Otoplasty: Jeffrey E. Janis, M.D., Rod J. Rohrich, M.D., and Karol A. Gutowski, M.D
Otoplasty: Jeffrey E. Janis, M.D., Rod J. Rohrich, M.D., and Karol A. Gutowski, M.D
Otoplasty: Jeffrey E. Janis, M.D., Rod J. Rohrich, M.D., and Karol A. Gutowski, M.D
Otoplasty
Jeffrey E. Janis, M.D., Rod J. Rohrich, M.D., and Karol A. Gutowski, M.D.
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Learning Objectives: After studying this article, the participant should be able to: 1. Understand the anatomy of the
prominent ear. 2. Correctly and precisely analyze the prominent ear deformity. 3. Establish and implement a surgical plan
to treat the prominent ear based on the available techniques. 4. Recognize the potential complications of surgical
correction of the prominent ear.
postoperatively to avoid leaving a visible fold in periosteum suture. Another method involves a
the conchal floor. curvilinear, fusiform excision from the ante-
Finally, careful scoring may be used alone or rior to posterior lobe margin with a central V
in combination to reduce conchal promi- excision to effect easy closure.1
nence. Using the Gibson principle, the ante-
rior surface of the concha can be scored so as
to warp the conchal wall in a posterior direc- Combined Techniques
tion. This essentially converts the prominent There have been countless descriptions by
conchal wall into scaphal surface. individual surgeons detailing their particular
combination of the above techniques to effect
Lobule Positioning
reproducible results. Stal et al. (1997) pub-
Wood-Smith uses a modified fishtail correc- lished an algorithmic approach for otoplasty
tion to correct the prominent lobule (Fig. 5).56 that uses many of the techniques in a logical,
Spira et al.23 treat the protruding lobule by systematic, graduated fashion (Fig. 6).57
wedge-excision and a deep dermis–to–scalp An ear with a deep concha but well-devel-
oped antihelical fold may only require a con-
chal resection, with the addition of a conchal
setback if the conchal-cephalic angle is greater
than 90 degrees. Commonly, a poorly devel-
oped antihelical fold will be present with or
without a deep concha. In this case, Mustardé-
type sutures should be used to create the fold.
Anterior cartilage scratching should be used as
an adjunct to help fold the cartilage. Superior
pole overcorrection should be considered be-
cause this area is prone to recurrence
A prominent lobule not corrected by finger
pressure on the helix rim will require one of
the previously described additional proce-
dures. Posterior scratching is contraindicated
because it results in cartilage bending in the
opposite rather than the desired direction.
Likewise, through-and-through cartilage inci-
FIG. 5. Modified fishtail technique to correct a prominent sions should be avoided because of the result-
lobule. ant visible step-off deformity.1
66e PLASTIC AND RECONSTRUCTIVE SURGERY, April 1, 2005
FIG. 6. An algorithmic approach to otoplasty. Reprinted with permission from Stal, S., Klebuc, M., and Spira, M. An
algorithm for otoplasty. Oper. Tech. Plast. Reconstr. Surg. 4: 88, 1997.
Vol. 115, No. 4 / OTOPLASTY 67e
Minimally Invasive Otoplasty Infection is another potentially devastating
To minimize operative dissection, scarring, complication of otoplasty, especially because it
and postoperative discomfort, two recent re- can lead to the development of chondritis and
ports advocate “incisionless” or “knifeless” oto- residual deformity. Infection can be caused by
plasty. Fritsch58 describes his incisionless tech- a break in proper sterile surgical technique or
nique whereby he places percutaneous, dehiscence secondary to excessive tension dur-
permanent subcutaneous horizontal mattress ing closure, or it can be an untoward sequela of
sutures. He reported this in 13 patients and prior hematoma evacuation. If redness, swell-
found one recurrence caused by suture failure ing, and drainage are encountered, treatment
at a 6-month mean follow-up. Peled’s tech- with intravenous antibiotics is recommended,
nique59 involves a similar suture technique but as is the use of topical mafenide acetate cream.
includes anterior cartilage scoring as well. No The usual pathogens are Staphylococcus, Strepto-
recurrence was found at follow-up at 6 to 30 coccus, and sometimes Pseudomonas.
