Prominent Ear

The pinna makes only a tiny contribution to the function of hearing. The main function of the pinna is to "look normal." Normal is, of course, a subjective judgment with a cultural bias. In Western society, popular comic cartoon characters often are endowed with large, prominent, or protruding ears. A child with prominent ears is often the target of invidious comparison to such characters and must carry the burden of an "unacceptable" evaluation from peers, a burden that may be carried into adulthood. The image below illustrates surgical correction of prominent ear.

Despite recognized standards in idealized facial proportions and anthropomorphic measurements for each facial feature, societal standards change depending on which new fashion model is popular or which current figures are revered in today's media. Often, in this increasingly visual world, when wishing to depict the oddball character, the less intelligent individual, and the funny looking kid, the media often select subjects with large, prominent, or oddly shaped ears. These subjects are initially assigned a level of immaturity or low intellect. The fact remains that, without calipers or other instruments of measure and without memorizing a set of standards, humans visually understand when facial features appear in balance, and few, if any, features elicit such negative responses as ears that are prominent, overly large, or misshapen.[1, 2] Unfortunately, these individuals are often assigned many of the above negative traits.

Ely is credited with the first otoplasty in 1881. At the turn of the century, Morestin expanded on Ely's technique with ingenuity. He described concha-mastoid (C-M) sutures, antihelix (Mustardé) sutures, an antihelix incision, and thinning of the posterior surface of the cartilage. Morestin's article appeared in an orthopedic journal in 1903 and contained only a single drawing, thus it was overlooked in subsequent decades. In a 1910 publication, Luckett dealt with the flat antihelix by incising the cartilage and creating a crest by joining the cut edges with mattress sutures.

In a 1930 article, GW Pierce reported weakening the line of the crest of the antihelix by scoring the posterior surface of the cartilage, facilitating the formation of the fold. Gibson in 1958 demonstrated that disruption of a balanced cross-section of costal cartilage caused warping away from the site of disruption. Stenstrom studied cross-sections of scored auricular cartilage while working with Pierce. He noted that the cartilage curled away from the scored surface, following Gibson's principle; therefore, he replaced posterior scoring with anterior scoring of the antihelix.[3] Converse and Tanzer made parallel cartilage incisions, which were joined to form a tubelike crest.[4] Mustardé employed mattress sutures to create the fold of the antihelix.[5, 6] Morestin's C-M sutures for reducing the deep concha were redescribed by Furnas in a 1978 article. Elliott and Gault added improvements.[7, 8]

Anterior approaches for altering the antihelix were described by J Davis in 1978 and by Kaye in 1967. Nordzell and Erol described recent modifications of the anterior approach.[9, 10] More recently, the authors have stressed the importance of conchal enlargement on overall ear structure and prominence.

Essentially, all current otoplasties are effective in reducing the prominence of the ear; however, one technique may be better than another for a special problem and each technique is characterized by certain incidental changes in the nature or the shape of the auricle. For the most part, these incidental changes are an acceptable exchange.

An ear appears prominent or protruding if it projects more than 15-20 mm or more than 21-30° from the temporomastoid plane of the skull. The mean length of the ear (sa-sba, ie, superaurale to subaurale) in boys is 55 mm when aged 6 years, 60 mm when aged 12 years, and 62 mm when aged 18 years. In girls, the values are 54 mm, 58 mm, and 58 mm at ages 6, 12, and 18 years, respectively. The mean width of the ear (pra-pa, ie, preaurale to postaurale) is 34 mm, 35 mm, and 36 mm in boys and 33 mm, 34 mm, and 34 mm in girls at ages 6, 12, and 18 years, respectively. One standard deviation in width is 2.0-2.5 mm and in length is 3.0-3.5 mm. An ear that is 2 or more standard deviations from the mean is viewed as abnormally large (macrotia). Excessive projection is a far more frequent problem than excessive size.

The first step in assessing the patient for otoplasty is determining the anatomic causes of protrusion of the ear. The most common causes of protrusion of the external ear are (1) underdevelopment or effacement of the antihelix, (2) overdevelopment of the deep concha, or (3) a combination of both of these features.

Contributing features that accentuate auricular protrusion are (1) prominence of the mastoid process, (2) protrusion of the lower auricular pole (ie, cauda helicis, lobule, cavum concha), and (3) a prominent tipped upper auricular pole. Cranial deformity as in uncorrected positional plagiocephaly can significantly affect ear position and prominence.

Auricular protrusion may be one element of a more complex auricular deformity such as a constricted ear, Stahl ear (third crus), macrotia, or syndromic facial deformity.

True macrotia is rare. It can be seen in association with vascular malformations, hemihypertrophy, neurofibromatosis, and secondary to hemangioma. It is more obvious if the ear is prominent; the above otoplasty methods apply in mild macrotia. If the ear is so large as to be truly conspicuous, the Antia-Buch technique and its variations provide true reduction of the ear with minimal aesthetic compromise.

This article discusses the evolution of current technique for correction of the prominent ear and demonstrates how the technique has been modified to correct a wide variety of deformities from simple ear prominence to those with accompanying deformation of the helical rim, excessive prominence of the lobule, and moderate degrees of constriction. Inherent in the technique is an understanding of the proper balancing and subtle positioning of the varied ear contours to obtain an outcome that has a satisfactory appearance and that does not immediately appear to have been operated on. While the final ear position and shape are critical, the exact measurements are not.

Many of the patients presenting for otoplasty have visibly prominent ears, but not all people with large and prominent ears have a desire to change their appearance, and many, even if teased in childhood, have become comfortable with their appearance. That being said, experience has demonstrated that many of the parents bringing their children in for prominent ear correction are strongly motivated by the desire to spare their child the embarrassment and teasing that they endured. Parents may subsequently elect to undergo otoplasty after their child has had surgery. In these cases, satisfaction and feelings of relief are constant features of their recovery.

These issues are important when deciding the appropriate timing for the surgery, and whether the decision to operate should be made based on the parents' concerns or should wait until the child expresses these concerns. This is a decision that needs to be made on a case-by-case basis. However, by the time children approach 5 years of age, they may have been teased, even if the teasing has not started to affect the way they feel about themselves. Once the discussion ensues, they express their willingness to go through the surgery to avoid this teasing.

Children younger than 5 years of age are rarely perceptive enough about their appearance or comments made about them to feel that surgery is urgent. Likewise, experience has demonstrated that these younger children may have significant difficulty cooperating with the postoperative routines (ie, dressings and activity limitations). Taken together, with very rare exception, age 5 years is the low end of the spectrum of patient age.

More subtle cases of ear prominence, distortion of ear shape, or ear asymmetry may not spark the desire for correction until a child is older, more concerned about overall appearance, or eager to adopt a different style and wear his or her hair back or cut short. In each case, the ear or ears that may have been hidden are now exposed.

There are very few contraindications for otoplasty. In the pediatric population, surgery is appropriate and extremely well tolerated provided that the child does not strongly resist the idea of surgery. If a child begins to misbehave or becomes excessively worried about even going to the doctor for a preoperative discussion or going to the hospital, it is best to delay the surgery until the child openly requests the procedure. Another contraindication is a history of chronic ear infections and ear drainage that has not been thoroughly investigated and corrected. It is not uncommon for kids to have previously had myringotomy and pressure equalizer (PE) tube placement. If there is no active infection or significant drainage, then otoplasty can be performed safely.

At the other end of the age spectrum, adults seeking changes in ear shape, size, or prominence must, as with any aesthetic surgery candidate, be able to express their reasons for seeking a change at this stage and demonstrate realistic expectations of what the change is going to mean for them. Careful case selection is critical and is never more important than when the deformity is a minimal or subtle one. While beyond the scope of this article, the same careful case selection is important in patients who have previously undergone one otoplasty and are dissatisfied with the outcome.

