eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Cosmetic Surgery
Otoplasty
Updated: Nov 14, 2008
Introduction
Congenitally prominent ears are a cosmetic deformity that can have a severe emotional and behavioral effect on a child. Otoplasty is a description of surgical procedures designed to give the auricle a more natural and anatomic appearance.
History of the Procedure
In 1845, Dieffenbach described correction of a posttraumatic auricular deformity. In 1881, Ely first described cosmetic otoplasty.1 He performed a wedge excision of full-thickness skin and cartilage from the conchal bowl to reduce the prominence of the ear. Throughout the 1890s, numerous skin and cartilage excision techniques, aimed at reducing noticeable scarring, were used by Keen, Monks, and Cocheril. These procedures were further advanced during the first 2 decades of the 20th century by Morestin, who excised elliptical pieces of skin and cartilage in 1903; Luckett, who attempted to reconstruct the antihelical fold in 1910;2 and Kolle, who contributed to mobilizing the "springy shell of the ear" by linear incisions in 1911.
Over the course of the next 20 years, tissue grafting became a popular practice; however, according to Alexander (1928), Demel (1935), and Eitner (1937), each of whom used conchal excisions, sharp cartilaginous protrusions and wrinkling of the skin often remained.
By the 1940s, New and Erich used mattress sutures to maintain the stability of the antihelix and found that shaving the cartilage was just as adequate as excising whole fragments. The Mustarde technique, which uses permanent mattress sutures to maintain the superior crus, gained popularity in the 1970s because of its efficiency.3 The use of permanent mattress sutures to re-create the antihelix remains in practice, as does postauricular soft-tissue excision for the correction of deformed auricles. Most surgeons now perform cartilage-sparing otoplasty, in which cartilage is neither incised nor excised to achieve the natural folding of the cartilage.
Problem
Prominent ears typically do not affect a child's self-image until the child is older than 5 or 6 years, and surgery for lop ear deformity is best performed before this age. Conversely, adult patients often seek otoplasty to correct a long-standing defect. Before surgery, patients typically style their hair to camouflage their deformity. Postoperatively, patients often feel comfortable enough to wear their hair short or combed back.
Frequency
Five percent of white individuals are affected. Protruding ears are genetic; 59% of affected individuals have a family history, and transmission is in an autosomal dominant pattern with variable penetrance. Since the inner ear develops independently from the auricle, patients with prominent ears generally have normal hearing; however, other congenital deformities (especially of the genitourinary tract) may be present.
Etiology
The auricle develops in utero during weeks 6-16. Six hillocks of His originate from the first and second branchial arch. Most authors believe the first, second, and third hillocks arise from the first arch, while hillocks 4-6 are derived from the second arch. Streeter believed that the first arch hillocks contribute only to the tragus, crus helices, and helix, while the second arch is responsible for approximately 85% of the auricle.4
The auricle is fully shaped at birth. It achieves 85% of adult size by age 3 years and is nearly adult size by age 5 or 6 years. As an individual ages, elongation of the lobule gives the appearance of ear growth.
Pathophysiology
Streeter believed that the shape of the auricle is predetermined, rather than influenced by any folding process.4 During 8-12 weeks' gestation, the helix develops rapidly and overhangs the antihelix. Despite Streeter's theories, most embryologists believe the antihelical furl develops over the subsequent 4 weeks, medializing the helical rim. The furl of the helical rim develops during the sixth week.
Presentation
Prominent ears can be in a myriad of forms, including cup ear, shell ear, bat ear, Machiavellian ear, and lop ear. Many patients attempt to camouflage the deformity with hairstyling.History
Question patients about excessive bleeding, poor wound healing, and keloid formation. A patient must also be judged to be intellectually and emotionally mature enough to cooperate with the postoperative regimen.
Physical examination
Perform a general assessment of the auricles. Asymmetries and irregularities should be noted and discussed with the patient. Auricles should measure 5-6 cm in height, and the long axis should recline approximately 20° from the vertical plane. The auricle should diverge from the occipital scalp at no greater than a 35° angle. The antihelix should form a 75-105° angle between the scaphoid fossa and the concha. The inferior crus is generally well developed, but the common and the superior crura can be affected. Isolated hypoplasia of the superior crus causes a superior pole deformity; if the common crus is also affected, the entire ear appears lateralized.
