The key tools needed to make the base frame include the template, scalpel, and U-shaped gouge tool. The template is used at the beginning of the procedure to determine what large incisions should be made to the cartilage from the 6th and 7th ribs as the main base frame. Here, the cartilage is being joined using a double-armed 38-gauge wire suture. Each suture should be around three millimeters apart, which allows for the development of a tight fibrous union. There is never a fusion, since it is not part of the cartilaginous healing process. This is the final base frame, which does not contain the helix portion. Here, we are outlining where the helix piece will ultimately be as it is made as a separate step. The height of the base frame is 5 mm, and the total height of the framework is 10 to 11 mm. Here, we are measuring the height of the 8th rib cartilage, which should be reduced to 6 mm as it will ultimately form the helix. The 8th rib is thickest at the bony rib junction, and the Nagata technique attaches this thicker portion to the cruise helices. Furman's approach attaches the tapered portion of the 8th rib to the tragus, so the helix is not a complete spiral. Peeling off thin layers of the lateral surface of the 8th rib cartilage is done to prevent warping, as the cartilage will be bent against its natural curve to create the helix. The gouge is used to create the medial concave curve of the helix, which helps make the helix flexible and creates space for the skin flap to settle in. Furman's approach does not require this curve, so those procedures may be shorter. Here, the increased flexibility of the 8th rib can be seen. The thickest portion of the 8th rib cartilage is fixed to the posterior surface of the framework. Note how as the helix curves around, it remains fixed at the margin of the framework and does not go beyond its width. As a result, the addition of the helix will only increase the framework's height, but not its width. The helix wraps around to the level of the antihelix. When comparing the template to the framework, the surgeon's eyeline must be directly above the template, not an oblique visualization, as this may compromise precision. The edges and corners of the framework should be rounded. Otherwise, the ear may look square posteriorly. Here is the base frame with the helix attached next to the 9th rib cartilage, which will form the antihelix. First, the cartilage is cut to create a flat surface along the lateral side while maintaining maximal height. The thicker end of the cartilage, which was previously at the bony rib junction, is split into the superior and inferior cruise. Carving the medial surface, as shown here, increases flexibility. The cartilage is then fixated to the framework. The superior and inferior cruise may need to be shaved down to maintain the curve of the antihelix as it spirals upward. Here, the tragus is being designed from the leftover 6th rib cartilage. It is fixated at the medial portion of the intertragal notch where it meets the antihelix. A concavity should be made along the medial surface of the tragus, so the skin flap can be accommodated. The tragus is then fixated to the framework. From any smaller pieces of remaining cartilage, a cap can be made for the posterior surface of the Simba conchae. By having the cap in place, the soft tissue will not create a deeper cavity. Here is the final framework with remaining large pieces of cartilage that should be saved for banking.

ear reconstruction

rib cartilage

surgical procedure

Nagata technique

framework stability