6 year old boy suffering from bullying at school as a result of bilateral cryptotia, a very unusual congenital ear anomaly in which the superior helix is buried under temporal skin.
Repair of bilateral cryptotia using modified trefoil flap procedure.
This is a 6 year old patient with a history of congenital cryptotia of both ears. His mother was very concerned because he was at the age where bullying occurs. The keys to operative planning in this procedure is a precise understanding of the anatomic points of the auricle that catch the observers eyes. Pre-operative physical exam revealed that a complete superior helical rim was present, but was buried under temporal skin and was able to be identified by pulling up and out on the superior auricle. The identification of the buried cartilage on pulling and noting that all auricular components were present distinguished this case of cryptotia from a variant of microtia. On account of this finding a plan for cartilage repositioning and coverage with a local flap can continue. A modified Trefoil flap was planned out and incised, this is an anteriorly based flap that will be repositioned to cover the buried cartilage, and help in creating a posterior auricular sulcus superiorly where it is missing. The corresponding scalp portions of the opposing flap is undermined widely for advancement anteriorly for a low tension closure. Key steps in surgical technique include division of muscle fibers that are holding the buried cartilage in place and observing a full release from the temporal region. Once this release is achieved an additional security measure of suturing the bent superior helical rim cartilage to its straighter mid helical portion (in order to keep it strongly in place) can be performed with permanent 5-0 nylon suture. At this point observation by redraping the skin of the anteriorly based trefoil flap should reveal a normal appearance to the auricle. If this is the case closure can be performed, staggering the high tension points of the trefoil flaps through the posterior auricular area so that there is no single point of significant tension. Post-op instructions include coverage of the ear at night with a glasscock dressing to prevent traumatic injury. Glasses can not be worn in the first 10 post-operative days, but can be resumed immediately after this.
The cartilage that is buried can be secured with additional sutures onto the remainder of the helical rim as an extra measure, but this is certainly not necessary as release of the muscle and repositioning of the skin allows it to remain in a more natural position.
Bullying, unacceptable aesthetic appearance.
Sterile set up, head wrap with ears exposed.
Must have an intricate knowledge of the external ear anatomy to distinguish what is missing and/or hidden. Need to be aware of the helix, fossa triangular, scaphoid fossa, and how the root of the helix should appear as it is normally distorted in cryptotia.