Cosmetic Facial Surgery

Chapter 10  •  Facial Implants
433
References
  1. Niamtu J: The adjustable vector deep plane midface lift. Atlas Oral Maxil-
lofac Surg Clin North Am 12(2):199–214, 2004 Sep.
  2. Niamtu J, Chisholm B: The Adjustable Vector Deep Plane Midface Lift.
J Oral Maxillofac Surg 62:630–637, 2004
  3. Watson S, Niamtu J, Cunningham L: Endoscopic Midface Lift: Endoscopic
Techniques in Oral and Maxillofacial Surgery. In Cunningham L: Atlas of
Oral and Maxillofacial Surgery Clinics of North America, Philadelphia,
2003 Sep, W.B. Saunders, 11(2):145–155.
  4. Niamtu J: Rejuvenation of the lip and Perioral Areas. In Bell WH, Guerroro
CA, editors: Distraction Osteogenesis of the Facial Skeleton, Canada, 2007,
BC Decker, Ontario.
  5. Niamtu J: Advanta ePTFE Facial Implants in Cosmetic Facial Surgery.
J Oral Maxillofac Surg 64:543–549, 2006.
  6. Niamtu J III: Advanta Facial Implants. In Niamtu J III: Minimally Invasive
Cosmetic Surgery Oral and Maxillofacial Surgery Clinics of North America.
17:1, Philadelphia, 2005, Saunders, pp 29–39.
  7. Le Louarn C, Buthiau D, Buis J: The face recurve concept: medical and
surgical applications. Aesthetic Plast Surg 31(3):219–231, discussion 232;
2007 May–Jun.
  8. Niamtu J: The use of Restylane in cosmetic facial surgery. J Oral Maxillofac
Surg 64:317–325, 2006.
  9. Niamtu J: New lip and wrinkle fillers. In Niamtu J III: Minimally Invasive
Cosmetic Surgery Oral and Maxillofacial Surgery Clinics of North America,
17:1, Philadelphia, 2005, Saunders, pp 17–27.
10. Steinsapir KD, Steinsapir SM: Deep-fill hyaluronic acid for the temporary
treatment of the naso-jugal groove: a report of 303 consecutive treatments.
Ophthal Plast Reconstr Surg 22(5):344–348, 2006 Sep–Oct.
11. Niamtu J: Accurate and Anatomic Midface Filler Injection by Using Cheek
Implants as an Injection Template. Dermatol Surg 33:1–4, 2007.
12. Graivier MH, Bass LS, Busso M, Jasin ME, Narins RS, Tzikas TL: Calcium
hydroxylapatite (Radiesse) for correction of the mid- and lower face:
consensus recommendations. Plast Reconstr Surg 120(6 Suppl):55S–66S,
2007 Nov.
13. Little JW: Applications of the classic dermal fat graft in primary and sec-
ondary facial rejuvenation. Plast Reconstr Surg 109(2):788–804, 2002 Feb.
14. Obagi S: Autologous fat augmentation for addressing facial volume loss.
Oral Maxillofac Surg Clin North Am 17(1):99–109, 2005 Feb.
15. Obagi S: Autologous fat augmentation: a perfect fit in new and emerging
technologies. Facial Plast Surg Clin North Am 15(2):221–228, vii, 2007
May.
16. Burgess CM: Principles of soft tissue augmentation for the aging face. Clin
Interv Aging 1(4):349–355, 2006.
17. Roy D, Mangat DS: Facial implants. Dermatol Clin 23(3):541–547, 2005
Jul.
18. Burres S: Midface volume replacement with a transmaxillary implant.
Aesthetic Plast Surg 29(1):1–4, 2005 Jan-Feb.
19. Binder WJ: Malar and submalar augmentation. Facial Plast Surg Clin
North Am 16(1):11–32, 2008 Feb.
20. Terino E, Edwards MC: Alloplastic contouring for suborbital, maxillary,
zygomatic deficiencies. Facial Plast Surg Clin North Am 16(1):33–67, 2008
Feb.
21. Constantinides MS, Galli SK, Miller PJ, Adamson PA: Malar,
submalar, and midfacial implants. Facial Plast Surg 16(1):35–44, 2000.
Review.
22. Brody HJ: Complications of expanded polytetrafluoroethylene (e-PTFE)
facial implant. Dermatol Surg 27(9):792–794, 2001 Sep.
23. Adams JR, Kawamoto HK: Late infection following aesthetic malar aug-
mentation with Proplast implants. Plast Reconstr Surg 95(2):382–384,
1995 Feb.
24. Dodson TB: Infection of Proplast malar implants and dental injections.
Plast Reconstr Surg 91(1):195–196, 1993 Jan. No abstract available.
25. Wilkinson TS: Complications in aesthetic malar augmentation. Plast
Reconstr Surg 71(5):643–649, 1983 May.
26. Logani SC, Conn H, Logani S, Terino EO: Paralytic ectropion: a complica-
tion of malar implant surgery. Ophthal Plast Reconstr Surg 14(2):89–93,
1998 Mar.
27. Lypka M, Yamashita DD: Exuberant foreign body giant cell reaction to a
Teflon/Proplast temporomandibular joint implant: report of a case. J Oral
Maxillofac Surg 65(9):1680–1684, 2007 Sep.
28. Mercuri LG, Giobbie-Hurder A: Long-term outcomes after total alloplastic
temporomandibular joint reconstruction following exposure to failed mate-
rials. J Oral Maxillofac Surg 62(9):1088–1096, 2004 Sep.

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11 
Cosmetic Otoplasty and
Related Ear Conditions
T
alking to cosmetic surgeons about otoplasty is like
asking people about politics: everyone has a different
opinion. There is no doubt that a myriad of procedures
exist for a seemingly simple operation. Search the word otoplasty
on PubMed, and you will find 302 entries. In the PubMed
search, 41 articles were written in the 18 months prior to this
writing, and the earliest PubMed reference is 1915.1 Search for
the word otoplasty on Google, and there are 281,000 entries, so
there is no doubt much is written on the subject.1 Numerous
seminal articles have paved the way to contemporary oto-
plasty,2-13 and numerous articles have presented refinements of
various other techniques.14-21
Embryology
The external ear appears only in mammals. Internal, middle,
and external ear development is a beautiful and complex embry-
ologic orchestration. The external ear forms from tissues of the
first and second pharyngeal arches, which can be seen at 5 weeks
(Figure 11-1). Six tissue elevations termed auricular hillocks of
His become apparent at 6 weeks in utero (Figure 11-2). Three
form from the first arch, and three from the second arch. Each
of the auricular hillocks forms a distinctive portion of the defini-
tive external ear.22 For example, hillock #1 forms the tragus, and
hillock #6 forms the antitragus and part of the helix23 (Figure
11-3). The lobule of the ear is not derived from the hillocks.22
The developing external ears are initially more caudal than the
lower jaw. Growth of the lower jaw places the external ear in a
relatively higher and more vertical orientation.22
The classic embryologic tenets have been challenged. In this
description, the first branchial arch contribution is limited to
the tragus.24
Normal Anatomy
The developed external ear has evolved to capture and focus
vibrations through the middle ear canal to the inner ear. In
humans, many of the functions remain vestigial. Anyone who
has ever witnessed animals whose life depends on detecting
predators in nature, such as deer, has a better understanding of
the complex movements and function of the mammalian exter-
nal ear. Figure 11-4 shows the normal anatomic components of
the developed ear.
Common measurements of the ear include the long
axis, which inclines posteriorly at approximately a 20-degree
angle from the vertical. The anterolateral aspect of the helix
protrudes at a 21- to 30-degree angle from the scalp. The lobule
and antihelical fold lie in a parallel plane at an acute angle to
the mastoid process. The ear is positioned at approximately one
ear length (5.5 to 7 cm) posterior to the lateral orbital rim
between horizontal planes that intersect the eyebrow and
columella.
The average length of a male auricle is 63.5 mm and the
female, 59 mm. The average width of the male auricle is
A
B
FIGURE 11-1.  A human embryo is shown at 5 weeks. The first and second pharyngeal arches contribute to the tissues of the
external ear.

