Superior Crus Research Articles

Phenotypic sub-grouping in microtia using a statistical and a clinical approach.

The clinical presentation of microtia varies widely from minimal morphological abnormalities to complete absence of the ear. In this study we sought to identify and characterize sub-groups of microtia using a statistical and a clinical approach. Photographs of 86 ears were classified in relation to all the external ear components. We used cluster analysis and rater's clinical opinion to identify groups with similar phenotypes in two separate analyses. We used Cramer's Phi coefficient of association to assess the similarity among the clinician's groupings as well as among the statistical sub-phenotypic groups and each of the clinician's groupings. The cluster analysis initially divided the 86 ears into a more and a less severe group. The less severe group included two sub-groups that included ears classified as normal and a group that had very few anomalous components. The group of 48 more affected ears all had abnormalities of the helix crus; antihelix-stem, -superior crus and -inferior crus; and antitragus. These were further divided into 4 sub-phenotypes. There was a moderate degree of association among the raters' groupings (Cramer's Phi: 0.64 to 0.73). The statistical and clinical groupings had a lower degree of association (Cramer's Phi: 0.49 to 0.58). Using standardized characterization of structural abnormalities of the ear we identified six distinct phenotypic groups; correlations with clinicians' groupings were moderate. These clusters may represent groups of ear malformations associated with the same etiology, similar time of insult or target cell population during embryonic development. The results will help inform investigations on etiology.

External ear anthroposcopy in female students of the University of Szczecin

Background: Personal identification based on anthroposcopic characteristics, including the features of the external ear, has recently become highly desirable. This growing interest results from increasin public safety requirements, as well as the ever more numerous practical applications of somatometry and somatoscopy. Especially when there is no biological material necessary for DNA testing, and where instead there are photographs or surveillance footage, being able to identify a person based on anthroposcopic features is an attractive alternative.Aim:The aim of this paper is to investigate the structural diversity of the external ear among the female students of the University of Szczecin and to demonstrate the viability of external ear biometrics in personal identification.Materials and methods: a group of young women n = 65, students of the University of Szczecin, aged 21–29 years (x= 23.7). Structural differences were assessed based on photographs of the left and right ear. Individual characteristics describing the ear were classified according to the adopted criteria. The prevalence of each external ear feature included in the somatoscopic assessment was described as a percentage. Results: The majority of students included in the study had a moderately or prominently curled helix and a long crus of helix. The antihelix with its superior crus were often found to be prominent, as was the antitragus. The tragus was predominantly single and the intertragic notch – moderate. The lobe surface was observed to be rather underdeveloped; attached lobes were found in half of the participants, whereas the remainder had detached lobes.Conclusion:Ear somatoscopy may be an auxiliary method in personal identiication when video recordings or photographs are available.

The importance of costal cartilage framework stabilization in microtia reconstruction: Anthropometric comparison based on 216 cases

This study explored anthropometric changes in the reconstructed auricle and the contralateral normal ear in a series of 216 microtia patients using different stabilization methods. Our main personal modifications concerning the preparation of the framework were the following: 1. The individualized framework grafting was based on patients with different ages and different degrees of the strength and thickness of the rib cartilage. 2. The framework was stabilized as a "C" shape by using a piece of cartilage or suture to reinforce the two end points of the "C". In group A (the thickness of cartilage was more than 5 mm), a block of residual cartilage fixed by wire was added between the tragus and the base frame of the inferior crus by the modified method but was not applied in the original method. In group B (the thickness of cartilage was less than 5 mm), a 4-0 braided suture was used to reinforce the two structures but was not used in the original method. No significant differences were found in the height or width measurements of the cartilage framework and the contralateral normal side in either group at the time of implantation. At the follow-up, the height and width measurements were obviously increased in both groups operated on by the original method compared with the initial implanted or contralateral normal measurements. There were no significant differences in the height or width measurements by the modified method in either group. The authors' techniques produced acceptable results and generated some useful parameters for the growth study of the reconstructed auricle and the contralateral normal ear. The modifications in framework stabilization allow a harmonious outline of the reconstructed auricle to be attained, which is almost symmetrical to the contralateral normal auricle.