The most common deformity seen in prominent ears is an underdeveloped antihelix at a greater than 90° angle, often observed with a prominent lateral projection of the conchal bowl. Additional deformities may include a superior pole deformity, a prominent lobule, or a Darwinian tubercle.
Assess, measure, and document lateralization of the auricle. Document and demonstrate to patients any pre-existing asymmetry between the ears in size, shape, and position. Evaluate the helix for contour deformities, and assess its prominence at the superior pole, mid portion, and just above the lobule. Examine the antihelix for appropriate folding of the superior, inferior, and common crura. The lateral margin of the lobule should lie along the plane of an appropriately positioned helix. Prominence of the lobule may result from medial skin excess or an anterior cauda helicis; failure to identify and correct this anomaly may ruin an otherwise excellent surgical result. The lateral conchal wall may extend excessively and can cause excessive lateralization of the helix and antihelix despite appropriate antihelical folding.
Take preoperative photographs in standard frontal, lateral, and oblique positions. Additionally, a bird's eye view from above and/or posterior views can help document lateralization. Close-up lateral and oblique photographs can aid in analyzing the particular deformities in each ear.
Indications
Otoplasty is indicated for correction of ears that protrude more than 20 mm and at an angle greater than 35° from the occipital scalp. One or multiple malformed auricular subunits may be managed.
Relevant Anatomy
The auricle is a fibroelastic cartilage structure medially covered by connective tissue and skin and laterally covered by skin only. The normal auricle measures approximately 6 cm vertically. The helical rim is generally 12-20 mm from the mastoid scalp.
The auricle is a complex 3-dimensional structure (see Image 1). The helical rim is a smooth, curved arch extending anteriorly into the crus helices. This structure divides the conchal bowl into the superior conchae cymba and inferior conchae cavum. The helix is separated from the concha by the antihelix, an inferior single structure that bifurcates into superior and inferior crura. The trough between the helix and antihelix is referred to as the scaphoid fossa, while that between the 2 antihelical crura is called the fossa triangularis. Inferiorly, 2 small excrescences of cartilage form the tragus and antitragus, separated by the incisura intertragica. The cauda helicis extends posteriorly to the antitragus, and the fissura antitragohelicina separates the two.
A number of muscles insert upon the auricular cartilage. These muscles are rudimentary in most people. The superior auricular muscle inserts on the posterior surface of the fossa triangularis. The posterior auricular muscle connects the posterior auricle to the mastoid, while a number of poorly developed intrinsic muscles (ie, oblique auricular, transverse, antitragal, tragal, major and minor helical muscles) are located on the anterior and posterior surfaces of the auricular cartilage.
The arterial supply to the auricle is derived from the posterior auricular (posterior auricular surface) and superficial temporal (anterior auricular surface) arteries, which are both end branches of the external carotid artery. Sensory innervation is from the auriculotemporal (V3) and great auricular (C3) nerves, Arnold's nerve (CN X), and twigs from the facial nerve (CN VII). Lymphatics drain to preparotid, occipital, and high jugular nodes.
Contraindications
Otoplasty is contraindicated in any patient with unrealistic expectations. Patients must receive appropriate preoperative counseling. Discuss existing facial asymmetries, and emphasize that a restoration of anatomic balance to the face is the goal of any surgery. Patients unable or unwilling to cooperate with postoperative care are not candidates for surgery. Advise patients with a history of hypertrophic scarring or keloids that these may occur after otoplasty, possibly distorting an otherwise excellent surgical result.
Treatment
Medical Therapy
Nonmedical management of lop ear deformity is generally achieved by the patient using effective hairstyling to camouflage the defect. Nonsurgical treatment of prominent ears is limited to the Far Eastern practice of applying tape or conforming bandages in early infancy to influence the growth and shape of the ear. Sustained restriction and pressure can guide the growth of the auricular cartilage during infancy. This is particularly useful for treatment of cryptotia, a condition in which the superior pole lacks lateral projection and is often covered by a fold of skin.