months in 20 ears. Although the long-term Chondritis is a surgical emergency. If left
effects of this suture method are not known, untreated, it can result in deformity. There-
Fritsch points out that cartilage may be perma- fore, prompt débridement of devitalized tissue
nently bent by external splints and suggests is necessary.
internal sutures may have the same effect. Late sequelae. Residual deformity is, by far, the
Thus, long-term suture failure may not be clin- most common unsatisfactory result of otoplasty.
ically significant. It usually is apparent by 6 months postopera-
Graham and Gault’s endoscopic-assisted oto- tively and is manifested by one or more of the
plasty60 approaches the posterior aspect of the following61: a sharply ridged antihelical fold;
auricular cartilage through a port in the tem- lack of normal curvature of the superior crus;
poral scalp. The posterior cartilage is weak- irregular contouring; a malpositioned or poorly
ened by abrasion, and the antihelical fold is constructed antihelical roll; an excessively large
created and maintained by nonabsorbable scapha; and a narrow ear.
scaphal-mastoid sutures placed by means of Most of the time, the residual deformity is a
small postauricular stab incisions. By moving a result of poor surgical planning and execution
large scar into the temporal scalp, an ear ke- rather than an inherent technical problem.
loid or hypertrophic scar may be avoided. This However, there are several studies, some with
endoscopic approach was used on 18 promi- long-term follow-up, that illuminate several key
nent ears, with good results and no recur- differences in technique and potential
rences. Although these minimally invasive drawbacks.
techniques show promise, long-term follow-up In a retrospective comparison of Mustardé’s
and reproducible results are needed before posterior suturing technique to Stenstrom’s an-
they can be recommended as procedures of terior scoring technique, Tan62 found that
choice. although patient satisfaction with the aesthetic
results were the same between the two ap-
proaches, ears treated by Mustardé’s method re-
Outcomes and Complications quired more than twice as many reoperations
Elliott divided unsatisfactory results of oto- (24.4 percent versus 9.9 percent). Furthermore,
plasty into early complications and late sequel- Tan confirmed the complication of sinus forma-
ae.43 Early complications include hematoma, tion and wound infections caused by the pres-
infection, chondritis, pain, bleeding, pruritus, ence of sutures (15 percent incidence).
and necrosis. Late sequelae include unsightly Mustardé himself has conducted two reviews
scarring, patient dissatisfaction, suture prob- of his own procedure. The first, in 1967, sur-
lems, and dysesthesias. veyed his results with 264 ears over a 10-year
Early complications. Hematoma is one of the period.18 Seventeen cases were judged as unsat-
most dreaded immediate postoperative compli- isfactory with problems such as kinking within
cations. It is heralded by the acute onset of the antihelix, sutures cutting out, sinus forma-
severe, persistent, and often unilateral pain. If tion, recurrence of prominence, and horizon-
encountered, the head dressing should be re- tal projection of the antitragus and lobule. He
moved and sutures released to drain the hema- details the causes for each of these complica-
toma. If there is evidence of ongoing bleeding, tions and includes guides on avoiding these
reoperation and exploration are mandatory. pitfalls. A subsequent study in 1980 of 600 ears
68e PLASTIC AND RECONSTRUCTIVE SURGERY, April 1, 2005
FIG. 7. Preoperative views of a 13-year-old girl with a lack of antihelical fold definition, conchal bowl
hypertrophy, and prominent lobules. (Above, left) Anteroposterior view; (above, center) oblique view;
(above, right) lateral view; (below) posterior view.