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
435
A
B
FIGURE 11-2.  Auricular hillocks are shown in a human embryo at 6 weeks (A) and 9 weeks (B). These structures will develop
into the complex external ear anatomy.
5 weeks
9 weeks
1
2
3
4
5
6
1
1
2
2
3
3
4
4
5
5
6
6
FIGURE 11-3.  Human embryologic development of the external
ear begins with the first and second pharyngeal arches and is
apparent at 5 weeks. Each arch contributes three hillocks that
will develop into external auricular anatomic components. The
tragus is formed from the mandibular arch and the remaining
five hillocks. In the first diagram, hillock 1 will become the
tragus, hillock 2 will become the helical crus, hillock 3 the
ascending helix, hillock 4 the upper helix, scapha, and antihe-
lix, hillock 5 the descending helix, middle scapha, and antihelix,
and hillock 6 the inferior helix and antitragus.
35.5 mm, and the female is 32.5 mm. The helix should project
2 to 5 mm more laterally than the antihelix on frontal view
(Figure 11-5).
A very important measurement estimate to keep in mind
is the distance the auricle sits from the cranium. This will
become paramount when diagnosing, planning, and performing
corrective otoplasty. Although it varies from patient to patient,
the distance from the outside of the superior helical rim to the
temporal skin is about 10 mm, and the distance from
the posterior helical rim to the mastoid skin is about 20 mm
(Figure 11-6).
When viewed from above, the normal ear angulations are the
result of a 90-degree conchomastoid angle and a 90-degree
conchoscaphalic angle (Figure 11-7, A). With protruding ear
deformities, the conchomastoid angle may remain at 90 degrees,
but the conchoscaphalic angle will become obtuse, between 140
and 150 degrees (see Figure 11-7, B).
The auriculocephalic angle measures how far the pinna sits
away from the posterior cranium and should be less than 35
degrees. Figure 11-8 shows a normal auriculocephalic angle and
an exaggerated one of greater than 35 degrees, whereas the pinna
is anteriorly displaced.

436
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
1
2
3
4
5
6
7
8
9
10
11
12
13
14
FIGURE 11-4.  1, Tragus; 2, antitragus; 3, lobe; 4, helix; 5, scapha;
6, antihelix; 7, superior crus; 8, anterior crus; 9, fossa triangularis;
10, cymba concha; 11, cavum concha; 12, helical radix; 13, helical crus;
14, intertragal incisure.
FIGURE 11-5.  In the normal ear, the antihelix protrudes several millimeters
past the helical rim at the mid ear.
A
B
FIGURE 11-6.  The superior helical rim rests about 10 mm from the temporal skin (A), and the posterior helical rim lies about
20 mm from the mastoid skin (B). Using a plastic ruler with a notch cut out at 10 mm on one side and 20 mm on the other
side is a useful tool for quick and accurate measurement.
Neurologic Anatomy
The auriculotemporal nerve is a branch of the mandibular divi-
sion of the trigeminal nerve and supplies sensation to the tragus
and helical crus. The anterior branch of the greater auricular
nerve (from the cervical plexus) innervates most of the ear,
including the helix, scapha, antihelix, concha, antitragus, exter-
nal acoustic meatus, and lobule. The posterior branch of the
greater auricular nerve also innervates some of the posterior
ear. The mastoid branch of the lesser occipital nerve (from the
cervical plexus) also innervates the posterior region of the exter-
nal ear (Figures 11-9 and 11-10). The external auditory meatus
also receives innervations from branches of the vagus (Arnold’s
nerve) and glossopharyngeal nerves. The entire ear can be anes-
thetized by injecting local anesthesia along the base anteriorly
and posteriorly. Supplemental anesthesia may be needed at the
posterior wall of the external ear canal, which is supplied by the
auricular branches of the vagus nerve. For other supplemental
local anesthesia, a “ring block” is performed by injecting
circumferentially around the ear (Figure 11-11).

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
437
90
90
145
90
A
B
FIGURE 11-7.  The axial view of the normal ear exhibits a conchomastoid angle of 90 degrees with a conchoscaphalic angle of
90 degrees. Protruding ears can result in conchoscaphalic angles of 140 to 150 degrees.
A
B
FIGURE 11-8.  A, This section is taken at the level of the helical crus. The auriculocephalic angle measures the distance from
the posterior pinna to the cranium and should be less than 35 degrees. B, The larger angle is consistent with protruding ears
(green line).
Vascular Anatomy
Arterial blood supply to the external ear is from the posterior
auricular from the external carotid, the anterior auricular from
the superficial temporal, and a branch from the occipital artery.
The anterior arterial blood supply to the ear is primarily
derived from the external carotid artery via the superficial tem-
poral branch. The superficial temporal vessel exits the parotid
capsule, passes under the anterior auricular muscle, and divides
into superior, medial, and inferior branches to supply the ante-
rior surfaces of the auricle.14 The posterior auricular artery
branches from the external carotid artery and runs parallel to
the posterior auricular crease, deep to the posterior auricular
muscle and greater auricular nerve. The posterior auricular
artery (a branch of the external carotid) supplies the posterior
surface of the ear and also has superior, medial, and inferior

438
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
A
B
FIGURE 11-9.  A, Main dermatomes of the cervical plexus. B, Dermatomes of other nerves that provide innervation to the head
and neck. Note that the external ear receives innervation from the greater auricular nerve, the auriculotemporal nerve, and the
lesser occipital nerve.
ATN
V
LON
GAN
FIGURE 11-10.  The greater auricular nerve supplies the main innervation to
the anterior portion of the external ear. The auriculotemporal nerve also
supplies the tragus and helical crus regions, and the mastoid branch of
the lesser occipital nerve supplies innervation to most of the posterior
surface of the ear. The external auditory meatus also receives innervation
from the vagus nerve.
FIGURE 11-11.  Although injecting at the base of the anterior and posterior
regions of the ear (and the region of Arnold’s nerve) will provide anesthesia
to the entire ear, a “ring block” provides supplemental local anesthesia for
local procedures.
branches. The posterior ear also has arterial contribution from
the mastoid branch of the occipital artery, a branch of the
external carotid (Figures 11-12 and 11-13).
The veins accompany the corresponding arteries. Venous
drainage is from the superficial temporal and posterior auricular
veins, and lymphatic drainage is from the parotid preauricular
nodes (anterior), the superficial cervical nodes (inferior), and
the retroauricular (mastoid) nodes posteriorly.
Muscular Anatomy
The muscles of the auricle consist of two sets. The extrinsic,
which connect it with the skull and scalp and move the auricle
as a whole; and the intrinsic, which extend from one part of the
auricle to another.
The extrinsic muscles are the anterior, superior, and posterior
auricular (Figure 11-14). The anterior auricular, the smallest of

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
439
arise from the mastoid portion of the temporal bone by short
aponeurotic fibers. They are inserted into the lower part of the
cranial surface of the concha.
The temporal branch of the facial nerve (cranial nerve VII)
supplies the anterior and superior auricular muscles. The poste-
rior auricular branch of cranial nerve VII supplies the posterior
auricular muscle and the intrinsic auricular muscles. In humans,
these muscles possess very little action: the anterior auricular
draws the auricle forward and upward; the superior auricular
slightly raises it; and the posterior auricular draws it backward.
Cartilaginous Anatomy
The delicate and complex ear cartilage is one of the most unique
anatomic forms in the body. The entire external ear possesses a
cartilaginous framework, with the exception of the lobe and the
tragal incisure (Figure 11-15).
Aberrant Anatomy
Growth disturbances of the auricle have been described to occur
in 1 in 12,500 births,14 or 5% of the population.25 The ear grows
proportionally at a rapid rate; 85% of ear development is com-
plete by age 3,26,27 and the ear is fully developed at age 7 to
8.28,29 Matsuo et al. also observed that the percentage of protrud-
ing ears increases from 0.4% at birth to 5.5% at 1 year of age
and concluded that most protruding ears are acquired deformi-
ties.25 The only difference between the neonatal ear and the
adult ear is that in the neonate, the cartilage is more malleable
and soft. Otherwise, the anatomy is the same. Ear width reaches
its mature size in boys at 7 years and in girls at 6 years. Ear
length matures in boys at 13 years and in girls at 12.25 The older
the person becomes, the stiffer and more calcified the cartilage.
This progression has an effect on surgical techniques.26,27
the three, is thin and fan shaped; its fibers are pale and indis-
tinct. It arises from the lateral edge of the galea aponeurotica,
and its fibers converge to be inserted into a projection on the
front of the helix. The superior auricular, the largest of the three,
is also thin and fan-shaped. Its fibers arise from the galea apo-
neurotica and converge to be inserted by a thin, flattened tendon
into the upper part of the cranial surface of the auricle. The
posterior auricular consists of two or three fleshy fascicles which
FIGURE 11-12.  The arterial supply to the external ear is from the superficial
temporal, posterior auricular, and occipital arteries, which are branches of
the external carotid artery.
FIGURE 11-13.  The main arterial and venous blood supply to the external
ear.
2
3
1
A
B
C
D
FIGURE 11-14.  The extrinsic muscles of the ear include the anterior auricu-
lar (1), the superior auricular (2), and the posterior auricular (3).

