Atlas of Operative Otorhinolaryngology and Head and Neck Surgery: Otology and Lateral Skullbase Surgery (Volume 1) Bachi T Hathiram, Vicky S Khattar
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The Surgical Technique of OtoplastyChapter 1

Murat Songu
The prominent ear is the most common congenital deformity of the auricle, occurring in approximately 5% of the Caucasian population and is inherited as an autosomal dominant trait (Figs 1A and B).1 Although the physiological consequences are insignificant, the psychological and aesthetic consequences on the patient can be considerable. The most common defects that prompt surgical consultation are a poorly developed or absent antihelical fold, an abnormally large concha and a prominent lobule.1
Otoplasty is a century-old procedure that has undergone many modifications over the years. Over 200 different procedures have been described in the literature that excise, bend, suture, scratch, or reposition the auricular cartilage. This plenty of surgical techniques show that no simple “best” technique exists.
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Figs 1A and B: (A) Preoperative; (B) Postoperative photographs of two brothers with protruding ears
 
INDICATIONS FOR THE SURGERY
Appropriate surgical planning relies on a thorough understanding of the normal and prominent ear. The major visible and palpable landmarks of the ear are composed of five critical elements, concha, helix, antihelix, tragus and lobule, and parts of lesser importance, including the antitragus, intertragic notch and Darwin's tubercle (Fig. 2).2
The anatomical divisions of the ear are based in embryology, with its origins based from the first mandibular and second hyoid branchial arches. The hyoid arch is the predominant contributor leading to the formation of the helix, scapha, antihelix, concha, antitragus and lobule, whereas the mandibular arch only contributes to the tragus and helical crus. The ultimate shape is essentially determined by 20 weeks gestation and 85% of growth occurs by age of 3 years.34
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Fig. 2: The major landmarks of the external ear
Kalcioglu et al. compared the growth ratios of the auricle in 1,552 volunteers from birth until age of 18 years.4 The development of the auricle regarding the transverse growth and the growth of the conchal depth was fully completed by the age of six years, independent of gender. Only the growth in auricular length continued until the age of 11 years. Even so, the length of the auricle increases during the natural aging process because of the natural skin and soft tissue elasticity. Ito et al. evaluated 1958 volunteers aged 5 to 85 years regarding their growth in auricular length and revealed that the increased replacement of elastic auricular cartilage fibers by collagen-like fibers is responsible for the growth in auricular length at an advanced age.5 Despite these results, otoplasty in pediatric patients has no significant influence on later auricular growth.6
The vascular supply to the auricle is provided by branches from the external carotid artery. The superficial temporal artery supplies much of the anterior portion, including the lobule, whereas the posterior supply is derived from the posterior auricular artery. The venous drainage replicates the arterial supply in reverse. The parotid lymph nodes and posterior auricular nodes with further contribution from level 2 and level 5 cervical beds serve lymphatic drainage. The innervation to the external ear consists of the anterior and posterior branches of the great auricular nerve, which innervates the first branchial arch structures tragus and helical crus, and the auriculotemporal nerve, which innervates the second branchial arch structures helix, scapha, antihelix, concha, antitragus, external acoustic meatus and lobule. The external auditory meatus also receives innervation from branches of the vagus and glossopharyngeal nerves.
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Fig. 3: Prominent ears showing increased helix-mastoid angle, antihelical hypoplasia, cavum hyperplasia and protruding lobule
The most common indication for performing otoplasty is the prominent ear (Fig. 3). Other indications for otoplasty include trauma, cupped ear deformity or to correct a previous poor result. Anatomic norms for human ears have been established, thus it is possible to more objectively quantify patients who have irregular, prominent ears. Janis and Rohrich summarized the proportions that are common in the normal, esthetic ear Table 1.7-13
While the measurements and proportions of a “normal” ear have been well documented, the position of anatomical landmarks, and relation to one another at the end of the otoplasty procedure, are far more important. The ears must look proportional to the facial features and have a natural appearance. Prominent ear occurs as a result of one or more anatomic variants. Most often there is a lack of an adequate antihelix; the ear is less furled back on itself and thus protrudes from the skull. Another common anatomic finding in patients with prominent ears is a relative excess of conchal bowl cartilage. A third component can be an ear lobule that is excessive in size or positioned laterally. The basic goals of otoplasty were summarized by McDowell in 1968 and are listed in Table 2.7
LaTrenta suggested that three common anatomical goals always must always be kept in mind: production of a smooth, rounded and well-defined antihelical fold; a conchoscaphal angle of 90; and conchal reduction or reduction of the conchomastoidal angle.145
Table 1   Proportions of the esthetic ear
The long axis of the ear inclines posteriorly at approximately a 20° angle from the vertical.
The ear axis does not normally parallel the bridge of the nose the angle differential is approximately 15°.
The ear is positioned at approximately one ear length 5.5–7 cm posterior to the lateral orbital rim between horizontal planes that intersect the eyebrow and columella.
The width is approximately 50–60% of the length width, 3–4.5 cm, length, 5.5–7 cm.
The anterolateral aspect of the helix protrudes at a 21 to 30º angle from the scalp.
The anterolateral aspect of the helix measures approximately 1.5 to 2 cm from the scalp although there is a large amount of racial and gender variation.
The lobule and antihelical fold lie in a parallel plane at an acute angle to the mastoid process.
The helix should project 2 to 5 mm more laterally than the antihelix on frontal view.
 
