The bistoury is thrust through the lobule at the point _A_ and an incision is made to follow at a little distance the defect along the line _D_. This frees the cicatrix except at the pedicle _A_. A transverse incision is now made above the point _A_ corresponding to the curved exsection of the opposite side except for a thin strip of tissue _B_. This delicate little flap is preserved and severed a short distance beyond. The raw edges when now brought in apposition will assume the form in Fig. 119. The wound is sutured as in the simpler operation. [Illustration: FIG. 120.—NOYES’S CLAMP.] These operations are best performed under local anesthesia, the two-per-cent eucain being preferred. There is practically little bleeding, but even this may be avoided by applying a large Noyes’ compression clamp with its angular arms so placed as to include the entire lobule (Fig. 120). MALFORMATION OF THE LOBULE There may be an enlargement of or an absence of the lobule. ENLARGEMENT OF THE LOBULE In the enlargement of the lobule the operation last described may be resorted to, making the now supposed coloboma the triangular amount of tissue to be removed. It will be found that the upper curve of the incisions must be carried much higher in cases of this kind, furthermore, that they should define a sharper angle at this point. The simple exsection of a triangular piece of the lobule and suturing is commonly practiced, with the objection of the notch previously referred to. This operation is very quickly done, and if care be taken in bringing the raw surfaces together neatly a splendid result is attained, especially if the incisions are made obliquely to the plane of the skin. ATTACHMENT OF THE LOBE There may be a shortening of the lobule, or, as is more frequently seen, the attachment of the inner lateral border of the lobe to the skin opposite. This attachment of the lobe has been alleged by criminologists to be a mark of the degenerate. If this be so it can scarcely apply to the Japanese, in whom it is found as a racial fact. As the defect is often objected to by patients its correction may be considered briefly. An incision is made in the inferior auricle and in the skin below it, as shown by the dotted lines in Fig. 121, removing the triangular piece of tissue included therein. [Illustration: FIG. 121. FIG. 122. CORRECTION OF ATTACHED LOBE.] The wound is then sutured with fine silk, as shown in Fig. 122, and allowed to heal. The result is very gratifying in most cases. MALFORMATION OF THE AURICLE Malformations of the ear are due to the arrest of development, termed microtia, excessive development, or macrotia, and malposition. MICROTIA The total absence of the auricular appendage is quite rare. One or the other part of the ear is usually found, either partially or fully developed, giving to the ear an irregular rolled-up appearance. This defect may be unilateral or bilateral.