Otoplasty Outcomes and Results: Does Furnas Setback Suture Affect Complication Rates?

lems, or auricular atresia or patients or their parents who were diagnosed with psychiatric problems. We evaluated 27 male and 27 female patients for the clinical outcomes, revision needs, elastic headband wearing time, and complications, such as infection and hematoma, after otoplasty for surgical correction of prominent ears when Furnas suture was used. Photographic documentation was done preoperatively and postoperatively. Surgical Techniques Otoplasty was performed under general anesthesia. The operative site was prepared with povidone-iodine solution. To reduce the bleeding, 1% lidocaine with 1:200.000 epinephrine was infiltrated with a fine needle to postauricular subcutaneous tissue. The position of the antihelix was arranged by pressing the ear backward. The key markings of folds and suture sites were plotted with a violet marker. The skin incision was made postaurically and long enough for accessing the posterior helix (Mustarde suture) and mastoid area (Furnas suture). Hemostasis was obtained with monoand bipolar cautery. Small elliptical skin with subcutaneous tissue was excised from the posterior part of the concha. Subcutaneous tissue was separated from the conchal cartilage. The formation of a new antihelical fold was created according to the Mustarde technique. A row of horizontal mattress sutures was centered along the long axis of the root and superior crus of the antihelix. Each suture brought the cartilage of the scapha near to the concha. When tightened, they created or augmented the roll of the crest of the antihelix by drawing the scaphoid fossa towards the concha. The lowermost Mustarde suture was placed from the cauda helicis to the concha, and the uppermost suture was from the concha to the triangular fossa. These sutures were performed with 4/0 white polypropylene (3). Later, if performed, conchal setback procedure was applied to the Furnas technique. The posterior edge of the incision was elevated from the mastoid fascia. The postauricular soft tissue was dissected to expose the mastoid fascia. Furnas suture was applied as a 2/0 polypropylene mattress suture. After careful hemostasis, the skin was closed with 5/0 Ethilon suture (4). A “mastoid” head wrap was wrapped to all patients postoperatively. The dressing was opened on the first postoperative day; if there was no hematoma, it would not be wrapped again. The patient was instructed to wear an on-ear elastic headband after surgery for a week. Statistical Analysis All data were analyzed using the Statistical Package for the Social Sciences (SPSS) 15.0. The following statistics were used: t-test, homogeneity of variance (Levene) test, Mann-Whitney U-test, Fisher’s chi-square test, simple correlation, and regression analysis method. Results A total of 54 patients (95 ears) were detected retrospectively after otoplasty. Twenty-seven (50%) of them were male and 27 (50%) were female. The patient age range was 5-46. Twenty-one patients (40 ears) were children and 33 (55 ears) were adults. Primary surgery was performed on 95 ears of 54 patients (41 of the patients had bilateral surgery and 13 had unilateral). Five patients (9%) needed revision surgery due to inadequate correction (Table 1). In 7 (13%) patients with an isolated absence of the antihelix, only Mustarde suture was performed (Figure 3). Both Furnas and Mustarde sutures were used in 47 (87%) of patients-41 bilaterally (Figures 4a, b). While using the Mustarde and Furnas suture, all patients underwent the same procedure described above (Table 2). The minor complication rate of our cases that did not require any additional surgical intervention was found to be 12.6% (12/95). These minor complications included minimal low-flow bleeding for 1 day despite pressure headwrap and bandages in three ears of two patients (3.9%). Four ears of four patients had a hematoma (4.2%); 50 of them did not (95.8%). All hematomas Figure 1. Furnas (setback) suture application Figure 2. Mustarde suture application Turk Arch Otolaryngol 2014; 52: 52-6 Kuscu et al. Otoplasty Outcomes 53

Single-Stage Autologous Ear Reconstruction for Microtia

The authors have been using the Nagata technique since 2002. In this review of 100 consecutive ear reconstructions, the authors present technique modifications that have evolved over this period that have contributed to improved auricular contour and that now allow for auricular reconstruction in a single stage. This study is a retrospective review of a prospectively acquired database. The series is restricted to primary reconstructions performed for congenital microtia. Photographs of 10 consecutive patients are presented to demonstrate the results of the technique. Surgical complication rates are discussed. One hundred ear reconstructions were performed in 96 patients. There were 75 primary cases of congenital microtia. Twenty-four ears underwent a two-stage reconstruction, and 51 ears were reconstructed with a Nagata stage I procedure or a single-stage reconstruction. There was a gradual shift in technique, with a trend to perform fewer Nagata stage II outsetting procedures and more single-stage reconstructions. In patients who underwent an ear reconstruction in two stages, the surgical complication rate was 22 percent. In the last 40 consecutive ear reconstructions since abandoning the two-stage approach, the surgical complication rate is now 15 percent. A modification of Nagata's technique of autologous ear reconstruction for microtia is described. Modifications of the three-dimensional framework address the contour of the inferior crus and control tragal projection and position. Inclusion of a projection block and recruitment of retroauricular skin allow for symmetric projection of the ear in a single stage. Therapeutic, IV.