SPECIFIC PREOPERATIVE EVALUATION
Low self-esteem, general lack of self confidence and social isolation are amongst the reasons why parents of affected children or affected adults decide for otoplasty. In a study by Sheerin et al. children with prominent ears were evaluated by a psychiatrist before undergoing surgical correction.15 An increased tendency towards depression, lower achievements in school, lower self-esteem, and socio-communicative problems in school and at home were observed. Schwentner et al. interviewed patients before and after otoplasty regarding their pre- and postoperative emotional state, using a standardized questionnaire.16 The results showed an improved attitude towards life, increased courage to face life, and better self-confidence among the patients, with no difference between male and female subjects. Horlock et al. stated that 74% of adults and 91% of children reported an improvement in self-confidence resulting in improved quality of life.17
The appropriate time for the correction of prominent ears should depend on a rational approach based on auricular growth and age of school matriculation. Although the concern for ridicule and its effect on social development has been clearly illustrated, many children are not referred for otoplasty until teasing becomes an issue.17,18 Otoplasty procedure in children is recommended to be performed prior to the start of schooling.19 The hope is to correct the malformation before the time of socialization in order to minimize ridicule by peers. However, substantial psychological pressure exposed to children with protruding ears among the peers at the preschool period or in kindergarten is usually underestimated.
Table 2   McDowell's basic goals of otoplasty
All upper third ear protrusion must be corrected.
The helix of both ears should be seen beyond the antihelix from the front view.
The helix should have a smooth and regular line throughout.
The postauricular sulcus should not be markedly decreased or distorted.
The helix to mastoid distance should fall in the normal range of 10 mm to 12 mm in the upper third, 16 mm to 18 mm in the middle third, and 20 mm to 22 mm in the lower third.
The position of the lateral ear border to the head should match within 3 mm at any point between the two ears.
Changing socioeconomic trends have increased the proportion of families in which both parents work outside of the home. As a result, children have been increasingly exposed to peers through day care centers well before age four or five years. This intense early exposure to peers and caretakers outside of the family may significantly affect development of self-esteem. We observed that these children can provide information about their psychological strain or possible problems with other children associated with their protruding ears. Furthermore, these children can also express concern about the abnormal appearance of their ears before age five.20
Like many procedures involving the child's face, there is a concern about how the operative site will respond to pressures of normal growth. Until recently, very few surgeons felt comfortable operating on the ear of a young child due to concerns about longevity and altered growth. Adamson et al. studied the growth patterns of the external ear of 2,300 ears and showed that the ear reaches 85% of its adult size by 3 years of age.3 On the other hand, Farkas differed some in his measurements stating that the ears reach 85% of full size by age 6, 90% by age 9, and 95% by age 14.21 Balogh and Millesi were the only authors to objectively study growth alterations following otoplasty and concluded that growth of the ear is not arrested following otoplasty.6 Recently, Gosain and colleagues reported that otoplasty can be safely performed under age 4 and as young as 9 months without significant effect on ear growth in a cohort of 12 patients with prominent ears.22,23 Due to our experience, in unilateral “Jumbo” ears, we observed that the protruding ear is usually bigger than the unaffected ear in all dimensions. Growth alteration should be a desired consequence among these patients and this desire is another rationale for the early surgical intervention. 6Nevertheless, we did not observe any visible disturbance or growth restriction in our patients, even in the unilateral operated group (Figs 4A and B).
An important advantage of performing otoplasty at these younger ages is the increased malleability of the auricular cartilage, decreasing the need to use cartilage-cutting techniques. At this age, the auricular cartilage is characteristically pliable; however, elasticity decreases with advancing age, often demanding more aggressive treatment. The softer the auricular cartilage, the easier it is to shape the cartilage or auricle into the appropriate form and pin it back, using gentle surgical techniques. We have previously published the surgical technique we prefer for management of the prominent ears in children.24 The Négrevergne otoplasty technique was popularized in the Institut Georges Portmann in France. The technique includes partial-thickness posterior scoring of the auricular cartilage using monopolar cutting diathermy. Because the ear cartilage is weak under age five, cartilage scoring can be conservative, sufficient to release the cartilage spring only.
The main disadvantage of the surgery before age five is postoperative difficulties dealing with the dressing. The procedure is best performed when the auricle has reached maturation and the child is old enough to cooperate with the postoperative care. It must be kept in mind that correction before age five may complicate the postoperative course when the child, even if not intentionally pulls apart the bandage and potentially disrupts the repair. Our practice has shown that, all patients were followed by multiple extra visits for redressings, and as their fingers were constantly inside the bandage this resulted in more swelling and certainly greater risk of postoperative complications. Nevertheless, at the end of the follow-up period, no serious complications occurred and the patient showed full recovery in our series (Figs 5A and B).20
Following a detailed medical history, a meticulous evaluation of the anatomy is performed. Another aspect with significant impact on procedure planning is the analysis of the cartilage consistency and, in particular, the stiffness and thickness of the cartilage. The consistency of the cartilage is typically evaluated by palpitation and cautious, controlled bending. It is important in surgical planning to remember that the cartilage becomes more calcified and brittle with age. Different combinations of abnormalities on either ear are frequently observed.
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Figs 4A and B: (A) Preoperative; (B) Postoperative photographs of the patient who underwent left unilateral otoplasty and adenoidectomy are shown to demonstrate the normal growth of the ear that had been operated on relative to the unaffected ear
Furthermore, additional abnormalities, such as auricular appendages, Darwin tubercle etc., can also be excluded in many cases 7simply by an inspection-based diagnosis. Awareness of the potentially different contributions of deformities on either side is crucial, if symmetry is to be attained.
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Figs 5A and B: (A) Preoperative; (B) Postoperative photographs of the patient who underwent bilateral otoplasty and adenoidectomy in combination with tonsillectomy. The ears remain relatively symmetric postoperatively
Standard preoperative photographs and consent form for the procedure are taken. The purpose of the photographic documentation is to document the preoperative situation. A basic series should include full facial frontals and laterals of both ears. Frontal close-ups, obliques and posterior images of each ear are also helpful (Figs 6A to F).
Taking postoperative photos at intervals of 6 and 12 months helps to monitor postoperative success and is also recommended for medicolegal reasons (Figs 7A and B).25,26 Prophylactic antibiotics are recommended for the majority of aesthetic and reconstructive procedures on the ear. The risk of chondritis is a sufficient indication to use an intraoperative dose of a broad spectrum antibiotic, and to prescribe a few postoperative days dosage of the similar agent.
Just as important as the anatomic irregularities of the auricle are the expectations of the patient and family. It is important to discuss the potential outcomes and complications, and to ensure the patient has realistic expectations. The patients or the parents of the child are informed about the potential risks and unwanted complications, including hematoma and infections of skin or cartilage, and also regarding the possibility of an unsatisfactory cosmetic result. The importance of diligent postoperative care to avoid complications must be also established before surgery. When counseling younger patients and their families, the ability of the younger otoplasty patient to appropriately participate in postoperative care and protection of the dressings should be addressed.
 
