Orthognathic Surgery

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CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
suturing over the grafts. This is managed by the
following:
• The dissection and release of the nasal lining, but
without perforation
• If necessary, the reduction of the height of the strut
grafts (i.e., the new nasal tip) to accommodate any
intrinsic soft-tissue limitations
• The dorsal and caudal strut grafts can be reinforced with
an internal no. 35 threaded K-wire to limit the risk of
warping. The decision to do so must be made before inset
and before the grafts are secured in place.
• The stair-step columella (skin) incision is closed with one
deep layer stitch (5-0 Vicryl). The closure of the skin
layer is accomplished (6-0 nylon), and the rim incisions
are closed with resorbable sutures (5-0 chromic).
• Antibiotic ointment (Bactroban) is injected into the
nasal cavity. Gentle packing in each nostril (Telfa) is
carried out to decrease intranasal swelling and
bleeding.
• Tape is placed over the dorsal skin (Steri-Strips).
• A custom splint (Aquaplast) is conformed over the
dorsum.
• The packs are removed after 48 hours.
• The dorsal splint is removed after 5 to 7 days.
The reconstructive outcomes for cocaine-related, auto­
immune, and iatrogenic cartilaginous vault collapse may
not be perfect, but they should provide a relatively normal
nasal form, often with an improved airway. The presenting
septal perforations will remain. The dorsal and caudal
support for the external nose that was deficient should be
restored without the need for replacement of the soft-tissue
envelope. The goal is for the individual to become socially
presentable without excessive attention being drawn to the
previous nasal deformity. This should be possible with a
single-stage reconstruction without extensive donor-site
scarring or disability in most patients.
Conclusions
Successful rhinoplasty is accomplished after the obtaining
of an accurate patient history; the performance of a thor­
ough head and neck examination that includes the intra­
nasal cavity; and the completion of a facial aesthetic
analysis. This is followed by engaging in a frank discussion
with the patient and the family about the treatment objec­
tives; the quality of the individual’s skeletal and soft tissues;
what is technically possible; and an appreciation of the
individual’s overall facial proportions. When combining
sound clinical judgment, technical expertise, and safe con­
ditions, the surgeon may perform precise functional and
aesthetic rhinoplasty with a predictable level of patient
satisfaction. Relieving nasal obstruction to improve breath­
ing and achieving an aesthetically pleasing nose that pre­
serves the individual’s uniqueness through a combination
of reduction and augmentation techniques remain the clear
objectives.
• The overlying cutaneous soft-tissue envelope is elevated
up the columella, superficial to the LLCs and ULCs,
subperiosteal over the nasal bones to the radix, and later­
ally toward the maxillary process on each side. The fully
elevated soft-tissue envelope will later be advanced cau­
dally over the reconstructed cartilaginous vault and nasal
tip at wound closure.
• The elevated mucosa lining is protected throughout the
dissection without perforation into the nasal cavity.
• Dissection also extends under the nasal bones (≈5 mm)
for later insertion (i.e., tongue and groove) of the dorsal
strut graft.
• If a dorsal bony “hump” requires reduction, this is con­
servatively completed with rasps.
• The medial crura are separated from each other via
scissors dissection down to the base of the maxilla and
the anterior nasal spine. This is accomplished without
perforation through the mucosal lining into the nasal
cavity.
• The deficient dorsal and caudal portions of the quadran­
gular cartilage are reconstructed with rib cartilage that
has been crafted into two separate struts. After the struts
are secured at their points of origin, they are sutured
together to form the new tip and to serve as a replace­
ment for the deficient cartilaginous vault.
• The caudal strut graft extends from the base of the
maxilla (i.e., the anterior nasal spine region) and then
up to the new nasal tip; this graft is approximately
25 to 30  mm in length. It is secured to the base of
the maxilla with a no. 35 threaded K-wire that has
been drilled into the anterior nasal spine region for
a depth of approximately 5  mm. If there is perfora­
tion through the palatal mucosa, the K-wire is backed
out. The K-wire is cut, with an extension of several
millimeters left above the exposed base of the maxilla.
The caudal strut graft is then pierced into the K-wire
to prevent the movement of the graft during the
healing process.
• The dorsal strut graft is notched via a tongue and groove
to extend several millimeters deep to the nasal bones and
then flush with the osseous surface that extends caudal
to the new nasal tip; the graft is approximately 35 to
40 mm in length. It is positioned either in between or
on top of the ULCs and then sutured in place to limit
movement during healing.
• The dorsal strut graft meets the caudal strut graft at the
tip. The two grafts are further crafted using a knife (no.
15 blade) to form the new nasal tip. They are secured
together with several interrupted non-resorbable sutures
(4-0 Prolene).
• The LLCs, having been trimmed of any cephalic excess,
are sutured together and then over the strut grafts to
form the most superficial aspect of the nasal tip (4-0
Prolene).
• One of the challenges is the management of any scar
contracture of the mucosa lining, which may limit
the caudal and anterior advancement of the LLC for

1692 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
Rhinoplasty (Reshaping the Nose) Surgery
A rhinoplasty surgical procedure may be designed to improve the appearance of the nose, to correct nasal breathing,
or both. The operation usually requires about 1.5 hours, and it is performed on an outpatient basis with the patient
under anesthesia. An additional several hours are spent in recovery before the patient is discharged home. A
customized splint is applied to the outside of the nose, and packing material is often placed inside. There will be some
discomfort for which pain medication is prescribed. Antibiotics will be given just before surgery and continued at least
until the packing is removed.
Discoloration and swelling occur in the cheeks and the eyelid region. The swelling gradually disappears, although
inadvertent trauma or sunburn may cause it to persist a great deal longer. The tip of the nose is usually numb for
several months after surgery, but this too improves with time.
The final results after rhinoplasty are not fully apparent for 6 to 12 months, at which point the nasal swelling has
subsided. For some patients, after rhinoplasty, there are dramatic changes; for others, the improvements may be more
subtle. Nasal surgery is an art and a science, but it is not magic. Your surgeon will try to preserve the positive
characteristics that make your nose unique while modifying the aspects that distract from your appearance. The goal
will be to modify specific undesirable characteristics to achieve a more harmonious balance of nasal and facial features
given your specific anatomic limitations. In general, aesthetic judgments will be conservative. When it comes to
rhinoplasty, it is better to remove less than more.
INSTRUCTIONS FOR RHINOPLASTY SURGERY
The purpose of these instructions is to help you to prepare for and then recover from your operation with as little
discomfort as possible and to minimize the risk of complications.
Preoperative Instructions
1.  For at least 2 weeks before surgery, do not take any aspirin, aspiring-containing products, or aspirin-like products
(e.g., ibuprofen). Do not take any medication that may increase bleeding during surgery or bruising afterward.
2. No smoking or nicotine in your bloodstream for at least 2 weeks before and 2 weeks after surgery.
3. Do not eat or drink anything after midnight the night before surgery, not even a sip of water.
4. Starting 2 days before surgery, we request that you shampoo your hair and shower at least once per day. The
morning of surgery, you may also shower and shampoo again.
5. Do not apply makeup the morning of surgery, and leave your jewelry at home.
6. Make arrangements for someone to accompany you home from the hospital the day of surgery, because you will
not be able to drive yourself.
Postoperative Instructions
1. After discharge from the hospital, eat lightly (mostly liquids). During the first week, avoid eating anything that is
difficult for you to chew.
2. Unfortunately, nausea and sometimes vomiting during the first 12 to 24 hours after surgery is not uncommon. If
you develop nausea or vomiting, take only clear fluids for the next 12 hours. Resume a normal diet gradually, as
tolerated.
3. Apply cold compress intermittently over your eyelids during the first 24 to 36 hours after surgery. By 36 hours after
surgery, the maximum facial swelling will have occurred. Cold compresses are of limited value after this time, but
they may be applied for comfort, if desired.
4. For the first week after surgery, sleep primarily on your back, with your head elevated on two pillows.
5. As before surgery, do not take aspirin or aspirin-like products (e.g., ibuprofen) for 2 weeks after surgery. You may
take Tylenol (acetaminophen) as you wish.
6. For comfort, you may wish to use Vaseline petroleum jelly or any over-the-counter antibiotic ointment around the
nostrils to keep them from drying out. Do not insert anything deep inside the nostril. Use and change the dressing
beneath your nose as needed.
7. You may shower from the neck down the day after surgery. You should also wash your face and hair, but do not
get the nasal splint wet. After the splint has been removed, you may shower and shampoo your hair and face in a
more regular way.
Patient Education Materials

1693
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
8. Take your usual prescription medication as directed and approved by your surgeon beginning the day after
surgery.
9. Get lots of rest and don’t do anything that requires more than limited physical exertion during the first week after
surgery. You may then gradually increase your activity level, but no sports or gym activities may be performed
during the next 4 to 6 weeks as per discussion with your surgeon.
10.  You may take the prescribed pain medication as directed on the label. Take the antibiotic medications as directed
until the supply is exhausted.
11. When you sneeze, try to do so through your mouth. Do not blow your nose for 2 weeks, and only use nasal
sprays that have been approved by your surgeon.
12. Do not consume beverages that contain alcohol or drive while taking prescription pain medications.
13. If you wear contact lenses, you may be comfortable enough to resume lens wearing within 48 to 72 hours. In
addition, eyeglasses may be adjusted to rest on or just above the splint. After the removal of the splint (i.e., 5 to 7
days after surgery), you should avoid letting your glasses press heavily on your nose for at least 6 weeks.
14. Make an appointment to see your surgeon on the specified day by calling the office.
Remember the following:
1. Your skin will be noticeably discolored around the eyes and swollen for about 2 weeks. The discoloration will move
down your face and neck. The extent of the swelling and discoloration will vary on the two sides of the face.
When the nasal packs are removed (approximately 2 days after surgery), further intranasal swelling will occur and
create ongoing difficulty with breathing through the nose. This will gradually resolve over several weeks.
2. The shape of your nose will go through its biggest changes during the initial 3 to 6 weeks after surgery, but it will
take about 6 months to 1 year before the final swelling subsides. This is especially true for the nasal tip region.
3. Because of the surgery and the need to cover the nasal soft tissues with a splint during the first week, expect
peeling of the skin and blocked pores. You may also go through a short period of acne breakouts. Just wash the
affected area gently. The condition of your skin will improve over the course of 5 to 10 days and should gradually
return to normal.
Jeffrey C. Posnick, DMD, MD
Director, Posnick Center for Facial Plastic Surgery
Consent for Rhinoplasty Surgery
_____
INSTRUCTIONS
Initial here
This is a document that has been prepared by your surgeon to help educate and inform you about your
rhinoplasty surgery and its risks as well as alternative treatment options. It is important that you read
this document carefully and completely. Please initial each section on each page to indicate that you
have read and understand it. When all of your questions are answered, please also sign the consent for
surgery on the last page as proposed by your surgeon.
_____
INTRODUCTION
Initial here
Rhinoplasty (surgery of the nose) is an operation that is frequently performed to produce changes in the
appearance, structure, and function of the nose. Rhinoplasty maybe carried out to alter the dorsum
(height or width) of the nose; to change the shape of the nose’s tip; or to change the angle between
the nose and the upper lip. This operation can also help to correct birth defects or nasal injuries and to
help relieve breathing problems.
There is not a universal type of rhinoplasty surgery that will meet the needs of every patient. The surgery
is customized in accordance with your needs and any specific anatomic limitations. Incisions are
generally made within the nose and also into the skin of the nose. Internal nasal surgery to improve
breathing can often be performed at the same time.
Continued

