The Double-reverse Wedge Excision Technique: A Novel Approach to Reconstruction of Stahl’s Ear Deformity

Supplemental Digital Content is available in the text.

Summary:

Stahl’s ear deformity presents with an abnormal third crus of the antihelix and varying degrees of severity. This paper aims to describe a novel technique for reconstruction of Stahl’s ear involving a double-reverse wedge excision of the third crus cartilage and skin, as well as use of Mustardé sutures to recreate the superior crus and Furnas sutures to complete the auricular setback. This novel technique for correction of Stahl’s ear deformity produces a more stable aesthetic result versus classic otoplasty with desired auricular setback, minimal reduction in the size of the ear, and limited scarring on the anterior auricular surface. Reconstruction of Stahl’s ear deformity can be accomplished using this double-reverse wedge excision technique of the third crus cartilage and skin with Mustardé and Furnas sutures to recreate the superior crus and complete auricular setback, effectively restoring anatomic harmony to the ear.

INTRODUCTION

Stahl’s congenital auricular deformity is characterized by an abnormal third crus in the scaphoid fossa, extending from the antihelix to the margin of the helix. This third crus causes flattening and deformity of the helix and unfurling of the helical rim. Significant prominence of the upper pole is also usually present. A posterosuperior projection of the helical rim, resembling a “Dr. Spock” ear, is often present and the superior crus is usually hypoplastic or absent. The degree of deformity in Stahl’s ear varies widely among patients. Mild deformities are technically easier to correct and can be reconstructed by a number of methods. Severe deformities are more difficult to reconstruct, often require multiple techniques, and are prone to reconstructive failure. Stahl’s ear is more common in Asian races and usually presents unilaterally but can be seen bilaterally in about 20% of cases.^1,2 The etiology of this deformity is unknown but may be related to an abnormal insertion of the transverse auricular muscle.³

Previously described techniques for reconstructing Stahl’s ear involve either excising the third crus or sparing the third crus and reshaping the ear with scoring incisions, molding techniques, and fixation sutures. Excision of the third crus is prone to wound dehiscence and contour irregularities associated with approximating the cartilage under tension. Techniques that spare the third crus and reshape the ear using less invasive methods are hindered by unpredictable and poor cosmetic results. This paper describes a novel approach for reconstruction of Stahl’s ear that minimizes some of the shortcomings of previously described techniques.

CLINICAL CASE

An 18-year-old male presented with bilateral congenital Stahl’s ear deformity. The right-ear deformity was more severe than the left. Both ears were characterized by the abnormal third crus, unfurling of the helical rim, and absence of the superior crus (Figs. 1, 2) and were classified as Type II deformities, according to the classification system originally described by Yamada and Fukuda⁴ and also used by Ogawa and Hyakusoku.⁵

Fig. 1.

Right lateral view preoperative photograph of an 18-year-old man with bilateral congenital Stahl’s auricular deformity, showing the more severe right-ear deformity, with the abnormal third crus, unfurling of the helical rim, absence of the superior crus of the antihelix, and prominence of the upper pole.

Fig. 2.

Anterior view preoperative photograph of an 18-year-old man with bilateral congenital Stahl’s auricular deformity, showing the abnormal third crus, unfurling of the helical rim, absence of the superior crus of the antihelix, and prominence of the upper pole.