ANESTHETIC CONSIDERATIONS
In an effort to reduce the potential surgical morbidity related to general anesthesia, current trends in aesthetic surgery have moved toward local anesthesia combined with sedation, as opposed to general anesthesia.27 Remifentanil has gained specific popularity due to its rapid effect and high patient tolerance for such indications.28 In children, general anesthesia has broadly been accepted a reasonable choice; however, at least one group is looking at the possibility of using local anesthesia with conscious sedation in children.29 Regardless of whether general anesthesia or monitored sedation is used, the use of local anesthesia results in decreased postoperative narcotic use and decreased pain scores.30 Local anesthesia can be delivered in a number of ways. A peripheral nerve block can provide broad range analgesia with one injection, as opposed to local infiltration, which must be precisely placed to have the appropriate effects. Local infiltration, however, has the added benefit of hemostasis when low-dose epinephrine is included.
8
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Figs 6A to F: Photographic documentation
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Figs 7A and B: (A) Preoperative (B) Postoperative photographs of the patient who underwent bilateral otoplasty. The ears are symmetric postoperatively and rising self-confidence is apparent even in the photograph
9There are multiple choices of substances available as local anesthetics, including prilocaine, lidocaine, mepivacaine, bupivicaine and ropivaeaine. Koeppe et al. found that prilocaine and lidocaine were most commonly used while ropivaeaine had the lowest side-effect profile.31 Another study on ropivacaine found it to have comparable efficacy to bupivacaine specifically in otoplasty, but with a more desirable risk profile.32
 
SURGICAL STEPS
In considering the proper surgical technique, there is a room for surgeon preference and vision. The surgeon should develop a complete surgical plan that is a conglomerate of the individual techniques necessary to correct each observed anatomic irregularity. Surgical techniques for the correction of the prominent ear can be grouped into maneuvers used to create the antihelical fold, to correct the conchal defect and to affect lobule positioning.
 
