Otoplasty Treatment & Management
- Author: Anthony P Sclafani, MD; Chief Editor: Arlen D Meyers, MD, MBA more...
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.
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.
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).
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. 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. 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.
"Incisionless" otoplasty uses small stab incisions to pass mattress sutures on both sides of the antihelical curl. The suture is passed through these incisions below and out of the skin, then turned and passed through the incision again to exit at the next incision site. One incision is slightly enlarged to allow the suture to be tied and the knot buried. The technique can work well in cases of isolated lack of antihelical folding.
The standard otoplasty incision is elliptical and based just lateral to the postauricular crease, with the auricle in a lateralized position (see the first image below). 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. This incision (see the second image below) 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 the image below). 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 the image below). 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 the image below).
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. 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 the image below).
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.
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.
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 the image below).
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.
A study by Papadopulos et al indicated that patients who undergo otoplasty have an improved quality of life postsurgery. Evidence in the study, which involved 81 children and adults, included postoperative scores on the Glasgow Benefit Inventory and the Glasgow Children’s Benefit Inventory, as well as on the Rosenberg Self-Esteem Scale and the Freiburg Personality Inventory-Revised.
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.
A literature review by Leclère et al found a promising success rate for laser-assisted cartilage reshaping of protruding ears. The seven clinical studies used in the report addressed results from three different wavelengths: 1064 nm (Nd:YAG); 10,600 nm (CO2); and 1540 nm (Er:Glass).
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