It may be associated with congenital fistula (_Fistula auris congenita_), varying in length from one fourth to one inch, and secreting a serouslike fluid. These fistulæ are usually found anteriorly and above the tragus, the lobule, or more rarely at the crus helix, or even behind the ear. Sometimes these fistulæ communicate with the middle ear or even the esophagus. They are due to imperfect development _in utero_. In microtia little can be done surgically, since the malformation is usually so pronounced as to exclude all methods of restoration. Szymanowski advises making an ear from the skin immediately back of the auditory canal if present, making the incisions of the shape shown in Fig. 123. [Illustration: FIG. 123.—RESTORATION OF AURICLE, SZYMANOWSKI METHOD.] The flap included in these incisions is dissected up and doubled on itself posteriorly. The doubled flap thus formed is brought forward and placed as near into the linear position as the ear should have. The flap is then sutured through and through to make the raw surfaces heal together. The secondary wound and the treatment of the flap are carried out as already referred to under restoration of the auricle. Several later delicate operations are done to add to the shape of the newly made organ, but at best the effect is far from even good. In the case of Mr. B., illustrated in Fig. 124, an attempt was made to enlarge the somewhat elastic roll of tissue corresponding to the helix by several injections of paraffin. The result proved to be anything but satisfactory; in fact, the prominence of the malformed upper ear was made more evident, and painful when subjected to pressure, so that the patient was compelled to refrain from lying on that side of the head. [Illustration: FIG. 124.—AURICULAR STUMP FOR ATTACHMENT OF ARTIFICIAL EAR.] [Illustration: FIG. 125.—AURICULAR PROTHESIS.] There had been also congenital atresia of the auditory meatus, which had been operated for, leaving a hair-lined opening, leading down to a useless middle ear, a condition sometimes associated with microtia. In presenting himself to the author for operation it was decided that the otoplastic methods for the restoration of the ear were out of the question, as is usually the fact in these cases. The hard mass of tissue referred to and corresponding to the helix was reduced considerably, so that the stump obtained was soft and pliable, with not only the object of overcoming the sensitiveness and inconvenience of the part, but to obtain as good a base for the attachment of an artificial ear as possible (see Fig. 124). [Illustration: FIG. 126.—AURICULAR PROTHESIS APPLIED TO STUMP.] [Illustration: FIG. 127.—ANTERIOR VIEW OF AURICULAR PROTHESIS.] [Illustration: FIG. 128.—POSTERIOR VIEW OF AURICULAR PROTHESIS.]