1. Perioperative Routine
There are as many variations in perioperative routine as there are in surgical technique for otoplasty. The hair is covered with a standard head bandage along the hairline. A small sterile cotton ball is placed in the external auditory canal to prevent blood from accumulating on the tympanic membrane (Figs 8).
The cleansing of the external ear is performed with povidone-iodine solution. Surgical draping with Tegaderm 3M Health Care, St Paul, MN or other clear sticky drape keeps the hair out of the surgical field. Drapes are placed so that both ears are simultaneously on view providing intraoperative comparison to obtain optimal symmetry (Figs 9).
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Fig. 8: Small sterile cotton ball placed in the external auditory canal
 
2. Skin Incision
As symmetry is the key, it is recommended to begin with the more severely affected side. Before local infiltration and associated tissue distortion, the area of redundant postauricular skin to be excised is estimated by gentle manipulation of the ear and traction in the desired position. The postauricular skin excision is then marked based on the estimation. Although most investigators have advocated an excision of skin, some have described a simple incision.25,33 The desired ear contours are simulated by exerting gentle digital pressure on the helix and newly formed antihelical fold is marked on the skin (Fig. 10). The posterior auricular skin and mastoid soft tissues are infiltrated subcutaneously with 1% Lidocaine HCl and 1:100,000 epinephrine solution. Local anesthesia enhances hemostasis and demarcates the plain of dissection.
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Fig. 9: Surgical draping with clear sticky drape
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Fig. 10: Ear contours are simulated by exerting gentle digital pressure on the helix. Newly formed antihelical fold and planned mattress sutures are marked on the skin
10The estimated skin excision on the posterior surface of the ear can be done safely with the narrowest width at the middle third to avoid ‘‘telephone ear’’ deformity. This occurs when the middle portion is reduced to a relatively greater degree than the superior helix and lobule. This overcorrection in the middle breaks the straight line of the caudal helix and leaves a relatively over-projected superior helix and lobule, giving the ear a convexity similar to the shape of a traditional telephone (Fig. 11). The reverse phenomenon can also occur, if relatively less mid-portion correction is performed. This is termed a reverse telephone deformity. If a lobule prominence accompanies, the skin excision is finished with a diamond-shaped inferior end to correct the lower pole prominence. The maximal width of the diamond-shaped excision is designed to rest at the point of maximal lobule prominence (Fig. 12). Others describe creating a medial-based skin flap that is re-draped over the posterior auricle at the end of the case and excising the distal portion of the skin flap as needed to precisely fill the defect without tension or excess.17 The main advantage of this approach is tension-free closures, which may reduce the incidence of hypertrophic scars.
The previously marked postauricular skin is widely undermined exposing the perichondrium. Hemostasis is meticulously maintained and dissection is developed peripherally to the free edge of the helix and posteriorly to the level of the mastoid bone. The bulky postauricular soft tissue, auricularis posterior muscle fibers and fibrofatty tissues cleanly excised off the perichondrium and mastoid fascia with preservation of the periosteum (Figs 13 and 14).
Creation of a deep, mastoid pocket accommodates the repositioned conchal cup, facilitates posterior rotation of the concha, removes the postauricular tissues that may act as a lever producing excessive prominence and enhances the setback by effectively reducing conchal height.
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Fig. 11: “Telephone ear'' deformity evident on the sixth month control
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Fig. 12: The estimated skin excision with a diamond- shaped inferior end
Utilization of the mastoid pocket also serves to reduce distortion of the external auditory meatus.
 