1694 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
Nasal surgery is an art and a science, but it is not magic. Your surgeon must work with your specific
tissues (e.g., skin, bone, cartilage, mucosa lining) in an attempt to improve nasal appearance and
function. The results of the operation depend on the characteristics and qualities of your specific
tissues and on complicating factors such as scarring, tissue deficiencies, and irregularities from
previous surgery, injuries, or nature.
No nasal surgery is totally perfect. If you believe that small imperfections in the surgical result will prevent
you from appreciating the positives, you should not proceed with rhinoplasty. Every small imperfection
cannot be corrected or reoperated on; this approach would lead likely to an “operated” appearance
that is unfavorable. Your surgeon will do his or her best to communicate what the planned procedure
can and cannot do for you. You are encouraged to ask questions and to openly communicate your
concerns.
To reshape a nose, cartilage or other types of grafts may be useful to provide structure and support.
Usually these grafts are not visible, but sometimes they can be seen as small bumps or edges through
the skin. You may be able to feel them, even if they cannot be easily seen. In some patients, it is
possible that cartilage or bone grafts can be partially absorbed by the body or change shape to the
extent that they may need to be replaced.
The best candidates for rhinoplasty surgery are individuals who are looking for improvement but not
perfection with regard to the appearance of their nose. In addition to realistic expectations, good health
and psychological stability are important qualities for a person who is considering rhinoplasty surgery.
You must also understand the possible risks and complications and consider the other options
available. Rhinoplasty can be performed in conjunction with other procedures (e.g., genioplasty) to
enhance your facial appearance.
_____
ALTERNATIVE TREATMENT
Initial here
Alternative forms of management include not undergoing any surgery at all or considering other more or
less extensive nasal procedures. Risks and potential complications are also associated with alternative
forms of treatment or surgery and should be considered before you make a decision about the
procedure that is right for you.
_____
RISKS OF RHINOPLASTY SURGERY
Initial here
With any type of surgery, there is inherent risk. An individual’s decision to undergo a specific rhinoplasty
procedure is based on the comparison of the risk to the potential benefit. Although the majority of
patients do not experience the complications detailed below, you should discuss each of them with
your surgeon. Be sure that you understand the risks, potential complications, and consequences of the
specific rhinoplasty procedure that you intend to undergo.
_____
BLEEDING
Initial here
It is possible, although unusual, that you will have problems with bleeding during or after surgery. Should
postoperative bleeding occur, it may require urgent treatment. Do not take any aspirin or similar
anti-inflammatory medications for 2 weeks before and after surgery, because such medications
contribute to a greater risk of bleeding. Hypertension (high blood pressure) that is not under medical
control may also cause bleeding during or after surgery.
_____
INFECTION
Initial here
Infection is unusual after rhinoplasty surgery. If an infection does occur, further treatment (e.g., change in
antibiotics, drainage, additional procedures) may be necessary.
_____
SCARRING
Initial here
Although good wound healing after a rhinoplasty procedure is expected, abnormal healing may occur
within both the skin and the deeper tissues. Scars may be unattractive and of a different color than the
surrounding skin. Additional treatments may be possible to treat scarring.

1695
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
_____
DAMAGE TO DEEPER STRUCTURES
Initial here
Deeper structures (e.g., nerves, tear ducts, blood vessels, muscles) may be altered during the course of
surgery. The potential for this to occur varies with the type of rhinoplasty procedure performed and your
individual anatomy. Injury to the deeper structures may be temporary or permanent.
_____
UNSATISFACTORY RESULTS
Initial here
The rhinoplasty surgery may result in visible or tactile deformities, loss of function, or structural
malposition. You may be disappointed that the aesthetic results of surgery do not meet your
expectations. Additional treatment or surgery may be possible should the result be unfavorable for you.
_____
NUMBNESS
Initial here
There is a potential for permanent numbness within the nasal skin after rhinoplasty. The occurrence of this
is not entirely predictable. Diminished sensation in the nasal soft tissues may not totally resolve after
rhinoplasty.
_____
FACIAL ASYMMETRY
Initial here
The human face is normally asymmetric. There can be variations from one side of the face to the other
with regard to the results obtained with a rhinoplasty procedure.
_____
CHRONIC PAIN
Initial here
Chronic pain may occur infrequently after rhinoplasty. The chronic pain or discomfort may be felt on either
the inside or outside of the nose.
_____
SKIN DISORDER/SKIN CANCER
Initial here
Rhinoplasty is a surgical procedure that is performed to potentially reshape both the internal and external
structures of the nose. Skin disorders and skin cancer may occur independently of an elective
rhinoplasty procedure.
_____
ALLERGIC REACTIONS
Initial here
Skin allergies to tape, suture material, and topical preparations can occur. Systemic allergic reactions,
which are more serious, may occur in response to drugs used during surgery and prescription
medicines taken afterward. Allergic reactions may require additional treatment.
_____
DELAYED HEALING
Initial here
Wound disruption or delayed wound healing is possible. Some areas of the face may not heal normally  
or may take a long time to heal. If so, further treatment or surgery may be possible to improve the
affected tissue.
_____
LONG-TERM EFFECTS
Initial here
Subsequent alterations in nasal appearance may occur as a result of aging, sun exposure, or other
conditions that are not related to the rhinoplasty surgery. In these circumstances, future surgery or
other treatments may be possible.
_____
NASAL SEPTAL PERFORATION
Initial here
There is the possibility that nasal septal surgery will cause an opening between the two sides of the nose.
If a perforation (opening) occurs, additional treatment may be possible.
Continued

1696 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
_____
NASAL AIRWAY ALTERATIONS
Initial here
After rhinoplasty, septoplasty, or turbinate reduction procedures, changes may interfere with the ideal
passage of air through the nose. If this occurs, additional surgery or treatment may be possible to
improve breathing.
_____
SURGICAL ANESTHESIA
Initial here
Both local anesthesia with an intravenous anesthetic and general anesthesia involve risk. Complications
and injuries are possible with all forms of anesthesia and sedation.
_____
HEALTH INSURANCE
Initial here
Most health insurance companies exclude coverage for surgical operations such as rhinoplasty and any
related complications that may occur. Please carefully review your medical health insurance subscriber
information to better understand your specific policy.
_____
FINANCIAL RESPONSIBILITIES
Initial here
The cost of surgery involves several charges for the services provided, including the fees charged by your
surgeon (i.e., surgeon’s fees); the cost of surgical supplies and the use of the operating room (i.e.,
facility/hospital charges); and the costs associated with anesthesia (i.e., anesthesiologist’s fees).
Depending on whether the cost of surgery is covered by your medical insurance plan, you will be
responsible for necessary copayments, deductibles, and all other charges that are not covered.
Additional costs may occur should complications develop from the surgery. Any secondary surgeries
and all charges involved with additional procedures (i.e., surgeon’s fees, facility/hospital charges,
anesthesiologist’s fees) would also be your responsibility.
_____
DISCLAIMER
Initial here
This consent document is written to communicate information about the proposed nasal surgery as well
as to disclose information about risks and alternative forms of treatment. The informed-consent process
attempts to define principles of risk disclosure that should generally meet the needs of most patients in
most circumstances.
However, this consent document should not be considered all-inclusive with regard to defining other
methods of treatment to consider and potential risks encountered. Your surgeon will provide you with
additional verbal and written information that is based on all of the facts of your particular case and the
current state of medical knowledge.
Consent documents are not intended to define or serve as the standard of medical care. Standards of
medical care are determined on the basis of all of the facts involved in an individual case and are
subject to change as scientific knowledge and technology advance and practice patterns evolve.
There are many variable factors in addition to the specific risks and potential complications that may
influence the long-term results of rhinoplasty. The risks cited are those that are particularly associated
with rhinoplasty. The practice of medicine and surgery is not an exact science. Although good results
are hoped for, there is no guarantee or warranty expressed or implied with regard to the results that
may be obtained.

