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 Table of Contents  
SURGICAL TECHNIQUE
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 92-94

Congenital cleft earlobe repair by triangular flap technique


Department of Plastic Surgery, Pt. Bhagwat Dayal Sharma PGIMS, Rohtak, Haryana, India

Date of Submission26-Mar-2021
Date of Acceptance01-Jul-2021
Date of Web Publication01-Jan-2022

Correspondence Address:
Dr. Krittika Aggarwal
Department of Plastic Surgery, Pt. Bhagwat Dayal Sharma PGIMS, Rohtak - 124 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_10_21

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  Abstract 


Introduction: Congenital cleft earlobe is a common congenital deformity of earlobe. Various techniques have been described for its repair, but cosmetic deformity usually persists. We present our result using triangular flap repair for simple longitudinal cleft of earlobe. Materials and Methods: The procedure was done in five cases who presented between 2017 and 2020. The technique uses the same principles as in Randall-Tennison triangular flap repair for cleft lip. Results: Earlobes were near-symmetrical, postoperative scar minimal and patient satisfaction was very good in all cases. Ear piercing was done without any complications at least 6 months after surgery. After a follow-up of 1 year, no complications were noted. Conclusions: Triangular flap repair technique for cleft earlobe follows the principles of Randall-Tennison triangular flap repair for cleft lip. It provides very good results with esthetic contour, minimal scar with no complications in case of simple longitudinal cleft.

Keywords: Congenital cleft earlobe, flap repair, reconstruction


How to cite this article:
Singh K, Aggarwal K, Beniwal M. Congenital cleft earlobe repair by triangular flap technique. J Cleft Lip Palate Craniofac Anomal 2022;9:92-4

How to cite this URL:
Singh K, Aggarwal K, Beniwal M. Congenital cleft earlobe repair by triangular flap technique. J Cleft Lip Palate Craniofac Anomal [serial online] 2022 [cited 2022 Jan 25];9:92-4. Available from: https://www.jclpca.org/text.asp?2022/9/1/92/333637




  Introduction Top


Ear pinna is important in localization of sound in humans and in lower animals for hearing. Lobe of ear pinna has esthetic role more than functional and it is important traditionally for ear piercing, especially in Asian women. The presence of cleft in the earlobe causes visible esthetic deformity. According to Hillock's theory, cleft lobe is due to cleft between Hillock 6 and 1 during embryonic period.[1] The cleft, soft-tissue deficiency, and round margins at the cleft are common features. We present our technique to correct simple longitudinal cleft earlobe.


  Materials and Methods Top


Surgical technique

Our technique uses the principles of Randall-Tennison triangular flap repair described for cleft lip. In this technique, the basic principle is tissue rearrangement which helps in correcting soft-tissue deficiency. [Figure 1] shows the diagrammatic representation of the procedure. The length of each limb of cleft is measured and the difference between the two is noted. This difference is equal to the base of the triangular flap which is to be made on the longer limb. Incisions are marked to freshen the margins of the cleft with minimal tissue excision on the tip of the lobule. The triangular flap is marked 1.5–2 mm from the tip of the lobule. Equal corresponding cut is marked on the shorter limb. Local anesthesia (2% lignocaine with adrenaline) is infiltrated. Incisions are made full thickness, and procedure is completed as per marking done. Skin closure is done with Nylon 5-0 for both anterior and posterior skin surfaces. Suture removal was done after 7–10 days.
Figure 1: Schematic diagram for triangular flap repair showing marking and incisions planned

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  Results Top


We performed congenital earlobe repair using this technique under local anesthesia in five patients. Patients with cleft apart from longitudinal cleft and the presence of accessory lobes were excluded from the study. [Figure 2]a shows preoperative presentation in case 1 with triangular flap made as shown in [Figure 2]b and [Figure 2]c. Immediate postoperative photograph is also shown in [Figure 2]d. [Figure 3] and [Figure 4] show preoperative and postoperative photographs for case 3 and 4. Ear piercing was done without any complications at least 6 months after surgery. Earlobes were near-symmetrical, postoperative scar minimal and patient satisfaction was very good. After a follow-up of 1 year, no complications were noted.
Figure 2: (a) Preoperative photograph, (b and c) Intraoperative photograph after incisions made and triangular flap made; (d) Postoperative photograph for case 1

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Figure 3: (a) Preoperative photograph of left ear (affected); (b) Right ear (normal) for comparison; and (c) Postoperative photograph of left ear for case 3 at 1 year

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Figure 4: Preoperative and postoperative photograph for case 4

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  Discussion Top


The auricle is derived from first and second mandibular arches.[2] His[3] noted the formation of hillocks during development of auricle. He hypothesized that these hillocks lead to formation of specific parts of the pinna. However, it has been noted that these hillocks are incidental and transitory in nature.[4] It has been shown that the dorsal segments of mandibular arch and dorsal and ventral segments of hyoid arch are more important. The ventral segments form the tragus, antitragus, intertragic notch, lobule, helical root, and anterior helix. The dorsal segments give rise to the concha, the triangular fossa, inferior crus, and body of the antihelix. The remainder of the helix, the scaphoid fossa, and the superior crus of the antihelix are derived from free ear fold. This develops posterior to hyoid hillock region.[4],[5]

Congenital auricular anomalies can be categorized into malformations and deformities.[6] Malformations arise due to abnormal development during embryogenesis, for example, anotia, microtia, cleft earlobe, and polyotia. Since the auricle develops from first and second branchial arches, associated anomalies of maxilla, mandible, and facial nerve can also be seen. In utero or ex utero forces on the auricular cartilage can lead to deformational auricular anomalies, for example, cryptotia, prominent ear, and Stahl's ear.

