Microtia is a congenital hypoplastic malformation of the pinna with a worldwide prevalence of 0.83 to 4.34 per 10,000 births.Reference Harris, Kallen and Robert1–Reference Canfield, Langlois, Nguyen and Scheuerle5 Males are more than twice as likely to be affected and the condition is usually unilateral (77 per cent to 93 per cent unilateral involvement).Reference Luquetti, Heike, Hing, Cunningham and Cox6 The severity of the malformation may range from slightly smaller subunits of an otherwise completely developed auricle to a completely missing pinna, also called anotia. Microtia is often associated with partial or total atresia of the external auditory canal, as well as malformations of the middle ear. We hereafter refer to the combination of microtia and atresia as congenital aural atresia (CAA).

A widely used classification to describe congenital deformities of the auricle has been published by Weerda and proposes three different grades of dysplasia.Reference Weerda and Weerda7 Depending on the severity of dysplasia, congenital ear deformities are challenging regarding both aesthetic and functional reconstructive surgery. The aim of auricular reconstructive surgery of congenital aural atresia is to achieve an aesthetically pleasing ear with restoration of recognisable anatomical landmarks.

At our centre, the reconstruction of congenital aural atresia is a threefold procedure involving the insertion of a rib cartilage framework. It can be combined with functional reconstruction of the acoustic meatus and eardrum in the event of a favourable middle-ear anatomy, or in combination with the implantation of an acoustic implant. In the first session, the auricular rudiments are removed and a rib cartilage framework is placed under the skin. After at least three months, the healed ear framework is lifted off the back of the head and the earlobe is correctly positioned, with a skin graft to cover the exposed wound area behind the reconstructed auricle. Fine-tuning of the reconstructed pinna can be performed subsequently. It involves scar correction, removal of excess skin or modelling of an eventual depression of the auditory canal.

Several reconstructive surgical techniques are available, but few attempts have been made so far to develop an easy-to-use reliable tool to compare post-operative outcomes. Skarzynski et al.Reference Skarzynski, Mickielewiczl, Lazgckal, Skariynski and Skarzynski8proposed a weighted 10-point scoring system based on anatomical landmarks, hereafter called the Skarzynski scale. Outcomes are classified into four categories (I = perfect reconstruction, II = complete functional and aesthetic reconstruction, III = satisfactory functional reconstruction, IV = unsatisfactory functional and aesthetic reconstruction).

Another grading system by Sharma et al.Reference Sharma, Dudipala, Mathew, Wakure, Thankappan and Balasubramaniam9 uses a weighted 13-point scoring system also based on anatomical landmarks and classification into four categories (poor, average, good, excellent). The helix is the highest weighted anatomical landmark in both scoring systems. While Sharma et al.Reference Sharma, Dudipala, Mathew, Wakure, Thankappan and Balasubramaniam9 use anatomical landmarks exclusively, Skarzynski et al.Reference Skarzynski, Mickielewiczl, Lazgckal, Skariynski and Skarzynski8 also consider the complete elevation of the helix from the surface of the skin.

Others have used a 12-point scoring system to compare aesthetic outcomes after different types of skin-coverage methods, considering skin colour, thin coverage (convolution), ear size and bilaterally balanced projections.Reference Park10 Constantine et al.Reference Constantine, Gilmore, Lee and Leach11 compared the reconstruction technique with rib cartilage versus a porous polyethylene implant, using a five-point scale to rate six categories: protrusion, definition, shape, size, location and colour match.