1697
CHAPTER 38  Aesthetic Alteration of the Nose: Evaluation and Surgery
CONSENT FOR RHINOPLASTY SURGERY
1. I hereby authorize my surgeon, __________, and such assistants as may be selected by my surgeon to perform the
following procedure: rhinoplasty.
2. I have received, read, and understand the following information sheets:
• Rhinoplasty (Reshaping of the Nose) Surgery
• Book chapter about Rhinoplasty Surgery
• Consent for Rhinoplasty Surgery
3. I recognize that, during the course of the operation, unforeseen conditions may necessitate different procedures than
those listed above. I therefore authorize my surgeon, __________, and my surgeon’s assistants or designees to
perform such other procedures that are in the exercise of professional judgment necessary and desirable. The
authority granted under this paragraph shall include all conditions that require treatment and that are not known to my
surgeon at the time that the procedure is begun.
4. I consent to the administration of such anesthetics as are considered necessary or advisable. I understand that all
forms of anesthesia involve risk and the possibility of complications, injury, and even death.
5. I acknowledge that no guarantee has been given by anyone with regard to the results that may be obtained from this
procedure.
6. I consent to the photographing of me (head and neck region) before, during, and after surgery. These photographs
may be used by my surgeon for medical, scientific, or educational purposes now and in the future.
7. For the purposes of advancing medical education, I consent to the admittance of observers into the operating room.
8. I consent to the disposal of any body tissues or medical devices that may be removed.
9. THE FOLLOWING INFORMATION HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
• THE PREVIOUSLY DESCRIBED PROCEDURES TO BE UNDERTAKEN
• ALTERNATIVE PROCEDURES AND METHODS OF TREATMENT THAT I HAVE DECIDED AGAINST
• THE SPECIFIC RISKS AND POTENTIAL COMPLICATIONS OF THE PROCEDURES THAT I PLAN TO
UNDERGO
I CONSENT TO THE PROCEDURES AND THE ABOVE LISTED ITEMS (1 THROUGH 9). I AM SATISFIED WITH
THE EXPLANATION GIVEN TO ME.
____________________________
_____________________________
Patient (or Person Authorized to Sign for Patient)
Date
____________________________
_____________________________
Witness
Date
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1703

39
Aesthetic Alteration of Prominent Ears:
Evaluation and Surgery
JEFFREY C. POSNICK, DMD, MD
• Historic Perspective
• Embryology and Anatomy
• Timing of Surgery
• Aesthetic Objectives
• Surgical Principles
• Surgical Technique
• Otoplasty for Prominent Ears: Step-by-Step
Approach
• Assessment of Results
• Complications and Suboptimal Aesthetic
Results
• Non-Surgical Correction of Prominent Ears in
the Newborn
• Conclusions
• Patient Education Materials
elongation of the soft tissue covering and the earlobe is to
be expected. Provided that the ear has a morphology that is
in balance with the other facial features and that there is
reasonable symmetry from one ear to the other, these varia­
tions are considered to be in an acceptable aesthetic range.
However, when ear shape, size, and proportion are per­
ceived as distracting to the casual observer at conversational
distance, the ears may become a source of ridicule and
personal anguish. Affected children are frequently stigma­
tized by their peers and commonly ask their parents if a
solution for their visible abnormal ear shape can be found.
In these circumstances, the surgical correction of the promi­
nent ear is likely to have a beneficial effect on the person’s
self-esteem and body image.
A failure of scaphal folding (i.e., limited antihelical fold)
as well as conchal hypertrophy (i.e., increased depth of the
conchal wall), prominent lobules (i.e., protruding ear lobes);
and anterolateral rotation of the concha (i.e., cupping
of the ear) frequently create prominence of the external
ear.5,13,14,30,52,57,67 Noticeable ear protrusion often results
from a combination of these deformities. An accurate
assessment of the ear dysmorphology is essential to the
achievement of an unobtrusive look through surgery.
Adjusting the scaphal (antihelical) folding with sutures,
reducing the conchal wall depth via conchal excision and
conchal mastoid sutures, and performing lobe set-back
with sutures and excision are typical components of the
surgical correction that is undertaken to achieve a favorable
result.3,4,6,11,26,50,55,60,70,72
Overemphasis on the surgical creation of an antihelical
fold without paying proper attention to conchal hyper­
trophy often results in an oversharpened antihelix and a
buried helical rim (i.e., “telephone ear”). Some surgeons
advocate cartilage-cutting (i.e., scoring) procedures rather
than sutures to achieve a preferred antihelical fold.11 These
cartilage-scoring techniques generally require dissection of
the soft tissues off of the anterior surface of the cartilage.
This can result in hematoma, skin necrosis, and chondritis,
which may result in irreversible cartilage or external ear
irregularities. Surgical correction of the outstanding ear
Aside from the excision of auricular tags and the repair of
traumatically clefted ear lobes, the prominent ear is the most
commonly treated external ear deformity. Approximately
5% of the Caucasian population has protruding ears,
thereby making this the most frequent congenital anomaly
of the external ear. Otoplasty is a common aesthetic opera­
tion that is carried out among children and adolescents to
address this issue. There is a wide variation with regard to
what is considered normal for ear size, prominence, and
shape (Fig. 39-1). An “outstanding” ear is said to be present
when the distance of the helical rim from the temporomas­
toid surface of the skull is excessive. As a general rule, a
measurement of more than 16 to 21 mm is said to result in
a prominent ear (Fig. 39-2). The average ear is 6.5 cm long
and 3.5 cm wide, but significant variations are considered
acceptable. After the completion of normal ear growth and
with ongoing age, the external ear changes in that the

1704 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 39-1  A, The topographic anatomy of the external ear is shown. Key anatomic landmarks are demonstrated and labeled. B, Drawing
by Leonard da Vinci that confirms the importance of achieving Euclidian proportions of the external ear within the face.
Helix
Triangular
fossa
Inferior crus
Helical root
Tragus
Antitragus
Superior crus
Antihelix
Cymba
Cavum
Concha
Lobule
A
B
•  Figure 39-2  Ear protrusion is measured as the distance of the
helical rim from the cranium; it is measured in millimeters. The specific
locations where measurements are taken include the helical apex, the
midpoint, and the lobe.
10-12 mm
20-22 mm
16-18 mm
Helical apex
Lobule
Midpoint
should in general be uncomplicated and result in reliable,
long-lasting, favorable aesthetics with minimal downtime
for the patient and minimal chance of relapse.
When considering the ideal timing for external ear
surgery, it is important to balance what we know about ear
and facial growth, psychosocial development, and the ability
of the child to comply with the necessary routines after
surgery.1,20,21,39 The goals of otoplasty for the management
of congenitally prominent ears, as outlined by McDowell,
remain universal despite a multitude of etiologies and
suggested surgical techniques.42 According to McDowell,
the surgical goals should include the following:
1. Correcting ear protrusion, by addressing the over
prominent helix and antihelix
2. Achieving a smooth antihelical fold without a “sharp”
crease
3. Limiting any disturbance to the postauricular sulcus
4. Avoiding a “plastered down” appearance of the ear
Historic Perspective
Dieffenbach is credited with reporting the first otoplasty in
the medical literature in 1845.15 This was performed to
reconstruct a traumatically deformed ear. The ear surgery
consisted of excising skin from the postauricular sulcus and
suturing the conchal cartilage to the mastoid periosteum
(i.e., conchal–mastoid suturing). In 1881, Ely was the first
surgeon to report a procedure for the aesthetic correction
of a congenitally prominent ear.19 He resected both the skin
and the conchal cartilage, but he did so as a two-stage pro­
cedure (i.e., one ear at a time).56 Moristin further developed
these skin-excision and cartilage-resection otoplasty tech­
niques.44 In 1910, Luckett realized that a prominent ear
frequently resulted from the congenital failure to form an
antihelical fold.38 He was the first to describe setting the ear
back via the removal of postauricular skin and by simultane­
ously completing an incision through the length of the ear
cartilage in an attempt to create the deficient antihelical
fold; he also placed sutures to hold the new fold in place.
In 1960, Stenstrom used the known principles of cartilage
biology as described by Gibson and Davis in 1958 to
propose the scoring and abrading the anterior cartilage
surface to weaken it and thereby create an antihelical

1705
CHAPTER 39  Aesthetic Alteration of Prominent Ears: Evaluation and Surgery
the posterior three hillocks ultimately drain into the poste­
rior triangle of the neck. Lastly, the ear is supplied by the
great auricular nerve on its lower lateral and inferior cranial
surfaces, by the lesser occipital nerve on its superior cranial
surface, and by the auriculotemporal nerve on its superior
lateral surface as well as the anterior superior surface of the
external acoustic meatus. The Arnold nerve, which is an
auricular branch of the vagus nerve, supplies the posterior
inferior external auditory canal and meatus as well as the
inferior conchal bowl.34,35
The most frequently seen deformity or malformation of
the external ear arises from the failure of the antihelix to
fold. The conchoscaphal angle widens and results in a flat
superior crus, antihelical body, and inferior crus. The helical
roll (i.e., the antihelical fold) may be absent altogether or
only partially formed, with a wide variation of deformity.
Conchal widening (i.e., the presence of a deep conchal
bowl) may also occur either as an isolated deformity or in
conjunction with antihelical fold deformities. These con­
genital abnormalities are usually bilateral and often asym­
metric, and they frequently demonstrate a familial pattern.
Bauer pointed out that the external ear may be thought
of as consisting of a three-tiered cartilaginous framework
with tightly adherent skin on the anterior surface and
loosely applied skin on the posterior surface.4 The three
tiers of sculpted cartilage form are the helical–lobular
complex, the antihelical–antitragal complex, and the conchal
complex. Key anatomic (aesthetic) landmarks of the normal
ear include the scapha, the concha, the helix, the antihelix,
the tragus, and the lobule (see Figs. 39-1 and 39-2).
Timing of Surgery
Auricular deformations are best suited for ear molding cor­
rection techniques. Molding therapy is preferably carried
out during the first few days of life, as described later in this
chapter. In general, the surgical correction of a malforma­
tion of the external ear is planned with an appreciation of
normal ear maturation. As a result of differing interpreta­
tions of ear growth and the effect of an operation on residual
growth of the auricle, opinions vary with regard to the
preferred timing of definitive external ear reconstruction.
In a study by Farkas, two anthropometric surface mea­
surements, ear width and ear length, were taken directly
from the ears of normal subjects with the use of an anthro­
pometric sliding caliper.20,21 At the age of 1 year, ear width
is highly developed in both sexes (mean, 93.5%), and it is
mostly completed at the age of 5 years (mean, 97%). The
width of the ear reaches its full mature size in boys at the
age of 7 years and in girls at the age of 6 years. At 1 year of
age, the length of the ear has already attained 75% of its
eventual adult size. By 5 years of age, 87% of its eventual
development is observed. Ear length achieves its full adult
size in 13-year-old boys and 12-year-old girls. Adamson and
colleagues reviewed the growth patterns of the external ear
and concluded that the ear reaches 85% of its overall adult
size by the age of 3 years and that little change in ear width
fold.61,62,25 In 1963, Mustarde introduced the placement of
mattress sutures in the posterior cartilage surface of the
ear as a technique for the creation of a new antihelical
fold.46-48
In 1967, Kaye combined the anterior scoring technique
of Stenstrom and the posterior suture placement technique
of Mustarde to limit the relapse that surgeons complained
about when using either technique alone; he also advocated
the use of nonresorbable suture.32 In 1968, Furnas reintro­
duced the technique of conchal–mastoid suturing to set
back the prominent conchal bowl.22-24 He also advocated
cleaning out the soft tissue in the postauricular groove (i.e.,
postauricular muscle and fibrofatty tissue) so that the
concha could be rotated in a sagittal plane from posterior
to anterior (clockwise rotation) before anchoring it to the
mastoid fascia (conchal–mastoid sutures) with nonresorb­
able sutures. In 1969, Webster advocated paying special
attention to the prominent earlobe to achieve a successful
otoplasty.69 He noted that the “tail” of the helix could be
repositioned with suture to change the lobe’s orientation.
In 1972, Elliott combined and refined all of the previously
described techniques to manage, the deep conchal wall, the
limited antihelical fold, and the abnormal earlobe that were
frequently seen in the prominent ear.18 He advocated the
use of elliptical partial conchal wall excision when conchal–
mastoid suturing alone was felt to be insufficient to correct
the ear prominence. He used an anterior incision placed
within the “shadow zone” of the conchal margin when
conchal resection was required. Bauer advocated the use of
the Elliott anterior conchal cartilage excision but preferred
to also excise anterior skin to avoid postoperative skin
folding or bunching.4
Embryology and Anatomy
Embryologically, the ear arises from six hillocks of the first
and second branchial arches during the second to fourth
month of gestation. Hillocks 1 through 3, from the first
arch, form the anteromedial aspects of the auricle (i.e., the
tragus, the helical crus, and the helix, respectively). Hillocks
4 through 6, from the second arch, develop into the pos­
terolateral aspects of the ear (i.e., the antihelix and the
antitragus, respectively).34,35 During the third month of ges­
tation, protrusion of the auricle increases. By the end of the
sixth month, the helical margin curves, the antihelix forms
its folds, and the antihelical crura appear at the superior
aspect of the forming external ear. Congenital ear deformi­
ties result from the disruption of one or more of the auricu­
lar hillocks during embryogenesis. Any deforming forces to
the side of the head of the fetus may also alter the shape of
the external ear.
The ear is supplied by branches from the superficial
temporal artery anteriorly and the posterior auricular and
occipital arteries posteriorly. The superficial temporal, pos­
terior auricular, and retromandibular veins provide venous
drainage. The lymphatic drainage of the anterior three hill­
ocks is mainly to the anterior triangle of the neck, whereas

