Phẫu Thuật Thẩm Mỹ Tạo Hình Tai Nâng Cao (Advanced Cosmetic Otoplasty)

463
42 Balanced Otoplasty: Dividing the Ear into Vertical Thirds
e
j
Fig. 42.15 (continued)
Fig. 42.16 ( a ) Preoperative 49-year-old gentleman. ( b ) One year after reductive otoplasty of a cup and lop ear defor-
mity and lobule reduction with good aesthetic improvement and improved symmetry in the result
a
f

464
S.M. Lam
b
c
h
g
Fig. 42.16 (continued)

465
42 Balanced Otoplasty: Dividing the Ear into Vertical Thirds
Bandage
At the completion of the case, all the povidone-
iodine solution is gently but deliberately removed
before dressing application. The patient is shown
how the ears look at the end of the procedure if
the surgery was performed under intravenous
sedation rather than general anesthesia so that
they do not fret that night of how their ears look
and before greater edema sets in. Because the
d
i
e
j
Fig. 42.16 (continued)

466
S.M. Lam
entire procedure takes between 1 and 1.5 h to
complete, there is not a lot of edema and the
patient can be shown the ears without much dis-
tortion. Clearly if there is signi fi cant edema, then
the patient would not be shown the ears at the
conclusion of the operative case.
On an adjacent Mayo stand, a metal basin is
fi lled with non-sterile cotton balls impregnated
thoroughly with mineral oil as well as conform-
ing bandages. There is also a 5-mL syringe loaded
with topical antibiotic ointment. Half a syringe of
antibiotic ointment is injected along the postau-
ricular incision on both sides. Then open cotton
balls are fl uffed and made sure that they are thor-
oughly soaked with mineral oil before conform-
ing them carefully and attentively to the front and
back sides of the ear on one side. A stacked pile
of 4 × 4 gauze is placed on top, and the assistant
holds that gauze in place on one ear as the same
dressing is applied on the other ear. The assistant
then holds stacked gauze on both ears while mul-
tiple layers of conforming bandage are placed
around the head in two directions: from top of
head to the neck and from the crown of the head
to the neck. It is so important to place the ban-
dage along these two vectors, or the bandage is
liable to fall off the fi rst night after the surgery,
which can predispose toward hematoma forma-
tion and protracted edema. The bandage is then
secured with multiple strips of clear plastic tape.
After Care and Recovery
The patient and family are advised that with the
drains in place, they are intended to emit blood
into the dressing and that the dressing can even
be soaked up and soil the bed sheets. In addi-
tion, the fi rst night following surgery as the
bupivacaine wears off, the patient can have quite
a bit of achiness and discomfort, and a prophy-
lactic narcotic is advised to be given before
retiring for the evening even if no pain has
started. Typically, this discomfort is the most
severe the night after surgery and greatly dimin-
ishes by the following day. When a conchal
resection has been performed for cup ear reduc-
tion, the discomfort can linger somewhat longer
for another day or two. For some patients, that
discomfort can last up to a week but in my expe-
rience is typically much less after the fi rst
1–3 days following surgery.
The next day the patient returns to the of fi ce
with an athletic headband that has been previously
purchased or that the of fi ce supplies. The dressing
is carefully removed from the head by a combina-
tion of unwrapping it and cutting away the dress-
ings. The drains are removed painlessly and the
ears carefully inspected for edema and hematoma.
If there is signi fi cant edema, the same operative
bandage may be reapplied for another 2–3 days.
However, this is only the situation in less than 5 %
of cases in my experience. The postauricular inci-
sion is cleaned with hydrogen peroxide and the
wound redressed with topical antibiotic ointment.
The patient holds a mirror and the author stands
behind the patient to show him how to apply the
athletic headband. The fi ngers on both hands are
spread widely, having the hands go upward
through the headband on both sides pushing very
fi rmly apart so that the headband is gently lowered
over the head and the ears are not abraded or dis-
turbed. The hands are slowly removed from the
head one side at a time lowering the headband
onto the ears in a gentle manner. At this point, the
headband sometimes sits over the eyes, so that
point is adjusted upward. Then if the headband is
too tight (it should be snug but not overly tight),
the author takes a pair of heavy scissors and a par-
tial cut is made through the headband to alleviate
the tension. This cut can be performed as many
times as needed to relieve excessive tension with-
out making the headband too slack.
The patient is advised to wear the headband
24 h a day for the fi rst week and then thereafter
only at night during sleep for a total of 6 weeks
time. Chromic sutures tend to dissolve over a
period of 2–3 weeks. If they are still present after
the second week and they disturb the patient, then
they can be removed as desired.
That patient is advised not to shower for 24 h
after the procedure and then can resume normal
showering thereafter. Bathtub bathing should be
avoided especially considering that the presence
of permanent sutures can become infected. This
admonition should also apply to any other