Cleft earlobe is the most common congenital anomaly of earlobe. It can be classified into four types according to morphology as suggested by Kitayama et al.[7] – longitudinal clefts, transverse clefts, triple lobes, and defective lobes.

Various techniques have been documented for correction of longitudinal and transverse congenital cleft of earlobe. Simple closure of cleft earlobe leads to visible notching. L-plasty technique described by Fatah, in comparison to simple closure, avoids scar contracture.[8],[9] A modification of Z-plasty with two local flaps was recommended by Lee et al., especially in case of severe tissue deficiency.[10] Local flaps have also been used for simple clefts.[11],[12],[13] Techniques based on cleft lip repair – triangular flap repair[14] and modified Millard's technique[15] have been used for mild-to-moderate tissue deficiency. Both of these techniques provide tissue redistribution and rounded contours. Triangular flap repair for cleft earlobe avoids notching, provides good contour of earlobe, and has acceptable scar with no complications. These techniques result in a scar on anterior surface of the earlobe and cannot be used in case of severe tissue deficiency. Chondrocutaneous flap based on middle branch of posterior auricular artery introduces more soft tissue and cartilage prevents scar contracture. The successful results have been reported by various authors.[16],[17]

As can be seen from [Figure 2], triangular flap technique has good results with mild–moderate tissue deficiency. However, it cannot be used in case of severe soft-tissue deficit. The scar on anterior surface of the earlobe was acceptable to all patients. A similar technique with triangular flap was also reported by Padhy et al.[18] They reported good cosmetic outcome with no complications. However, the technique was done in a single patient.


  Conclusions Top


Longitudinal cleft of earlobe is a common congenital deformity. Triangular flap repair technique follows the principles of Randall-Tennison triangular flap repair for cleft lip. The technique resulted in very good cosmetic outcome with no early or late complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Weerda H. Abnormalities. In: Weerda H, editor. Surgery of Auricle. New York: Thieme; 2007. p. 106-234.  Back to cited text no. 1
    
2.
Rubin L, Bromber B, Walden R. An anatomic approach to the obtrusive ear. Plast Reconstr Surg 1962;29:360.  Back to cited text no. 2
    
3.
His W. Aufstellung von Entwickelungsnormen. Zweit Monat Anat Menschlich Embryonen 1882;2:55.  Back to cited text no. 3
    
4.
Streeter GL. Development of the auricle in the human embryo. Contrib Embryol 1922;69:111.  Back to cited text no. 4
    
5.
Schwalbe G. Beitrage zur Kenntis des ausseren Ohres der Primaten. Z Morphol Anthropol 1916;19:545.  Back to cited text no. 5
    
6.
Porter CJ, Tan ST. Congenital auricular anomalies: topographic anatomy, embryology, classification, and treatment strategies. Plast Reconstr Surg 2005;115:1701-12.  Back to cited text no. 6
    
7.
Kitayama Y, Yamamoto M, Tsukada S. Classification of congenital cleft earlobe. Jpn J Plast Reconstr Surg 1980;23:663-70.  Back to cited text no. 7
    
8.
Fatah MF. L-plasty technique in the repair of split ear lobe. Br J Plast Surg 1985;38:410-4.  Back to cited text no. 8
    
9.
Fearon J, Cuadros CL. Cleft earlobe repair. Ann Plast Surg 1990;24:252-7.  Back to cited text no. 9
    
10.
Lee PK, Ju HS, Rhie JW, Ahn ST. Two flaps and Z-plasty technique for correction of longitudinal ear lobe cleft. Br J Plast Surg 2005;58:573-6.  Back to cited text no. 10
    
11.
Maral T, Tuncali D, Ozgür F, Gürsu KG. A technique for the repair of simple congenital earlobe clefts. Ann Plast Surg 1996;37:326-31.  Back to cited text no. 11
    
12.
Hwang K, Kim DH, You SH. Correction of congenital transverse cleft of the earlobe. J Craniofac Surg 2011;22:279-80.  Back to cited text no. 12
    
13.
Qing Y, Cen Y, Xu X, Chen J. A new technique for correction of simple congenital earlobe clefts: Diametric hinge flaps method. Ann Plast Surg 2013;70:657-8.  Back to cited text no. 13
    
14.
Fujiwara T, Matsuo K, Taki K, Noguchi M, Kiyono M. Triangular flap repair of the congenital earlobe cleft. Ann Plast Surg 1995;34:402-5.  Back to cited text no. 14
    
15.
Eser C, Kerem M, Olguner AA, Gencel E, Kesiktas E. A new technique for the surgical repair of double cleft earlobe: Modified Millard's rotation–advancement flap. Int J Oral Maxillofac Surg 2015;44:374-6.  Back to cited text no. 15
    
16.
Park C. Lower auricular malformations: their representation, correction, and embryologic correlation. Plast Reconstr Surg 1999;104:29-40.  Back to cited text no. 16
    
17.
Yotsuyanagi T, Yamashita K, Sawada Y. Reconstruction of congenital and acquired earlobe deformity. Clin Plast Surg 2002;29:249-55, vii.  Back to cited text no. 17
    
18.
Padhy N, Mohapatra DP, Meethale Thiruvoth F, Chittoria RK, Kumar Shivakumar D, Kumar SH, et al. The triangular rotation advancement flap for congenital longitudinal earlobe cleft. Clin Otolaryngol 2018;43:986-8.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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