In a 1978 article, Macgregor speaks of the "exquisite cruelty of young children toward the child who happens to look 'different.'"[11] These pediatric patients are highly motivated and cooperative. A truly gratifying psychological response to a well-performed otoplasty generally occurs.[12, 13] These children do not seek perfection in their otoplasties, but the surgeon must be aware that the occasional parent and/or caregiver has unrealistic expectations. A frank discussion about the operation and what it can achieve is in order, including the adverse effects, risks of surgery, and risks of anesthesia. Adolescent and adult patients often relate a history of embarrassment about their prominent ears from childhood years, but circumstances have precluded corrective surgery. These patients also are likely to be highly satisfied with the results of surgery.

Asymmetric features of the ears should be called to the attention of the patient and parents and/or caregivers, and a distinction should be made between features that are likely to be improved by surgery and those that will stay the same. The postoperative evaluation of the otoplasty by patient, family, and friends is inevitably more detailed than any preoperative evaluation.

Ethnic and cultural considerations may enter the algorithm. Prominent ears are typical among Celtic people, and in Japan, prominent ears are said to denote intelligence. However, it usually does not take long for children to conform to the cultural values of their adopted country.[14]

While the majority of otoplasty techniques have historically concentrated on the effaced antihelical fold as the main cause of ear prominence, failure to fully appreciate all the elements distorting the ear position and shape is a recipe for an unfavorable outcome. Experience has revealed that the vast majority of prominent ears demonstrate some degree of conchal hypertrophy, and the concha may be the cornerstone of the treatment of the prominent ear.

Correct analysis of each deformity is the most important step in otoplasty. Ear prominence results from one or more of the following features: 1) effacement or deficient antihelical fold, 2) conchal hypertrophy or abnormalities in conchal shape, 3) deformity of the underlying skeletal anatomy, and 4) macrotia, or generalized overgrowth of the ear. The first 2 of these features are accentuated when seen in combination with the decreased radius of the curve of the helical rim in the constricted ear.

The anterior (lateral) surface of the ear is the traditional reference plane for the anatomic nomenclature of the ear. However, many steps in an otoplasty, such as placing cartilage sutures, removing soft tissue, or trimming cartilage, may be performed on the posterior (medial) surface of the ear. From a posterior perspective, the concha and the fossa are viewed as eminences, and the crura are seen as grooves.

On cursory inspection, the shape of the cartilage framework appears to duplicate the visible ear. However, on closer examination, the auricular cartilage proves to be an incomplete skeleton with gaps, drop-offs, and irregularities in thickness, augmented with connective tissue and muscle. The surgeon must be facile in integrating these hidden features and illusions into his or her thought model of the patient's auricular anatomy. The images below illustrate auricular anatomy.

The qualities of the auricular cartilage as a material and its biomechanical responses to external and internal forces must be assessed preoperatively, intraoperatively, and through the early postoperative period. Whether the auricular cartilage is made up of limber, stiff, or floppy cartilage is of prime importance in choosing the appropriate operative steps.

Cephaloauricular and scaphoconchal angles

Da Silva Freitas et al compared the cephaloauricular and scaphoconchal angles of 15 patients with prominent ears with 15 persons in a control group. The average of cephaloauricular angle was 47.7 degrees for the study group and 31.1 degrees for the control group. The average scaphoconchal angle was 132.6 degrees for the study group and 106.7 degrees for the control group. They concluded that measuring both angles may help in diagnosis of protruding ears.[15]

Antihelix

The antihelix normally forms a symmetric Y in which the gently rolled or folded crest of the root of the antihelix continues upward as the superior crus. The inferior crus branches forward from the root as a folded ridge. The root of the inferior crus of the antihelix sharply defines the rim of the concha. The inferior crus also forms the wall that separates the concha from the triangular fossa. The root and superior crus of the antihelix form the anterior wall of the scaphoid fossa, and the helix forms the posterior wall. The triangular fossa dips within the Y arms of the superior and inferior crura.

The corrugated contours of these auricular crests and valleys provide a pillar effect that stabilizes the pinna. The vertical walls of the conchal cup are translated to a semihorizontal plane as the concha merges with the folded crest of the antihelix. The scapha-helix is nearly parallel to the plane of the temporal surface of the head. If the roll of the antihelix and its crest are effaced and flat, rather than rolled or folded, the steep pitch of the conchal wall continues into the unformed antihelix and scapha and ends at the helix with little interruption. This places the scapha-helix complex nearly perpendicular to the temporal plane of the head, and the ear appears prominent. Such an ear also lacks the stability provided by the pillar effect and allows the superior auricular pole to protrude.

The literature has described effacement or deficiency of the antihelical fold as ranking foremost in most discussions of the prominent ear. This deformity manifests as a spectrum from a totally indistinguishable antihelix, with a confluent concavity from antihelix to scapha and the helical rim projected outward and forward, to loss of definition of only the superior antihelix with prominence of the upper pole of the ear.

Concha

The concha is an irregular hemispheric bowl with a defined rim. The normal scapha-helix surrounds the posterior part of the bowl as the brim of an inverted hat surrounds the crown. The pitch at which the scapha-helix projects from the conchal cup is determined by (1) the acuteness of the fold of the crest of the antihelix, (2) the height of the posterior wall of the conchal bowl, and (3) the completeness of the partial sphere formed by the concha.

If the posterior wall of the concha is excessively high and the concha is excessively spherical, then the angle and the distance between the plane of the scapha-helix and the plane of the temporal surface of the head are excessive. Usually such protrusion is distributed evenly around the posterior conchal wall. However, the cephalad part of the concha can protrude disproportionately, another cause for a protruding upper pole. Similarly, the caudal part of the concha can project disproportionately and cause a protruding lower auricular pole. These features require special attention in the operating room.

While less attention has been directed toward the importance of the concha in overall shape and projection of the ear, consider the 3-tiered configuration of the auricular cartilage framework. The more delicate antihelix and helical complex are mounted on the sturdier concha such that changes in conchal size and shape profoundly influence the overlying tiers. Bauer describes that it is rare to see prominence of the ear that does not have a conchal element.

The concha affects the prominence of the ear in 3 ways. These include 1) overall enlargement of the concha projects the ear away from the mastoid surface, 2) an extension of the helical crus across the concha creates a firm cartilage bar that pushes the ear outward, and 3) the effect of the angulation of the cartilage at the junction between the cavum concha; the sweep of cartilage up to the antitragal prominence affects the position and prominence of the lobule and lower third of the ear. The first of these is well recognized. Little attention has been drawn to the second, but once seen, it is easy to understand. Understanding the third element leads to understanding the approach to the isolated lower pole and lobule prominence.

The latter feature of conchal shape, while not the only cause of prominence of the lobule, appears to play a key role. As the cartilage angle between the concha cavum and antitragus becomes more acute (ie, as the antitragus tips closer toward the concha), this supporting structure projects the lower third of the ear and lobule outward. This feature has a greater influence on the lobule position than the commonly described helical tail.

A literature review by Mogl et al indicated that conchal hypertrophy can reliably be corrected via otoplasty using conchal excision. The investigators found no evidence that in such procedures a posterior approach to the concha in which the skin excision is separated from the cartilage excision is better than an anterior approach or vice versa. The literature also indicated that following resection, satisfactory results can be achieved either by approximating the cartilage edges using cartilage sutures or by allowing the edges to collapse spontaneously.[16]

Combination of protruding antihelix and concha

The combined effect of an effaced antihelix and a deep concha is also additive, causing a severe auricular protrusion.

Protruding mastoid process

A prominent mastoid process tends to push the concha forward, causing auricular prominence. Furnas has reported marked auricular protrusion caused by a dermoid cyst in the recess between the mastoid process and the concha. Removal of the cyst corrected the problem.