Surgical Therapy
Otoplasty can be categorized as either cartilage splitting (cutting) or cartilage sparing. Cartilage-splitting techniques involve incisions through the cartilage and repositioning of large blocks of auricular cartilage. Cartilage-sparing techniques avoid full-thickness incisions, attempting to create more effective angles and curls in the cartilage.
Preoperative Details
Generally, prominent ears are treated surgically. Proper preoperative management includes a detailed medical history, a psychological assessment (formal or informal), a careful physical examination, and photography (see Clinical).
Intraoperative Details
Two philosophies of otoplasty exist, cartilage cutting (splitting) and cartilage sparing. Beginning with Ely in 1881, the earliest descriptions of otoplasty techniques emphasized cartilage-cutting procedures to reduce the prominence of the auricle.1 A significant drawback of incisional cartilage techniques is the potential loss of the smooth, undulating surface of the auricle because of the sharp angles at the cartilage cuts. Cross-hatching, rasping, or abrading the lateral surface of the auricular cartilage allows for medialization by contracture of the medial side and expansion of the lateral surface of the cartilage.
Mustarde continued a progression away from cartilage incisions by popularizing sutures placed from the scaphoid fossa to the concha to create an antihelical fold.3 Because no cartilage incisions are made, the antihelical contour is smooth, and no sharp, unnatural edges are visible. Correct placement and incremental tension on the Mustarde sutures creates a conchoscaphoid angle of 90°. Others have described additional suture techniques to correct other features of prominent ears.
Stenstrom described rasping alone of the lateral surface of the antihelix in order to promote medially directed folding of the antihelix.5
The standard otoplasty incision is elliptical and based just lateral to the postauricular crease, with the auricle in a lateralized position (see Image 2). Romo et al proposed an alternative incision that improves access and visualization and allows the surgeon to determine the amount of skin excised at the end of the procedure, rather than at the beginning.6 This incision (see Image 3) begins over the mastoid surface approximately 1 cm from the postauricular crease at the level of the root of the helix. The incision crosses the postauricular crease and extends along the medial surface of the auricle approximately 5 mm from the margin of the helical rim.
Inferiorly, the incision turns away from the helical margin at the cauda helicis and again crosses the postauricular sulcus onto the mastoid skin. If the lobule is prominent because of excess medial skin, the flap is extended inferiorly onto the lobule; this portion of the flap is closed in a V-to-Y fashion after appropriate skin excision (see Image 4). The outlined flap is then elevated in a supraperichondrial plane, raising a robust posteromedially based skin flap.
Once exposed, the specific cartilaginous abnormalities are addressed. To medialize excessive projection of the conchal bowl, the medial conchal surface is shaved and flattened, and 2-4 sutures of 3-0 Mersilene on a tapered needle are passed from the conchal cartilage through the mastoid periosteum, as described by Wright (see Image 5).7 Each suture is passed through cartilage and both layers of perichondrium from medial to lateral surfaces and back, in mattress sutures approximately 1 cm wide. Directing the sutures posteriorly is important to avoid advancing the conchal bowl into the external auditory meatus. After placement of these sutures, attention is directed toward creating an appropriate antihelix.
Sutures are used to decrease the conchoscaphoid angle. The antihelical fold is created manually, and a straight needle is placed through concha and antihelix. The ear is then reflected anteriorly, and the site where the needle enters and exits the medial surface of the cartilage is marked. The needle is removed, and mattress sutures are placed between the marks. Generally, 2-4 sutures are required along the common and superior crura of the antihelix. These sutures must be placed 8-10 mm from the peak of the antihelical curl to avoid a pinched contour. The sutures are incrementally tightened and tied to produce a natural antihelical contour (see Image 6).
Many novice surgeons conclude the procedure at this stage and fail to address superior and auricular deformities. As described by Furnas, a suture from the fossa triangularis to the temporalis fascia can correct protrusion of the superior pole.8 Although this suture can be placed through the standard elliptical skin excision, placement is facilitated by use of the postauricular skin flap. Again, the suture is tightened to the desired effect (see Image 7).
