.  Management of the hairline using a local flap in total reconstruction for microtia. Plast Reconstr Surg. 1999;104(1):41-47.PubMedArticle
Alexander  G, Rajacic  N, Ibrahim  MK, Al-Zamil  S.  The combined posterior temporoparietal and galeal fascial flap: a new flap in the elevation of the constructed auricle (second stage of microtia correction). Br J Plast Surg. 2002;55(7):582-584.PubMedArticle