Journal of Plastic, Reconstructive & Aesthetic Surgery (2006) 59, 494–498

Innovative technique for correction of the

congenital lop ear
K. Ho*, C. Boorer, U. Khan, A. Deva, L. Chang

Department of Plastic and Reconstructive Surgery, Liverpool Hospital, Sydney, NSW, Australia

Received 19 February 2005; accepted 8 September 2005

KEYWORDS Summary Congenital lop ear is a deformity affecting the upper third of the ear. It
Congenital; is characterised by varying degrees of lidding of the helix, reduction in the fossa
Lop ear; triangularis, scapha compression, reduction or absence of the superior crus of the
Ear deformit 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.
q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All
rights reserved.

Lop ear is a deformity involving elements of the
upper third of the ear. Features include varying
degrees of turning down (lidding) of the helix,
reduction in the fossa triangularis, scapha comp-
ression, and reduction of the superior crus of the
antihelix resulting in a reduced vertical height of
the ear (Fig. 1).
The incidence of lop ear has been reported as 2–
5% in the Caucasian population, 10–15% in Blacks,
and as high as 38.1% in Japanese babies.1,2 It
* Corresponding author. Address: 29 Probert Street, Camper-
down, Sydney, NSW 2050, Australia.
E-mail address: kho@plasticsurgery.org.au (K. Ho).
represents less than 10% of ear anomalies treated
by plastic surgery in the United States.3 Most cases
are sporadic, however, in familial cases it appears
to be an autosomal dominant trait with variable
penetrance.1
Embryologically, the auricle arises from the first
and second branchial arches. Hillock 3 of the second
branchial arch specifically accounts for the upper
third of the ear and it is the failure of the helix to
unfold from this by the 16th week of development
which creates the features of lop ear.4
In 1975, Tanzer classified lop ear to clarify the
semantic confusion between terms such as ‘lop ear’,
‘cup ear’, ‘prominent ear’, ‘constricted ear’, and

S0007-1226/$ - see front matter q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2005.09.029
Innovative technique for correction of the congenital lop ear
Figure 1 (a) Anatomy of the auricle (a, helix; b,
superior crus of antihelix; c, inferior crus of antihelix;
d, fossa triangularis; e, scapha; f, conchal cavity). (b)
Features of the lop ear.
‘canoe ear’. The degrees of severity he described
enabled selection of a suitable repair. Tanzer class I
was that in which only the helix was involved with
lidding, IIA included helix and scapha involvement,
Class IIB was as per IIA but supplemental skin is
required to correct the lop ear, and class III was
complete lidding covering the conchal cavity with
only the lobule maintaining normality.5
The technique we propose is suitable for class I
and IIA deformities. It uses the memory of the
conchal concavity to strut the deformed antihelix
posteriorly.
Method
The patient is placed supine on a head ring. Under
general anaesthetic with 1 g of cephazolin prophy-
laxis both ears are swabbed with povidine iodine
Figure 2 Incision.
495
Figure 3 Unfurled lop ear.
solution. Sterile fenestrated auricular drapes are
used to expose both ears and a periauricular block
with 0.5% bupivicaine and 1:200 000 epinephrine is
performed for local anaesthesia and haemostasis.
A posterior auricular incision to the inferior
margin of the conchal cavity is made with a size
15 scalpel (Fig. 2). Through this incision, the upper
pole of the ear is degloved and the lidding unfurled
(Fig. 3). A radical conchalectomy 15 then per-
formed using a size 25 French gauge needle
impregnated with gentian violet dye to tattoo
accurately the concha from anterior to posterior,
allowing an accurate harvest of conchal cartilage
without creating scars on the anterior ear (Figs. 4
and 5).
The conchal graft is then harvested, trimmed to
an appropriate size, reversed so that the anterior
surface faces posteriorly, and sutured to the
unfurled antihelix with 5/0 monocryl sutures to
support the corrected ear (Fig. 6). Haemostasis is
performed with bipolar diathermy and a
Figure 4 Template of conchal cartilage.
496 K. Ho et al.