467
42 Balanced Otoplasty: Dividing the Ear into Vertical Thirds
submersible activity like swimming for a period
of at least 6 weeks. In fact, the author prefers no
submersion for a minimum of 3 months if at all
possible. Also, no contact sports for a minimum
of 6 months would be advisable.
Patients are advised that at times the Mustarde
sutures can become exposed and require removal.
If this is the case, the patient should not attempt
this by himself but come to the of fi ce for an easy
removal. The author prefers to leave any exposed
sutures for a minimum of 6 months so as to ensure
that they do not compromise the tenacity of the
position of the ear.
Patients are also warned that ears may relax
somewhat during the recovery phase even for
several months following the procedure espe-
cially with very thick cartilages that can recoil a
bit over time. If patients are forewarned of this
eventuality, they will not deem it a surgical error
mandating a revision procedure. It is always
emphasized that ultimate ear position can vary up
to a year following a procedure.
Discussion
As with any cosmetic procedure, reproducibility
of a result depends on the surgeon’s experience
and expertise with otoplasty. Learning from what
works in one’s hands is critical and only using the
basis of what is written here as a guideline should
be emphasized. The author constantly adapts
small changes in the technique based on evaluat-
ing the results. This is a natural progression of
any procedure, as mastery is only an asymptote in
which one continues to improve but never attains
it, especially for a mindful and diligent surgeon
who cares about his results.
The author always undersells a patient on what
is possible so that they are focused on improve-
ment rather than perfection. When a patient
insists on perfect symmetry, the author explains
that is not possible based on the possibility of
some relaxation in the ear position over time that
can be somewhat variable. In addition, consent
forms and also verbal reinforcement during
the preoperative session “Should reiterate the two
sides of the body are not the same and can never
be made the same.” One should remember the
admonition that the difference between an educa-
tion and an excuse is simply when it was told
before or after surgery, respectively.
Complications
Despite rigorous preoperative counseling and
meticulous surgical technique, complications can
still arise. Any surgeon who has never experi-
enced a complication simply has not operated on
enough cases. That is the nature of the imperfect
science of surgery.
The most common complication that I have seen
with otoplasty is unfavorable relaxation of the
Mustarde sutures. Since the author has incorporated
more frequently the reduction of the conchal bowl,
there has been a more reliable reduction in ear posi-
tion with more stability in the results over time.
Nevertheless, if the ears relax too much, a revision
procedure is warranted, and this is the most com-
mon reason for a corrective procedure for me.
The second most common “complication” is
extrusion of the Mustarde sutures over time that
requires removal of them in the of fi ce setting.
Before when 4-0 braided polyester (Mersilene)
sutures were used, the removal process was grue-
some and painful. Since converting to 4-0 clear
polypropylene sutures, intermittent extrusion has
not been encountered and removal of the suture is
easy and painless. That is a big reason why poly-
propylene sutures are a preferred suture material.
At times some minor step-off deformities are
seen at the conchal bowl from cup reduction that
typically are very hard to notice unless closeup.
Again, the author tries to explain the possibility
of all “deformities” so that the patient will accept
any minor fl aws as normal rather than an unex-
pected deviation. To improve this situation, some
fi ller material can be injected into the subcutane-
ous plane to soften any noticeable abrupt
transitions.
The hardest thing to correct is an overcorrected
ear. Once the scar tissue sets, an overcorrected
ear possibly cannot be brought back to a less
over-torqued position, at least in the author’s
hands. If the ear exhibits very resilient cartilage,

468
S.M. Lam
the author tends to slightly overcorrect the ear
with the knowledge that some relaxation will
take place. Obviously, this maneuver should only
be taken with experience that one’s ears would
relax. It is far easier to pull an ear farther back
than to relax it when it is over pulled.
Conclusions
Otoplasty is a very rewarding cosmetic endeavor
because it can almost be viewed as correcting a
physical deformity that can be the source of
teasing and low self-esteem for many individu-
als. Patients can be overwhelmingly satis fi ed
with even the smallest degree of correction, and
individuals are seeking this correction much
more commonly later in life. In fact, the major-
ity of my patients are adults rather than children
who determine they would like some improve-
ment in how they look later in life. This mono-
graph is intended to guide a prospective surgeon
through the trials, tribulations, and rewards of
otoplasty through a single surgeon’s experience
with the procedure. Using a systematic approach
to correct the ear and evaluating the ear as
upper, middle, and lower deformities, the sur-
geon can achieve balanced results that are aes-
thetically pleasing without needing to be a
supreme artist.