1706 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
Ear Protrusion
Although the spectrum of protrusion of the helical rim from
the scalp varies widely, a measurement of 1.5 to 2.0 cm is
aesthetically acceptable.2
Patient and family satisfaction should be anticipated if the
reconstructed ears are no longer a facial feature that draws
attention when viewed at conversational distance by the
casual observer. Sharp angles, unnatural contours, overcor­
rection and “eye-catching” asymmetry from ear to ear are
not ideal. In the operating room, the surgeon should view
the reconstructed ear from several feet of distance in frontal
and profile views and from the rear. From the rear, the
helical contour should form a relatively straight line; this
will indicate that the antihelical fold (the upper third), the
conchal depth (the middle third), and the lobe (the lower
third) are in sync. From the front, the helical rim above and
the lobe below should be seen to an extent just beyond the
antihelix without any cupping of the upper and lower thirds
of the ear. In profile, the contours should be gentle and the
folds rounded.
Surgical Principles
A reconstructed prominent ear should be reasonably sym­
metrical with its counterpart and without a sharply angu­
lated antihelical fold. If the upper third of the ear protrudes
as a result of an absent or weak antihelical fold, then the
fold should be improved (i.e., Mustarde and superior helix–
mastoid stitches). If the middle third of the ear is too
prominent (i.e., outstanding and away from the side of the
head), then the concha must be recessed (i.e., conchal wall
excision and conchal–-mastoid stitches) and the antihelical
fold improved (i.e., Mustarde stitches). In the lower third
of the ear, if the lobule protrudes, the surgeon must resect
or reposition the cartilaginous tail, excise the retrolobular
skin, or both.
Historically, the creation of an antihelical fold was carried
out by techniques that involved either scoring or abrasion
of the cartilage to control the direction and extent of fold­
ing.16,25,28 Later, suture techniques (i.e., Mustarde sutures)
were added to reshape the cartilage. Many surgeons com­
bine these methods. Interestingly, some “cartilage scorers”
recommend partial-thickness scoring, whereas others score
the full thickness of the cartilage.11 This author prefers to
avoid scoring the cartilaginous surface all together, because
this requires separation of the anterior skin from the carti­
lage surface with increased risk of hematoma, flap necrosis,
and visible sharp edges on the anterior (cartilage) surfaces.
The careful placement of Mustarde mattress sutures in a
gentle curve will form a smooth antihelical fold. The Mus­
tarde sutures are placed along the posterior surface of the
cartilage as needed in the upper, middle, and lower thirds
to accomplish aesthetic antihelical folding.46-48
Conchal hypertrophy is a frequent component of the
ear deformity. The correction of this aspect is usually
or the distance of the ear from the scalp occurs after 10 years
of age.1 The authors concluded that, for all practical pur­
poses, the normal ear is almost fully developed by the age
of 6 years.
Although children notice differences in each other begin­
ning very early in life, they are rarely self-conscious about
differences in ear protrusion before 5 years of age.39 From
this point on, however, social interactions with peers fre­
quently elicit negative comments that can affect self-esteem
and body image. The correction of external ear deformities
before this age is possible, but the postoperative course
may be compromised if the ear bandage is removed early
by the uncooperative child or with disruption of the repair
by pulling on the ears after the bandage is removed. Con­
sideration is given to setting back the protruding ears as
early as 3 years of age, although many children display
improved cooperation and parents are more confident in
their decision when children are between the ages of 5 and
6 years.
Aesthetic Objectives
It is recognized that there are wide variations with regard to
ear proportions, projection, and position among individu­
als. When feasible, the surgically reconstructed (previously
protruding) ear should be of ideal size and shape and have
a good relationship with the other facial features and the
contralateral ear. Loose guidelines for the assessment of
preferred ear shape and position have been summarized by
Tolleth.67
Ear Axis
A line that passes through the longest dimension of the
ear is called its axis. In the majority of people, an angle
of 20 degrees formed between the axis of the nasal bridge
and the axis of the ear is considered the most aestheti­
cally pleasing. The axis of an aesthetically pleasing ear is
rarely vertical.
Ear Position
When the head is in the true horizontal (natural head) posi­
tion, the top of the ear will generally be level with the
eyebrow, whereas the bottom of the ear will generally be on
a line with the base of the columella of the nose or slightly
lower. In the anteroposterior dimension, the ear is roughly
positioned one ear length (i.e., 6.5 to 7.5 cm) posterior to
the lateral rim of the orbit.
Ear Size
A wide variation exists with regard to what is considered
normal ear size in terms of length and width. The length of
a “normal” ear varies from 5.5 to 7.5 cm, whereas a normal
ear width varies from 3.0 to 4.5 cm. The normal width-to-
length ratio is 50% to 65%.

1707
CHAPTER 39  Aesthetic Alteration of Prominent Ears: Evaluation and Surgery
accomplished through a combination of techniques, includ­
ing the following: 1) the repositioning of the concha into
the surgically “cleaned out” mastoid recess; 2) conchal set-
back with conchal–mastoid sutures; and 3) conchal reduc­
tion through direct elliptical cartilage excision. If the
anterior approach is selected for conchal wall resection, an
incision (scar) must be placed on the anterior surface, but
the folding of redundant skin is limited.4 If a posterior
approach is used, there is a risk that the redundant anterior
skin that is left behind may not shrink sufficiently and thus
result in a visible fold in the conchal floor. Some surgeons
believe that a redundant anterior skin fold may be more
noticeable than a “fine” anterior conchal scar. This author
prefers to excise conchal cartilage with the use of a posterior
approach. The anterior skin is then released from the resid­
ual conchal floor cartilage to avoid bunching, as discussed
later in this chapter.
To review, the ear set-back procedure will generally require
the resection of conchal (wall) cartilage, the cleaning out of
excess soft tissues in the retroauricular sulcus, and three
rows of deep sutures. These three rows of sutures include
the following: 1) Mustarde horizontal mattress sutures to
create an antihelical fold; 2) conchal sutures for reconstruct­
ing after elliptical (conchal wall) resection; and 3) Furnas-
type sutures, including placement in the conchal–mastoid
region and the superior helix–mastoid region. Non-
resorbable sutures should be used to limit relapse (4-0 Mer­
silene versus 4-0 clear nylon).
Surgical Technique
(Figs. 39-3 through 39-9)
The intraoperative draping of the patient within the sterile
field should provide visualization of both ears and the
entire forehead, face, and neck as well as the ability to
safely turn the patient’s head from side to side. An orotra­
cheal tube with a natural curve at the level of the lower lip
is used and secured to the skin of the chin with a minimal
amount of tape (e.g., an Oral RAE endotracheal tube).
Ophthalmic eye ointment and eye protectors (corneal
shields) are placed below the eyelids to limit corneal injury
and to prevent the need for tape or dressing material on
the face. The patient’s head is placed on the Mayfield
horseshoe head ring in the neutral neck position. The May­
field provides stability and adequate exposure and allows
for the turning of the head without disrupting the surgical
field. The majority of the hair is wrapped in a sterile towel,
and prophylactic intravenous antibiotics are given. A
mouth pack is placed to limit saliva contamination of the
surgical field.
The ears are marked on the anterior surface for the cre­
ation of a new or improved antihelical fold and on the
posterior surface for an elliptical skin excision. Lidocaine
(Xylocaine) 1% with 1 : 100,000 epinephrine is injected
into the postauricular skin fold.
The postauricular incisions (i.e., elliptical skin excision)
are completed with a scalpel (see Fig. 39-3). All soft tissue
•  Figure 39-3  Intraoperative views of postauricular skin incisions and excision as part of otoplasty. A, The location
of the postauricular elliptical skin excision is demonstrated. The planned long axis of the ear excision extends from
the superior helical rim to the earlobe. B, With the use of a knife (No. 15 blade), the full thickness of the skin ellipse
is incised. C, With the use of blunt-tip Stevens scissors, the full thickness of the skin ellipse is removed, down to the
surface of the cartilage.
A
B
C
Mark out planned excision
Incise ellipse
Excise ellipse down to cartilage