440
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
triangularis. In developmental ear deformities, the antihelical
fold is often ill defined or absent (Figures 11-18 and 11-19).
This deformity can be bilateral or unilateral (Figure 11-20).
Conchal Wall or Bowl Hypertrophy
This is also a very common type of ear deformity leading to the
protrusive ear. In this deformity, there is excessive growth of the
poster wall of the concha, and the chondroplasia can include
the entire conchal bowl (Figures 11-21 to 11-23).
Combination Deformities
More commonly, patients exhibit lack of an antihelical fold and
conchal bowl hypertrophy (Figures 11-24 and 11-25). This
combination deformity is very common. I rarely see patients
with the sole deformity of undefined antihelical fold or posterior
conchal wall excess; 98% of the surgical corrections I have
performed included both problems.
Many more complex deformities exist as a result of develop-
ment: microtia, cryptotia, and branchial arch syndrome. Their
treatment is beyond the scope of this text.
Cosmetic Otoplasty Procedural Timing
One of the most important factors concerning otoplasty surgery
is at what age to operate. Despite being a benign condition,
emotional trauma and behavioral problems, lack of self-esteem,
and a permanent problem with body image can be seen in
children with protruding ears. These problems remain the prime
reasons for performing this surgery early to avert peer ridicule
in grade school.30-32 Realizing this, correcting the deformity
before the child starts school is advantageous. To reiterate, 85%
of ear development is complete by age 3, the ear is fully devel-
oped at age 7 to 8, ear width reaches its mature size in boys at
1
3
4
5
6
2
7
8
9
FIGURE 11-15.  The complex internal cartilaginous framework of the
external ear. 1, Helix; 2, antihelix; 3, fossa triangularis; 4, scapha; 5, tragus;
6, antitragus; 7, tragal incisure; 8, concha; 9, cauda helix.
A
B
FIGURE 11-16.  Prominauris (protruding ears) is an autosomal dominant trait, and heredity plays an obvious part in its transfer-
ence. This 7-year-old white male is shown with conchal bowl excess and lack of antihelical fold, resulting in protruding ears.
His grandfather is shown possessing a similar deformity.
Heredity plays an obvious part in transference and develop-
ment of protruding ears and is an autosomal dominant trait15
(Figures 11-16 and 11-17).
Lack of Antihelical Fold
The antihelix includes the superior and anterior crus and forms
a curvilinear separation between the conchal bowl and the
scapha fossa. The region between the crus is the fossa
Text continued on page 445.

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
441
A
B
FIGURE 11-17.  A, These identical twins both manifest conchal bowl hypertrophy and lack of an antihelical fold, further underlining
genetic predisposition for protruding ears. B, Two siblings, one with normal ears and one with protruding ears.
A
B
FIGURE 11-18.  A, Normal antihelical fold. B, Ill-defined fold.

442
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
A
B
FIGURE 11-19.  A totally absent (or unfurled) antihelical fold.
FIGURE 11-20.  A unilateral antihelical fold deformity.
B
A
FIGURE 11-21.  Normal conchal wall height (A) and a patient with signifi-
cant conchal wall hypertrophy (B).

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
443
A
B
C
FIGURE 11-22.  Varying degrees of protruding ears from posterior conchal wall cartilaginous hypertrophy with increased auricu-
lomastoid angles.
A
B
C
D
FIGURE 11-23.  Patient with conchal wall hypertrophy. On the lateral view, the ear is cupped forward with an obtuse con-
choscaphalic angle.

A
B
C
D
FIGURE 11-24.  Patient shows both common deformities: lack of a defined antihelical fold and posterior conchal wall excess.
A
B
FIGURE 11-25.  This 6-year-old female exhibits a combination deformity of both posterior conchal wall cartilaginous hypertrophy
and lack of a defined antihelical fold.

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
445
designed to create an antihelical fold. Pinning the conchal car-
tilage to the mastoid fascia with sutures (Furnas procedure) has
not proven stable for many surgeons. In addition, pinning the
conchal bowl posteriorly causes the anterior portion of the bowl
to slide forward and can obscure or otherwise deform the exter-
nal auditory canal, which is a common complaint of some
patients.
The Davis Procedure
The procedure I prefer for conchal bowl excess was described by
Davis in 197811,13 and involves removing the excess conchal
cartilage to reduce the hyperplastic posterior wall of the conchal
bowl.
The Davis procedure and the Mustardé procedure are diffi-
cult to conceptualize without actually witnessing the procedures
several times. In the Davis procedure, the excess cartilage of the
posterior conchal wall and bowl are excised. It is this hypertro-
phic cartilage that makes the ear protrude. By resecting the
excess, the posterior conchal wall and bowl are shortened, thus
allowing the ear to lie passively in a normal position. An example
of this is shown in Figures 11-26 and 11-27, using an emesis
basin and beach ball as an example. The kidney bean–shaped
emesis basin with its high posterior wall is analogous to the
hypertrophic posterior conchal wall. In Figure 11-26, A the
basins “ears” protrude from the “head” owing to their height. If
part of the posterior wall and bowl of the basin is trimmed, the
basins sit in more retrusive position on the ball (see Figure
11-26, B). Figure 11-27 shows the “hypertrophic” emesis basin
“conchal wall and bowl” and its reduction after removing the
kidney bean–shaped “floor” of the basin.
All patients are seen preoperatively and begun on a course of
ciprofloxacin 500 mg every 12 hours beginning 48 hours before
surgery. Preoperative photographs are taken. It is sometimes
difficult to photograph the ears; a headband can be used, or the
hair can be pulled back in a ponytail or braids. Frontal, lateral,
and oblique views are taken. A submental view is also useful.
Because protruding ears cast a shadow, taking the images
without a flash is helpful to provide quality images.
The procedure is begun by measuring and marking 8 mm
inferior to the conchal/scaphal junction, which will be the pos-
terior portion of the conchal wall that remains. Cutting a notch
in a plastic or metal ruler at 8 mm makes a handy tool to
measure with (Figure 11-28). By leaving approximately 8 mm,
the ear will set back to a normal position in the average person.
Figure 11-29 shows a hyperplastic posterior conchal wall mea-
suring 14 mm in depth, which means that approximately
6 mm of reduction is necessary. This marking will include the
entire hypertrophic conchal bowl and result in an excision
shaped like a cashew nut or kidney bean (Figure 11-30). The
kidney-bean shape is marked with a surgical marker. Wiping
the marked area with alcohol will prevent the marker from
rubbing off. If a Mustardé procedure is planned, these markings
are also made at this point. It is imperative to make all markings
before injecting local anesthesia, because the injections will
distort the landmarks and surgical markings. Figure 11-31
shows markings in two different patients, and Figure 11-32
shows the 8-mm posterior conchal bowl markings on the ear
and intraoperatively.
age 7 and in girls at age 6, and ear length matures in boys at
age 13 and in girls at age 12.28 Goasain performed a study of
10 patients who had corrective otoplasty as early as 9 months
and up to 4 years of age and concluded that “experience using
this approach demonstrates that otoplasty can be performed
from the age of 9 months or older with safety, reliability, and a
high level of satisfaction on the part of the affected families.”32
In his study, recurrence was noted in 1 of the 12 patients. I
believe it is safe to say that the average surgeon performs inter-
ventional preschool otoplasty most frequently on children aged
5 to 7 years. Children with protruding ears or their parents have
been known to go to great lengths to mask their deformity,
including gluing the ears to the skull.33
Surgical Procedures
As with any surgery, the surgeon must have a distinct set of goals
in mind for appropriate surgical outcome. In a 1968 article,
McDowell outlined the classic goals of otoplasty.34 They include:
• All upper-third ear protrusion must be corrected.
• The helix of both ears should be seen beyond the antihelix
from the front view.
• The helix should have a smooth and regular line
throughout.
• The postauricular sulcus should not be markedly decreased
or distorted.
• The helix-to-mastoid distance should fall in the normal range
of 10 to 12 mm in the upper third, 16 to 18 mm in the
middle third, and 20 to 22 mm in the lower third.
• The position of the lateral ear border to the head should
match within 3 mm at any point between the two ears.
Nonsurgical Intervention
Nonsurgical correction of ear deformities, including prominent
ears, usually has poor results. There is evidence, however, that
intervention within the first few days of life may adequately treat
a prominent ear. Excellent results were reported by Tan et al.
when auricular molding was started within 3 days of birth and
continued for up to 6 months.35,36 Delay of treatment yielded
poor results. Tan attributes the loss of cartilage pliability after
birth to decreasing levels of circulating maternal estrogens,
which are highest in the first 3 days after birth and decrease to
normal levels by 6 weeks of age.
So many techniques exist for cosmetic otoplasty, it is impos-
sible to cover them all. This chapter presents the two techniques
that can be applied to most common ear deformities and have
produced stable and predictable results for many surgeons
including myself. Although I have performed other techniques
for otoplasty, including conchal setback and cartilage-splitting
procedures, they have not proven as aesthetic or stable in my
hands, and I must formally thank Todd Owsley, DDS, MD, for
“showing me the light” in terms of the simplicity of otoplasty
by combining the Mustardé and Davis procedures.
Obviously there is a lot of personal preference involved with
otoplasty. I believe that attempting to correct a hypertrophic
conchal bowl by merely “setting it back with sutures” is a
mistake, because the elastic memory of the cartilage will fre-
quently trump conchal setback sutures. Ears in which the main
deformity is conchal excess will not be corrected by procedures