469
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_43, © Springer-Verlag Berlin Heidelberg 2013
43
Introduction
The pinna anatomically should sit within
the boundaries of the middle 1/3 of the face
(Fig. 43.1 ). It is usually only noticed in abnor-
mality, which is particularly apparent with
prominent ears. It has an extremely variable and
intricate internal anatomy [ 15 ] , but if the compo-
nent subunits and proportions of the pinna have
their appropriate anatomical relationships, then
the external ear will be considered “normal.”
A range of standard measurements for the
external ear has been previously described [ 4 ] .
The pinna, in appropriate proportion, is approxi-
mately 40–50 % longer than its width, with the
length being 5.5–7 cm and the width 3–4.5 cm.
[ 3, 4– 6, 8– 16 ] . Macrotia can be de fi ned as a
pinna that exceeds this normative data, but from
an aesthetic point of view, macrotia can be said to
exist when the pinna is larger than the boundaries
of the middle 1/3 of the face (Fig. 43.1 ).
There are four main anatomical subunits
of the pinna. These are the helix, the conchal
bowl, the antihelix, and the lobe. It is the ana-
tomical relationships of these that create the
overall appearance of the pinna. In any aes-
thetic ear surgery, de fi ning the anatomical dif-
ference will enable the surgeon to direct their
surgery to return the subunit relationships to
their appropriate proportions and relationships.
In de fi ning the anatomical issues in the large
ear, it is useful to divide the ear into unequal
1/3s. The upper third is superior to the inferior
crus, the middle third between the inferior crus
and the incisura, and the lower third inferior to
the incisura. Each of these “thirds” contributes
approximately the following amounts to the
overall length of the pinna: upper 1/3, 33 %;
middle 1/3, 44 %; and 23 % for the lower third
[ 16 ] . Knowing these proportions enables the
surgeon to determine where the excess is in the
large ear and also then create a surgical plan to
address the excess.
Ear reduction is usually performed for one of
two clinical presentations – either reduction of a
truly large ear or to correct ear asymmetry, for
example, with a unilateral lop ear deformity. In
the situation of true macrotia, the excess is usu-
ally in the upper third with an increased scaphal
height [ 7 ] . Also the earlobe can be increased in
length (Fig. 43.2 ). In planning correction of the
large ear, the surgeon may need to address both
the scaphal and lobe excesses, in isolation or
C. J. Coombs , M.D., MBBS (Hons), FRACS (*)
Department of Plastic and Maxillofacial Surgery,
Microtia Service , Royal Children’s Hospital ,
Flemington Rd , Parkville , VIC , Australia
The University of Melbourne ,
Grattan St , Parkville , VIC , Australia
Southern Plastic Surgery ,
883 Hampton St , Brighton , VIC 3186 , Australia
e-mail: chris@southernplasticsurgery.com.au
A. Yuen , MBBS, FRACS
Department of plastic Surgery
Royal Australasian College of Surgeons
Plastic Surgery Training Program ,
16 Win fi eld Road , Balwyn North , VIC 3104 , Australia
e-mail: ayuen7@hotmail.com
Reduction Otoplasty for Correction
of the Large or Asymmetrical Ear
Christopher J. Coombs and Alex Yuen