1708 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 39-4  Intraoperative views of postauricular flap elevation and then subcutaneous tissue excision as part of
otoplasty. A, Elevation of the medial postauricular flap is completed down to the mastoid fascia. B, Elevation of the
lateral postauricular flap is extended to the outer edge of the helical rim. The flaps are also elevated inferiorly to the
tail of the helix and superiorly to the upper aspect of helix. C, All soft tissue is cleaned out in the sulcus down to
mastoid fascia (i.e., muscle and fibrofatty tissue).
A
B
C
Remove fibro-fatty tissue from sulcus
Lateral post-auricular flap elevation
Medial post-auricular flap elevation
down to the posterior surface of the cartilage is removed.
The postauricular medial and lateral skin flaps are elevated
(see Fig. 39-4). The resection and removal of postauricular
muscle and fibrofatty tissue that is between the conchal
cartilage and the mastoid fascia is completed. This allows
the concha to rest in a deep pocket so that the bending of
the cartilage over a soft-tissue mound does not occur when
tying conchal–mastoid sutures (Fig. 39-6A).
When scaphal folding is needed to improve the antihe­
lical fold, the placement of postauricular horizontal mattress
(Mustarde-type) sutures is carried out (see Figs. 39-5 and
39-6). Before the creation of the improved antihelical fold,
the posterior cartilaginous surface is cleaned of all soft
tissue. The Mustarde sutures are placed in a radial fashion
to form a curved scaphal fold that extends from the superior
crus down to the lobule. Antihelical reconstruction usually
requires three to five Mustarde sutures to achieve a smooth
roll. Each suture is tested for its effectiveness after it is
placed, but none are tied until all are in position. If the
position of the superior helix remains protruded, one or two
additional superior helix–mastoid sutures can be placed to
further accomplish the ear set-back.
A conchal set-back with sutures (conchal–mastoid
sutures) is useful but generally inadequate for the manage­
ment of even moderate degrees of conchal hypertrophy.
Partial conchal wall resection is generally indicated (see Figs.
39-7 through 39-9). This author prefers to complete the
resection through a posterior approach. An ellipse of the
conchal wall that extends superiorly and inferiorly is excised
to allow the bowl to reposition itself without a cartilaginous
“dog ear” (i.e., puckering). If only minor degrees of conchal
prominence exist, management just with the placement of
conchal–mastoid sutures may be possible.
The position of the lobule can be further managed by
the setting back of the tail of the helix. The helical tail is
exposed on its posterior surface. The tail is sutured back to
the concha or the mastoid fascia. Each placed suture is
tested to determine if the desired position of the lobule will
be achieved. In some patients, it is useful to excise cartilage
at the lobule to achieve adequate positioning. In others, the
excision of a postauricular wedge of skin is helpful.
Otoplasty for Prominent Ears:
Step-by-Step Approach
Positioning on the Operating Room Table
• Place the patient supine on the operating table with his
or her head resting on the Mayfield horseshoe. The neck
should be in the neutral position.

1709
CHAPTER 39  Aesthetic Alteration of Prominent Ears: Evaluation and Surgery
•  Figure 39-5  Intraoperative views of the creation or deepening of the preferred antihelical fold as part of the oto­
plasty. A, The preferred antihelical fold is located and marked on the posterior surface of cartilage with a surgical pen
or methylene blue. B, The new antihelical fold is created or deepened by placing three to five carefully located hori­
zontal mattress (Mustarde-type) sutures. The sutures are placed in a natural curve like the spokes of a wheel. Each
placed Mustarde suture is tested for effectiveness with a single throw, after which it is loosened. C, After all sutures
have been placed and tested, each will be carefully tied and confirmed for the preferred aesthetic effect. Note that
the conchal wall excision is completed prior to placement of Mustarde stitches. Only after all of the Mustarde stitches
have been secured, are the edges of the conchal walls (after elliptical excision) approximated with the use of inter­
rupted sutures.
Confirm new anti-helical fold
prior to tying down
Placement of (3-5) horizontal mattress
“Mustarde” sutures (4-0 merseline)
Mark out anti-helical fold
A
B
C
General Anesthesia Intubation
• Place the orotracheal (Oral RAE) tub.
• Tape the endotracheal tube to the chin.
• Be sure that the anesthesia ventilation tubing extends
over the anterior chest in the midline and then goes off
to the side.
Corneal Protection
• Place the ophthalmic eye ointment.
• Place the corneal shields deep to the eyelids.
Medications
• Administer intravenous antibiotics (Cefazolin 17 mg/
kg/dose, max: 1 gm).
• Administer steroids via an intravenous bolus (Dexameth­
asone 0.5 mg/kg/dose, max: 8 mg).
Preparation and Draping
• If the patient has long hair, tie it in a ponytail; this will
keep the hair out of the surgical field.
• Prep the patient’s entire scalp, forehead, external ears,
face, and neck.
• Use Betadine solution (do not use soap, alcohol, Hibi­
clens, and so on) to avoid irritation of the mucous mem­
branes and the corneas of the eyes.
• Drape the patient, leaving the anterior scalp, forehead,
external ears, face, and neck exposed in the operative
field.
Surgical Markings
• Before preparation, use a surgical pen to locate and mark
the preferred location of the antihelical fold on the
anterior aspect of the ear, including the superior and
inferior crus.

1710 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 39-6  Illustrations and patient example of the surgical correction of an antihelical
fold. A, Illustration that demonstrates the removal of redundant fibromuscular tissue from
the postauricular fold. B, Illustration that demonstrates the placement of a Mustarde stitch
before tie down (cross section view). C, Illustration of a tied-down Mustarde stitch (cross
section view). D, Intraoperative view of the anterior surface of the ear just after the place­
ment of five Mustarde stitches that were used to create the preferred antihelical fold.
A
B
C
D
Removal of postauricular
fibro-muscular tissue
Horizontal mattress suture placed
and then tied down
Mustarde stitches in place
• Before preparation, use a surgical pen to locate and mark
the postauricular elliptical skin excision. Center the
ellipse at the long axis of the ear from the superior helical
rim to the earlobe. Stop the ellipse approximately 1 cm
short of the superior and inferior margins of ear.
Local Anesthesia
• Inject Xylocaine (1% with 1 : 100,000 epinephrine) into
the postauricular sulcus above the mastoid fascia and
superficial to the ear cartilage.
Postauricular Skin Excision (see Fig. 39-3)
• With a knife (no. 15 blade), incise the full thickness of
the skin ellipse.
• With blunt-tipped Stevens scissors, remove the full
thickness of the skin ellipse down to the surface of the
cartilage.
Elevation of the Postauricular Flaps
(see Fig. 39-4)
• Elevate the lateral postauricular skin flap near the outer
edge of the helical rim.
• Elevate the medial postauricular skin flap down to the
mastoid fascia.
• Clean out all soft tissue (i.e., muscle and fibrofatty tissue)
in the sulcus down to the mastoid fascia.
• Confirm the adequate elevation of the flaps inferiorly
(to the tail of the helix) for later control of the earlobe
position and superiorly (the upper aspect of the helix)

1711
CHAPTER 39  Aesthetic Alteration of Prominent Ears: Evaluation and Surgery
•  Figure 39-7  Intraoperative views of conchal wall resection and reconstruction as part of otoplasty. A, The preferred antihelical fold is located
on the posterior surface of the cartilage and marked with a surgical pen or methylene blue. In addition, the long axis for the planned elliptical exci­
sion of the conchal wall is located and marked on the posterior surface of the cartilage. B, The full thickness of the conchal wall ellipse for excision
is incised through the cartilage with a knife (No. 15 blade) but without perforation through the anterior skin. The cartilage is then removed with the
use of a Cottle elevator and Stevens scissors. This image was created after the ellipse of cartilage had been excised. C, Next, the anterior ear skin
is elevated off of the residual conchal floor toward the ear canal. This is accomplished to limit bunching of the skin during the healing phase after
the conchal wall edges are reapproximated with suture. D, The edges of the cut conchal wall are sutured together to limit overlap during healing.
Note that it is best to suture the conchal edges together only after the Mustarde sutures are placed and tied.
A
B
C
D
Mark out conchal “wall” ellipse for excision
Mark out preferred anti-helical fold
Ellipse of cartilage has been excised
Elevate skin off conchal floor
Suture closed cartilage gap
•  Figure 39-8  Illustration and patient example of deep conchal bowl correction. A, Illustration of the postauricular approach for access and then
for the excision of the ellipse of the conchal wall. B, Intraoperative view after the elliptical excision of the conchal wall to “set-back” the ear. The
anterior soft tissues of the ear remain intact. C and D, Clinical example of a child with a deep conchal bowl before and after surgical correction.
A
B
C
D
Ellipse of conchal wall excised and then sutured

1712 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
• With the use of a Cottle elevator, the incised ellipse of
cartilage is freed from the anterior ear skin and then
removed.
• The anterior ear skin is further elevated off of the residual
concha floor toward the ear canal. This will limit bunch­
ing of the skin during the healing phase after the conchal
wall edges are reapproximated with suture.
• The edges of the cut conchal wall will be sutured together
with 4-0 Vicryl to limit overlap. Wait to suture the
edges together until the Mustarde sutures are placed
and tied.
Deepening or Creation of the Antihelical Fold
(see Figs. 39-5 and 39-6)
• The new antihelical fold is created or deepened by
placing three to five carefully located horizontal mattress
(Mustarde-type) sutures. The sutures are placed in a
natural curve like the spokes of a wheel.
• Experience has taught that cartilage scoring is not neces­
sary and can cause complications (e.g., hematoma, skin
flap necrosis, sharp edges).
• Each placed Mustarde suture is tested for effectiveness
with a single throw, after which it is loosed.
• When all sutures have been placed and tested, each is
carefully tied and confirmed for the preferred aesthetic
effect.
• Experience has taught that use of non-resorbable suture
(4-0 Mersilene or 4-0 clear nylon) is useful to limit or
for later control of the position of the upper third of
the helix.
Marking of the New Antihelical Fold on the
Posterior Surface of the Cartilage
• With the use of a 27-gauge needle (i.e., a tuberculin
syringe filled with methylene blue), puncture through
the anterior surface of the skin along the previously
marked location of the new antihelical fold.
• Visualize the needle on the posterior surface of the car­
tilage, and use a surgical pen or methylene blue to mark
the location of the new fold along the full length from
the superior crus to the tail. This will allow for the accu­
rate placement of the Mustarde-type sutures.
• Mustarde sutures are not placed until after conchal wall
resection is complete.
Conchal Wall Resection for Set-Back
(see Figs. 39-7 and 39-8)
• The planned elliptical excision of the conchal wall (supe­
rior to inferior) is marked out with a surgical pen or
methylene blue on the posterior surface of the
cartilage.
• The conchal excision should include a portion of the
conchal wall. The full thickness of the ellipse of concha
for excision is incised with a scalpel (no. 15 blade)
but without perforation through the anterior skin.
•  Figure 39-9  Illustrations of a postauricular approach to the management of a prominent ear. Frequently, three rows of sutures
are required for successful ear set-back. A, The illustration demonstrates the three rows of sutures being placed, but they are not
yet tied down (cross section view). B, Illustration of the three rows of sutures (post auricular view) after they are tied down. The three
rows of sutures include the following: 1) Mustarde (scaphoconchal) sutures; 2) conchal wall resection and then suture reconstruction
of the cartilage defect; and 3) conchal–mastoid and superior helix–mastoid sutures.
1
2
3b
3a
Plane of section in 09b
1. Mustarde (Scapho-chochal) sutures
2. Chonchal wall resection and suture reconstruction
3a. Chonchal - Mastoid sutures
3b. Superior helix - Mastoid suture
B
A

