Major Tragal Malformations: Structural Feature, Classification, and Reconstruction

Major congenital tragal malformations are characterized by structural anomalies involving both the tragal and external auditory canal (EAC) cartilages, associated with the accessory auricle (AA). Despite their prevalence, previous classification systems and surgical techniques have focused primarily on the outer framework, particularly the AA cartilage. This retrospective study included 258 ears in 247 patients who underwent surgical reconstruction between 2013 and 2023. The structural components were analyzed, and a novel classification system was proposed based on the morphology and connectivity of the deformed tragal cartilage-rather than the AA cartilage. Type-specific surgical techniques were developed, focusing on reconstruction of both inner (EAC cartilage) and outer (tragal and AA cartilages) frameworks, followed by posterior skin flap coverage. Three consistent structural components were identified: a superior, large AA with its cartilage, a inferior, small AA with deformed tragal cartilage, and a conchal protrusion with a deformed EAC cartilage. Malformations were classified into type I (50.8%), type II (34.5%), and type III (14.7%). Surgical strategies were tailored using EAC cartilage repositioning combined with cartilage transposition flap or free grafting derived from the tragal or AA cartilage. At final follow-up, 95% of parents reported high satisfaction; most scars were inconspicuous. This classification system and surgical approach emphasize the critical role of the tragal cartilage in anatomic reconstruction. By addressing both outer and inner framework deformities, this method achieves natural tragal contour with minimal scarring and may offer valuable insights into the pathologic anatomy and embryologic development of the tragus.