METHODS AND TECHNIQUE

The third crus was marked as a wedge, wide inferomedially and narrow superolaterally, on the anterior auricular surface (SDC1; see figure, Supplemental Digital Content 1, which displays Double-Reverse Wedge Excision Technique, http://links.lww.com/PRSGO/B136). The postauricular incision was marked. Both ears were injected with 6 mL 1% lidocaine with 1:100,000 epinephrine along the postauricular incision for local anesthesia. The postauricular incision was made. A wide supraperichondrial dissection was performed over the postauricular cartilage. Using a 25-Gauge needle and methylene blue, the markings of the third crus on the anterior auricular surface were transposed to the postauricular cartilage. The third crus cartilage was excised full-thickness through the postauricular incision, without primary closure of the defect, but only approximation of the anterior and posterior edges. The superior crus was marked on the anterior auricular surface and transposed to the postauricular cartilage using a 25-Gauge needle. The superior crus was then recreated with horizontal mattress 4-0 Mersilene Mustardé sutures. To correct the auricular prominence, the conchal cartilage was secured against the mastoid fascia with two 3-0 Nylon Furnas sutures until the desired setback was achieved. The excess skin on the anterior auricular surface, remaining after excision of the third crus cartilage, was marked and excised full-thickness as a reverse wedge, narrow inferomedially and wide superolaterally, to avoid a dog ear medially. The excision extended superolaterally through the helical rim and slightly posteriorly. All incisions were closed using 5-0 chromic suture. Standard otoplasty headwrap with bacitracin, xeroform, and fluff dressing was applied.

RESULTS

This technique produced a stable aesthetic result with minimal reduction in ear size, limited scarring on the anterior auricular surface, and desired symmetry at 6 months postoperatively (Figs. 3, 4). This technique has also proven to be effective in otoplasty revision after failed reconstruction of Stahl’s ear with the classic otoplasty technique in a 7-year-old male and a 13-year-old male (both cases also classified as Type II Stahl ear deformities), producing a more aesthetic and reliable outcome than that achieved with the classic otoplasty technique.

Fig. 3.

Right lateral view postoperative photograph 6 months after reconstruction using the double-reverse wedge excision technique demonstrating a stable aesthetic result with minimal reduction in the size of the ear and minimal scarring on the anterior surface of the ear.

DISCUSSION

Techniques for reconstruction of Stahl’s ear include those that excise the abnormal third crus and those that spare the third crus and reshape the ear using scoring incisions, molding techniques, and fixation sutures. Excision of the third crus risks reducing the size of the ear, which can be problematic in unilateral cases, and is prone to wound dehiscence and contour irregularities associated with approximating the cartilage under tension. Techniques that spare the third crus and reshape the ear using less invasive methods often result in unpredictable and poor aesthetic outcomes. The approach described in this paper uses a combination of these 2 methods, the double-reverse wedge excision of third crus cartilage and skin and Mustardé and Furnas sutures to recreate the superior crus and to achieve setback, respectively. This approach offers several advantages over other techniques previously described. A wide inferomedially and narrow superolaterally wedge excision of the third crus cartilage avoids significant reduction in ear size and the potential for wound dehiscence associated with approximation of the cartilage under tension. Recreating the superior crus with Mustardé sutures avoids the complexity and risk of failure associated with cartilage grafts and other techniques previously described. Finally, this approach minimizes scarring on the anterior auricular surface, as most of the dissection and resection occurs postauricularly.

Sugino et al.⁶ described resection of the third crus cartilage through a posterior and helical rim incision and then reorienting this segment to create the superior antihelical crus. Similarly, in patients with small or hypoplastic superior crura, the excised third crus can be only grafted onto the existing superior crus to augment its form and projection.⁷ This method was first described by Kaplan and Hudson and is also the method preferred by Thorne and Wilkes.⁸ Although the third crus wedge excision of Kaplan and Hudson⁷ is narrow medially and wide laterally, and prone to wound dehiscence and excessive reduction in ear size, the technique described in this paper minimizes these potential complications by excising a wedge that is wide medially and narrow laterally. The double-reverse wedge excision technique is an effective alternative for reconstructing Stahl’s ear that can produce a stable, aesthetic result and minimize the shortcomings of previously described techniques. Further studies with a larger number of subjects are needed to validate the technical ease and improved outcomes associated with this innovative surgical modality.

Fig. 4.

Anterior view postoperative photograph 6 months after reconstruction using the double-reverse wedge excision technique demonstrating a stable aesthetic result with desired setback.

Patient Consent Statement

The patient provided written consent for the use of his image.

Supplementary Material

gox-7-e2313-s001.pdf ^{(2MB, pdf)}