1713
CHAPTER 39  Aesthetic Alteration of Prominent Ears: Evaluation and Surgery
chromic) is used for skin closure. This prevents the need
for postoperative suture removal.
Placement of Dressing (Fig. 39-10)
• A thick coat of antibiotic ointment is placed in the post­
auricular fold and over the anterior ear skin surface.
• A sheet of gauze (Xeroform) is placed in the postauricular
groove and also along the anterior ear surface.
• Two or three pieces of dry fluff gauze are placed over the
anterior skin surface of each ear.
• A gauze roll (Kerlix) is used as a wrap to apply gentle
pressure and to hold the gauze fluffs in place. The Kerlix
wrap is also secured across the anterior neck to prevent
the head dressing from loosening.
• An Ace wrap is then loosely placed as an outer layer of
the head and ear dressing.
• The whole dressing is removed 5 days later.
Postoperative Care
• After the ear dressing is removed, the patient is encour­
aged to shower and shampoo the hair and to wash the
external ears, face, and neck one or two times daily.
(Overly hot water should be avoided, because the ears
will have diminished sensation.)
• The ears are dabbed dry after washing. (Excess rubbing
of the ears should be avoided.)
• Ear protection is used when sleeping for 2 to 3 months
to prevent accidental anterior folding of the external ears.
A skier’s ear warmer or a tennis sweatband may be used
for this purpose.
• No vigorous sports activities are allowed for 4 to 6 weeks.
• No strong sun (ultraviolet) exposure to the ears is allowed
for approximately 3 months.
• When the patient has returned to more regular physical
or sports activities after 4 to 6 weeks, additional precau­
tions are encouraged, depending on type of sport activity
(e.g., wrestling, basketball), during the initial 3 months
after surgery.
Assessment of Results
Although prominent ears do not have any physiologic dis­
advantages, they play an important role in social life. Promi­
nent ears often provoke teasing by others, especially by
children; they can lead to emotional stress with a decline in
the patient’s health-related quality of life; they may nega­
tively affect school or job performance; and they may result
in social avoidance and a loss of self-confidence (Figs. 39-11
through Fig. 39-27). Today, health-related quality of life is
considered by many to be the most important parameter
for the evaluation of aesthetic procedures such as the cor­
rection of protruding ears.7,64
In a recent study by Braun and colleagues, a consecutive
series of patients (N = 84) who underwent otoplasty (suture
technique) were given a health-related quality-of-life survey.6
prevent late cartilage relapse with the loss of the antihe­
lical fold.
Conchal Wall Resection for
Set-Back (Continued)
• Now that the Mustarde sutures have been secured,
the cut edges of the conchal wall are approximated
with the use of interrupted 4-0 Vicryl sutures to limit
overlap.
Placement of Conchal–Mastoid Sutures to
Further the Set-Back of the Middle Third of
the Ear (see Fig. 39-9)
• Conchal–mastoid sutures are placed as needed only after
the conchal wall is resected and reconstructed with
sutures and the Mustarde sutures have been placed. The
conchal–mastoid sutures should be made of a non-
resorbable material (4-0 Mersilene or 4-0 clear nylon) to
limit cartilage relapse. They are placed to establish the
preferred clockwise rotation of the ear and to further set
back the middle concha, as needed.
• If more than one conchal–mastoid suture is required,
each is placed and tested with a single throw and then
loosened.
• When all of the conchal–mastoid sutures have been
placed and tested, each one is tied to confirm the pre­
ferred aesthetic effect.
Placement of Superior Helix–Mastoid Sutures
to Further the Set-Back of the Upper Third of
the Ear
• The superior helical rim may remain “outstanding” more
than is preferred even after the placement of Mustarde
sutures. A superior helical–mastoid suture (4-0 Mersi­
lene or 4-0 clear nylon) is often useful to further improve
the aesthetic result. The combination of these surgical
maneuvers will limit a sharp edge in the antihelical fold
that may otherwise occur as a result of the overtightening
of the Mustarde sutures.
Set-Back of the Earlobe (Lower Third of Ear)
• Excision of the postauricular skin and the subcutaneous
tissue of the lobe is sometimes helpful to set back the
lower third of the ear.
• The placement of a tail of helix–mastoid or tail of helix–
conchal base suture with the use of non-resorbable mate­
rial (4-0 Mersilene or 4-0 clear nylon) is sometimes
helpful to control the lobe position.
Skin Closure
• The placement of several interrupted sutures and then a
running and locking suture of resorbable material (5-0

1714 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 39-10  A 5-year-old with prominent ears underwent reconstruction. He is shown before and
5 days after reconstruction at the time of bandage removal. After bandage removal, the patient was
allowed to wash the hair, face, and ears in the shower with soap and water. Other than avoiding direct
trauma or forward folding of the ears while sleeping, the ears are then left open to the air.
Or
Orththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatathicicic Su
Su
Surg
r ery
ry
ry
ry
ry; J.C.
C.
C Pos
os
os
os
os
os
o nicick
Or
Orthththththththththththththtr ogn
gn
gn
gn
gn
g atata hicicic Su
Su
Su
Su
Surg
r ery
ry
ry; J.C.
C.
C.
C.
C Pos
os
os
os
os
os
osnicicicici k
Just prior to otoplasty
5 days after otoplasty,
day of dressing removal
The survey used was either the Glasgow Children’s Benefit
Inventory (N = 41; 73.8% of study group) or the Glasgow
Benefit Inventory (N = 21; 33.9% of study group). Both
of these quality-of-life surveys have been validated for mea­
suring the effect of plastic (aesthetic) operations on health-
related quality of life. Sixty-two patients (73.8%) returned
a valid questionnaire for analysis. For the study group, the
main reasons for carrying out the ear set-back operations as
reported by the patient and the family included teasing
(42.6%); aesthetic impairment (39.3%); and reduced self-
confidence (23%). The results of the study indicate that
100% of the adults were satisfied with their aesthetic
results and that 90.5% would again decide in favor of the
operation. Ninety-five percent of the parents of the children
and 95.1% of the children themselves were satisfied with
the aesthetic results. Ninety-seven percent of the parents
and 92.7% of the children then also stated that they would
again decide in favor of the operation. The authors also
speculated that an individual’s reluctance to participate in
certain social activities, if caused by reduced self-confidence
as a result of the protruding ears, was more likely to remain
constant with increased age. In other words, adults that had
lived through the social ridicule of prominent ears for many
years were more likely to retain reduced self-confidence even
after successful ear set-back.
Complications and Suboptimal
Aesthetic Results
Although the majority of patients state that they are satisfied
with their otoplasty results and say that they would undergo
such procedures again, complications and suboptimal
results will always occur in a minority of cases.10,17,31,37,53,54,63
Pinching of the External Auditory Canal
Conchal-mastoid sutures that are placed too far forward on
the mastoid or too far back on the concha may exaggerate
the conchal rotation. In theory, the created angular edge
of the auditory canal may diminish the diameter of the
canal. This problem can be minimized by managing conchal
hypertrophy with elliptical excision rather than with the
overaggressive use of conchal–mastoid sutures.
Inadequate Management of
Conchal Hypertrophy
Many patients who are dissatisfied with the aesthetic results
of an otoplasty demonstrate residual conchal hypertrophy
that was missed, ignored, or undertreated. When conchal
hypertrophy is part of the deformity, it should be adequately
addressed. This author prefers the elliptical resection of the
outstanding conchal wall in most cases. The placement of
conchal–mastoid sutures alone is often inadequate and
results in either immediate or late relapse.
A “Too-Sharp” Antihelical Fold
An unnaturally sharp antihelical fold may be created as a
result of overaggressive scoring of the cartilage or overtight­
ening of the Mustarde sutures in the presence of undercor­
rected conchal hypertrophy.
Text continued on p. 1730

1715
CHAPTER 39  Aesthetic Alteration of Prominent Ears: Evaluation and Surgery
•  Figure 39-11  A 4-year-old girl with asymmetric prominent ears that are characterized by conchal hypertrophy and deficient scaphal folding.
She underwent elliptical conchal wall resection (posterior approach); conchal rotation and stabilization (conchal–mastoid and superior helix–mastoid
sutures); and the creation of improved antihelical folds (Mustarde sutures). A, Frontal views before and after reconstruction. B, Oblique facial views
before and after reconstruction.
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B
Continued

1716 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C
D
C, Profile views before and after reconstruction. D, Posterior facial views before and after reconstruction.
• Figure 39-11, cont’d

1717
CHAPTER 39  Aesthetic Alteration of Prominent Ears: Evaluation and Surgery
•  Figure 39-12  A 7-year-old girl with
asymmetric prominent ears that are char­
acterized by both conchal hypertrophy and
deficient scaphal folding. She underwent
elliptical conchal wall resection (posterior
approach); conchal rotation and stabiliza­
tion (conchal–mastoid and superior helix–
mastoid sutures); and the improvement of
the antihelical folds (Mustarde sutures).
A, Frontal views before and after recon­
struction. B, Oblique facial views before
and after reconstruction. C, Profile views
before and after reconstruction.
C
Orth
r ogn
gn
g atatatatatathicicicicicicicicicicicicicic Su
Surg
r ery
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
o nicick
Or
Orthth
r ogn
gn
gn
gn
gn
gn
gnatatatatatatatathicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C Pos
os
os
os
osnicici k
Orthththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatata hicicicicic Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C. Pos
os
os
os
os
os
os
osnicicicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatathicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
o nicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
g
tatatatatatatatatathicicicicicic Su
Su
Surg
r ery
ry
ry
ry
ry
ry
r ; J.C.
C.
C.
C.
C.
C.
C. Pos
os
os
os
o nick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
osnicick
A
B