Finally, protrusion of the lobule is addressed. A prominent lobule can be caused by medial skin excess or an abnormal caudal helicis, and correct diagnosis is essential for proper treatment. Palpation of the lobule reveals either flaccid soft tissue or a firm, long, and abnormally positioned cauda helicis. In the latter case, simple resection of the cauda helicis corrects lobule position. Extending the posterior skin flap into the lobule can treat medial lobular skin excess. After excising a skin wedge, a V-to-Y closure is incorporated into the closure of the flap.
Auricle contouring is rarely necessary beyond the above steps. A prominent Darwinian tubercle can be excised through an incision on the medial or lateral surface, with appropriate degloving of the helical margin.
Once the desired changes have been made to the cartilaginous contour, the skin flap is redraped into the postauricular crease and over the medial auricular surface. Generally, 2-4 mm of excess skin is noted, marked, and excised. A small rubber band drain is placed, and the skin is closed with interrupted 6-0 Prolene sutures. In small children, the wound is closed with a running 5-0 chromic suture to obviate the need for suture removal. Sterile cotton soaked in mineral oil is then placed in the conchal bowl, scaphoid fossa, and postauricular crease. A mastoid-type compressive dressing is then placed.
Postoperative Details
The patient is seen on the first postoperative day. The dressings are removed, and the ears are inspected for any sign of hematoma. The drains are removed, and the ears are redressed, including conforming and compressive dressings. The patient is seen again on the second postoperative day; the ears are again inspected, and an elastic ski headband is placed over the head and ears. The patient wears this continuously for the next 5 days and during sleep for the following 2 weeks. Prolene sutures are removed on the seventh postoperative day. Moderate ecchymosis and edema are expected but usually resolve within the first 2 weeks.
Complications
Incomplete correction of prominent ears is probably the most common undesirable outcome of otoplasty. Careful preoperative analysis with specific attention to each area of the auricle can prevent an incomplete reconstruction. Correction of the mid portion of the auricle greater than the superior and inferior poles leads to a "telephone ear" deformity; a reverse telephone ear deformity is a result of inadequate medialization of the central portion of the auricle.
Overcorrection of a prominent ear can lead to obliteration of the postauricular sulcus. Adult patients often request overcorrection; surgeons should give careful consideration to the postauricular sulcus when deliberately overcorrecting auricular protrusion.
Hematomas or seromas can complicate recovery and should be managed as soon as possible. Careful hemostasis before closure can limit the incidence of hematoma, and a surgical drain left in place for the first 24 hours can reduce the chance of seroma formation. Unmanaged hematoma leads to fibrosis and chondroneogenesis that may blunt the natural contours of the auricle; should the hematoma dissect between the perichondrium and cartilage, progressive cartilage autolysis can occur from ischemia.
Chondritis is probably the most feared complication of otoplasty because it can deform the ear beyond recognition. Typically, clinical signs of infection (ie, pain increasingly resistant to analgesics, swollen erythematous ear) begin 3-5 days after surgery. Chondritis may require drainage and debridement of infected cartilage. Appropriate perioperative antibiotics and drainage of any collection of serum or blood can prevent chondritis.
Suture bridging may occur with excessive skin resection as the skin is tautly redraped over the sutures. Conservative skin excision can reduce the risk of seeing sutures through the skin.
Hypertrophic scars or keloids may form along the incision line. This is more likely if excess tension is placed on the closure. Careful and conservative skin resection can help limit excessive scar formation.
Loss of correction after otoplasty can be a frustrating complication. Early loss may be a result of manipulation by the patient, or it may be caused by suture breakage or poor suture placement. Thorough patient counseling is necessary to ensure proper postoperative compliance. When placing sutures through cartilage, the suture should include both layers of perichondrium and cartilage; the entry and exit sites of the suture should be separated by approximately 1 cm.
Cartilage-splitting techniques can give rise to sharp, irregular, and unnatural contours (see Image 10).
Outcome and Prognosis
Most patients can appreciate the results of otoplasty surgery as soon as the bandages are removed. Some adult patients require a period of psychological adjustment to their new appearance. If patients are appropriately selected, they resume their lives with an improved level of self-confidence.