the scapha and the Banner flap involved raising the

Figure 5 Template tattoo of conchal cartilage.
subcutaneous 5/0 monocryl suture is used to close
the incision.
The wound is dressed with saline-soaked gauze
(to absorb temporarily wound exubate) and secured
by half-inch micropore tape slung from the
ipsilateral cheek around the posterior ear and
back to the cheek. These dressings are removed
the next morning.
Fig. 7 shows the result in a patient with congenital
bilateral lop ear. This patient also underwent
resection of the Darwinian tubercle of her right ear
to remove excess overhanging cartilage and main-
tain symmetry with her corrected left ear.
helical dome as two flaps and inserting a conchal
cartilage graft between them.
Repairs such as Elsahy (1990) and Park (2000)
have involved rotating strips of cartilage including
the concha on a stalk to buttress the lop ear.9,10 In
1998, Horlock et al. developed the mastoid hitch
stitch as an adjunct to the Banner flap repair where
the refashioned upper neohelix is sutured to the
mastoid fascia to maintain helical elevation and
prevent recurrence.2
Our method described is a cartilage graft tech-
nique using the memory of the conchal cartilage to
buttress the antihelix, thus maintaining the upper
pole of the ear from turning down. The advantages
are that it is a simple one-stage technique, utilising a
posterior approach that does not require modifi-
cation of other defining features of the ear. None of
the cartilage incisions decrease the structural
integrity of the ear nor is there donor site morbidity.
Complex head bandages that may mask

Summary

Reported surgical strategies to correct lop ear fall

into five categories. These are excisional tech-
niques, flaps, cartilage modification, cartilage
grafts, and suture techniques.
The first documented repair was an excisional
technique described by Cocheril in 1894 whereby an
oval of cartilage was resected at the helical angle of
flexion.2 Local flap repairs for lop ear are used when
supplemental skin is required to correct the defect. 6
Cartilage modification techniques include that of
Ragnell in 1951 in which complex cartilage incisions
are made throughout the ear and the resulting leaves
are resutured to create a new construct.1 Stephen-
son in 1960 described a method whereby radial
cartilage incisions are made in the upper ear to open
it in a fan-like manner and Musgrave in 1966 added to
this a helical cartilage graft to support Stephenson’s
repair.7,8
In 1975, Tanzer described the commonly used
D-flap and Banner flap repairs.5 The D-flap tech- Figure 6 (a) Reversed graft. (b) Schematic
nique involved rotating the helical cartilage around representation.
Innovative technique for correction of the congenital lop ear 497

Figure 7 (a) Preop photos. (b) Postop photos—1 week postop. (c) Postop photos—12 months postop.
498
complications and cause patient discomfort are not
required.
However it is a technique only applicable to
Tanzer class I and IIA lop ear. A shallow donor
conchal cavity may preclude the use of the conchal
cartilage as a strut or it may require additional
support such as with a mastoid hitching stitch.
References
1. Cosman B. The constricted ear. Clin Plast Surg 1978;5:389.
2. Horlock N, Grobbelaar AO, Gault DT. 5-year series of
contricted (lop and cup) ear corrections: development of
the mastoid hitch as an adjunctive technique. Plast Reconstr
Surg 1998;102:2325.
K. Ho et al.
3. Cosman B. The repair of moderate cup ear deformities. In:
Tanzer RC, Edgerton MT, editors. Symposium on reconstruc-
tion of the auricle. St Louis: Mosby; 1974. p. 118–33.
4. Maniglia AJ, Maniglia JV. Congenital lop ear deformity.
Otolaryngol Clin North Am 1981;14:83.
5. Tanzer RC. The constricted (cup and lop) ear. Plast Reconstr
Surg 1975;55:406.
6. Padgett, EC. In: Thomas CC, editor. Plastic and reconstructive
surgery, 1st edition, Springfield, NY. 1948. p. 525–6.
7. Stephenson KL. Correction of lop ear type deformity. Plast
Reconstr Surg 1960;26:540.
8. Musgrave RH. A variation on the correction of the congenital
lop ear. Plast Reconstr Surg 1966;37:394.
9. Elsahy NI. Technique for correction of lop ear. Plast Reconstr
Surg 1990;85:615.
10. Park C. The tumbling conch-cartilage flap for correction of
lop ear. Plast Reconstr Surg 2000;106:259.