1718 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 39-13  A 5-year-old boy with asymmetric prominent ears that are characterized by both conchal hypertrophy and deficient scaphal
folding. He underwent elliptical conchal wall resection (posterior approach); conchal rotation and stabilization (conchal–mastoid and superior helix–
mastoid sutures); and the improvement of the antihelical folds (Mustarde sutures). A, Frontal views before and after reconstruction. B, Oblique facial
views before and after reconstruction.
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B

1719
CHAPTER 39  Aesthetic Alteration of Prominent Ears: Evaluation and Surgery
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C
D
C, Profile views before and after reconstruction. D, Posterior views before and after reconstruction.
• Figure 39-13, cont’d

1720 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 39-14  A 5-year-old boy with asymmetric prominent and cupped ears that are characterized by conchal hypertrophy, deficient scaphal
folding, and a prominent earlobe. He underwent conchal wall resection (posterior approach); conchal rotation and stabilization (conchal–mastoid
sutures); improvement of the antihelical folding (Mustarde sutures); and earlobe set-back. A, Frontal views before and after reconstruction.
B, Oblique facial views before and after reconstruction.
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B

1721
CHAPTER 39  Aesthetic Alteration of Prominent Ears: Evaluation and Surgery
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
C
D
C, Profile views before and after reconstruction. D, Posterior facial views before and after reconstruction.
• Figure 39-14, cont’d

1722 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
A
B
•  Figure 39-15  A 5-year-old boy with asymmetric prominent ears that are characterized by conchal hypertrophy and inadequate scaphal folding.
He underwent conchal wall resection (posterior approach); conchal rotation and set-back (conchal–mastoid sutures); and deepening of the antihelical
folding (Mustarde sutures). A, Frontal views before and after reconstruction. B, Oblique facial views before and after reconstruction.

1723
CHAPTER 39  Aesthetic Alteration of Prominent Ears: Evaluation and Surgery
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C
D
C, Profile views before and after reconstruction. D, Posterior views before and after reconstruction.
• Figure 39-15, cont’d

1724 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
A
B
•  Figure 39-16  A 5-year-old boy with small and prominent ears that are characterized by the absence of scaphal folding and deep conchal
hypertrophy. He underwent elliptical conchal wall resection (posterior approach); conchal rotation and stabilization (conchal–mastoid sutures); and
the creation of antihelical folds (Mustarde sutures). He returned 6 months after surgery with chronic irritation in the right postauricular fold. A stitch
granuloma was debrided, and he went on to develop a localized hypertrophic scar in the same region. One year after surgery, the scar and inflam­
matory issue were excised, with primary closure. Healing was uneventful, and no other treatment was required. A, Frontal views before and after
reconstruction. B, Profile views before and after reconstruction.

1725
CHAPTER 39  Aesthetic Alteration of Prominent Ears: Evaluation and Surgery
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatatatatatatatatatatatatatatatatatatata hicicici Su
Su
Su
S r
u g
r ery
r ; J.C.
C.
C.
C. Pos
os
os
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g
tatatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S r
u g
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C. Pos
osnick
C
D
E
C, Posterior views before and after reconstruction. D, Right ear postauricular
view that shows the inflammatory tissue hypertrophic scar just before excision. E, Facial views 3 years
after reconstruction and 2 years after scar tissue excision.
• Figure 39-16, cont’d

•  Figure 39-17  A 7-year-old boy with asymmetric prominent and cupped ears underwent reconstruction. This required limited elliptical conchal
wall resection (posterior approach); conchal rotation and stabilization (conchal–mastoid and superior helix–mastoid sutures); improvement of the
antihelical folding (Mustarde sutures); and earlobe set-back (tail of the helix–mastoid sutures). A, Frontal views before and after reconstruction.
B, Oblique facial views before and after reconstruction. C, Profile views before and after reconstruction.
C
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B

1727
CHAPTER 39  Aesthetic Alteration of Prominent Ears: Evaluation and Surgery
•  Figure 39-18  An 11-year-old girl with
asymmetric prominent ears that are char­
acterized by conchal hypertrophy and
inadequate scaphal folding underwent
reconstruction. The procedures included
conchal rotation and set-back (conchal–
mastoid sutures) and the creation of
improved antihelical folding (Mustarde
sutures). A, Frontal views before and after
reconstruction. B, Oblique facial views
before and after reconstruction. C, Profile
views before and after reconstruction.
Note that there is a degree of incomplete
correction or relapse of both the conchal
and superior helix set-back of the
right ear.
C
Or
Or
Or
Or
Orthththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatata hicic Su
Su
Surg
r ery
ry
ry; J.C.
C. Pos
os
os
os
os
os
o nicicicicicicici k
Or
Or
Or
Orthththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatata hic Su
Su
Surg
r ery; J.C.
C Pos
os
os
os
os
os
os
os
os
o nicicicicicicicicicicicicicicicick
Orththththththththththththththththtr ognatatatathici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
o nicicicicicicicicicicick
Orthththth
r ogn
gn
gnatathicic Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
r ; J.C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
o nicicicicicicicicicicicicicicicicicicick
Or
O thth
r ogn
gn
gn
gnatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
o nicicicicici k
Orth
r ogn
gn
gn
gnatata hicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicicicicicicicicicicicick
A
B

1728 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 39-19  A high-school student
with prominent ears that are characterized
by conchal hypertrophy and deficient
scaphal folding. She underwent elliptical
conchal wall resection (posterior ap­
proach); conchal rotation and stabilization
(conchal–mastoid sutures); and the cre­
ation of an improved antihelical fold (Mus­
tarde sutures). A, Frontal views before and
after reconstruction. B, Oblique facial
views before and after reconstruction.
C, Profile views before and after recon­
struction. Note the overly prominent anti­
helical crease of the right ear.
C
Or
Or
Or
O ththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatatatata hici Su
Su
Surg
r ery
ry
ry
ry; J.C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
osnicicicicick
Or
Orththththththththththththththththththtr ogn
gn
gn
gn
g athicicici Su
S rg
r ery
ry; J.C.
C Pos
os
os
os
os
os
osnicici k
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatata hicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C. Pos
os
os
os
os
os
o nicicick
r
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatata hicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
S rg
r ery
ry; J.C. Pos
osnicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatathicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C. Pos
os
os
os
os
os
os
os
os
o nick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatata hicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C Pos
os
os
osnici k
A
B

1729
CHAPTER 39  Aesthetic Alteration of Prominent Ears: Evaluation and Surgery
•  Figure 39-20  A high school student
with prominent ears that are characterized
by conchal hypertrophy and deficient
scaphal folding. She underwent elliptical
conchal resection (posterior approach);
conchal rotation and stabilization (conchal–
mastoid sutures); and the creation of
an improved antihelical fold (Mustarde
sutures). A, Frontal views before and after
reconstruction. B, Oblique facial views
before and after reconstruction. C, Profile
views before and after reconstruction.
C
Or
Orththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
o nicicick
Or
Or
Orththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatata hicicicicic Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatathicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
o nicicicicicicicicicicicicicicicick
Or
Or
Or
Or
Or
Or
Orththththththththtr ogn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatatatathicicicicicicicicicicicicicicicici Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicicicicicicicicicicicicicicicicicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C. Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicicicicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C Pos
os
o nici k
A
B

1730 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 39-21  A 9-year-old girl with a unilateral (right-side) prominent ear that is characterized by
conchal hypertrophy and a lack of scaphal folding. She underwent a unilateral otoplasty. The ear
cartilage was extremely thin and flexible. She underwent conchal rotation and set-back (conchal–
mastoid sutures) and the creation of antihelical folding (Mustarde sutures). A, Frontal views before and
after reconstruction. B, Right profile views before and after reconstruction.
Or
Or
Or
Orththththththththththththththththththth
r ogn
gn
gn
gn
gn
g atatathicicicic Su
Su
Su
Su
S rg
r ery
ry
ry; J.C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
osnici k
Or
Or
Or
Or
Or
Or
Or
O thththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatata hici Su
Su
Su
Surg
r ery
ry; J.C.
C Pos
os
os
os
os
os
os
osnicicicicicicicicicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C Pos
os
os
o nicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatathicicicicicicicicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C. Pos
os
o nicicicick
A
B
Excessively Prominent Earlobe
After the traditional surgical management of the antihelical
fold, one area of the prominent ear that may require addi­
tional attention is the earlobe. At times, this problem can
be addressed with additional posterior skin excision. If the
lobe still projects forward and laterally, consideration should
be given to the removal of cartilage deep to the antitragus
(cavum conchalis) to allow the lobe of the ear to be aestheti­
cally retropositioned. This may be carried out as an exten­
sion of the conchal bowl excision. For others, the prominent
earlobe is managed with suturing of the tail of the helix to
either the mastoid fascia or the conchal base.
Failure (Relapse) of Scaphal (Upper
Helix) Folding
In some patients, the created antihelical fold will open
(relapse) with recurrence of the prominent ear appearance.
This may occur for one of several reasons. If a Mustarde
stitch becomes inflamed or infected, it may loosen, which
results in the unfolding of the helix. In other situations, an

1731
CHAPTER 39  Aesthetic Alteration of Prominent Ears: Evaluation and Surgery
•  Figure 39-22  A 9-year-old boy with malformed and asymmetric external ears who underwent
reconstruction. His procedures included asymmetric elliptical conchal wall resection (posterior
approach); conchal rotation and stabilization (conchal–mastoid and superior helix–mastoid sutures);
the creation of the antihelical fold (Mustarde sutures); and earlobe set-back (soft-tissue sutures).
A, Frontal views before and after reconstruction. B, Profile views before and after reconstruction.
Or
O ththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatathicicicicicici Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
r ; J.C.
C.
C.
C.
C.
C.
C.
C. Pos
os
osnick
Orththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatatatathicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
osnicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
o nicicicicicicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
osnicicicici k
A
B
uncooperative child may pull on the ears, thereby causing
shearing of the sutures with a recurrence of ear prominence.
For others, the sutures may not have a sufficient “bite” into
the cartilage and thus not withstand the recoil forces. In this
author’s experience, the use of non-resorbable (4-0 Mersi­
lene or 4-0 clear nylon) suture is an important aspect for
the limiting of relapse tendency.
In some patients, despite the placement of Mustarde
stitches, the upper helix still protrudes. If residual pro­
trusion of the upper third of the helix is observed early
after surgery, it is most likely an intraoperative technical
error rather than cartilage relapse. To prevent this
problem during operation, rather than overtightening the
Mustarde stitches, it is best to place a superior helix–
mastoid suture.
Residual Ear Asymmetry
When managing unilateral or bilateral ear prominence, the
preoperative assessment should clarify any baseline asym­
metry of the auricles. Each ear should be treated indepen­
Text continued on p. 1739