Future and Controversies
In appropriately selected patients, otoplasty can tremendously improve the appearance and self-image of adults and children. Techniques continue to be refined, attempting to re-create the normal appearance of the ear with minimal incisions and recuperative time. With the technique described in this article, excellent results can be obtained with a thorough preoperative evaluation and a careful individualized technique.
Multimedia
Media file 1: Otoplasty. Lateral auricular landmarks.
Media file 2: Standard postauricular skin excision for otoplasty.
Media file 3: Postauricular skin flap for otoplasty.
Media file 4: Postauricular skin flap for otoplasty with lobular extension.
Media file 5: Conchal setback sutures.
Media file 6: Mustarde suture placement.
Media file 7: Suture to medialize the superior pole.
Media file 8: Preoperative view of prominent ear.
Media file 9: Postoperative result of otoplasty.
Media file 10: Irregularity and sharp angles after cartilage-incision technique of otoplasty.
References
Ely ET. An operation for prominence of the auricles. Arch Otol. 1881;10:97-99.
Luckett WH. A new operation for prominent ears based on the anatomy of the deformity. Surg Gynecol Obst. 1910;10:635-637.
Mustarde JC. The correction of prominent ears using simple mattress sutures. Br J Plast Surg. Apr 1963;16:170-8. [Medline].
Streeter GL. Development of the auricle in the human embryo. Contributions to Embryology. 1922;14:111-113.
Stenstrom SJ. A "natural" technique for correction of congenitally prominent ears. Plastic and Reconstructive Surgery. 1969;42:189-201.
Romo T 3rd, Sclafani AP, Shapiro AL. Otoplasty using the postauricular skin flap technique. Arch Otolaryngol Head Neck Surg. Oct 1994;120(10):1146-50. [Medline].
Wright WK. Otoplasty goals and principles. Arch Otolaryngol. Dec 1970;92(6):568-72. [Medline].
Furnas DW. Correction of prominent ears with multiple sutures. Clin Plast Surg. Jul 1978;5(3):491-5. [Medline].
Adamson PA, Strecker HD. Otoplasty techniques. Facial Plastic Surgery. 1995;11:284- 300.
Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg. Apr 2005;115(4):60e-72e. [Medline].
Salgarello M, Gasperoni C, Montagnese A, et al. Otoplasty for prominent ears: a versatile combined technique to master the shape of the ear. Otolaryngol Head Neck Surg. Aug 2007;137(2):224-7. [Medline].
Keywords
otoplasty, ear surgery, ear pinning, lop ear deformity correction, cup ear, shell ear, bat ear, Machiavellian ear, prominent ear, ear prominence, mattress sutures, auricle, ear surgery, superior pole deformity, prominent lobule, Darwinian tubercle, pin back ears, ears pinned back
Contributor Information and Disclosures
Author
Anthony P Sclafani, MD, Director of Facial Plastic Surgery, The New York Eye and Ear Infirmary; Professor of Otolaryngology, New York Medical College
Anthony P Sclafani, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American College of Surgeons
Disclosure: Medicis None Speaking and teaching; Contura None Board membership; Cascade Medical Grant/research funds Independent contractor; Cascade Medical None Board membership
Coauthor(s)
Jeffrey Ranaudo, Department of Biology and Chemistry, Manhattanville College Center for Facial Plastic Surgery
Disclosure: Nothing to disclose.
Medical Editor
Cliff A Megerian, MD, FACS, Medical Director of Adult and Pediatric Cochlear Implant Program, Vice-Chairman and Director of Otology and Neurotology, University Hospitals of Cleveland; Professor, Department of Otolaryngology-Head and Neck Surgery and Neurological Surgery, Case Western Reserve University School of Medicine
Cliff A Megerian, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Neurotology Society, American Otological Society, Association for Research in Otolaryngology, Massachusetts Medical Society, Society for Neuroscience, Society of University Otolaryngologists-Head and Neck Surgeons, and Triological Society
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Managing Editor
Dean Toriumi, MD, Department of Otolaryngology, Associate Professor, University of Illinois Medical Center
Disclosure: Nothing to disclose.
CME Editor
Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.
Chief Editor
Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
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