T-bar reconstruction of constricted ears and a new classification

For the correction of constricted ears, many techniques are described in the literature, the majority based on Tanzer's classification of 1975. The improvements in ear reconstruction published by Brent, Nagata, Firmin and Park make better outcomes possible. It is therefore that a new classification for constricted ears is proposed, together with an alternative technique for correction of group IIA and IIB deformities, using a T-strut of costal cartilage to reconstruct the underdeveloped or missing superior crus of the antihelix.

Stahl Ear Correction Using the Third Crus Cartilage Flap

Stahl ear is usually associated with the existence of a third crus that traverses the scapha. The absence of the superior crus of the antihelix, a broadened scapha, and unfolded, long helical rim may contribute to the formation of the deformity. The method presented in this article is a combined technique intended to recreate the absent superior crus using the third crus as a cartilage flap along with elimination of the third crus, reducing the scapha size, and correcting helical rim deformities by skin and cartilage excisions. One bilateral and three unilateral cases were operated on with this technique (five auricles). The first unilateral cases were performed without scapha reduction and helix correction which was used in the other three cases with successful results. This procedure can be used to correct Stahl ear variations in the case of an absent superior crus when a third crus is present, the scapha is of increased size, and the helix is long without a fold.

Interrater reliability of a phenotypic assessment tool for the ear morphology in microtia

The Elements of Morphology Standard Terminology working group published standardized definitions for external ear morphology. The primary objective of our study was to use these descriptions to evaluate the interrater reliability for specific features associated with microtia. We invited six raters from three different subspecialities to rate 100 ear photographs on 32 features. We calculated overall and within specialty and professional experience intraclass correlation coefficients (ICC) and 95% confidence intervals. A total of 600 possible observations were recorded for each feature. The overall interrater reliability ranged from 0.04 (95% CI: 0.00-0.14) for the width of the antihelix inferior crus to 0.93 (95% CI: 0.91-0.95) for the presence of the inferior crux of the antihelix. The reliability for quantitative characteristics such as length or width of an ear structure was generally lower than the reliability for qualitative characteristics (e.g., presence or absence of an ear structure). Categories with very poor interrater reliability included anti-helix inferior crux width (0.04, 95% CI: 0.00-0.14), crux helix extension (0.17, 95% CI 0.00-0.37), and shape of the incisura (0.14, 95% CI: 0.01-0.27). There were no significant differences in reliability estimates by specialty or professional experience for most variables. Our study showed that it is feasible to systematically characterize many of structures of the ear that are affected in microtia. We incorporated these descriptions into a standardized phenotypic assessment tool (PAT-Microtia) that might be used in multicenter research studies to identify sub-phenotypes for future studies of microtia.

The human hippocampus observed by scanning electron microscopy (SEM): The dentate gyrus is made of an array of the neuronal lamellae.

Scanning electron microscopy (SEM) was employed to clarify the three dimensional structure of the human hippocampus.The polymorphic layer was L-shaped in coronal histological sections. The superior limb and lateral two thirds of the inferior limb formed a continuous plate. This plate consisted of L-shaped bars that were fused side by side with borders that were, although incompletely, demarcated by the stratum granulosum. The medial one third of the inferior limb was independent part of these L-shaped bars and took part in formation of the dentes. There were 40 to 50 dentes, and each had segmental blood vessels. Thus, the polymorphic layer was organized on a segmental plan, 40- 50 in number, arrayed along the antero-posterior axis.CA4 was surrounded by the L-shaped polymorphic layer and also had the superior and inferior crura. The medial end of the inferior crus was enveloped by the medial one third of the polymorphic tissue and was completely independent from its neighbors. Therefore, CA4, too, may be segmentally constructed following the same plan as the bars of the polymorphic layer. These observations suggest that, first, three major components of the hippocampus, the stratum granulosum, polymorphic layer, and CA4, are constructed based on the same lamellar unit in the dentate gyrus, and, second, the individual lamellae appear as distinct bars in the medial one third, but form a plate in the lateral two thirds of these structures. There were 7 to 12 pyramidal hillocks, organized of the central process and its covering, in the subiculum. Pyramidal cells showed clear polarity in the hillock; the cell apex oriented to the central process and the base to the periphery. The axon emitted from the cell base and formed the alveus. Pyramidal hillocks caused slight waves of the stratum pyramidale on the lateral border of the hippocampus but did not affect the superior surface. Functional aspects of the segmental arrangement of neuronal units along the antero-posterior axis and their medio-lateral diversity were discussed in terms of the three-synapse pathway in the hippocampus.