3. Creation of the Antihelical Fold
Many cases of prominent ears require reshaping of the antihelix. As mentioned earlier, a practical way to 11determine how much reshaping is needed is to bend the antihelix with digital pressure and then mark how the new anti-helix should look (Fig. 10).
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Fig. 13: The subcutaneous tissue over the mastoid surface of the cartilage is dissected
Cartilage incision techniques: The first aesthetic otoplasties described by Ely in 1881 and Luckett in 1910 were examples of cartilage incision techniques.34 These techniques include cartilaginous incisions or wedge excisions addressing either the antihelix or the cavum concha. 35-39 Luckett's original procedure to create a new antihelical fold involved excising a crescentic segment of cartilage posteriorly and reapproximating the remaining edges to each other. When the edges of this cartilage bridge are folded back, it forms a tube, which is subsequently sutured to form a smooth, rounded, more natural-appearing antihelix. With any cartilage-cutting technique, there is the risk of creating visible contour irregularities and sharp edges, overcorrection and the appearance of an operated-on ear.
Cartilage-sparing techniques: Cartilage-sparing techniques are emerged in an attempt to prevent potential contour irregularities that may develop with aggressive cartilage-cutting techniques. Mainly, suturing rather than cutting, is used to create the desired auricular contours, thereby preserving cartilaginous support and minimizing contour irregularities. In 1963, Mustarde first described the use of multiple horizontal mattress sutures placed in the posterior cartilage that incorporate the full thickness of the cartilage and anterior perichondrium but not the anterior skin to form the antihelical fold (Figs 15A and B).40 The sutures are then tightened to the extent required to appropriately reduce the defect and create an antihelix (Fig. 15C). To create the superior crus, the same type of stitch is secured onto the fossa triangularis.
Mustarde has conducted two reviews of his own procedure. Of 264 ears operated over a 10-year period, 17 cases were judged as unsatisfactory with problems, such as kinking within the antihelix, sutures cutting out and recurrence of prominence.41
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Fig. 14: The bulky postauricular soft tissue, auricularis posterior muscle fibers and fibrofatty tissues excised
A subsequent study of 600 ears operated over a 20-year period revealed a 0% incidence of stitch rejection, a 0.01% incidence of sinus tract formation and a 0.02% incidence of reoperation.42 Spira and Hardy studied their experience with the Mustarde technique and determined that there were a large number of relatively minor complications and a high rate of partial recurrence of the original deformity.43
Criticisms of the cartilage-sparing technique have focused on the relatively high rate of up to 25% loss of correction or the possibility of stitch extrusion up to 15%.43 Permanent sutures, more frequently initiate development of indolent infections or foreign-body granulomas. In these instances, removal of the offending suture is curative. Kaye and Tramier advocate an anterior approach to place the plication sutures in an effort to eliminating the need for extensive flap dissection and minimizing postoperative discomfort and risk of infection and hematoma.44,45 Horlock et al. proposed a method for eliminating problems with extrusion by raising a postauricular fascial flap.46 In this technique, rather than dissecting a single subperichondrial plane, a separate plane is dissected subdermally first and followed by the cartilage exposure to leave a mastoid-based fascial flap that can be repositioned over the sutures and provide a layer of protection to prevent extrusion. This maneuver did not significantly change the incidence of loss of correction when compared with other studies but did eliminate stitch extrusion.
Adamson et al. retrospectively reviewed their experience with conchal setback and antihelical suture placement in 119 ears.47 They found that the superior pole became lateralized to approximately 40% of the original 12correction, which led to revision in 6.5% of the ears. They recommended adding fossa triangularis–temporalis fascia sutures to correct this superior pole lateralization.
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Figs 15A to C: Mustarde suture. (A) Side and posterior views of a constructed antihelix; (B) Dental needles marking the planned mattress sutures; (C) Precise tension placed on mattress sutures are shown in a patient operated for prominent ears accompanied by macrotia
Loss of superior pole correction was also reported by Messner and Crysdale in patients who underwent cartilage-sparing otoplasty, including placement of fossa triangularis–temporalis fascia sutures.48 The corrected ears returned to their preoperative position in one third of their cases and one third of their cases had a final position between their preoperative and postoperative positions. Despite this loss of correction, 85% of patients were satisfied with their results.
Cartilage weakening techniques: Cartilage-weakening techniques are often used in an attempt to reduce the complications created by cartilage-cutting and cartilage-sparing techniques. Although scoring of either the posterior or anterior auricular surfaces are injurious to cartilage, no full-thickness cartilaginous incisions are performed. Many different tools have been used, including scalpel, rasp, hypodermic needle, diamond burr drill and dermabrasion tool. Tan et al. advocated the widely available Adson-Brown forceps as their scoring instrument of choice while Di Mascio et al. reported a cartilage incising procedure that uses a dermabrader drill to score the anterior surface of the cartilage.49,50 Azuara reported his experience using a no. 15 blade in his technique, where the cartilage incisions allow a tension-free rolling of the cartilage posteriorly.51 Scoring techniques are mainly based on the observations that cartilage tends to warp away from an injured surface.52 Fry later confirmed this observation and 13attributed it to “interlocked stresses” that were released by a perichondrial incision.53 Stenstrom and Chongchet applied this theory to otoplasty.54,55 Stenstrom's initial technique consisted of anterior scaphal scoring to produce an antihelical fold.56 Qureshi observed the combination of the two cartilage-weakening methods and stated that scoring by scalpel blade on one side of the cartilage and bipolar diathermy on the other, produces greater warping towards the direction of the bipolared side.57 Heftner surveyed patient satisfaction with use of the Stenstrom technique and found that 89% were either very satisfied or just satisfied.58 He also noted that 14% of patients had a sharp contour. Calder reviewed 562 Stenstrom otoplasties and found a 16.6% overall complication rate with an 8% incidence of residual deformity.59 Many methods of posterior surface weakening were also described in the literature.24 These maneuvers include abrasion, scoring, partial-thickness incisions and longitudinal wedge excision.60-65 The deficiencies of these maneuvers are the need for special instrumentation and unreliability in producing consistent results. Nearly all of them are combined with a cartilage-sparing technique by using additional suture fixation.
Combined techniques: Understanding the principles behind the various techniques may lead the surgeons to form surgical strategies based on personal surgical philosophies. Nolst Trenite used a scalpel to make multiple partial-thickness cartilage incisions posteriorly, but stresses the importance of not incising the anterior surface perichondrium.66 In this approach, mattress sutures are added to set the final position. He reported two cases with noticeable sharp and two cases with ‘‘telephone-ear’’ deformities from poor suture placement in his series of 65 ears. Bulstrode et al. reported their experience using a precisely bent hypodermic needle to perform percutaneous cartilage scoring followed by posterior mattress suturing.67 Fritsch also described an approach that used a 21-gauge needle to score the cartilage anteriorly through a puncture site and Mustarde-type mattress sutures are placed percutaneously with the goal of the suture passing sub-perichondrially, with a common entrance and exit site.68 Yugueros et al. also reported a combined approach with anterior scoring through a small anterior incision, Mustarde-type mattress sutures and conchal-mastoid sutures.69
One major difficulty in trying to objectively evaluate these techniques is the small number of literature of head-to-head comparisons of the surgical philosophies. One European group compared a cartilage-cutting method of incising and folding the cartilage to reconstruct an antihelix with a modified mattress suture technique that included anterior scoring.70 Twenty eight patients were selected and compared by the length and breadth of the ear; the superior, medial and inferior cephaloauricular distances and the conchoscaphal angle, as well as by using the Strasser evaluation system for appearance.71 They observed a statistically significant greater amount of asymmetry and decreased patient satisfaction when cartilage is incised. Panettiere et al. reported a study that compared a cartilage-incising technique versus a cartilage-weakening and mattress suture technique.72 Comparison was made by a blinded, independent surgeon's review of follow-up photos. Ninety-two percent of the ears in the cartilage-incising technique group had noticeably sharp edges, whereas none of the weakened and sutured ears displayed this irregularity in follow-up. Both methods were without recurrence in a 12-month follow-up.
Tan et al. compared Mustardé's posterior suturing technique with Stenstrom's anterior scoring technique and found that although patient satisfaction with the aesthetic results were the same between the two approaches, ears treated by Mustarde's method required more than twice as many reoperations.73 In a comparative study, Hyckel et al. compared Mustarde's and Converse's methods and found no objective or subjective differences.74
 