470
C.J. Coombs and A. Yuen
simultaneously, with the aim being to recreate the
appropriate internal proportions of the pinna and
improved symmetry [ 18 ] .
Historically, procedures have been described
for ear reduction [ 2, 7, 17 ] . The fi rst operations
performed involved a full-thickness wedge
resection of the ear’s widest part with direct
closure of the defect. Cupping of the ear and
prominent scars resulted in poor aesthetic out-
come. Later techniques described have placed
the incisions at the edge of the helical subunit
to improve the scars, using principles similar to
the helical advancement fl ap described by Antia
and Buch [ 1 ] . The key to a successful outcome
for ear reduction surgery is appropriate preop-
erative assessment to determine where the
excess is and strategic placement of incisions to
hide the resultant scars at the junctions of the
aesthetic subunits of the ear [ 18 ] . The place-
ment of scars at the junctions of aesthetic sub-
units in the face leads to the least notable scars.
Similarly, incisions on the anterior surface of
the pinna at the junction of its anatomic sub-
units (the helical rim, the antihelix with the
superior and inferior crura, the conchal bowl,
and the lobe) will reliably produce scars that
become virtually imperceptible.
The following procedure [ 18 ] follows these
reconstructive and aesthetic principles. It can be
used for correction of the scaphal height alone or
for simultaneous correction of the scaphal height
and the lobe length. It produces a consistent and
predictable result, with excellent patient accep-
tance of the scars.
Operative Technique
Initially the length of the pinna is measured along
its long axis. Analysis of the overall length is
then done to determine the contribution of the
upper, middle, and lower thirds to assess where
the excess exists (Fig. 43.2 ). The required resec-
tion of the scapha, and amount of lobe lift, can
then be determined to achieve the appropriate
postoperative outcome in length reduction. The
appropriate reduction in the scapha will result in
a crescentic resection (Fig. 43.3 ) to reduce the
upper third so that its postoperative height contri-
bution is closer to 33 % of the overall height of
Fig. 43.1 The anatomical “correct” position of the pinna and when there is macrotia

471
43 Reduction Otoplasty for Correction of the Large or Asymmetrical Ear
the pinna. The shape and position of the scaphal
crescent will also determine the reduction in the
upper third width, if this is required. The degree
of lobe elevation also is estimated for recreation
of its approximate 23 % contribution to the fi nal
overall height.
The procedure can be performed under local
or general anesthesia. The incisions are marked,
as is the amount of scaphal resection, which has
been determined by careful preoperative assess-
ment. The helical rim incision is taken inferiorly
to the junction of the helical and earlobe subunits.
This point is variable and needs to be determined
for each patient by the surgeon. If there is excess
length of the lobe and this requires elevation, then
the helical incision is carried further inferoanteri-
orly in the groove the lobe creates with its junc-
tion with the antitragus and the inferior portion of
the conchal bowl (Fig. 43.4 ).
Fig. 43.2 Excess in both the upper and lower 1/3 of a
macrotic ear
Fig. 43.3 Proposed incision and scaphal resection (in green )

472
C.J. Coombs and A. Yuen
Fig. 43.4 Dotted representation of continued incision
required for lobe elevation and chondrocutaneous scaphal
resection, leaving postauricular skin intact
Fig. 43.5 Elevation of the superior postauricular skin
fl ap with resection of the posterior “dog ear”
Fig. 43.6 Elevation of lobe if required on postauricular
fl ap
Fig. 43.7 Superior helical rim fl ap is advanced inferiorly
to close the scaphal resection defect and rim resection
amount determined

473
43 Reduction Otoplasty for Correction of the Large or Asymmetrical Ear
With the patient appropriately anesthetized
and the incisions in fi ltrated with local anesthetic
and epinephrine, the helical incision is initially
made through the cartilage, leaving the postau-
ricular skin intact. The predetermined scaphal
crescent is then resected with the underlying car-
tilage (Fig. 43.4 ). The helical incision is contin-
ued inferiorly to the junction of the helical and
earlobe subunits and then continued on to the
posterior aspect of the pinna in a horizontal
direction. The postauricular skin above the hori-
zontal posterior incision is then raised from the
posterior aspect of the ear cartilage just super fi cial
to the perichondrium. This then creates a superior
helical rim fl ap based on the postauricular skin to
allow advancement of the rim in an inferior direc-
tion (Fig. 43.5 ).
If the lobe requires elevation to reduce its
length, it is then also raised on the postauricu-
lar skin as a fl ap. The inferoanterior incision is
continued in the groove between the earlobe and
the antitragus and conchal bowl. The earlobe is
then raised as a fl ap, similarly to the helical rim,
based on the postauricular skin, which is dis-
sected from the posterior aspect of the conchal
bowl (Fig. 43.6 ). This dissection is carried as far
as required to allow adequate elevation of the
earlobe.
The helical rim on the fl ap of superior postau-
ricular skin is then advanced inferiorly to close
the scaphal defect, thus reducing the height of the
upper 1/3 of the pinna. If the earlobe is not being
altered, then following inferior advancement of the
helical rim, the excess rim is marked and excised
with the postauricular “dog ear” (Fig. 43.7 ). If the
lobe is being elevated as well, then the ends of the
superior helical rim and inferior earlobe are over-
lapped, and the appropriate excision of redundant
tissue is performed (Fig. 43.8 ), again with the
“dog ear” of the postauricular skin. Meticulous
wound closure is then performed with particular
attention given to approximation of the helical
rim and lobe junction to avoid any “hour glass-
ing” of the repair (Fig. 43.9 ).
Postoperatively the ears are dressed with a
routine post-otoplasty dressing of gauze and head
bandage for 5–7 days.
Fig. 43.8 Advancement and overlapping of both fl aps
when also elevating the earlobe to determine amount of
resection