1732 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 39-23  A woman in her mid 20s
with prominent ears that are characterized
by a mild degree of conchal hypertrophy
and deficient scaphal folding. She under­
went elliptical conchal wall resection
(posterior approach); conchal rotation
(conchal–mastoid sutures); and the cre­
ation of the antihelical fold (Mustarde
sutures). She is shown before and just
2 weeks after surgery. At this stage of
healing, residual edema and skin discolor­
ation remain. A, Frontal views before and
2 weeks after surgery. B, Oblique facial
views before and 2 weeks after surgery.
C, Profile views before and 2 weeks after
surgery.
C
Orth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatathicic Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
r ; J.C.
C.
C Pos
os
os
os
os
os
os
os
os
os
o nick
Orthththththththththththththtr ogn
gn
gn
gn
gn
g atata hicic Su
Su
Surg
r ery
ry; J.C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
o nick
Or
O thth
r ogn
gn
g atata hicicicic Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C. Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
o nicici k
Orth
r ogn
gn
gnata hicic Su
Su
S rg
r ery
ry
ry
ry
r ; J.C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
o nicicicicicick
Or
Or
O thth
r ogn
gnatatathicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C. Pos
os
os
os
os
os
os
os
o nicicicicicicicicicicicicicicicick
Or
Orthth
r ogn
gnatatatata hicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C. Pos
os
os
os
os
os
os
os
osnicicicicicicicicicicicicicicick
A
B

1733
CHAPTER 39  Aesthetic Alteration of Prominent Ears: Evaluation and Surgery
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B
•  Figure 39-24  A high school student with prominent ears that are characterized primarily by conchal hypertrophy requested setback. He under­
went conchal wall resection (posterior approach); conchal rotation and stabilization (conchal–mastoid sutures); and stabilization of the antihelical
folding (Mustarde sutures). A, Frontal views before and after reconstruction. B, Oblique facial views before and after reconstruction.
Continued

1734 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C
D
C, Profile views before and after reconstruction. D, Posterior views before and after reconstruction.
• Figure 39-24, cont’d

1735
CHAPTER 39  Aesthetic Alteration of Prominent Ears: Evaluation and Surgery
•  Figure 39-25  A middle-aged man with
a lifelong history of prominent ears that are
characterized by limited antihelical folding
and a degree of conchal hypertrophy.
He underwent conchal wall resection
(posterior approach); conchal stabilization
(conchal–mastoid sutures); and deepen­
ing of the scaphal folding (Mustarde
sutures). A, Frontal views before and after
reconstruction. B, Oblique facial views
before and after reconstruction. C, Profile
views before and after reconstruction.
C
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththththththth
r ogn
gn
gn
gn
g atata hicicicic Su
Su
Su
Surg
r ery
ry
ry
ry; J.C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicicicicicicicicicicick
Or
Orththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatathicicicici Su
Su
Su
S rg
r ery
ry
ry
ry; J.C.
C.
C Pos
os
os
os
os
os
osnicicicicicicicicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththththth
r ogn
gn
gn
gnatatatathicicic Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
o nicicicicicicicicicicicicicicicicicicicicicicicick
Or
Or
Or
Or
Or
Or
Or
Or
Orththththth
r ogn
gn
gn
gn
g atatatatatatathicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
o nicicicicicicicicicicicicicicick
Orth
r ogn
gn
gnatatatata hicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C. Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicicicicicicicick
Orth
r ogn
gn
gn
gn
gn
gn
gn
gn
gnatatata hicicic Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C. Pos
os
os
os
os
os
os
os
os
os
os
os
os
o nicicicicicicicicicicicicicicicick
A
B

1736 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B
•  Figure 39-26  A high school student who was born with hemifacial microsomia underwent simultaneous jaw and external ear reconstruction
(see Fig. 28-15). Although the ears are asymmetric in morphology and position, they were simply set back. The left ear underwent both conchal
wall resection (posterior approach) and improvement of the scaphal fold (Mustarde stitches). The right ear required improvement of the scaphal
fold (Mustarde stitches) and the placement of superior helix–mastoid sutures. A, Frontal views in repose before and after reconstruction. B, Frontal
views with smile before and after reconstruction.

1737
CHAPTER 39  Aesthetic Alteration of Prominent Ears: Evaluation and Surgery
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C
D
C, Left oblique facial views before and after reconstruction. D, Right oblique facial views before and after
reconstruction.
• Figure 39-26, cont’d

1738 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 39-27  A 5-year-old child with
Treacher Collins syndrome underwent zygo­
matic–orbital reconstruction and bilateral
external otoplasty (see Fig. 27-11). The exter­
nal ear procedures included elliptical conchal
wall resection (posterior approach); conchal
rotation and stabilization (conchal–mastoid
suture); and the improvement of the anti­
helical folds (Mustarde sutures). A, Frontal
views before and after reconstruction.
B, Oblique facial views before and after
reconstruction. C, Worm’s-eye views before
and after reconstruction.
C
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththththththththththththththththtr ogn
gn
gn
gn
gn
gn
gnatatatatatatatathicicicicicicicicici Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
osnicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicick
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatathicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
o nicicicicicicicicici k
©Elsevier Inc.
Or
Or
Or
Or
O ththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatatatatathicicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicick
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatathicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C. Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
o nicicicicicicicicicicicicicicicicicicicicicicicick
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicicicicici Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
o nicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicici k
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicicicici k
A
B

1739
CHAPTER 39  Aesthetic Alteration of Prominent Ears: Evaluation and Surgery
dently but with consideration of overall facial symmetry
and balance. Ear asymmetry is easily glossed over preopera­
tively; however, when scrutinizing the ears after surgery,
even minor asymmetry may take on greater importance.
Good-quality facial photographs before and soon after
surgery should be reviewed with the patient and the family
to avoid misunderstandings.
Postsurgical “Telephone Ear” Appearance
The “telephone ear” deformity is caused by overaggressive
set-back (antihelical folding) in the middle third of the
helical rim in combination with the undercorrection of the
earlobe and the superior third of the helix. This generally
occurs when conchal hypertrophy has not been appropri­
ately addressed.
Postsurgical “Flat Ear” Appearance
The postsurgical “plastered back” appearance of the
external ears occurs when the antihelical fold is sharp and
excessive in combination with the overreduction of the
conchal wall.
Infection of the Cartilage (Chondritis)
Infection after ear surgery is not common. Chondritis is
more likely after aggressive anterior flap elevation and car­
tilage scoring, especially when contamination occurs.
Necrosis with Loss of Skin
Necrosis is more likely to occur with wide anterior flap
undermining when inadequate attention has been given to
circulation requirements. It may also occur as a result of an
overly tight ear dressing or bandage, a hematoma beneath
the dressing, or a combination of these factors.
Abnormal Scar Formation
Hypertrophic scarring can occur at any wound closure. It
is more likely in the presence of infection or poor circula­
tion or with excessive scratching or rubbing by the patient
postoperatively. Keloid formation can occur and may be
differentiated from hypertrophic scarring by a positive per­
sonal or family history and scar enlargement that extends
outside of the operative site. Current options for the man­
agement of a keloid scar are often suboptimal but may
include intralesional steroid injections, cutaneous irradia­
tion, or re-excision.
Suture Granuloma (“Stitch Abscess”)
Occasionally a buried suture will develop a granulomatous
reaction around it. The offending suture will either sponta­
neously exfoliate or require surgical removal. This seems to
be more frequent with Mersilene suture material. Removal
under local anesthesia can be difficult in a child.
Non-Surgical Correction of Prominent
Ears in the Newborn
Although the idea of “binding” the external ears in an
attempt to correct abnormalities is not a new one,
Matsuo and colleagues can be credited with examining
the efficacy of doing so in newborns.40 Byrd and col­
leagues convincingly demonstrated that there are particu­
lar auricular deformities in the newborn that are amenable
to molding back toward normal.9 In their publication,
the types of deformities that can be most effectively
treated and details concerning methods of molding are
discussed. Auricular deformations are characterized by a
misshapen but fully developed pinna.65,66 Ear molding
techniques are best suited for deformations rather than
malformations.8,12,29,36,41,43,45,59,68,71 Interestingly, approxi­
mately one third of the ear deformations that are present
at the time of birth self-correct during the first week of
life. The patterns of deformation that are frequently seen
include the following: prominent/cupped ears; lidded/
lopped ears; Stahl (or Spock) ears; helical rim deformities
(with an absent or deficient rim); and conchal crus
deformities.49,51,58 Byrd and colleagues found that birth
deformations of the auricle more often than not involve
the upper third of the ear, with incomplete formation
of the superior limb of the triangular fossa being a
frequent finding. This leads to a helical rim scapha defor­
mation. The authors stressed the importance of accom­
plishing three key molding forces to correct the majority
of these ear deformations in newborns:
1. A stent or conformer that rests along the retroauricu­
lar sulcus and that is in alignment with the antihelix
is placed.
2. A second conformer that is curved to match the
natural shape of the helical rim is used. It is placed
anteriorly but with force directed against the scapha.
The anterior conformer is carefully located to avoid
excess direct pressure against the posterior conformer
for the avoidance of skin necrosis.
3. As the helix is retracted, the molding technique is also
used to expand the rim to its full dimension.
The authors described good to excellent results in 90% of
the newborns whose external ear deformities were treated in
this way. Complications were seen in only approximately 5%
of patients and were mostly characterized as localized skin
excoriations. The authors recommend withholding ear-
molding therapy until the end of the first week to identify
those infants whose ears spontaneously self-correct soon after
birth. It is believed by most that, for treatment to be effective,
it should be instituted by the second or (at most) third week