446
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
A
B
Back of head
FIGURE 11-26.  The emesis basins and beach ball are analogous to protruding ears (as viewed from behind) with hypertrophic
conchal posterior walls and bowls. If a portion of the “conchal wall and floor” is excised, the basin “ear” will sit in a less protrusive
position.
A
B
C
FIGURE 11-27.  A, This image is analogous to removing height from the posterior conchal wall and bowl. B, The kidney bean–shaped excess “excised
cartilage.” C, The emesis basin “posterior conchal wall and bowl” reduced, thus lowering the height of the basin or protrusion of the ear.
FIGURE 11-28.  An 8-mm measurement (and mark) is made from the anti-
helix (conchal/scaphal junction) to the posterior conchal wall to serve as
the new height of the posterior conchal wall. This allows the ear to sit back
in a normalized position. A plastic or metal measuring device notched at
8 mm makes an efficient tool to perform markings.
I have performed otoplasty procedures with local anesthesia
only but prefer to use IV sedation, which is a requisite for chil-
dren. It is preferable to tape the hair off the surgical field and
use a circular drape to isolate the ear and mastoid region.
The entire ear, ear canal, and mastoid region are prepped with
a surgical scrub, and a cotton ball is placed in the external audi-
tory canal to prevent blood from collecting.
Local anesthetic is injected subcutaneously in numerous
areas for anesthesia and hemostasis and to hydrodissect
overlying skin. The entire conchal bowl is injected, as is the
antihelix if a simultaneous Mustardé procedure is planned. The
entire posterior auricular is also infiltrated, as is the mastoid
region. When performing the Davis procedure, significant
dissection is required to the level of the mastoid fascia, so it is
paramount to inject the multiple tissue planes behind the ear
to periosteum.
The posterior auricular incision is made in a routine fashion.
Although some surgeons use various geometric incision tech-
niques, a simple “lemon-wedge” outline has worked well for me

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
447
8 mm
A
B
FIGURE 11-30.  The 8-mm marking is made on the
posterior conchal wall (A), and the remainder of the
conchal bowl is traced for excision. The tracing
includes the entire conchal floor and nears the
external auditory canal. A sharp “arrowhead” is
made at the helical radix (B).
FIGURE 11-29.  Patient has a posterior conchal wall measurement of
14 mm, which will require 6 mm of reduction to allow the ear to lie pas-
sively in a normal position.
(Figure 11-33, A-B). This incision is only required to be wide
enough to accommodate the excess skin that will be present
proportional to the amount of ear setback. Excising excess skin
does not keep the ear back or prevent relapse, and wounds
closed under tension (especially over a convexity) are prone to
scarring.
Posterior dissection proceeds immediately to the perichon-
drium of the posterior conchal cartilage, and all soft tissues
including the vestigial posterior auricular muscles are removed
to the level of the mastoid fascia. Tissue dissection with a small
radiofrequency bipolar forceps (Ellman International, Oceans-
ide, NY) greatly facilitates dissection and provides simultaneous
hemostasis (see Figure 11-33, C and D). If the surgeon does not
immediately proceed to the perichondrium, dissection is more
difficult.
Significant soft tissue exists immediately posterior to the ear,
and it must be cleared in a space big enough to serve as the new
conchal bowl floor. This includes resecting the vestigial posterior
auricular muscle (see Figure 11-33, E).
It is important to have a smooth surface of the exposed
mastoid fascia, because it will serve as the “new” floor of the
conchal bowl (see Figure 11-33, F).
After the posterior auricular dissection is completed, the
planned conchal cartilage excision is marked with a 25-gauge
needle and methylene blue transfixion tattoo (see Figure 11-33,
G and H).
The kidney bean–shaped outline of conchal floor is then
incised with a scalpel or radiofrequency fine-wire electrode and
then dissected from the anterior skin (see Figure 11-33, I to O).
Finally, the excess cartilage is removed with a radiowave
microneedle or tenotomy scissors, leaving the anterior auricular
skin (see Figure 11-33, K and L).
By removing the excess conchal cartilage and leaving 8 mm
of height, the ear will generally lie in a normal passive position.
Figure 11-33, P shows the excised hypertrophic conchal carti-
lage. Some adjustment of the excision margins may be necessary
to achieve the desired posterior ear position (see Figure 11-33,
Q). For patients with a normal antihelical fold, this procedure
may be all that is necessary for correction of protrusion. If the
patient does not have a defined antihelix, a Mustardé procedure
is performed next.
At this point, the wound is inspected for hemostasis, and the
field is irrigated with antibiotic solution. Measurements are
Text continued on page 452.

448
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
A
B
FIGURE 11-31.  The “kidney bean” proposed excision markings are shown on two different patients.
8 mm
8 mm
A
B
FIGURE 11-32.  A marking is made from the antihelical rim 8 mm deep on to the posterior conchal wall (A), and the correspond-
ing 8-mm posterior conchal wall height is shown after resection intraoperatively (B).

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
449
A
B
C
E
F
D
FIGURE 11-33.  A, A simplified elliptical posterior auricular incision is made in a conservative manner, only wide enough to account
for the skin excess present after the ear is set back. B, Retroauricular incision being made with the Ellman radiowave surgery
microneedle for hemostasis. C–D, After the skin ellipse is removed, dissection proceeds immediately to the perichondrium.
Bipolar radiowave forceps and a radiowave microneedle provide gentle cutting with simultaneous hemostasis. The bipolar
forceps, especially, have made soft-tissue dissection much easier. E, The posterior auricular muscle must be resected on the
way to clearing the soft tissue to the level of the mastoid fascia. F, It is imperative to complete the postauricular dissection to
the level of the mastoid fascia and to have a smooth surface as it will underlie the thin skin of the conchal bowl and serve as
the new floor of the conchal bowl.
Continued

450
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
G
8 mm
H
I
J
K
L
G–H, Needles can be used to serve as landmarks (or methylene blue dye transfixion tattoos can be
made) for the lower extent of the posterior conchal wall (G). H, Needles marking the 8-mm measurement of the new height
of the posterior conchal wall. I, Kidney bean–shaped outline of the proposed cartilage excision. J, Scissor undermining of the
cartilage from the delicate conchal bowl skin. K, Progressive undermining of the dermal surface of the skin from the cartilage.
L, Dermal surface of the skin of the conchal bowl after the cartilage is removed.
FIGURE 11-33, cont’d

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
451
M
N
O
P
Q
R
M–O, Additional images showing the small scissor undermining of the cartilage from the skin (M–N) and
the excised cartilage placed in the ear to show its previous position (O). P, Bilateral specimens of excess cartilage removed
from the posterior conchal wall and floor. Q, The ear will not set back passively because of remaining excess cartilage on the
posterior conchal wall (dotted outline). This excess must be trimmed so the ear can lie passively in the new position. Adjust-
ments like this are sometimes necessary to have the ear lie passively. R, Bolster sutures are placed through the conchal skin,
then secured to the mastoid fascia, then back through the mastoid skin to retain a dental cotton roll.
FIGURE 11-33, cont’d
Continued