474
C.J. Coombs and A. Yuen
a
b
Fig. 43.9 Typical postoperative result showing reduction in upper 1/3 and elevation of lower 1/3. ( a ) Right ear. Left
preoperative and right postoperative. ( b ) Left ear. Left preoperative and right postoperative

475
43 Reduction Otoplasty for Correction of the Large or Asymmetrical Ear
Conclusions
Reduction otoplasty can be a challenging pro-
cedure requiring accurate preoperative assess-
ment and planning. The advantage of this
technique is that it allows correction of the
upper and lower third excesses simultaneously,
thus restoring the appropriate internal propor-
tions of the external ear while reducing the
overall height of the pinna in a predictable and
reproducible way. The resultant scars become
imperceptible over time with their placement
at the junctions of the pinna subunits.
References
1. Antia NH, Buch VI. Chondrocutaneous advancement
fl ap for the marginal defect of the ear. Plast Reconstr
Surg. 1967;39(5):472–7.
2. Argamaso RV. Ear reduction with or without setback
otoplasty. Plast Reconstr Surg. 1989;83(6):967–75.
3. Broadbent TR, Mathews VL. Artistic relationships in
the surface anatomy of the face: application to recon-
structive surgery. Plast Reconstr Surg. 1957;20(1):
1–17.
4. Farkas LG. Anthropometry of normal and anomalous
ears. Clin Plast Surg. 1978;5(3):401–12.
5. Farkas LG. Anthropometry of the normal and defec-
tive ear. Clin Plast Surg. 1990;17(2):213–21.
6. Farkas LG, Posnick JC, Hreczko TM. Anthropometric
growth study of the ear. Cleft Palate Craniofac J.
1992;29(4):324–9.
7. Gault DT, Grippaudo FR, Tyler M. Ear reduction. Br
J Plast Surg. 1995;48(1):30–4.
8. Hunt HI. War surgery of the face. Philadelphia: Lea
and Febiger; 1926. p. 218.
9. Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast
Reconstr Surg. 2005;115(4):60e–72.
10. Kotler HS, Robertson K, Tardy Jr ME. Pre- and post-
operative management in otoplasty. Facial Plast Surg.
1994;10(3):244–54.
11. McDowell AJ. Goals in otoplasty for protruding ears.
Plast Reconstr Surg. 1968;41(1):17–27.
12. Sheehan HL. General and plastic surgery with empha-
sis on war injuries. New York: Hoever; 1954. p. 331.
13. Skiles MS, Randall P. The aesthetics of ear placement:
an experimental study. Plast Reconstr Surg. 1983;
72(2):133–40.
14. Smith HW. Calibrated otoplasty. Laryngoscope. 1979;
89(4):657–65.
15. Tolleth H. Artistic anatomy, dimensions, and propor-
tions of the external ear. Clin Plast Surg. 1978;5(3):
337–45.
16. Tolleth H. A hierarchy of values in the design and con-
struction of the ear. Clin Plast Surg. 1990;17(2):
193–207.
17. Yavuzer R, Sari A, Kandal S, Atabay K. A new ear
reduction method without an anterior scar: posterior
approach. Plast Reconstr Surg. 2003;112(2):701–2.
18. Yuen A, Coombs CJ. Reduction otoplasty: correction
of the large or asymmetric ear. Aesthetic Plast Surg.
2006;30(6):675–8.