over 20 years found a 0 percent incidence of 89 percent were either very satisfied or satis-
stitch rejection, a 0.01 percent incidence of fied. He also noted that in 81 percent of pa-
sinus tract formation, and a 0.02 percent inci- tients, the Stenstrom technique produced a
dence of reoperation.63 round, natural antihelical fold, whereas only
Spira and Hardy critically examined their 14 percent had a sharp contour. Calder and
experience with the Mustardé technique and Naasan reviewed their experience with 562
did not find the same success rates. They de- Stenstrom otoplasties and found a 16.6 percent
termined that there were a large number of overall complication rate with an 8 percent
relatively minor complications and a high rate incidence of residual deformity (follow-up, 12
of partial recurrence of the original deformi- months). After analysis of these results, they
ty.64 In a comparative study, Hyckel et al. com- concluded that the fault at the primary proce-
pared Mustardé’s and Converse’s methods and dure was mostly that of design (73.4 percent),
found no objective or subjective differences.65 although many other residual problems were
Heftner66 surveyed patient satisfaction with caused by poor execution of technique (26.6
use of the Stenstrom technique and found that percent).67
Vol. 115, No. 4 / OTOPLASTY 69e
Adamson et al. retrospectively reviewed their lage that was bent to create an antihelix, the
experience with conchal setback and antiheli- more likely the ear was to lose its correction.
cal suture placement in 119 ears, with a median Persistent superior pole prominence was
follow-up of 6 months.68 They found that pa- also noted by Georgiade et al.36 They recom-
tients who had cartilage-cutting procedures mended additional superior helix scoring or
tended to have higher revision rates and per- higher posterior vertical mattress suture place-
sistent postoperative stigmata compared with ment to resolve this problem. Webster recom-
those who had cartilage-sparing procedures. mends slight overcorrection of the superior
Specifically, they also found that the superior pole to allow for postoperative changes.
pole became lateralized to approximately 40 The psychological and social outcomes of
percent of the original correction, although no prominent ear correction were evaluated by
significant loss of correction was noted in the Bradbury et al.,4 who found improved well-
middle and inferior areas of the ear. This led to being in 90 percent of the children 12 months
revision in 6.5 percent of the ears. Adamson et postoperatively. However, just as preoperative
al. recommend adding fossa triangularis– distress could not be predicted from the de-
temporalis fascia sutures to correct this supe- gree of ear prominence, postoperative satisfac-
rior pole lateralization. tion could not be predicted from the quality of
Loss of superior pole correction was also surgical correction. Bradbury et al. recom-
reported by Messner and Crysdale69 in patients mend psychological evaluation for any child
who underwent cartilage-sparing otoplasty us- showing evidence of marked social isolation or
ing a combination of Mustardé’s and Furnas’ acute distress before any operation.
techniques, including placement of fossa trian-
gularis–temporalis fascia sutures. The cor-
CASE REPORT
rected ears returned to their preoperative po-
sition in one third of their cases, and one third A 13-year-old otherwise healthy white girl presented with
bilateral prominent ears. Physical examination revealed bi-
of their cases had a final position between their lateral prominent ears, lack of helical fold definition (right
preoperative and postoperative positions. De- greater than left), bilateral conchal hypertrophy (right
spite this loss of correction, 85 percent of pa- greater than left), and prominent lobules (Fig. 7). The op-
tients were satisfied with their results. Messner erative plan was as follows: general anesthesia; preoperative
and Crysdale noted that ears short in their marking of the antihelix with methylene blue dye; posterior
lenticular incision; excision of the auricularis; placement of
vertical dimension (less than 50 mm) were three Mustardé sutures (superior, middle, and inferior) using
much more likely to maintain their postopera- 4-0 clear nylon (Fig. 8); placement of two (superior and
tive corrected positions. The larger the carti- inferior) conchomastoid sutures using 4-0 clear nylon; and
FIG. 8. Intraoperative view of the right ear. (Left) Before the Mustardé sutures
were placed, the anticipated sites chosen to suture were marked with methylene
blue dye. Note the lack of definition of the antihelical fold. (Right) After the
Mustardé sutures were placed.
70e PLASTIC AND RECONSTRUCTIVE SURGERY, April 1, 2005
FIG. 9. Postoperative views at 6 months. (Above, left) Anteroposterior view; (above, center) oblique
view; (above, right) lateral view; (below) posterior view.
placement of a single lobule-fascial suture (4-0 clear nylon) described by Walter and Nolst Trenité.70 An oblit-
to bring back the prominent lobule. erated postauricular sulcus can be corrected by a
At 6 months postoperatively, the patient demonstrated
significant improvement in her antihelical fold definition.
posterior zigzag skin incision, approximation of
She had more properly proportioned ears without conchal the skin triangle points, and filling of remaining
bowl excess and less prominent lobules (Fig. 9). The patient defects with full-thickness skin grafts. A pros-
was very satisfied with her outcome. thetic device is worn to prevent tissue retraction.