4. Correction of the Conchal Bowl
Conchal deformity can be addressed by several methods, including scoring and suturing and excisional techniques and scoring. Conchal mastoid sutures can be used to correct conchal prominence of the ear. This suture technique was originally described by Owens and Delgado.75 Their method was subsequently modified by Furnas,76 who used nonabsorbable mattress sutures placed in the conchal cartilage and sutured it to the mastoid fascia (Fig. 16A). He stated that sutures placed too far forward on the mastoid or too far back on the concha will cause outward and forward rotation of the conchal cup, causing reduction of the external auditory canal diameter (Figs 16B and C). A popular excisional technique to control conchal bowl prominence involves separating the cartilage where the concha meets the tail of the helix and removing an adequate portion along the conchal rim. The cartilage must then be re-approximated. Proponents of this technique claim that this cartilage incision hides well in the natural convexity of the junction of the conchal bowl and antihelical fold. Excision techniques can also be used to reduce conchal hypertrophy. These techniques can be grouped into those that excise cartilage alone and those that excise both skin and cartilage. The cartilage-only procedures are usually performed through a posterior approach, whereas the skin and cartilage techniques are usually performed through an anterior approach. Finally, careful scoring may be used alone or in combination to reduce conchal prominence.
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Figs 16A to C: Furnas suture. (A) Constructed conchal bowl on the axial plane. Permanent suture is used to medialize the conchal bowl (B) to the mastoid periosteum (C)
14
 
