Keywords
auricular - multiple V-Y - cryptotia - advancement flap
Introduction
Cryptotia is a relatively common congenital auricular deformity in Asians but rare
in Caucasians. The characteristic anatomic feature of cryptotia is the invagination
of the superior half of the auricle under the temporal skin.[1] With this deformity, the buried portion can be pulled out by hand, but it falls
back into the skin again if released. Patients have difficulty wearing glasses and
masks, which affect aesthetics. Treatment goals can be summarized as follows: (1)
restoration of the auriculocephalic sulcus, (2) replacement of the deficient skin
flap to cover embedded cartilage, (3) establishment of collapsed cartilage, and (4)
release of abnormal intrinsic auricular muscles.
Various operative techniques have been described, such as Z plasty, skin graft, and
local skin flap, among which V-Y advancement has been effectively applied in all cases
of cryptotia. Despite its many advantages, the disadvantages of V-Y advancement are
the development of a visible scar and a lowered hairline. In this study, we introduce
a new technique: Multiple V-Y plasty advancement modification or using multiple consecutive
V-Y flaps in the postauricular area. This advancement can overcome the disadvantages
of the previous V-Y technique, such as a visible scar and a lowered hairline but still
retain the inherent advantages.
Idea
The main disadvantage of the previous V-Y technique is that the V-flap must be long
and wide enough for skin supplementation. Therefore, the correction of cryptotia using
the technique is mainly designed for the hair-bearing scalp area. After the flap slides
down to create auriculocephalic sulcus, the area where the flap is taken leaves a
scar. This scar area can be covered by hair, but most of it is still exposed, affecting
the aesthetics. The temporal triangular flap has hair, so when it slides down, the
hairline is lowered. Our idea was to use multiple small consecutive V-Y flaps with
short incisions in the retroauricular region to limit scarring while not lowering
the hairline ([Fig. 1]).
Fig. 1 Diagram to illustrate multiple V-Y and modified multiple V-Y. The flaps were sutured
together to a discrete central focal point (C point). The dashed line is the expected
auriculocephalic sulcus.
Surgical Steps
Patients Receive General Anesthesia
-
Skin incision design: The buried portion is pulled out by hand, and the position of
the auriculocephalic sulcus is drawn. A zig-zag line is designed in the temporal skin
and superior skin of the auricle. The zig-zag line is created by three consecutive
V-Y flaps that are not on a straight line but on a curve (position of auriculocephalic).
The beginning point of the line is in the skin of the anterior part of the buried
portion of the superior helix. The posterior point is the endpoint of the auriculocephalic
sulcus fissure to be reconstructed ([Fig. 2]).
-
Skin incision and flap dissection: Before skin incision, physiologic saline to which
epinephrine had been added is injected into the auricle to reduce bleeding. The triangular
flaps are elevated from the temporal scalp above the superficial temporal fascia level
and slid to both sides ([Fig. 3]). Abnormal intrinsic auricular muscles in the cartilage are removed, and cartilage
deformities are fixed with autogenous cartilage grafting if necessary.
-
Stitch closure: The skin flaps are sutured together to a central focal point (C Point)
located in the auriculocephalic sulcus ([Fig. 4]). Nylon 5.0 sutures are used to stitch the subcutaneous organization of the flap
edge with cartilage to deepen the auriculocephalic sulcus. The skin incisions were
closed with Vicryl 5.0 and the outer layer with Nylon 6.0 sutures. Sutures were cut
after 7 days of operation.
Fig. 2 Skin incision design.
Fig. 3 Surgical skin incision of triangular flaps. Abnormal intrinsic auricular muscles
were removed.
Fig. 4 The flaps were sutured together to a discrete central focal point. The subcutaneous
tissues were sutured to the cartilage to form the auriculocephalic sulcus.
The authors have received written consent from the patient's parents for permission
to use the images.
Discussion
Many operative methods to treat malformations have been reported, such as skin graft,[2] subcutaneous pedicled flap,[3] Z plasty,[4] local rotation flap,[5] and V-Y plasty.[6] Each method has its advantages and disadvantages with respect to skin flap deficiencies.
Among these methods, the V-Y flap is said to have many advantages in recreating cryptotia
from mild-to-severe cases. The application of the V-Y advancement flap to treat cryptotia
was first reported by Kubo and then improved by many other authors for better effectiveness.[3]
[7]
[8]
[9]Cho and Han have summarized and briefly outlined the characteristics of the V-Y flap
as follows: (1) simple, straightforward design and a short operation time; (2) provision
of enough skin to the upper and posterior portions of the auricle; (3) provision of
sufficient depth of auriculocephalic sulcus; (4) correction of cartilage deformities
with unrestricted access; (5) no need for additional skin grafting; (6) applicable
for other ear deformities including constricted ear; (7) visible scarring at the donor
site; and (8) lowered hairline created by advancement of the temporal triangular flap.
The problems of adopting the V-Y technique were the development of a visible scar
on the temporal skin and lowered hairline, which have not been effectively solved
with any measures. Therefore, we propose the multiple V-Y advancement modification
to enhance the cryptotia treatment techniques further. Multiple Y-V flaps were first
used by Bier et al in 1922 for the treatment of soft tissue defects or stretch marks
caused by burns.[10] We improved this technique for reconstructing cryptotia by creating maximal sliding
flaps and suturing the postauricular triangular flaps together to a discrete central
focal point. With this technique, we have found the following advantages:
-
–Triangular flaps are designed in the retroauricular region, so the scar is less visible
as it is located in the retroauricular region ([Fig. 5]).
-
–The skin flaps are small and not located in the hair-bearing scalp, so the hairline
is not lowered.
-
–Multiple V-Y flaps and maximum sliding flaps are used so more skin could be mobilized
to cover the cartilage, and no skin grafting was required.
-
–There was a scar line in the auriculocephalic sulcus, ensuring the depth of the auriculocephalic
sulcus. Scars were fixed, reducing the possibility of recurrence.
-
–Long and low skin incision facilitated easy access and repair of cartilage deformities.
Fig. 5 After suturing the incision. The scar was located in the retroauricular region so
it is less visible.
A high percentage of cryptotia patients presents cartilage adhesion malformations.[11] Depending on the deformations of auricular cartilage, the surgery was performed
to remove the fibrous fascia or thin muscle layer, a piece of conchal cartilage was
harvested and fixed to the postauricular cartilage where the released space was widened
for correction and creation of the curve of antihelical fold.
According to Cho et al, the conchal cartilage was used in mild cases; Medpor sheet
was used in severe cases to the posterior aspect of the corrected sharply curved antihelical
crus for preventing relapse as a splinting.[4]
From 2018 to 2022, six cryptotia patients were treated by multiple V-Y advancement
modification including five male and one female. Two patients had bilateral and four
patients had unilateral cryptotia.
This technique has shown high efficiency. On long-term follow-up postoperatively,
there were no complications such as skin necrosis, infection, cartilage inflammation,
or recurrence ([Fig. 6]). However, there was one patient with hypertrophic scar.
Fig. 6 Preoperative (A), immediate postoperative (B), and 4-year postoperative (C) views of a patient.
The disadvantage of the technique is that the design is more complicated than the
V-Y technique, but due to the elasticity of the skin, the design line is flexible
and does not require strict precision.