Minor antihelix irregularities can be treated by
curettage, and larger defects may be corrected by
REVISION OTOPLASTY insertion of temporalis fascia, cartilage grafts, or
Otoplasty procedures may result in new defor- prosthetic materials. An obliterated ear canal
mities that need to be corrected, including an caused by improper conchal setback may be cor-
obliterated postauricular sulcus, contour defor- rected by cartilage resection through a posterior
mities of the antihelical fold, a telephone defor- approach. Revision for recurrence of ear promi-
mity, a protruding lobule, an obliterated external nence, especially at the superior pole, can be
ear canal, and postperichondritis deformity. Ap- achieved by posterior cartilage thinning and an-
proaches to these common problems have been terior scoring if the cartilage is thick and stiff.
Vol. 115, No. 4 / OTOPLASTY 71e
Replacement of the sutures should include 13. Luckett, W. H. A new operation for prominent ears
broad chondral anchorage points.71 based on the anatomy of the deformity. Surg. Gynecol.
Obstet. 10: 635, 1910.
14. Becker, O. J. Correction of protruding deformed ear.
SUMMARY Br. J. Plast. Surg. 5: 187, 1952.
15. Converse, J. M., Nigro, A., Wilson, F. A., and Johnson, N.
Auricular deformities, specifically, prominent A technique for surgical correction of lop ears. Plast.
ears, are relatively frequent. Although the physi- Reconstr. Surg. 15: 411, 1955.
ological consequences are negligible, the aes- 16. Converse, J. M., and Wood-Smith, D. Technical details
thetic and psychological effects on the patient in the surgical correction of the lop ear deformity.
can be substantial. This article reviewed the his- Plast. Reconstr. Surg. 31: 118, 1963.
17. Mustardé, J. C. The correction of prominent ears
tory of otoplasty, its anatomical basis and a using simple mattress sutures. Br. J. Plast. Surg. 16:
method for evaluation, techniques for correction 170, 1963.
of the deformity, and potential complications of 18. Mustardé, J. C. The treatment of prominent ears by
the procedure. Outcome studies show that, over- buried mattress sutures: A ten-year survey. Plast. Re-
all, patient satisfaction is extremely high, with a constr. Surg. 39: 382, 1967.
recurrence rate generally less than 10 percent. 19. Gibson, T., and Davis, W. The distortion of autogenous
cartilage grafts: Its cause and prevention. Br. J. Plast.
Accurate preoperative diagnosis of the specific Surg. 10: 257, 1958.
components of the deformity, proper planning, 20. Chongchet, V. A method of antihelix reconstruction.
and excellent technical execution of the proce- Br. J. Plast. Surg. 16: 268, 1963.
dure are paramount to obtaining a good, long- 21. Stenstrom, S. J. A “natural” technique for correction of
lasting, aesthetic result. congenitally prominent ears. Plast. Reconstr. Surg. 32:
509, 1963.
22. Furnas, D. W. Correction of prominent ears by concha-
Rod J. Rohrich, M.D. mastoid sutures. Plast. Reconstr. Surg. 42: 189, 1968.
Department of Plastic Surgery 23. Spira, M., McCrea, R., Gerow, F. J., and Hardy, S. B.
University of Texas Southwestern Medical Center Correction of the principal deformities causing pro-
5323 Harry Hines Boulevard, HX1.636 truding ears. Plast. Reconstr. Surg. 44: 150, 1969.
Dallas, Texas 75390-8820 24. Tolleth, H. Artistic anatomy, dimensions, and pro-
rjreditor–@plasticsurgery.org portions of the external ear. Clin. Plast. Surg. 5: 337,
1978.
25. Farkas, L. G., Posnick, J. C., and Hreczko, T. M. An-
thropometric growth study of the ear. Cleft Palate
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