Although the effect of the underlying skeleton on ear prominence has had little attention, it should be recognized and taken into account in planning correction of the prominent ear. The external ear is mounted upon the bony base of the underlying temporal bone. Anomalies in skeletal shape and skeletal asymmetries can affect one or both ears. Perhaps the most recognizable example of this relationship is the change in ear position and projection in association with positional, nonsynostotic plagiocephaly. With the parallelogram deformation of the cranial vault, the ear on the side of occipital plagiocephaly is projected forward and is often more prominent.

In more subtle cases of this deformity, the ear prominence may become more evident in an older patient, in whom the ears are asymmetrically positioned and residual occipital flattening and mild facial asymmetry may not be readily apparent on first view. This effect of head shape on ear position is clear when viewing illustrations of Ely's description of his otoplasty technique in 1881.

A less subtle example of the influence of the skeleton on ear position is the effect of deficient temporal bone and medial positioning of the temporomandibular joint in hemifacial microsomia. In more severely affected cases, seen without microtia, the normal ear may seem to be sheared off the head, with the upper half of the ear projecting outward and the lower half canted medially toward the hypoplastic face. An additional example with some similarities occurs when the general craniofacial shape includes a relatively broad head, with a narrow face and mandible. Seen from the frontal view, there is a triangular configuration to the head and face. This slope from head to face may project the upper ear outward, creating the ear prominence but with otherwise normal features proportional to the ear.

Protruding cauda helicis

The cauda helicis is bound to the fibrofatty tissues of the earlobe by a network of connective tissue. The cauda helicis, which projects outward from the concha, carries the earlobe with it, causing it to protrude. This contributes to prominence of the lower pole.

Protruding earlobe

Some earlobes are not only large and pendulous but also are prominent due to the structure and form of the dense interlacing connective tissue fibers that shape the earlobe independent of the cauda helicis.

Soft tissues

The auricularis posterior attaches superficially to the ponticulus of the conchal cartilage and the posterior auricular ligament and most often consists of 2 bellies. This muscle is surrounded by fibroareolar tissue. Deep to the muscles and within the areolar tissue, small branches of the postauricular vessels and fine rami of the greater auricular nerve are found. Deep to these structures lie the mastoid fascia and the tendinous origin of the sternomastoid muscle.

The surgeon must be alert for the occasional adult who magnifies the severity of a small defect or who sees serious deformity in ears that others would judge as normal.

The authors prefer that a child considering surgery be at an age of awareness of his or her prominent ears and want them corrected. If parents are anxious to correct the child's prominent ears at an earlier age, the authors tend to defer surgery until later, although exceptions are made. Furnas has performed an otoplasty in an infant concomitant to correcting the webbed neck of a patient with Turner syndrome. Repeat otoplasty was performed when the patient was older. This likelihood of an incomplete correction or need for recurrent surgery speaks against early intervention except in rare cases.

An important step in gaining patient satisfaction is development of an individual surgical strategy that provides an excellent result for that patient. This starts with careful assessment of the defect.

Chronic otitis media, otitis externa, or conditions such as scalp infections or acne must be treated well in advance of surgery. A simple surgical wound infection can lead to an ear-threatening chondritis.

Nonsurgical otoplasties in neonates and infants

In 1990, Matsuo reported successful nonsurgical treatment of all protruding ears and other deformities in neonates. He described a molding device of malleable plastic material that he secured to the ear with Steri-Strips. Commencement of treatment as early as possible is a key to success.

Matsuo commonly begins treatment in the newborn nursery. The age at which nonsurgical therapy can be offered is debatable; opinions vary from "newborn only" to up to 6 months of age.[17] Furnas considers this method excellent if commenced within the first 2-3 months of life. A molding armature formed with a core of thin solder or copper wire and padded with a wrapping of 3M Microfoam tape or plastic tubing is bent to fit the ear and is shaped to press the deformed areas into a normal shape. The hair is clipped in a radius of approximately 2 inches around the ear. The ear, scalp, and armature are coated with surgical liquid (Mastisol) adhesive or tincture of benzoin. The armature is positioned on the ear and is secured with multiple 0.125- or 0.25-inch Steri-Strips. The armature and the ear are secured to the periauricular skin and scalp with more Steri-Strips.

The ear of the neonate is delicate, and any pressure point can cause damage; therefore, recheck the ear frequently and readjust or replace the armature as needed. As soon as the ear begins to retain the desired shape, the metal core is omitted from the rolled Microfoam tape, and the tape is shaped to serve as a mold. The metal core is omitted as soon as possible to avoid pressure points. Finally, the tape mold is omitted and the ear is held with tape alone until the new position is stable. Repeated clipping of the infant's hair is needed to provide a surface for the tape. The time needed for correction varies widely from a few days to a number of months.

Once the neonatal period has passed, a surgical procedure is needed to correct prominent ears. The surgeon has a number of approaches and maneuvers from which to choose in developing the strategy that best suits the patient's problem and the surgeon's experience. The following emphasizes the repositioning of auricular cartilage with sutures, but the surgeon should be familiar with a spectrum of maneuvers for flexibility in dealing with unusual or unexpected problems.

Carefully listen to each patient and parent preoperatively and solicit and answer the patient's and parents' questions. Dealing with concerns and expectations preoperatively increases the probability that a technically excellent otoplasty will be viewed with satisfaction and gratitude postoperatively.

An important step in gaining patient satisfaction is development of an individual surgical strategy that provides an excellent result for that patient. This starts with careful assessment of the defect.

Proper assessment of the patient's deformity is the key element of the preoperative planning. The current approach to correction of the prominent ear evolved from the Stark Saunders technique that combined posterior thinning (dermabrasion) of the proposed antihelical fold and suture fixation to a technique that emphasizes chondrocutaneous conchal resection as the cornerstone of correction of the prominent ear combined with posterior suture shaping and fixation of the antihelical fold. The current approach that Bauer employs avoids thinning or potential irregularities in the antihelix seen with many of the cartilage scoring techniques, while still minimizing the risk of recurrence that may occur with suture techniques alone. The integrity of the antihelical cartilage is maintained because the perichondrium overlying both surfaces of the antihelix is left undisturbed, but the cartilage spring is diminished secondary to the break at the conchal level.[18]

The evolution followed both assessment of postoperative results and critical evaluation of a reasonably large series of patients seeking revision otoplasty. In the latter group, most demonstrated an overaccentuation of the antihelical fold and failure to recognize that conchal hypertrophy was the underlying cause of the initial ear prominence. Addressing conchal hypertrophy in these patients, alone or in conjunction with ancillary techniques, has produced consistent and reproducible outcomes satisfactory to both patient and surgeon.

The goals of otoplasty should be to 1) correct protrusion, 2) correct the prominently visible helix and antihelix while leaving a visible helical rim, 3) create a smooth antihelical fold, 4) avoid disturbance of the postauricular sulcus, and 5) avoid a plastered down or pinned back look. To achieve these goals, each deformity must be critically evaluated and the technique modified to correct subtle differences in the 2 sides. Previous emphasis has been placed on the importance of correction of the antihelical effacement; however, this approach demonstrates an emphasis on the role of the concha in the prominent ear. This results in a treatment plan that readily achieves each of the above goals while guaranteeing that a sharp, irregular antihelix and pinned back look is avoided.

With the exception of rare cases where there is no visible conchal component to the deformity, the procedure begins with a conchal incision and excision of a crescent of cartilage with a smaller skin component. For lesser degrees of cartilage resection, no skin may be excised. Following repair of the concha, attention is turned to the postauricular surface where squid-shaped skin excision and exposure of the posterior perichondrium over the scapha, helical sulcus, and helical tail is followed by suture placement. Sutures are tied to correct prominence, and closure of the inferior incision sets the shape and correction of the lobule. With these steps completed, attention is turned to adjunctive procedures such as correction of helical rim deformities, excessive prominence of the antitragus, and additional reduction of lobule size. Corrections of adhesion or defects of the helical rim may make use of the resected conchal cartilage as a graft.