5. Lobule and Helical Rim Positioning
The lobule can be an overlooked component of the prominent ear and appear accentuated after the auricle is repositioned. The lobule should rest in a straight line with the helical cartilage when viewed from the front. Beernink, in a study of 159 ears, stated antihelical correction corrected an associated protruding lobule in 28% of patients.63 Wood-Smith suggested a “fish tail-like” retrolobular skin excision with a subsequent V-Y plasty.77 Posterior lobule skin and fibrofatty tissue can be also excised in a V-shape, heart shape and eccentric elliptical patterns with suture approximation producing the desired setback. Additionally, a Z-plasty can be fashioned at the most inferior aspect of the postauricular incision, producing a similar effect. Gosain advocated a single stitch approach in which the loble is secured to the mastoid region.78 The excess skin is then excised and the incision is closed. Spira et al. treat the protruding lobule by wedge-excision and a periosteum suture between the dermis and the scalp.79 Another method involves a curvilinear, fusiform excision from the anterior to posterior lobe margin with a central V excision to effect easy closure.1
One further consideration in the prominent ear, not mentioned elsewhere, is the helical curl itself. Often this can be flattened and floppy, further contributing to the overly abnormal appearance. Few investigators have focused on this particular aspect. One study does describe a simple wedge excision along the helix alone without extending into the scaphae.80 This shortens the outermost edge of the helix, enhancing its curl inward. This is used as an adjunct when the helix itself is noticeably flattened.
In majority of our cases, we prefer a diamond-shaped posterior skin excision behind the lobule and suture the opposing points of the diamond in the closure using a 15running, locked, 4-0 long-term absorbable suture. It obviates the discomfort of suture removal, especially in children (Fig. 12).
 
6. Dressing and Postoperative Care
The appropriate dressing for the ear is a critical aspect of the procedure. At the completion of the procedure the wounds are carefully cleansed and dressed with greasy gauzes soaked in Bepanthen Plus® 50 mg Dekspantenol, 5 mg klorheksidin HCI. It is extremely important that the greasy gauze be carefully molded to fit the new folds and contours of the ear and to gently pad the postauricular surface (Fig. 17).
All patients are placed on a five-day regimen of antibiotics and acetaminophen as needed for pain. Aygit reported a custom-made mold for 2 weeks postoperative.81 Azuara used a moldable porous polyester splint in a similar fashion for 72 hours with a compression dressing fulltime for the first week postoperatively followed by 1 month of night time compression (Fig. 18).54
In our practice, the dressing is removed on the first postoperative day to inspect the ears. This facilitates early identification of complications, such as hematoma formation or skin ischemia. A slightly lighter dressing is replaced and is changed every other day for a further 7 days. After removal of the dressings, patients are instructed to wear a headband nightly for one month to prevent inadvertent nocturnal trauma. Patients are discouraged from any rough play or circumstances that might lead to accidental trauma, as a history of external trauma has been associated with about half of the cases of loss of correction requiring revision surgery.47 Patients are then typically seen at 3 to 6 months postoperatively and 1 year postoperatively to document results (Fig. 19).
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Fig. 17: Molded greasy gauze placed to fit the new folds and contours of the reconstructed ear
 
NEW TECHNIQUES IN THE SURGERY
 
The Négrevergne Otoplasty Technique
The Négrevergne otoplasty technique adopted in the Institut Georges Portmann is a simple method of cartilage weakening mainly preferred in young children in our 16practice.26
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Fig. 18: Headband to prevent inadvertent nocturnal trauma
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Fig. 19: Seventeen-year-old boy before and six months after surgery
A surgical instrument, monopolar diathermy, which is already present in the surgical field, is used. Since the technique is suture-free, low-complication rates can be obtained. Common complications, such as suture failures and extrusions, suture material induced foreign-body granulomas and wound breakdown are never observed.
In this technique, the cartilage under the desired fold is marked by inserting dental needles at two or three points from anterior-to-posterior fashion. The inserted needles mark the lines of cartilage weakening (Fig. 20).
The monopolar diathermy in cutting mode is adjusted to a setting sufficient to create a partial-thickness trough through the cartilage. Three passes are made to form the antihelical fold while maintaining sufficient flexibility to prevent a sharp angle at the fold (‘A’ in Fig. 21 and ‘A’ in Fig. 22). Next, the conchal hypertrophy component is addressed. The conchal-mastoid groove has been cleared of the fibrofatty tissue and the postauricularis muscle previously as described. The ear is drawn backward into the desired position and the site of contact between the conchal cartilage and mastoid fascia is checked. The marked conchal limits are used to mark proposed conchal scoring incisions, which are parallel the long axis of the ear. Two or three incisions are made with a monopolar diathermy in cutting mode (‘B’ in Fig. 21 and ‘B’ in Fig. 22). This maneuver breaks the spring of the conchal bowl and leads the fibrosis to the mastoid fascia.
 