452
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
S
U
V
T
S, The posterior incision is closed before placing the bolster (assuming only a Davis procedure is per-
formed). The bolster sutures in place (T) and the dental cotton roll in place (U). The sutures are then gently tied to secure the
cotton roll (V).
FIGURE 11-33, cont’d
made with the ear lying passively, and generally the previously
mentioned 10 mm at the superior helical rim and 20 mm at
the mastoid portion of the helical rim are used, as shown in
Figure 11-6. If the measurements are not as desired, further
adjustment is made to the posterior conchal wall and bowl.
The final step in the Davis procedure is to place 3-0 silk
bolster sutures to secure a cotton roll in the revised conchal
bowl. The sutures are placed through the skin, securing the
mastoid fascia, and then back through the skin again (see Figure
11-33, R). The bolster serves to eliminate dead space, prevent
hematoma, and keep the ear in the desired position during the
initial healing. After the bolster sutures are placed, a dental
cotton roll is saturated with triple-antibiotic ointment and tied
down gently in the concha. The tip of the cotton roll is placed
into the external auditory meatus to prevent stricture. For ease
of operation, the posterior auricular incision is closed first
(assuming a Mustardé procedure is not planned), then the
bolster sutures are tied (see Figure 11-33, S to V). These sutures
are removed at 14 days post surgery.
An alternative to bolster suture placement is to secure the
inferior surface of the posterior conchal wall to the mastoid
fascia with 4-0 Vicryl suture (Figure 11-34).
Mustardé Otoplasty for Antihelical
Fold Reconstruction
More frequently, patients manifest conchal excess as well as an
underdeveloped antihelical fold and require reconstruction of
the antihelical fold along with the Davis procedure. In my
practice, 98% of otoplasty patients require both procedures. If
a Mustardé procedure is required, I personally perform this after
the conchal bowl reduction and before the bolster suture
placement.
Patients without hypertrophic conchal cartilage may benefit
from antihelical fold reconstruction as a sole procedure. This
procedure will set back the helix to a more normal position as
well as create a normalized antihelical fold. Attempting to
perform this procedure in a patient with conchal cartilaginous
hypertrophy will not properly and aesthetically correct the
problem. The Mustardé procedure was described in the 1960s5-7
and has since progressed with numerous modifications. The goal
of this procedure is to recreate the antihelical fold and reduce
helical protrusion by using horizontal mattress sutures.
I perform the Davis procedure first, the Mustardé
sutures second, and finish with lobe adjustment if necessary.

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
453
A
B
C
D
FIGURE 11-34.  A–B, A 4-0 Vicryl suture is used to place a mattress suture through the inferior border of the conchal wall. C–D,
The three sutures are then placed through the deep mastoid fascia to anchor the inferior border of the posterior conchal wall
to the fascia.
Preoperatively, the helical rim is positioned posteriorly with the
finger to create an antihelical fold (Figure 11-35). This fold and
the planned suture entry points are then marked with a surgical
marker. The suture entry marks are placed 7-8 mm lateral on
each side of the center line of the newly marked antihelical fold.
This means that the final horizontal sutures will be about 15 mm
in width on the underside of the carriage.
The art of the Mustardé procedure is to realize how many
sutures to place and where to place them to obtain a naturally
formed, rounded, and curved antihelical fold. The shape and
position of the new fold is directly related to the placement and
position of the 4-0 white Mersilene horizontal mattress sutures.
Placing them too close will create a narrow fold, placing them
too far apart will create too wide a fold, and improper spacing
can result in a straight antihelical fold, which is a sine qua non
of poor otoplasty technique. Although sometimes frustrating, it
is not uncommon to replace the sutures in lieu of a better posi-
tioned suture during the procedure. Continual attention to
suture placement and anatomy of the new antihelical fold is
imperative.
As with the Davis procedure, the Mustardé procedure is dif-
ficult to conceptualize for the novice surgeon. One must think
in reverse terms: sutures are placed on the posterior surface of
the ear to effect changes on the anterior surface. Figure 11-36
shows a cadaver dissection of an ear with an unfurled antihelical
fold and the desired recreation of the fold.
If the procedure is performed with a Davis procedure, the
incision is obviously already open. If the Mustardé procedure is
the sole procedure, the local anesthesia and the postauricular
incision are made as previously described. Prior to injecting local
anesthesia, the new antihelical fold and respective mattress suture
entry points are made on the ear skin (see Figure 11-35, C).
After the patient is prepped, draped, and anesthetized,
25-gauge 112-inch needles are used to place transfixion tattoos
on the cartilage, using methylene blue. The needle is placed from
the anterior skin surface through the cartilage and through the
posterior ear skin, where it is marked (Figure 11-37, A). The
marks should be spaced at least 7 mm on each side of the anti­
helical side of the antihelical fold midline. When the perichon-
drial dissection is performed, the tattoo marks are visible markers
of suture placement (see Figure 11-37, B).
Cartilage Weakening
Before placement of the horizontal mattress sutures, the poste-
rior portion of the proposed antihelical fold is generally weak-
ened by incision, abrading, puncturing, or crushing. Controversy
exists as to which surface of the cartilage should be weakened,
but most surgeons perform this maneuver on the posterior
surface of the ear. Some surgeons do not perform any cartilagi-
nous weakening.
The simplest means of weakening the cartilage is to score the
posterior ear surface with a scalpel blade or radiowave

454
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
A
B
C
FIGURE 11-35.  A, Patient with no defined antihelical fold. B, By using a finger to displace the pinna posteriorly, a new antihelical
fold is created. C, The newly anticipated fold and mattress suture points are marked on the skin and are placed 7-8 mm on
each side of the center line of the proposed antihelical fold.
A
B
FIGURE 11-36.  A, A cadaveric ear with an unfurled antihelical fold. B, Folding the ear posteriorly and retaining with a suture (on
the inferior surface) creates and maintains the new antihelix.
microneedle (Figure 11-38). This can be done in longitudinal
rows of scoring or by “pie-crusting” along the posterior cartilage
with a scalpel tip. It is vital to keep the scoring on the central
portion of the new fold and not overscore the cartilage. Lateral
positioning that is too wide or score grooves that are too deep
can cause the new antihelical fold to collapse or assume a peaked
surface instead of a smooth, round surface. The pearl here is to
score the cartilage just enough but not too much—again,
enough to weaken the fold but maintain a natural surface. In
addition, the scoring must be kept in the center of the proposed
fold, or the cartilage can fragment and cause sutures to pull
through or present a visible deformity through the skin.
At this point, the posterior incision and perichondrial dis-
section is made, and the 4-0 white Mersilene sutures are placed
in a horizontal mattress configuration (see Figure 11-38).
Another means of weakening the fold is to puncture the
posterior cartilage and then dissect under the anterior cartilage
subdermal plane. After this, a Brown-Adson forceps with teeth
is inserted in the tunnel, and the cartilage is crushed on both
sides. This is done for the length of the fold (Figure 11-39).

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
455
A
B
FIGURE 11-38.  A, Cartilage is scored with a radiofrequency microneedle, with care to not perforate full thickness. B, Cartilage
grooves in the center of the proposed fold undersurface.
FIGURE 11-39.  A, Entrance incision of the posterior cartilage surface. B, Subdermal tunnel being dissected with a Freer elevator.
C, Brown-Adson forceps inserted and crushing the cartilage.
A
B
FIGURE 11-37.  A, Cartilage tattoo is performed with transcutaneous and transhelical needles and methylene blue dye. B, The
cartilage tattoo marks serve as reference points for the horizontal mattress sutures and are placed about 7 mm on each side
of the midline of the new fold.

456
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
A
B
FIGURE 11-40.  A, At the desired entry points, 112-inch 25-gauge needles are placed through the skin to correspond with suture
entry points on the posterior surface (B).
Horizontal Mattress Suture Placement
The horizontal mattress sutures are placed through the tattoos
previously made on the cartilage (see Figure 11-37, B). An
additional method of locating the suture points is to insert
25-gauge 112-inch needles through the skin surface from one
side of the fold to the other. The needles’ positions on the
undersurface of the cartilage will correspond to the suture inser-
tion points (Figure 11-40).
The actual placement of the sutures is described in numerous
ways in various texts and articles and sometimes makes the task
more complex than necessary. The surgeon must keep in mind
that the goal of suture placement is to fold the scaphoid cartilage
to reconstruct a normal-appearing antihelical fold. Most sur-
geons place three sutures, one superiorly, one in the middle, and
one inferiorly. Some cases warrant more or less sutures. Again,
the goal is to bend the weakened cartilage to appear natural.
For the novice surgeon, it is helpful to take a preoperative
photograph of the ear with the scapha being pushed back (see
Figure 11-35, B) to serve as a guide to the final appearance of
the fold.
The 4-0 braided white Mersilene sutures (Figure 11-41) are
inserted into the cartilage in a full-thickness manner to engage
the entire cartilage but spare the overlying skin (Figure 11-42).
Failure to “take a big enough bite” of cartilage with the needle
can cause tearing of the cartilage and affect stability. The curva-
ture of the P-3 needle on the suture when taking a full vertical
“bite” will exit at the perfect distance through the cartilage on
either side of the fold. The P-3 needle is 13 mm in length and
when inserted, the curved needle will exit at about 10 mm,
which is the desired length of the vertical component of the
horizontal mattress suture. Figure 11-43 shows the approximate
positioning of the three horizontal mattress sutures. The sutures
should be placed horizontally at a distance of about 15 mm as
not to make a constricted fold.
As a model for a Mustardé suture concept, the operator
should keep in mind Figure 11-36 to understand the goal of
the procedure. The first suture is superior and will improve the
fossa triangularis as well as set the helix and helical rim poste-
riorly. If this is placed too cephalad, it can distort the superior
margin of the helical rim. If placed too inferiorly, the upper
portion of the helix will not be set back far enough. The superior
suture is important to the outcome and amount of setback and
also gives the pleasing superior curvature of the superior crus.
The next suture is placed about midway down the antihelical
fold and should be placed in a manner to curve and taper the
new antihelical fold. A third suture is usually placed at the lower
third of the fold and aids in definition and taper. The most
inferior suture is generally placed no lower than 1 cm from
above the cauda helix. In some cases, less than three sutures will
suffice, whereas other patients require additional sutures depend-
ing on the deformity.
The suture tension is adjusted with direct vision to control
the formation of the new antihelical fold and the amount of
superior helix setback. Keeping the “10-mm and 20-mm rule”
in mind (see Figure 11-6), the suture tension is gently adjusted
for accurate setback. Some surgeons place all three sutures first
FIGURE 11-41.  The 4-0 white Mersilene suture with a P-3 needle is a
permanent suture used for mattress sutures. The white color prevents the
suture showing through the thin ear skin.