In the majority of cases, providing that the patient is a child at the appropriate age to undergo the procedure, the preoperative assessment is completed with the initial evaluation and one subsequent preoperative visit (usually within the week prior to surgery). For children too young for surgery or not presently concerned with the deformity, a return visit is planned at the appropriate age. For the adult patient, particularly cases with repeat procedures, the authors may elect to meet one additional time to assure that the patient's expectations are appropriate and can be fulfilled. All patients require a routine history and physical examination (plus laboratory work in adults) completed by the family doctor. Preoperative photographs are taken and reviewed to assure that all appropriate views are documented.

The specifics of the deformity are discussed, and care is taken to point out asymmetries that may exist between the 2 ears. The procedure is discussed in detail, including a review of the anesthesia (eg, general anesthetic in the majority of pediatric cases, possibly local anesthesia with or without sedation in minor cases or in adults) and discussion of incisions, dressings, and postoperative routine. Risks, including infection, chondritis, and hematoma, are discussed along with a review of their implications and treatment. Included is a discussion of possible minor asymmetry following the otoplasty that may be corrected with a minor revisional procedure.

In the majority of cases, and particularly with children, it is helpful to review photographs of a series of otoplasty cases with a spectrum of prominent ear deformities illustrated. With some of the more atypical deformities of helical rim and with constricted ears, it helps to clarify potential limitations of the surgery while still demonstrating its benefits.

Specific techniques are discussed in the sections below.

General anesthesia

In pediatric patients, after induction of anesthesia, place the endotracheal tube in the midline and secure it with a circummandibular or transalveolar suture of 0 or #1 Prolene. The table is turned 180°, with the anesthesiologist near the foot of the table. A single intravenous dose of a cephalosporin or other appropriate intraoperative antibiotic is administered. The hair is shampooed with surgical soap. The face, neck, ears, and adjacent ventilating tube are prepared with aqueous povidone iodine (Betadine). A head drape is placed with both ears exposed. Apply Mastisol adhesive solution to the face and place a series of 1-inch Steri-Strips to hold the head towels securely to the face and neck. Place Steri-Strips over the eyes. The body sheet is made of clear plastic and provides visibility of the entire ventilating system. After markings have been placed, inject the postauricular areas with 0.25% bupivacaine with epinephrine 1:200,000.

Local anesthesia

Children vary immensely in their suitability for local anesthesia. Occasionally, a mature child aged 10 years who has high motivation and uncomplicated prominent ears is a candidate for local anesthesia without premedication. A parent reads a favorite story or plays a favorite audio tape for the child during the procedure. Apply a thick coat of eutectic mixture of local anesthetics (EMLA) cream to the postauricular area 2-3 hours in advance. Administer an oral antibiotic an hour before surgery. Slowly infiltrate the posterior surface and retroauricular surface of each ear with buffered 1% lidocaine (Xylocaine) with epinephrine 1:100,000 by a 27- or 30-gauge needle. This is followed by infiltration with bupivacaine (0.25%) with epinephrine 1:100,000. Lidocaine or bupivacaine (Marcaine) is reinforced during the procedure, if needed, staying within range of the recommended dosage.

Aids in visualization

Attention to fine detail can make the difference between a good and an excellent result. High-power loupes (4.5X, 11- to 13-in working distance) and a coaxial headlamp add greatly to the surgeon's ability to evaluate the anatomy and to conduct operative steps.

Markings

Manipulations are carried out as on the planning visit. Markings are made with gentian violet to indicate the crests of the antihelix and to indicate the sites of all planned sutures. A set of photographs of the marked ears is made for use in the operating room, along with the other preoperative photos. In the operating room, the skin markings are reinforced after facial preparation has been completed. The marks are not tattooed; rather, judgments for suture placement or other adjustments are made by intraoperative manipulation and by careful observation of the effect on the anatomy of the posterior surface of the auricular cartilage.

Certain anatomic parts may tend to be recalcitrant to correction and require special surgical maneuvers. A detailed manual rehearsal of the otoplasty identifies such features so that problems do not appear during the operation. When pressing the central pinna into its corrected position, the examiner is alert to persistent protrusion of the upper or lower pole, to thick immobile auricular cartilage, or to cartilage that is so flabby that it bunches rather than folds when manipulated. Forewarned, the surgeon is prepared to deal with these during surgery.

Incision/excision of postauricular skin

Expose the posterior surface of the auricular cartilage by excising the premarked crescent of skin and subcutaneous tissue. Make the crescent wide enough to remove redundant skin and long enough to provide for exposure needed at the upper or lower pole. Maintain hemostasis with bipolar cautery (avoid monocular cautery because it inflicts damage if it touches cartilage).

Postauricular dissection

Postauricular landmarks are, of course, the reverse of the named anterior landmarks. Posteriorly, crests of crura become valleys and fossae become projections. The surgeon embraces this perception as he or she proceeds. Widely expose the posterior surface of the auricular cartilage. Combine scissors-spreading dissection with fine sharp-on-sharp iris scissors with scalpel dissection. Both intrinsic and extrinsic auricular muscles tend to insert directly into cartilage with no obvious intervening perichondrium, putting the insertion sites at risk of nicking. Nicks in the cartilage are studiously avoided. If C-M sutures are planned, divide the auricularis posterior muscle, the postauricular ligament, and the associated layers of fibroareolar tissue from the concha and flap them back (or excise them) to expose the mastoid fascia and the fibers of origin of the sternomastoid muscle.

Then, extend the dissection peripherally on the concha and the scapha-helix almost to the free edge of the helix. Completely expose the helix rim if trimming or manipulation of the rim is planned. Anticipate the site where the cauda helicis diverges from the concha. Expose the cauda with precision, preserving its attachments to the fibrofat and skin of the earlobe. A well-attached cauda is an aid in positioning the earlobe. The apex of the angle between the cauda and the concha is the site of entry if a tunnel is to be made on the anterior surface of the antihelix (see Stenstrom scoring below). If a prominent upper pole of the auricular cartilage is to be brought closer to the head with separate fossa-fascia (F-F) sutures, elevate the local skin and scalp from the superficial temporal fascia and perichondrium of the helix root (otobasion superius) in preparation for the steps described below.

Mustardé sutures (concha-fossa sutures)

Furnas employs Mustardé sutures to create an antihelix roll and crest when the cause of protrusion is deficiency or absence of the antihelix. These sutures create or augment the roll of the antihelix by approximating the scaphoid fossa closer to the concha. Place a series of horizontal mattress sutures in a row that centers on the crest of the antihelix. After surgical preparation has been completed, the surgeon shapes the ear with his or her fingers, forming the contours of the antihelix. See the images below.

Incision and dissection

Incision and dissection are carried out as above. Clear excess muscle and connective tissue from the area of the antihelix fold. Manipulate the ear and verify the suture sites.

Placement of sutures

The authors favor taper needles (eg, Ethicon RB-1, C-1, SH) because they have less tendency to split cartilage and currently use 5-0 or 6-0 blue monofilament polypropylene because clear polypropylene is not supplied with these taper needles. At the time of this writing, no suture has been visible through the skin. Clear monofilament polypropylene sutures are available on a variety of cutting needles (Ethicon P-4, PS-2), which also give satisfactory service.

The first mattress suture penetrates the full thickness of the cartilage of the (potential) scaphoid fossa. The bite is wide enough for secure engagement of the cartilage but not so wide as to bend the cartilage on any axis other than the crest of the antihelix. The second bite engages a full thickness of the corresponding conchal cartilage. With each bite, before the needle is passed completely through the cartilage, check the anterior auricular skin to see that the suture did not penetrate or catch the anterior skin or subcutaneous tissue. Complete the suture path and tentatively tighten the suture. Judge the resulting fold and adjacent contour changes.