The transverse occipital ligament: an anatomic, histologic, and radiographic study

The craniocervical region is an osteoligamentous complex that provides structural stability and movement by means of numerous ligaments. Fundamental knowledge of these ligaments is important for physicians who treat patients with disorders of this region to reduce morbidity and mortality. There is a paucity of data in the literature regarding the morphology, function, and classification of the transverse occipital ligament (TOL). The purpose of this study was to investigate the prevalence, morphology, and variations of the TOL in a large number of adult human cadavers using dissection, histology, and digital radiography. Cadaveric laboratory study. Thirty-two formalin-fixed human adult cadavers were dissected in the study. Fourteen cadavers were found to have a TOL. Measurements using a digital caliper, high-resolution digital photography, histologic staining with bright-field microscopy, and digital radiography. The posterior musculature and related soft tissues were dissected and underlying bony elements removed. The TOL was identified, isolated, measured, and then removed for histologic preparation with hematoxylin and eosin staining. Anteroposterior open-mouth digital radiographs of the upper cervical spine with monofilament attached to the TOL were used to demonstrate its relations to the occiput, atlas, and axis. The TOL was present in 14 of 32 (44%) of the dissected cadavers (six male and eight female). Three types of TOLs were identified. Type 1 had bilateral connections to the alar ligaments and had fibers inserting onto the dens. Type 2 also had bilateral connections to the alar ligaments but did not have fibers inserting onto the dens. Type 3 neither had any connections to the alar ligaments nor had fibers that connected to the dens. Male cadavers always had a Type 1 TOL compared with 3 of 8 (38%) female cadavers and this difference was significant (p=.031). The TOL consisted of dense regular connective tissue with parallel arrangements of collagen fibers and interposed fibroblasts. Our data suggest that the TOL is not an anatomic variant and can be classified into three types. Future biomechanical studies can be designed to investigate the function of the TOL, although we hypothesize that it may act as a fulcrum during flexion and extension of the head because it is located between the apical ligament and superior crus of the cruciform ligament. Anteroposterior open-mouth digital radiographs revealed the location of the TOL with respect to the upper two cervical vertebrae. Future research should investigate the radiologic characteristics of the TOL using magnetic resonance imaging.

A novel form of antihelix deformity

This report describes a novel form of congenital antihelix deformity. A 2-month-old female presented with an antihelix deformity. Her inferior crus of the antihelix had the third crus, which was smoothly divided from the inferior crus, orienting forward. This type of deformity is not included in the current classification of a third crus deformity; therefore, this is the first report of a novel type of deformity.

Stahl’s Ear Correction

Stahl ear deformity is characterized by a third auricular crus with a horizontal orientation. A diminutive superior crus and prominence of the upper pole of the ear are also generally present. Many acknowledge that Stahl ear is a challenging deformity to correct. In the present report, an effective technique is introduced that uses 3 different, yet synergistic, maneuvers to oblate the third crus, enhance the superior crus, and normalize superior pole projection. The maneuvers are posterior abrading of the third crus, strategic placement of a posterior Mustarde suture, and placement of an anterior anticonvexity suture. Postoperative care involves the use of a custom scaphoid fossa splint and headband.

A new method to correct Stahl’s ear

Stahl's ear is a rare congenital auricular malformation in which an abnormal 'third crus' traverses the upper pole of the scapha. A number of different treatment options have been published to correct Stahl's ear deformity; however, none of them corrects all the variations perfectly. In this article, we describe our new method to correct this deformity. To correct Stahl's ear and acquire a natural-looking appearance, a technique of cartilage scoring and a folding cartilage flap was used. The entire layer of the cartilage was cut through and the anterior skin covering the cartilage was dissected to the external border of the desired superior crus and antehelix to form a fan-shape flap. After scoring of the posterior surface of the cartilage, the cartilage flap was folded and sutured to the cartilage below to build the superior crus. Seventeen patients ranging in age from 9 to 46 years were operated upon using this technique. The ears that were created were of normal size and shape. All patients and their families were satisfied with the final result. There were no complications. We have developed a new method to correct Stahl's ear deformity. Outcomes of this technique on 17 patients suggest that our method is simple, effective and successful.

Pediatric otoplasty

Pediatric otoplasty

V-Y-Z Plasty for correcting cryptotia

Cryptotia is a congenital defect in which the upper pole of the ear cartilage is buried beneath the scalp of the temporoparietal area and the superior auriculocephalic sulcus is absent. There is a coexisting deformity of the cartilage with a severely curved superior crus of the antihelix. The most commonly used technique for repair is the local flap combined with correction of the cartilage. For local flaps, the Z-plasty, V-Y procedure, rotational flap, transposition flap, or subcutaneous pedicled flap can be used.