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
457
10 mm
15 mm
FIGURE 11-43.  This representation of Mustardé suture placement
illustrates the 15 mm horizontal and 10 mm vertical components of the
horizontal mattress suture.
A
B
FIGURE 11-42.  The 4-0 white braided Mersilene suture on the P-3 cutting needle is placed entirely through the cartilage (A),
and the surgeon then turns the ear over to make sure the needle or suture has not penetrated the overlying skin (B). If the
skin is pierced, the suture must be removed and repositioned.
then tie them, whereas others place and tie each suture individu-
ally, which is what I prefer. Before the knot is finally tightened,
the position and shape of the new antihelix must be confirmed
as acceptable. Figures 11-44 and 11-45 illustrate Mustardé hori-
zontal mattress suture placement.
If a Davis procedure is performed concomitantly with the
Mustardé operation, the bolster sutures are not placed until the
Mustardé procedure is completed. The posterior incision is
closed with 4-0 gut sutures before the bolster sutures are tied
down, otherwise access is limited. In the case of an isolated
Mustardé procedure, a 4-0 gut suture is used (Figure 11-46). It
is preferable to leave several millimeters of unsutured incision
at the inferior lobe to encourage drainage.
Correction of the Protruding Earlobe
Ears that protrude are frequently accompanied by protruding
ear lobes. Novice surgeons may not realize this, and the final
result can be compromised because the ear sits back to a normal
position, but the lobe protrudes. Numerous means of setting
back protruding lobes have been described. A “fishtail” skin
excision is a simple technique that utilizes triangular excision of
skin on the inferior lateral posterior lobe and a corresponding
excision over the mastoid region. Bringing the lobe to the
mastoid area with suture closure will posteriorly position the
lobe (Figure 11-47, A-B). In this procedure, a V marking is
made on the earlobe skin, and while the ink is still wet, the lobe
is pressed against the mastoid skin, making another V. The
“double V” looks like a fishtail, hence the name. Removing lobe
and mastoid skin in this configuration enables the lobe to be
tacked to the mastoid skin and heals in a more retrusive position
(see Figure 11-47, C-D). Additionally, a suture to the tissues at
the inferior conchal bowl to the mastoid fascia can also assist
retention in this procedure (see Figure 11-47, E).
Conservative resection of the cauda helix can also be
employed to prevent the tail of the helix from bowing the
earlobe laterally (Figure 11-48).
Postoperative Dressing
After the procedure, the patient’s hair is washed if necessary, the
ear canal is irrigated and gently suctioned, and a dressing is
placed. Xeroform gauze (Kendal Inc., Mansfield, MA) is placed
in the conchal bowl, the fossa triangularis, and the scapha
to conform to the new anatomy and eliminate dead space.
Similarly, another piece of Xeroform gauze is wrapped
circumferentially around the ear to cover the posterior incision
(Figure 11-49).
Alternatively to packing the anterior ear with gauze strips,
silicone dental impression material (Blu-Mousse; Parkell Inc.,
Edgewood, NY ) can be injected into the ear to conform to the
delicate new anatomy (Figure 11-50, A). This impression mate-
rial feeds into an automatic mixing tube on the end of a delivery

458
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
A
B
FIGURE 11-44.  A, Proposed suture entry points and vertical scoring marks and the final sutures for a combined Davis and
Mustardé procedure. B, The white arrows point to the Mustardé sutures, and the yellow arrows point to the bolster sutures
used in the Davis procedure.
A
B
FIGURE 11-45.  A, A horizontal mattress suture placed superiorly to reposition the helix posteriorly and create the pleasing curve
of the superior crus. B, A representation of the Mustardé suture.
FIGURE 11-46.  At the end of the Mustardé procedure, the posterior incision
is closed with 4-0 gut suture.
gun (see Figure 11-50, B). When this is done, a clear tube can
be placed into the ear canal and incorporated into the mold to
facilitate hearing. If this is not performed, the impression mate-
rial is simply not placed all the way into the external auditory
canal, thus not impeding hearing. The silicone impression mate-
rial is a handy dressing because it can be easily removed to
inspect the wound for hematoma and so forth and then replaced.
The silicone dental impression material can also be used in
lieu of a cotton roll bolster in the Davis procedure. I only utilize
this dressing on Davis procedures that have the Vicryl retention
sutures from the base of the posterior conchal wall to the
mastoid fascia. In this scenario, the sutures prevent relapse, and
the impression material compresses the ear skin against the
concave surfaces to prevent hematoma. In this case, the mold
can be removed at 1 week or less.
At this point, several “fluffs” of gauze are placed over the ear,
followed by a conventional mastoid dressing with rolled gauze
and elastic tape. By placing several unfurled gauze strips or
umbilical tape over the forehead before applying the dressing,
they can be tied after the dressing is applied to retract the
bandage above the eyes (Figure 11-51).

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
459
A
C
B
D
E
FIGURE 11-47.  A, A “fishtail” pattern is marked on the skin of the lobe and mastoid skin. B, This skin is then excised. C, The
ear skin margin is then sutured to the mastoid skin margin. D, The posteriorly positioned lobe is shown in a more retrusive
position. E, A Vicryl suture can be placed in the posterior lobe surface and secured to the mastoid region to assist in “tucking
in” a protruding lobe.

460
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
A
B
C
FIGURE 11-48.  The cauda helix can be hypertrophic and contribute to lateral bowing of the earlobe. By resecting a portion of
the cauda helix, the earlobe will sit more passively against the face.
A
B
C
FIGURE 11-49.  The ear dressing begins with Xeroform gauze packed into the concha, scapha, and around the antihelical fold.
Another piece is then wrapped around the ear.
A
B
FIGURE 11-50.  A, Silicone dental impression material can be used to obturate the conchal bowl. B, The self-mixing impression
delivery apparatus.

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
461
required during the day, but it is a good idea to have the patient
wear one at night for the aforementioned reasons.
Case Presentations
Otoplasty remains a joyous procedure insofar as the vast major-
ity of the patients are children who are most appreciative of their
improved appearance and body image. Adults who have lived
their life with this perceived deformity are equally appreciative
(Figures 11-52 to 11-65).
Otoplasty Complications
As stated earlier, otoplasty is much like rhinoplasty in that the
art sometimes exceeds the science. There is definitely a learning
curve to otoplasty, and I believe that if one were to examine the
The mastoid dressing is removed the following postoperative
day and the ear inspected for hematoma. It is important to
explain to the patient preoperatively that the ears will appear
overcorrected from the swelling and dressing. If a Mustardé
procedure only is performed, the patient is asked to wear a head
band day and night for the first week and at night for the second
week. The head band worn at night serves as a reminder to not
roll over on the ear or pick at it. If a Davis and Mustardé pro-
cedure was performed, the bolster or inferior conchal wall
sutures are adequate to prevent relapse, and no head band is
A
B
FIGURE 11-51.  A mastoid dressing is placed and left in place for 24 hours.
FIGURE 11-52.  A sweet thank you from an appreciative 7-year-old brings
a big smile to any surgeon.
FIGURE 11-53.  Most cosmetic surgeons work primarily with adults, and
putting a smile on a child is very rewarding.
Text continued on page 470.