Final positioning of sutures

Mustardé sutures are pulled just tight enough to create the desired antihelix roll and to allow for a small amount of postoperative settling. Judge the final position of the ear by examining the full face with both ears in view, placing the table low enough to provide good perspective. An effort is made to place the fold so that the rim of the helix is just visible outside the new antihelix crest.

Once the correct antihelix roll has been achieved, tighten the mattress sutures no more than needed to maintain the roll. No effort is made to coapt the cartilage surface to surface. A double bowstring of suture spans the intervening gap. If the axis and curve of the antihelix appear correct, a surgeon's throw is laid, and the suture ends are clamped and set aside. After the complete series of sutures has been placed, recheck the position of the ear and readjust, knot, and cut the sutures. The maximal stresses occur around stitches in Mustardé sutures.[19] In some situations, placing, knotting, and cutting the sutures individually is more convenient.

Anterior approach for folding the antihelix

An alternative to the posterior approach is placement of a series of tiny incisions anteriorly, through which the mattress sutures are passed through the cartilage, and subcutaneously. The knots are cut anteriorly beneath the skin.

Modifications

The most superoanterior Mustardé suture may be more effective if it is placed from the triangular fossa (rather than the concha) to the scaphoid fossa, enhancing the superior crus of the antihelix. The remaining sutures pass from the scaphoid fossa to the concha. The most caudad suture usually passes from the cauda helix to the posterior conchal wall. This suture tends to reinforce the antihelix roll and to influence the position of the earlobe.

C-M Sutures

C-M sutures are mattress sutures that correct the excessively deep concha. They lower or flatten the protruding concha, diminishing the distance between the conchal rim and the mastoid area, as shown below.

Incision and dissection

The initial incision and dissection are started as above; then further dissection and soft tissue excision are carried out to aid in lowering the concha.

Elevation of the musculoareolar flap or exposure of the conchal nest

Continue elevation of the musculoareolar flap posteriorly, protecting obvious branches of the postauricular vessels and the great auricular nerve if possible. Identify the mastoid fascia and sternocleidomastoid origin as the bottom of a postauricular nest that accommodates the repositioned conchal cup. (Bulky postauricular soft tissue is excised if needed to enhance the nest.) Retain sufficient layers of mastoid fascia, sternomastoid aponeurosis, and periosteum on the floor of the nest to provide reliable anchorage for the C-M sutures.

Once the anchorage provided by the postauricular ligament and other soft tissues has been freed, the ear loses positional stability. Take care to maintain orientation of the pinna and patency of the auditory canal as the sutures are placed.

Placement of sutures

C-M sutures are mattress sutures that correct the excessively deep concha. They lower or flatten the protruding concha, diminishing the distance between the conchal rim and the mastoid area. The sutures pass from the posterior conchal wall to the mastoid periosteum and fascia, as shown below. Because the C-M sutures bear more force than the Mustardé sutures, 4-0 or 5-0 sutures are employed. The materials and needles are otherwise the same as for the Mustardé sutures.

Hold the ear in its new position to judge the correct placement of the sutures. If the cartilage bite is placed too high on the wall of the conchal cup, the mattress suture flattens the cup against the mastoid process excessively. If the cartilage bite is too low on the conchal wall, the suture is ineffective. Alignment of the sutures is important. A mastoid bite that is too far posterior elongates the concha transversely, while a mastoid bite that is too far anterior may flatten or even kink the external auditory canal. Superior-inferior alignment also must be accounted for because loss of ligamentous and muscular support makes vertical displacement of the ear possible.

Once the correct sites have been determined, place 4 or 5 monofilament sutures (4-0 or 5-0) according to the markings and the anatomic landmarks. The first bite of the needle engages the full thickness of the conchal cartilage. The second bite of the needle engages the mastoid fascia or the aponeurotic origin of the sternocleidomastoid muscle. Tighten the sutures, seating the conchal cup in its nest and compressing the protruding sidewalls so that the conchal bowl is shallower and wider.

Tying the concha-mastoid sutures

Tie each suture with the first throw of a surgeon's knot and evaluate the effect by a full frontal view of the face and both ears. If the conchal position is satisfactory, tie and cut the sutures. If extra holding power is needed during the initial placement of trial sutures, incorporate surgeon's knots with triple throws or figure-of-eight mattress sutures. Figure-of-eight sutures are more stable in holding their position after the first throw, but they also have a greater tendency to erode cartilage if pulled tight.

The elasticity of the conchal cartilage transmits a continuous force to the sutures during the period of healing and maturation. Therefore, the bites of tissue must be of ample thickness and breadth, and the tension under which they are tied must give approximation without strangulation. If the position of the ear appears incorrect once the sutures have been tied and cut, strategic placement of another suture or two usually corrects the problem. If the problem persists, removing and replacing some or all of the sutures may be necessary. If a particularly severe protrusion of the concha is corrected, a natural side effect is to lose the smooth transitional curve from conchal floor to posterior wall and instead to have a crease at the transition. The musculoareolar flap is sutured over the C-M sutures with absorbable material.

Fossa-Fascia Suture for the Prominent Upper Pole

Occasionally, the upper pole of a prominent ear is exaggerated in its protrusion and is difficult to correct with the usual combination of Mustardé and C-M sutures. This is usually the situation in the constricted ear. Occasionally, a sharply protruding upper pole is the patient's sole aesthetic problem. In such situations, the anchorage point selected is in the borderland of the mastoid fascia and the deep temporal fascia. For greatest effectiveness, using the deep temporal fascia yields the best result. Direct suturing of the cartilage of the triangular fossa or the scaphoid fossa to the deep temporal fascia provides excellent control over the upper auricular pole. See the image below.

Dissection

Carry out ample elevation of the skin and scalp on both sides of the superior auricular sulcus, exposing the cartilage of the anterior-most part of the scaphoid fossa and of the triangular fossa. On the medial side of the sulcus, the superficial temporal fascia is exposed. Manipulate the ear to judge the best sites for suture placement. The superficial temporal fascia then is windowed to expose the deep temporal fascia by scissors-spreading dissection in a vertical direction, avoiding injury to the branches of the superficial temporal and postauricular vessels.

Placement of sutures

Using the techniques described above, place mattress sutures from the deep temporal fascia to the auricular cartilage. One or two carefully placed sutures are usually all that are needed, since little resistance is present for the sutures to overcome.

An adverse effect is an inconspicuous effacement or elevation of the superior auricular sulcus.

Prominent Earlobes

Prominent earlobes frequently persist after a prominent auricle has been repositioned. Several techniques have proven useful.

Patterned lobe reattachment

Inferiorly extend the crescentic pattern of the postauricular skin excision into the postauricular sulcus. Widen the pattern in a dumbbell shape within the posterior sulcus of the earlobe. Thus, mirrored patterns of skin are removed from the medial surface of the lobe and from the mastoid. Skin closure reduces the prominence of the earlobe. An adverse effect is encroachment of the closure area on the earring area of the lobe. Medial placement of the lobe can be enhanced by placing mattress sutures from the fibrofatty tissue of the lobe to the conchal cartilage or to the aponeurotic fibers of the insertion of the sternocleidomastoid muscle. See the image below.

Percutaneous lobe-anchoring sutures

Make one or more 2-mm punctures in the lateral surface of the earlobe and, with fine-tipped scissors, undermine the skin around each puncture to minimize dimpling of the lobe. Pass a 7-0 Prolene suture on a P-6 needle through the puncture and then beneath the surface of the posterior skin of the lobe so that it emerges from the postauricular wound. Then place an anchoring bite through conchal cartilage, after which the path of the suture is reversed so that it emerges through the puncture wound. Direct the to-and-fro paths of the needle so that they are separated by ample fibrofat before they converge on the puncture.

