The external ear consists of a prominent outer rim, the helix, and a parallel, inner rim, the anti-helix. The helix terminates in a crux immediately above the external auditory meatus, and the antihelix terminates into superior and anterior crura which create the triangular fossa. The deep furrow which exists between the helix and anti-helix is known as the scaphoid fossa. The cavity the antihelix surrounds is the concha, which leads directly to the acoustic meatus.
Principles of Repair
Cover the cartilage: the cartilage is avascular and derives its blood supply from the skin overlying it. Thus, it is critical to ensure the cartilage is covered to ensure its integrity.
Technique for improving wound margins.
Optimize wound margins: For very macerated wounds along the helix, it is acceptable and sometimes advisable to perform a small triangular tissue wedge excision in order to create “surgical” wound margins that can be better approximated. Approximately 5mm of cartilage can be removed from this area without causing significant deformity.
Close the cartilage with simple interrupted deep dermal sutures using size 6-0 absorbable suture.
Use the outer cartilage layer, the perichondrium, rather than piercing the mid-portion of the cartilage which is more fragile and prone to tear.
Close the skin starting with the less noticeable posterior aspect of the ear with simple interrupted sutures using size 6-0 non-absorbable suture.
Auricular Hematoma Prevention
Even with a meticulous repair, the development of an auricular hematoma remains of concern. Hematoma formation associated with an ear injury can lead to separation of the cartilage from the overlying perichondrium, which can in turn lead to deforming neo-cartilage formation – commonly known as “cauliflower ear.”
Image from Mohseni, Michael & Szymanski, Theodore. (2019). Acute Non-Traumatic Spontaneous Auricular Hematoma. American Journal of Case Reports. 20. 204-206. 10.12659/AJCR.913464.
Traditional teaching is to pack the contours of the anti-helix with pieces of gauze impregnated with a petrolatum gel (ex. Xeroform). This is then sutured through-and-through the ear to hold them in place. Finally, the area behind the ear is buttressed with gauze, and the head is wrapped with a compression bandage.
An alternative is to use plaster to create a mold uniquely contoured to the patient’s ear to compress the helix. Apply antibiotic ointment to the surface of the ear before applying the mold, then use a compression bandage to hold the mold in place.