FIGURE 11-54.  Adults who have endured a lifetime of teasing about protruding ears are equally appreciative patients.
A
B
FIGURE 11-55.  These 6-year-old twin sisters underwent Davis and Mustardé otoplasty for protruding ears. Improving the self-
esteem of grateful children is truly one of the joys of cosmetic otoplasty.
A
B
FIGURE 11-56.  This 13-year-old male underwent Davis and Mustardé otoplasty for protruding ears.
462

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
463
A
B
FIGURE 11-57.  This 14-year-old male underwent Davis and Mustardé procedures as well as earlobe setback.
A
D
E
B
C
FIGURE 11-58.  A, This 7-year-old female underwent Davis and Mustardé procedures and is shown 6 weeks (B) and 6 years
(C) post procedure. D–E, Lateral views 6 years later.

464
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
A
B
C
D
FIGURE 11-59.  A–B, Adult patient underwent Davis and Mustardé procedures. C–D, Posterior view.

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
465
A
B
C
D
FIGURE 11-60.  A–B, This 20-year-old female underwent Davis and Mustardé procedures. C–D, Posterior view.

466
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
A
B
C
D
FIGURE 11-61.  A–B, This 14-year-old male underwent Davis and Mustardé procedures. C–D, Posterior view.

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
467
A
C
D
B
FIGURE 11-62.  A–B, This 24-year-old female underwent Davis and Mustardé procedures. C–D, Posterior view.

468
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
A
C
E
F
D
B
FIGURE 11-63.  A–B, This 17-year-old male underwent Davis and Mustardé procedures. C–D, Right side. Note the setback of
the ear and formation of a new antihelical fold. E–F, Left side. Note the setback of the ear and formation of a new antihelical
fold.

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
469
A
B
FIGURE 11-64.  This 14-year-old male underwent Davis and Mustardé procedures.
A
B
FIGURE 11-65.  A–B, This 9-year-old male underwent Davis and Mustardé procedures.
Continued

470
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
C
D
E
F
C–D, Right side. Note the setback of the ear and formation of a new antihelical fold. E–F, Left side. Note
the setback of the ear and formation of a new antihelical fold.
first 25 otoplasty cases from any surgeon, this would be
self-evident.
The most feared complication of otoplasty is necrosis and
tissue loss. Fortunately the ear has a tremendous vascular supply,
so this is rare. This factor must be kept in mind when placing
bolsters and dressings that could impede circulation (Figure
11-66 to 11-70).
Tissue necrosis in otoplasty is managed similarly to other
instances of tissue devitalization. First any constriction should
be relaxed. Topical application of nitroglycerin is also sometimes
used in hopes of producing local vasodilatation. Wound care
includes hydrogen peroxide soaks and covering the wound with
triple-antibiotic ointment. Biafine cream (Johnson and Johnson,
Langhorne, PA) is a prescription cream used to treat burns that
has worked well in my practice for postlaser treatment, burns,
and treating local necrosis.
Second to tissue loss, hematoma is the next complication
that can produce significant deformities (Figure 11-71). The
cartilaginous network of the ear is extremely delicate and sensi-
tive to insult. The formation of a hematoma that goes unrecog-
nized or untreated can lead to significant deformities consistent
with a “cauliflower ear.” For this reason, all hematomas, even
FIGURE 11-65, cont’d

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
471
white braided Mersilene suture that exfoliated 7 months post
otoplasty.
Another intraoperative pitfall is inadvertent perforation
(Figures 11-75 and 11-76). This can easily happen in the Davis
procedure when dissecting along the midconchal bowl around
the external auditory canal. A simple 6-0 gut suture to close the
perforation will usually result in uneventful healing.
Postoperative Otoplasty Problems
Otoplasty, like rhinoplasty, is a procedure of exacting detail, and
results can be affected by undercorrection or overcorrection.
Although not setting the ear back enough can produce an
unhappy patient, an overcorrected ear is very disturbing. In
the case of too-conservative correction, a patient may still accept
the surgical result, but a grossly overcorrected ear with a pasted-
back look is very hard for patients to accept. Undercorrection
minor ones, must be addressed and treated early. I see all
otoplasty patients 1 day postop, 1 week postop, and 1 month
postop.
Suture-related problems can manifest in the actual procedure
or the postoperative course. As stated numerous times in the
Mustardé section, it is imperative to check each suture pass
to make sure the suture did not penetrate the overlying skin
(Figure 11-72).
Suture dehiscence can occur in the early or late postoperative
period. Figure 11-73 shows a “spit” suture several months after
otoplasty. This surgeon used a stiff Prolene suture, which is a
poor choice because the nature of the material and the knot are
both sharp and palpable and can succumb to pressure necrosis
or exfoliation through the thin ear skin. Soft, flexible sutures
such as Mersilene material are favorable. No permanent suture
is immune to exfoliation, however. Figure 11-74 shows a 4-0
A
B
C
FIGURE 11-66.  Patient experienced a small area of blistering followed by tissue loss. The patient at 24 hours (A), 14 days (B),
and 4 months (C) after surgery.
A
B
C
FIGURE 11-67.  Patient experienced necrosis and tissue loss from wearing eyeglasses that produced pressure on the posterior
ear. She is shown at 2 weeks (A), 3 weeks (B), and 12 weeks postop (C).

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Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
preoperatively, it may be from the actual ear being smaller or
larger or even the bone or side of the face being different on the
specific patient. This should be realized and discussed in the
preoperative visits. In the case of post otoplasty asymmetry, the
offending ear can be revised.
Other situations of asymmetry exist in terms of the actual
ear anatomy. The “telephone ear deformity” occurs when the
central portion of the ear is overcorrected, and the superior and
inferior poles protrude like an old-fashioned telephone receiver
(Figure 11-77). This is generally from overcorrection of the
superior Mustardé suture or failure to set the lobe back. Over-
zealous or asymmetric correction of the ear is avoided by close
attention to suture tension, intraoperative measurements, and
lobe protrusion. A “reverse telephone” ear is the inverse situa-
tion, where the superior and inferior poles are overcorrected,
and the central antihelix protrudes (Figure 11-78).
One of the most common novice mistakes is inattention to
the natural curvature of the antihelix (Figure 11-79). A straight-
line antihelix is generally the result of improper horizontal mat-
tress suture placement. Close attention must be paid to the exact
placement of the sutures so when tightened, the antihelical fold
will be curved.
Another problem is a reconstructed antihelix that is too thin
or narrow (Figure 11-80). This can result from taking too small
a “bite” on each side of the Mustardé suture. This is one reason
why the horizontal component of the Mustardé sutures is not
placed closer than 7 mm on each side of the proposed anti­
helical fold midline.
Due to the sensitive characteristics of cartilage, it is not
uncommon to see reactive postoperative cartilage conditions.
Most are not problematic and represent situations that can go
untreated, although many cartilaginous problems can be
sculpted and corrected.
is correctable by removing more cartilage or replacing the hori-
zontal mattress sutures. An overcorrected ear can be corrected
if the problem concerns overly aggressive Mustardé sutures,
which can be redone with less tension. In the case of overzealous
posterior conchal wall excision, revision may not be possible;
therefore, surgeons must “measure twice and cut once.”
Postoperative asymmetry can result from one ear being
different than the other. If a significant deformity exists
FIGURE 11-68.  Blistering of tissue is usually a sign of impending tissue loss.
FIGURE 11-69.  Patient sustained minor necrosis of the concha under the
bolster dressing. Any sutures or compressive dressings used in otoplasty
should be secure but not excessively tight.
FIGURE 11-70.  Patient does not have a hematoma but rather bruising and
swelling that somewhat obscures the scaphal anatomy. There is no need
to drain this, but it must be differentiated from a true blood collection.

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
473
A
B
C
D
FIGURE 11-71.  A–B, Patient 1 day postop with a minor hematoma (but significant enough to be problematic) on the posterior
ear. C–D, The hematoma (C) and a 1-mm liposuction cannula (D) used at low wall suction to evacuate the blood.

A
B
FIGURE 11-72.  Attention must be paid to the placement of the horizontal mattress sutures so as not to perforate the thin overly-
ing skin. If a perforation occurs, the stitch must be removed and repositioned to lie between the cartilage and skin.
A
B
FIGURE 11-73.  A stiff, sharp suture such as Prolene can perforate the thin ear skin and is not a good choice for otoplasty.
A
B
C
FIGURE 11-74.  No suture is beyond extrusion, as seen in this 4-0 Mersilene suture that dehisced 7 months after otoplasty.