Then tie the suture so that the fibrofat incorporated in the suture is drawn toward the conchal anchorage point, thus drawing the prominent lobe into an inconspicuous position. Manipulate the skin edges of the puncture to avoid dermal penetration by the needle and resultant dimpling. Cut the suture on the knot and close the puncture with 7-0 polypropylene.

An alternative is to reverse the process, starting the first pass of the suture at the conchal cartilage, emerging from the puncture wound of the lobe, and then re-entering the puncture wound, passing the suture beneath the skin of the lobe and emerging near the concha. The knot is then placed on the conchal cartilage. A heavier suture can be used for this alternate variation but judgment of the correct tension for tying the suture is more difficult.

Combined Sites of Suture Placement

The steps in a suture otoplasty are selected to deal with the particular clinical problem. The above types of sutures can be used in any combination. The sequence of steps is planned for ease of suture placement and for the ability to evaluate the position of the ear as the steps proceed. Often, the conchal bites of the different types of sutures intermingle. When this is the case, the sutures are kept separated by group to avoid entanglement. The Mustardé sutures are held anteriorly in a single mosquito clamp, the C-M sutures are held posteriorly in another clamp, and F-F sutures are held caudad in another. The C-M sutures are tied first. Then the Mustardé sutures are tied, checking the changing position of the ears as these steps proceed. Finally the F-F and lobe sutures are tied.

Otoplasty and Stiff, Heavy Auricular Cartilage

If the cartilage of the protruding ears is stiff and heavy, the force required to move the unmodified auricle may provoke erosion of the sutures through the cartilage, with relapse of the otoplasty. C-M sutures bear more tension than the other types of sutures, and several modifications are designed to ameliorate the possibility of excess tension.

Conchal thinning

In the partial thickness cartilage excision, posterior approach, thin the accessible areas of the floor of the conchal cartilage with a scalpel or a Nagata-Hoshi gouge or with a looped Gillette Techmatic blade, if available. Take great care to avoid sharp edges or fractures at conspicuous sites. Continue trimming from the conchal floor to the conchal walls, thinning the junction area between floor and walls. Continue trimming as far forward as feasible on both the inferior and superior conchal walls. This step alone sufficiently may reduce the spring, or resistance, of the concha. The diminished conchal volume adds to the ease of conchal reduction. A side effect is a sharper angle or furrow at the transition zone between the conchal walls and the floor.

Full-thickness conchal cartilage excision, posterior approach may be indicated for stiffer, thicker cartilage. From a posterior approach, cartilage is removed from the floor and from the junction zone of the sidewalls. The farther forward the excision extends on the conchal bowl, the more thoroughly the spring is nullified.

The popularity of auricular cartilage grafts in nasal reconstruction has made the anterior approach to conchal cartilage familiar to all plastic surgeons. A full-thickness crescent of skin and cartilage, centered on the posterior wall but incorporating the entire posterior 180° of the concha, removes the resistance of the stiff cartilage. The cartilage crescent is designed for accurate approximation of the cut edges of cartilage with absorbable sutures. The crescent of excised skin is narrower than the crescent of cartilage. This provides for ease of skin closure while at the same time removing sufficient skin to avoid redundancy. An adverse effect is an anterior concha scar that, with careful placement, is inconspicuous. Occasionally, the slope of the conchal bowl makes the scar difficult to hide. Also, scars can bowstring within the concavity.

Stenstrom antihelix scoring, abrading, and thinning

When heavy cartilage resists the effect of Mustardé sutures, release of Gibson interlocked stresses by scoring or abrading the crests of the antihelix causes the antihelix to curl in the correct direction as observed by Stenstrom in 1978. Gain access to the antihelix crest by dissecting an anterior subcutaneous tunnel, which starts at the apex of the angle between the cauda helicis and the concha and continues subcutaneously along the crest of the antihelix. Direct careful scissors-spreading dissection with fine sharp-on-sharp iris scissors along the crest of the root and superior crus of the antihelix. To abrade the antihelix, use a hand-held Midas B3D or B2D diamond burr (no motor). Employ sufficient abrasion to gain the desired release but take care to avoid excessive abrasion with the possibility of fracture and a sharp edge. See the images below.

Posterior groove of antihelix

Direct posterior thinning of thick cartilage of the antihelix is another method of reducing the resistance to formation of an antihelix fold and to controlling the line of the fold. Removing cartilage from the posterior surface is counter to the Gibson effect, but this is overcome readily by Mustardé sutures. The cartilage excision must be performed over a wide enough swath, leaving sufficient thickness so that a sharp fold or fracture does not result. Such a complication significantly degrades the result.

Scoring the whole anterior surface of the auricular cartilage

Perez-Macias reported using a rasp to score the whole anterior surface of the auricular cartilage, including the concha, in combination with Mustardé and conchal-mastoid retention sutures in 675 ears over 23 years with good results for all patients, with minimal complications.[20]

Otoplasty for Prominent Ear With Soft, Floppy Auricular Cartilage

Prominent ears with soft, floppy cartilage are uncommon in children or adults. Such ears sometimes have an incomplete helix rim and usually have both a deficient antihelix and a deep concha. Some present as a Stahl ear (see paragraph below). A standard suture otoplasty for prominent ears with soft, floppy cartilage can be a treacherous procedure. Once the key sutures are placed, the correction may appear to be excellent and then, within a matter of minutes, the position or the cartilage changes, and what was at first a satisfactory antihelix roll has capsized into a series of transverse undulations.

In normal cartilage, the antihelix roll is formed by the compression of the limbs of the mattress suture, which are parallel to the axis of the antihelix. The limbs of the suture that traverse the axis serve to maintain the compression of the axial limbs. If the cartilage is unduly flexible, the transverse limbs of the mattress sutures can exert compression and deformation. This deformation takes the form of a transverse arch, such as a third crus, or a series of undulations. With some minor manipulation of the cartilage, the proper shape of the antihelix roll can be retrieved but this correction most likely is only temporary unless preventive measures are taken. Several steps are useful in correcting prominent ears with soft, floppy cartilage.

Multiple sutures

If the mattress sutures are placed at close intervals along the antihelix so that the axial limbs of sutures are shorter and closer together, the axial compression of the cartilage is strengthened, and the opposing compression is weakened.

Stenstrom scoring

Gently scoring the cartilage along the crest of the antihelix aids in giving stability to the roll of the antihelix. Deep abrasion can fracture the soft cartilage, causing sharp edges and angles.

Molding techniques

After completion of steps 1 and 2, further stability is provided by shaping the ear with a padded splint or a dental compound mold and Steri-Strips.

Bauer's Operative Technique

The details of the procedure are discussed with the above general sequence in mind. While every effort is made to describe the nuances of each step, the indications and benefits of each maneuver become readily evident as one gains more experience with the procedure and better appreciates the flexibility inherent in this approach. With rare exceptions, to be noted, the techniques used are similar in both children and adults.

Under general anesthesia with a reverse airway endotracheal tube (or under IV sedation), the face and both ears are sterilized with a green soap solution and subsequently draped with a standard head drape. Stray hairs are secured with a Tegaderm or other clear sterile drape. A 0.5% lidocaine with 1:200,000 epinephrine solution is infiltrated into the anterior and posterior surfaces of both ears. Bilateral great auricular nerve blocks with 0.25% bupivacaine are also injected for postoperative analgesia. A broad-spectrum antibiotic is given intravenously after placement of the IV.

The procedure typically begins on the more prominent side and starts with the incision on the anterior surface of the concha. The incision is placed at the junction of the posterior conchal wall and floor of the concha. It begins in the cymba concha and continues along the cavum concha to a point below the antitragus, but not as far as the external auditory meatus. This incision is deeper in the concha than the incision described by Elliott in 1990.