Posterior Z-plasty and J-Y antihelixplasty for correction of Stahl's ear deformity

The bifurcated Y-shaped antihelix characterises the normal human ear and gives it an aesthetically pleasing appearance. In Stahl's ear congenital anomaly an aberrant crus usually replaces the superior crus, crossing the scaphoid fossa from the site of the normal bifurcation of the antihelix posteriorly towards the helix, giving the antihelix an abnormal J-shape. A technique is described to correct Stahl's ear deformity adding a simple Z-plasty to the incision to lengthen the skin on the posterior surface, together with making use of the aberrant crus to reconstruct the superior crus without reducing the ear size using a modified Mustardé technique. This is achieved by posterior scoring and suturing without any cartilaginous excisions converting the 'J' antihelix into a 'Y'. Out of a series of eight cases examined, four unilateral and one bilateral cases were operated on (six ears). The first two unilateral cases were performed without Z-plasty, which was used in the third case on with very satisfactory results in different types and severities of Stahl's ear deformity. I believe that the technique detailed in this paper fulfils the main principles necessary for correction of Stahl's ear deformity and may be used in cases where the aberrant crus is reducible regardless of its shape.

Correlation between projection of the ear, the inferior crus, and the antihelical body: Analysis based on computed tomography

We investigated the correlation between projection of the ear and the antihelical folding angle to clarify which portion of the antihelix should be corrected in reconstruction of prominent ears using computed tomograms of 15 ears in 11 patients with fractures of the facial bones. The angle of the scaphotriangular fossa indicating the superior crus, cymba conchae-triangular fossa angle indicating the inferior crus, and the scaphoconchal angle indicating the antihelical body were measured. There was no relation between the cranioauricular angle and the angle of the scaphotriangular fossa. However, there were significant relations between the cranioauricular angle and the cymba conchae-triangular fossa angle, and the cranioauricular and scaphoconchal angles, which suggests that emphasis should be placed on reconstruction of the inferior crus and antihelical body when prominent ears are being corrected.

Strategisches Vorgehen in der Behandlung der horizontalen Lidverlängerung

Horizontal laxity of the lower lid is often unrecognized and leads to a wrong treatment. The proper analysis of periorbital anatomy is most important to identify the pathophysiology in each case. Typically, the lateral canthal tendon becomes lax, resulting in eyelid malpositions. The mainstay of treatment includes tightening of either the inferior crus of the lateral canthal tendon or repositioning the entire lateral canthal tendon. The types of procedure performed will be reviewed in detail. The evaluation of the tarsal strip and the lateral dermal orbicular pennant flap as unique reconstructive tools and as adjuncts to aesthetic surgery will be discussed.

Innovative technique for correction of the congenital lop ear

Congenital lop ear is a deformity affecting the upper third of the ear. It is characterised by varying degrees of lidding of the helix, reduction in the fossa triangularis, scapha compression, reduction or absence of the superior crus of the antihelix and an associated reduction in vertical height of the external ear. Reported strategies for the surgical correction of this deformity include simple excision of the excess overhanging cartilage, radial cartilage incisions of the helix to reverse its memory, various cartilage grafts from the surrounding ear or rib to strut or fill the defect, and mastoid hitching stitches to reinforce the repair. We present a novel technique using a reversed conchal cartilage graft to strut the deformed antihelix. The memory of the reversed conchal cartilage is used to correct lidding of the superior helix and obviates the need for intrinsic cartilage modification or excision. We have found a good aesthetic and structural result in a patient with bilateral congenital lop ear with 12 months follow up.

Aesthetic Otoplasty

T he prominent rim of the auricle known as the helix takes a more or less curvilinear shape, starting at the helical root anteriorly and ending approximately at the level of the intertragal notch posteriorly. Many types of malformations of the auricle exist, with the prominent ear being one of the most commonly discussed deformities in the cosmetic literature. In many of these malformations, especially in the classic lop ear deformity, a deficient lateral overhang of the helix can exist. Creating a lateral overhang of the helix, or helical curl, that will persist has so far been an elusive endeavor in cosmetic otoplasty. Most surgeons have been satisfied with the helix’s mere prominence and relationship to the antihelix. This report calls attention to this helical flattening and presents a simple approach to obtaining a more natural appearance of the helical curl. This effect is achieved by excising a composite wedge(s) from the superior helical rim in a fashion that promotes an aesthetic tubular appearance of the helix.