COMPLICATIONS
Elliott divided unsatisfactory results of otoplasty into early complications and late sequelae.82 Early complications include hematoma, infection, chondritis, pain, bleeding, pruritus and necrosis. Late sequelae include unsightly scarring, patient dissatisfaction, suture problems and dysesthesias.
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Fig. 20: Dental needles marking the lines of cartilage weakening
Early complications: Hematoma is one of the most dreaded immediate postoperative complications. It is heralded by the acute onset of severe, persistent and often unilateral pain. If encountered, the head dressing should be removed and sutures released to drain the hematoma.
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Fig. 21: Axial view demonstrate the sequential effects of surgical maneuvers on ear protrusion. (A) Partial-thickness scoring of scapha to create antihelical fold; (B) Partial-thickness scoring of concha to break the spring of the cartilage
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Fig. 22: (A) Frontal view shows partial-thickness scoring of scapha to create antihelical fold; (B) Partial-thickness scoring of concha to break the spring of the cartilage
If there is evidence of ongoing bleeding, reoperation and exploration are mandatory. Infection is another potentially devastating complication of otoplasty, especially because it can lead to the development of chondritis and 17residual deformity. Infection can be caused by a break in proper sterile surgical technique or dehiscence secondary to excessive tension during closure or it can be an untoward sequela of prior hematoma evacuation (Figs 23A and B). If redness, swelling and drainage are encountered, treatment with intravenous antibiotics is recommended, as is the use of topical mafenide acetate cream. The usual pathogens are Staphylococcus, Streptococcus and sometimes Pseudomonas. Chondritis is a surgical emergency. If left untreated, it can result in deformity. Therefore, prompt debridement of devitalized tissue is necessary.
Late sequelae: Residual deformity is, by far, the most common unsatisfactory result of otoplasty. It usually is apparent by 6 months postoperatively and is manifested by one or more of the following: a sharply ridged antihelical fold; lack of normal curvature of the superior crus; irregular contouring; a malpositioned or poorly constructed antihelical fold; an excessively large scapha; and a narrow ear.83 Most of the time, the residual deformity is a result of poor surgical planning and execution rather than an inherent technical problem (Figs 24A to C).
Persistent superior pole prominence was also noted by Georgiade et al.84 They recommended additional superior helix scoring or higher posterior vertical mattress suture placement to resolve this problem. Webster recommends slight overcorrection of the superior pole to allow for postoperative changes. The psychological and social outcomes of prominent ear correction were evaluated by Bradbury et al. who found improved wellbeing in 90% of the children 12 months postoperatively.85
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Figs 23A and B: (A) Redness and swelling observed on the second postoperative day; (B) Regressed with antibiotics treatment
 
OTHER TREATMENT OPTIONS AVAILABLE FOR THE SAME CONDITION
Nonsurgical correction of prominent ears usually has poor results. There is evidence, however, that intervention within the first few days of life may adequately treat a prominent ear. Several investigators have applied splinting to prominent ears that were identified at birth with promising long-term results when applied within the first 3 days of life.86,87 However, delay of treatment yielded poor results. Tan attributes the loss of cartilage pliability after birth to decreasing levels for circulating maternal estrogens, which are highest in the first 3 days after birth and decrease to normal levels by 6 weeks of age.88,89 Matsuo et al. also reported no recurrence after 6 months when the prominent ear was corrected with surgical tape within 3 days of birth.90 However, results were poor when the taping was started after this period. Matsuo et al. also observed that the percentage of protruding ears increases from 0.4% at birth to 5.5% at 1 year of age and concluded that most protruding ears are acquired deformities. They 18postulated that the mechanism is that when a baby is placed in a supine position, the weight of the baby's head will fold the ear forward when the baby turns its head to one side.91
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Figs 24A to C: (A) Tanzer type 2B cup ear deformity; (B) Persistent superior pole prominence in the postoperative period; (C) The ears are symmetric 6 months after the revision surgery
This mechanism has not been definitively proven; thus, behavioral modification techniques have not been a mainstay of nonsurgical treatment. The Auri method, popularized by Sorribes and Tos, uses a plastic clip device at night with a clear adhesive tape in the day to hold the auricle in a position that forces an antihelix. Treatment times were daily for 1 to 10 months. There is a substantial compliance related drop-out. Good correction is reported as high as 34% with an additional 55% with fair 19correction.87 The combination of this splinting technique with the use of injectable cartilage molding compounds may have promising applications in a broader range of age groups and potentially shorter treatment times.
Few basic science studies also focused on otoplasty procedure. Some recent research has been reported on cartilage reshaping in animal models. Preliminary studies using hyaluronidase and elastase injected into rabbit ears show statistically significant cartilage remodeling compared with saline alone when splinting is applied.92
 
SUMMARY
Auricular deformities, specifically, prominent ears, are relatively frequent. Although the physiological consequences are negligible, the aesthetic and psychological effects on the patient can be substantial. Accurate preoperative diagnosis of the specific components of the deformity, proper planning and excellent technical execution of the procedure are paramount to obtaining a good, long-lasting and aesthetic result.
 
ACKNOWLEDGEMENT
Medical photography consent forms are obtained from the patients or parents.
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