Placing the incision too high in the concha decreases control of the antihelical fold, allowing the cut edge adjacent to the antihelix to spring forward when the antihelix is shaped. The incision is carried through both the anterior skin and conchal cartilage, stopping shy of the posterior conchal skin. Sharp dissection in the loose areolar plane behind the concha (not in the subperichondrial plane) frees soft tissue and skin from the posterior surface of the conchal bowl. A gentle setback of the antihelix with finger pressure accurately estimates the degree of conchal hypertrophy and the amount of cartilage and skin resection needed to create an aesthetically pleasing position for the ear.

Usually a crescent-shaped chondrocutaneous segment is excised. To assure a tension-free closure, more cartilage is typically resected than skin, particularly along the inferior concha deep to the antitragus (where excessive resection tends to pull the antitragus upward and increase prominence of the lower pole of the ear and lobe). The edges of the conchal cartilage are then approximated with 3 or 4 interrupted 5-0 clear nylon sutures. The placement of the most inferior suture (at the junction of cavum concha and antitragus) adjusts the angle between these landmarks and strongly influences the cartilage support to the lobule. A slight overlapping of cartilage (antitragal segment over conchal segment) tips the lobule posteriorly.

Once the cartilage is repaired, the anterior skin is next closed with a combination of 5-0 chromic gut, with horizontal mattress sutures, followed by a running 6-0 mild (fast absorbing) chromic gut. With these maneuvers completed, the helical rim and ear may at first seem more prominent, but gentle pressure again applied to the antihelix demonstrates relaxation of the tension needed to bend the antihelix back for its desired correction.

Correction of the effaced antihelix and prominence of the lobule first begins with a retroauricular squid-shaped skin excision down to the perichondrium. The squid-shape excision (which, in essence, is the typical dumbbell-shaped ellipse with the inferior end widened to a diamond shape) is designed to allow access to the posterior surface of the scapha and helical sulcus for suture placement and to assist in correction of the lower pole prominence. The diamond-shaped inferior extension of the squid is positioned with its maximal width at the point of maximal lobule prominence. Exposure of the posterior surface of the conchal bowl and scapha is achieved without dissection of any perichondrium off the cartilage. Preserving the perichondrium is essential to lessen the possibility of subsequent sutures pulling through the cartilage.

As the dissection proceeds to expose the posterior surface of the cartilage, care is taken to identify and free the helical tail. The latter is seen as a duplication of cartilage extending inferiorly from the mid to lower third of the helical rim. This dissection must not free the cartilage of the tail from the skin overlying its anterior surface because this diminishes the effectiveness of correcting the prominence the lobule. The final dissection proceeds onto the mastoid surface, freeing the soft tissues sufficiently to assure that later sutures can be securely placed into the mastoid fascia. Bipolar cautery is used throughout to assure hemostasis.

Prior to placing the sutures that further correct the ear prominence, pressure on the helical rim and antihelix again demonstrates that the spring, or resistance of the cartilage to further shaping, of the antihelix is significantly decreased and the reshaping can be accomplished without any sharpening of the antihelix. This is a key point to recognize in this otoplasty technique because even a limited amount of conchal resection results in this lessened spring and increased ease of shaping the antihelix. With the current exposure of the posterior surface of the concha, if additional sutures are needed to complete an accurate closure of the conchal defect, they can be placed now, preceding placement of the key posterior shaping sutures.

Two or three 4-0 clear nylon sutures are placed from scaphal cartilage and helical sulcus cartilage to mastoid fascia to correct prominence of the upper and mid third of the ear. The third, most superior suture may be placed from the region of the triangular fossa to the temporal fascia. The proper placement of these permanent sutures is noted by applying pressure to the desired points on the anterior surface of the ear with a straight Keith needle, then passing the point of the needle through the selected spot so it can be visualized on the posterior surface of the cartilage. The nylon suture is then placed at each specific point without need of tattooing the cartilage. As the suture is placed, the Keith needle is withdrawn. The sutures are then passed through mastoid or temporal fascia.

Once all of the sutures are placed, they are tied beginning with the scaphal suture and are tied at the proper tension to create a smooth antihelical fold. Before cutting each suture, a forceps is used to grasp the knot and slide it down against the mastoid surface (minimizing any risk of later extrusion of sutures). As these sutures are tied, care should be taken to observe the relationship of the reshaped antihelix and the helical rim to assure that the helical rim remains visible from the frontal view. The triangular fossa to temporal fascia suture is only required if there is a need to pull the helical root closer to the head.

In adult patients, where the cartilage of the antihelix may be less flexible, 1 or 2 additional sutures may be required to shape and round the antihelix. These sutures are placed from scapha to the cut edge of the concha, deep to the inferior crus, and from helical sulcus to the cut edge of concha at right angles to the antihelix. These sutures are placed prior to the ones described above in order to preshape the antihelix, before further correcting the prominence. This maneuver is in lieu of other otoabrasion techniques that, even if done carefully, may still result in later irregularities on the anterior surface of the antihelix.

Once the upper and mid auricular prominence is corrected, the lobule position is addressed with closure of the posterior squid-shaped defect using 5-0 chromic gut. With the diamond-shaped inferior portion of the squid designed as described above, the appropriate contour, shape, and projection of the lobule is created by varying the initial suture position with A2 (ie, the point of the diamond at point of maximal lobule prominence). Once this initial suture is placed, the remaining closure is accomplished with a running 5-0 chromic suture. Correction of the more prominent side first allows for a symmetrical setback by providing a guide for placement of the sutures that define the antihelix and lobule prominence.

The most common adjunctive procedures include reduction of prominence of the antitragus and correction of irregularities in the helical rim in the area of the Darwin tubercle. Each of these procedures is accomplished through a small incision parallel to the border of the prominence (eg, within the concha for the antitragus, lateral to the helical rim for the helical rim adjustment), followed by direct exposure and resection of the excess cartilage. This is followed by closure with an interrupted and running 6-0 mild chromic suture. Additional procedures to treat major deformities of the helical rim, or reduction of excessively large lobule, are reviewed below with specific examples. Small degrees of lobule enlargement can be addressed with a small wedge resection within the lobule, while larger resections are best placed at the junction of the lobule and mid third (ie, helix, antihelix), where the splice can be stair stepped at the splice point. These procedures are the exception and not the rule.

Dressings

Tape the ends of the subcuticular sutures with Steri-Strips. Mold petroleum jelly gauze into the lateral contours of the ear and in the postauricular sulcus. Cover the ears with soft gauze pads. Preplace a long vertical Kerlix strip over each eye and wrap the head with a roll of Kerlix gauze, applying gentle, even pressure to both ears. Then, tightly tie each vertical gauze strip, compressing the head wrap to clear the visual fields. Compress the head wrap lightly with circumferential paper tape. Tape the wrap to the skin at several points to minimize shifting.

Remove the dressing on the first postoperative day to check for hematoma, pressure points, or shifts in position. Replace the dressing by gauze pads held in place with a circumferential elastic surgical net or with an elastic headband. Recheck the position of the ears at frequent intervals. Undesired features can be adjusted in the early postoperative period by molding the ears with nonsurgical treatment methods. Postoperative visits are scheduled frequently during the early postoperative phase, so one can intercede promptly with these conservative steps if needed. The authors ask the patient to look in the mirror daily to become familiar with the features of the newly positioned ears and to note any change that should be called to attention.

Preoperatively, Furnas asks the patient or the parents to select several attractive elastic headbands for postoperative wear. The headband diminishes the force borne by any C-M sutures and helps to allay edema. Tennis sweatbands usually suffice. The use of 2 headbands at the same time may be helpful. Parents can purchase patterned elastic material from which to make customized headbands for their children. The authors ask patients to wear the headband most of the time for 3-4 months, followed by wearing the bands at home for another 3-4 months. If the patient is truly embarrassed or reluctant to use the headband, the authors do not insist on it, but objections are a rarity when the rationale is explained. In adults, headbands are not used; careful observation is employed.