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
475
A
B
FIGURE 11-75.  An inadvertent intraoperative perforation of the external auditory canal from the posterior and anterior views. This
type of perforation can happen with the Davis procedure when dissecting near the external auditory canal. Having the assistant
place a cotton-tipped applicator in the canal can assist in identifying surgical limitations.
FIGURE 11-76.  Another example of intraoperative perforation in the region
of the external auditory canal.
FIGURE 11-77.  The “telephone ear” deformity is produced when the central
antihelix is overcorrected in respect to the superior and inferior portions.
A protruding earlobe can also contribute to the lack of inferior correction.
Close attention to horizontal mattress suture tension and intraoperative
measurements is requisite. This deformity is visible intraoperatively, and
the ear shape must be inspected before finalizing the procedure.
FIGURE 11-78.  The “reverse telephone ear” deformity is seen when the
superior and inferior Mustardé sutures are overtightened in respect to the
central sutures.

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Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
FIGURE 11-79.  A straight-line antihelix is one of most common novice
mistakes when performing the Mustardé technique. This is generally a
result of improper suture placement by spacing them too close or not
controlling the placement and tension.
A
B
FIGURE 11-80.  Patient has a narrowed antihelix as a result of horizontal mattress sutures being placed too close together. By
spacing the horizontal limb of the mattress sutures at least 15 mm apart, the fold will be fuller and more rounded.
Overzealous cartilage scoring or improperly placed horizon-
tal mattress sutures can cause postoperative buckling (Figure
11-81). This can be a difficult problem to correct, so the best
treatment is prevention by close attention to scoring and
suturing.
Before closing the skin during otoplasty procedures, the
surgeon must be sure that all cartilaginous surfaces are smooth,
or the uneven edges can show through the skin (Figure 11-82).
Various other cartilage hypertrophic conditions are seen after
otoplasty and usually represent inflammatory postoperative
reactions (Figures 11-83 and 11-84). These frequently go
untreated but can be smoothed through a small incision.
Infections are rare with otoplasty, in part because of the
extensive vascularity of the ears. Pseudomonas is a normal inhab-
itant of the middle ear, and this or other extensive postoperative
infection can produce disastrous complications due to cartilage
involvement and deformation. For this reason, all otoplasty
patients are prophylactically treated with ciprofloxacin 500 mg
beginning 48 hours before the procedure and lasting 1 week
postoperatively. I am happy to have no significant postoperative
infection pictures of my patients to show in this chapter.
Figure 11-85 shows a minor otitis that developed postopera-
tively and was treated with systemic antibiotics and antibiotic
otic drops.
The cotton rolls used in the Davis procedure can become
soaked with blood and serve as a nidus of infection (Figure
11-86). Coating the cotton rolls with a thick layer of antibiotic
ointment has prevented this. Alternatively, a clear plastic tubing
can be used as a nonabsorbent bolster. Also, the cotton roll can
be omitted by using Vicryl retention sutures as shown in Figure
11-34. My experience has shown the most aesthetic chonchal
bowls and those with smooth, flat anatomy are seen when using
the cotton roll bolster.
Another minor problem encountered in patients with pig-
mented skin is hyperpigmentation after the cotton roll is
removed (Figure 11-87). This will usually resolve spontaneously
and can be hastened with a bleaching cream such as hydroqui-
none 4%.
Adjunctive Earlobe Surgical Procedures
Although surgical procedures of the earlobe are an integral part
of cosmetic otoplasty, isolated cosmetic earlobe problems are
frequently seen in the cosmetic facial surgery practice. These
patients primarily present with large earlobes and want them
made smaller. A more common situation is a patient presenting
with torn earlobes or stretched earring holes and requesting
repair. A newer phenomenon is the patient presenting with
deformed earlobes from body piercing or dilation procedures;

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
477
FIGURE 11-81.  Patient developed cartilaginous buckling after otoplasty.
This can be a very difficult problem to correct.
FIGURE 11-82.  Patient underwent Davis and Mustardé otoplasty, and the
ragged edge of the inferior portion of the posterior conchal wall is visible
through the skin. Any cartilage imperfections must be smoothed prior to
skin closure.
FIGURE 11-83.  Patient developed postotoplasty cartilage hypertrophy just
above the antihelix. The deformity did not bother the patient, who did not
desire correction.
FIGURE 11-84.  Patient developed a fibromatous growth of the conchal bowl
postotoplasty and responded to intralesional steroid injection.
this cohort is likely to become one of the more common
presentations.
Earlobe Reduction
Many patients complain of hypertrophic earlobes. They some-
times do not decide to correct this, but when having facelift or
otoplasty, they may request treatment. Numerous means of cor-
recting the hypertrophic lobe have been described. I primarily
use wedge resection or lobe recontouring techniques for earlobe
reduction.
Wedge resection is a simple technique which can be done as
a triangular “pie-slice” excision or a curved excision. The wedge

478
Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
FIGURE 11-85.  Patient developed a minor middle ear infection after oto-
plasty and was treated with systemic antibiotics and antibiotic otic drops.
FIGURE 11-86.  The dental cotton roll used as a bolster can become satu-
rated with blood and serve as a source of infection. Coating the roll with
a thick layer of triple-antibiotic ointment has prevented this problem.
FIGURE 11-87.  This Asian patient developed hyperpigmentation of the
conchal bowl from the cotton roll bolster. The pigment corrected without
treatment several weeks later.
and using a scalpel or radiowave microneedle, the triangle is
excised (see Figure 11-88, B). It is important that the excision
at the base of the lobe is straight so the closure leaves a straight
margin. Several 5-0 gut subcutaneous sutures are used to prevent
dead space and fortify the wound strength (see Figure 11-88,
C). The skin closure is then made with either 6-0 fast-absorbing
gut sutures or 6-0 nylon sutures (See Figure 11-88, D). The first
skin suture is a key suture and should be placed at the inferior
portion of the lobe to ensure a straight border, similar to repair-
ing the vermilion border of the lip. If attention is not paid to
the inferior closure, a stepped incision can occur.
Some surgeons prefer to excise a curvilinear shape (“shark’s
fin ”) in a more horizontal vector (Figures 11-89 and 11-90). I
have used this technique but have found the scars more notice-
able. Laser resurfacing of the scar improves the situation.
Another means of reducing hypertrophic earlobes is the use
of a direct inferior lobe excision using scissors or radiowave
microneedle. With this technique, the excess lobe is simply
excised from the base of the existing lobe (Figures 11-91 and
11-92). By angling the cutting device (scissors, scalpel, or radio-
wave microneedle) inferiorly, more skin is left on the anterior
lobe than the posterior and this will hide the scar in the inferior
or posterior surface. In addition, a V-shaped excision of deep
tissue can be removed to taper the new lobe.
When performing inferior lobe excision, a dimple will fre-
quently occur at the end of the posterior incision and can be
immediately recontoured with a ball radiowave electrode (Figure
11-93).
Although most earlobe incisions will heal uneventfully,
sometimes an unfavorable scar can result. This can be easily
improved by several passes of high fluence/high density carbon
dioxide (CO2) laser resurfacing (Figures 11-94 to 11-96).
resection involves marking a triangle of lobe to be excised. The
triangle can be made at any aspect of the lobe to optimize the
result (Figure 11-88, A). This procedure is performed with local
anesthesia, and the lobe is marked before local anesthetic injec-
tion. The triangle to be excised is determined, and this is fre-
quently underestimated. A surprising amount of lobe can be
removed, especially in patients with a very stretchy lobule. After
the lobe is marked on both sides, local anesthetic is injected,
Text continued on page 484.

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
479
A
C
D
B
FIGURE 11-88.  A simple “pie-wedge” triangle is marked (A) and then fully excised (B). After resection, the deep layer is closed
with 5-0 gut suture (C), then the skin is closed with 6-0 fast-absorbing gut or 6-0 nylon suture (D).

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Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
A
C
E
F
D
B
FIGURE 11-89.  A, A curvilinear triangle is marked on the lobe. B, Radiowave microneedle incision. C, Excision site. D, Radiowave
cauterization of the vascular subcutaneous tissue. Subcutaneous sutures are used to strengthen the wound and close dead
space (E), and the skin is closed with the desired suture (F).

Chapter 11  •  Cosmetic Otoplasty and Related Ear Conditions
481
A
B
C
FIGURE 11-90.  Another case of curvilinear earlobe reduction.
A
B
C
D
FIGURE 11-91.  A, The excess lobe is marked in the anterior, inferior, and posterior surfaces. B, The excess lobe is then incised
(in this case with radiowave microneedle). C, The lobe is incised with a V shape to taper the lobe and then sutured with 5-0
gut tacking sutures to insure proper shape (D).
Continued