Remove any skin sutures on postoperative day 5-7. The subcuticular suture in the postauricular sulcus is left until day 10 or later.

Observe the patient for routine follow-up care on the first postoperative day and for suture removal and examination at 3, 6, and 12 months postoperatively. Follow-up photographs are made at the 3-, 6-, and 12-month visits with standard views for comparison. Subsequent follow-up visits are made electively.

Pain and hematoma

Excessive pain soon after surgery suggests the onset of a hematoma, which is a rare complication. It can result from the rebound effect of epinephrine, from inadequate hemostasis, from postoperative trauma, or from coagulopathy. The ears are inspected routinely on the first postoperative day.

Infection

Infection rarely develops with an otoplasty. At the first suggestive sign, instigate prompt and adequate antibiotic treatment to prevent chondritis. If chondritis is established, usually hospitalization, intravenous antibiotics, and drainage are required. Failure to control chondritis early can lead to major cartilage loss and deformity of the ear.

Late complications

Rarely, a patient develops hypertrophic scarring or keloids in the postauricular incision. Application of pressure and intralesional injection of corticosteroid preparations are the accepted treatments of hypertrophic scars, and they are of some use in the treatment of keloids. After excising keloids in adults, low-dose radiation appears to help prevent recurrence. Colchicine, penicillamine, and beta amino propionitrile are mentioned in the discussion of keloids but are not used widely.

Suture complications

The monofilament nonabsorbable sutures used for suture otoplasties can erode through the thin postauricular skin. If exposure of a suture occurs, it is usually many months after the original otoplasty, and the suture is no longer essential; it simply is removed.

Hypersensitivity

Occasionally, a patient has tenderness in the postauricular area, particularly during the peak of wound immaturity. Regenerating axons usually cause this tenderness, and it decreases with time.[21]

Recurrence of prominence of ear

Relapse of prominent ears is quite rare. It occurs when the stiff heavy conchal cartilage overcomes the strength of the anchoring tissues or when soft floppy cartilage buckles from the effect of the pull of the sutures. A repeat procedure is selected, taking into account the causes of the relapse. If the procedure is chosen well and executed with care, another relapse is unlikely. A postoperative elastic headband is worn for 6-12 months. In Bauer's earlier experience, the cases prone to recurrence were in younger children with a constriction component to the prominence. In these cases, the authors now use an additional scaphal suture to the cut edge of the concha to resist the forward spring of the upper pole of the ear. No recurrence has been noted since following this approach.

Contour defects and irregularities

An otoplasty that appears pleasing at the completion of surgery can shift, buckle, or curl from intrinsic biomechanical effects or from external pressures (eg, shifting head dressing, gravitational pressure when sleeping). Such irregularities often can be corrected in the early postoperative period using molding material and Steri-Strips for the finer irregularities and elastic headbands and ear wedges for larger areas of involvement. Prompt recognition and rapid treatment usually result in a favorable response. Emphasize that any procedure involving scoring or cutting the antihelical cartilage runs some risk of cartilage irregularities.

Hidden helix

If the ears are overcorrected, the helix cannot be seen on a frontal view. Even though this is a common finding in typical ears, it is considered unaesthetic in an otoplasty.

Telephone deformity

A relative prominence of the upper and lower poles is caused by excessive reduction of the concha or inadequate correction of the upper and lower poles.

Incidence of complications

Using pooled proportions, a literature review by Sadhra et al reported the following incidences of complications following prominent ear correction[22] :

• Pain and itching - 13%
• Skin/wound healing problems - 3%
• Hematoma and/or bleeding - 2.5%
• Suture-related problems - 1.8%
• Scarring - 1.6%
• Infection - 0.8%

The study also determined the incidence of revision surgeries/recurrences to be 5%.

A well-planned and carefully executed otoplasty in a properly selected patient achieves the goal of integrating the ears as an aesthetically pleasing part of the patient's appearance in accordance with the patient's body image. Prognosis for a permanent correction is excellent.

Despite the preponderance of techniques describing accentuation of the antihelical fold as the key component of correction of the prominent ear, the prominent ear has many and varied etiologies, but the common denominator has been hypertrophy of the concha. The degree of conchal hypertrophy does not need to be great to have a positive impact when employing chondrocutaneous resection as the cornerstone of the otoplasty technique. Recognizing this fact is imperative, and to date, it is underappreciated. With even limited resection and resuturing of the cut concha, the antihelix yields to the posterior placement of sutures with a soft, smooth, rounded shape unmarred by any sharp irregular surfaces.

Despite concerns expressed by some authors and criticism of the anterior approach to the concha as a potential source of a keloid scar, Bauer has not reported unsightly scarring in any of these cases, nor in a much larger series of conchal donor sites for composite grafts used for ear reconstruction. This approach allows for ready adaptation to treatment of less common deformities and can also be applied to correction of deformities seen in grade I and IIa constriction (where the deformity is bilateral and significant increase in ear height is not required).

While a small number of patients have demonstrated minor asymmetries in the upper pole correction or in lobule shape or prominence, the adjunctive procedures mentioned above have now been applied more regularly at the initial procedure to avoid these areas of concern. To date, all revisional procedures, even in younger children, have been accomplished with a single procedure under local anesthesia in the office setting.

As measured using the Beck Depression Inventory, State-Trait Anxiety Inventory I-II, Rosenberg Self-Esteem Scale, and Body Cathexis Scale, a study by Ozkaya et al indicated that adult patients who undergo otoplasty for prominent ear experience improvements in body perception, self-esteem, anxiety, and depression. Mean postoperative scores on each test differed significantly from the preoperative results, with a high Rosenberg Self-Esteem score found in 42.42% of patients prior to surgery and in 96.96% of them postsurgically.[23]

Dr. Bauer's clinical caveats

See the list below:

• Correct analysis of each ear deformity is the most important step in otoplasty.

• Failure to fully appreciate all elements distorting the ear position and shape (particular the role of conchal hypertrophy) is a recipe for an unfavorable outcome.

• Otoplasty techniques that involve scoring or abrasion of the cartilage all run the potential risk of visible cartilage irregularities and a sharp antihelical fold.

• Placing the incision for conchal resection too high in the concha decreases control of the antihelical fold, allowing the cut edge adjacent to the antihelix to spring forward when the antihelix is shaped.

• To assure a tension-free closure of the concha, more cartilage is typically resected than skin, particularly along the inferior concha, deep to the antitragus.

• Excessive resection of skin or cartilage in the latter area pulls the antitragus upward and increases the prominence of the lower pole of the ear and lobe.

• When designing the squid-shaped excision, failure to taper the skin excision in its midportion may result in a postoperative telephone ear deformity.

• Preserving the perichondrium on both surfaces of the cartilage lessens the possibility of subsequent sutures pulling through the cartilage with resultant partial recurrence of the deformity.

Other

Fioramonti et al reported success with an otoplasty procedure utilizing the following steps[24] :

• Using a scalpel to create longitudinal and transverse incisions
• Scoring with needles
• Employing an Adson-Brown forceps to squeeze the antihelix region in order to create a natural cartilage fold
• Maintaining the fold with posterior mattress suture fixation

A mean postoperative protrusion change of 7.96 mm for the superior cephaloauricular distance was achieved in 71 ears.

In an interim analysis of a study evaluating the efficacy of the earFold implantable clip system for prominent ear (1200 implants; 403 patients), the percentage of patients requiring intervention for adverse events was relatively low (9.7%) over a 30- to 48-month period. Those events included skin erosion over the implant (3.7% of patients) and infection (1.7% of patients). Implant revisions, usually to resolve implant visibility, were performed in 4.2% of patients.[25]