477
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_44, © Springer-Verlag Berlin Heidelberg 2013
44
Introduction
A key element to a successful otoplasty is the
appropriate relationship between the lobule and
the auricular cartilage architecture. If the lobule
is not adequately managed, a telephone-ear or
reverse telephone-ear deformity results.
The lobule is the lower non-cartilaginous third of
the auricle. It should rest in a straight line with the
helical cartilage when viewed from the front. Lobule
prominence is thought to be determined by either
excess skin or fi brofatty tissue behind the lobule or
the protrusion or excessive length of the tail of the
helix which pulls the lobule laterally (Fig. 44.1 ).
Failure to correct lobular protrusion during oto-
plasty will cause this deformity to appear even
more conspicuous [ 1 ] . Actually, in most of the
cases, after setting back the auricle and recreation
of the antihelical fold, the lobule will almost
always appear protruding. That is why lobule pro-
trusion correction may be necessary in every case.
Techniques to Correct
the Protruding Lobule
Lobule setback is a dif fi cult part in otoplasty. Few
techniques have been described to resolve this
deformity. In some cases, recreation of the antihe-
lical fold may control the lobule position, since the
lobule is attached to the helical framework [ 1, 2 ] .
In case of a mild protrusion, retrolobular skin
excision may achieve correction. Different skin
excision patterns of the lobule have been described:
fi shtail, dumbbell, tennis racket shape, swallowtail,
and rhomboid (Fig. 44.2 ). Many surgeons prefer
elongating the postauricular skin excision inferi-
orly on the posterior aspect of the lobule in a wid-
ened shape-open book [ 1 ] or diamond shape [ 3 ] .
Other approaches have included skin wedge
C. Isac , M.D., Ph.D. (*)
Department of Plastic Surgery ,
University of Medicine and Pharmacy “Carol Davila” ,
Bucharest , Romania
Department of Plastic Surgery ,
University Hospital for Plastic Surgery and Burns ,
Calea Grivitei 218, Sector 1 , Bucharest , Romania
e-mail: ina@drisac.ro ; inaisaac@yahoo.com
A. Isac , M.D., Ph.D.
Department of Plastic Surgery ,
University Hospital for Plastic Surgery and Burns ,
Calea Grivitei 218 , Bucharest , Romania
e-mail: ireli fl orin@yahoo.com
Correction of the Protruding Lobule
Cristina Isac and Aurelia Isac
Fig. 44.1 Protruding lobule determined by laterally
situated helical tail

478
C. Isac and A. Isac
excisions on the medial aspect of the lobule [ 4– 6 ]
or curvilinear excisions along the inferior aspect of
the lobule, anterior to the lobule-cheek junction [ 4 ] .
However, skin excision should not encroach the
retrolobular sulcus in order not to blunt it. In addi-
tion to the fi shtail or elliptical skin excision,
Karagoz et al. [ 7 ] excise one or more extra triangle-
shaped skin islands at the lateral and inferior aspects
of the elliptical excision to improve surgical results,
stating that with regard to the lobule, two resections
yield better results than a single excess resection.
Most authors agree that the lobule resting posi-
tion is mainly determined by the relative position
of the helical caudal end to the conchal bowl. This
means that controlling the helical tail would effec-
tively control the position of the lobule. Goulian
and Conway [ 8 ] described the helix and concha as
two separate units and advocated dissection of the
plane between them to restore their relative orien-
tation. Separating the helical tail from the concha
allows repositioning of the cauda helicis [ 9 ] ,
which, in turn, being attached to the cephalic por-
tion of the lobule allows lobular position chang-
ing. The helical tail can then be approximated to
the concha with different suture techniques.
Webster [ 10 ] identi fi es the tail of the helix as
the key to otoplasty and recommends suturing the
tail of the helix to the posterior side of the concha
with one or two permanent horizontal mattress
sutures. This is our preferred technique, also
(Fig. 44.3 ). A full thickness that separates the
helical tail from the newly formed antihelix is
needed to allow the cartilage to be folded 180°.
The lobule, which is attached to the helical tail,
can then be set back by a single horizontal mat-
tress suture which approximates the cauda helicis
to the concha (Fig. 44.4 ).
Bauer et al. [ 11 ] , by contrary, believes that the
main cause of prominent lobule is not the heli-
cal tail, but the conchal shape. He advises against
freeing the helical tail (which is a duplication of
the inferior part of the helix) from the anterior skin
because this maneuver will diminish the effec-
tiveness of correction of the lobule prominence.
Fig. 44.2 Rhomboid excision from the posterior part of
the lobule
Fig. 44.3 The authors’ preferred method: full-thickness
incision and separation of the helical tail from the newly
formed antihelix with 180° cartilage folded back and
sutured; the helical tail is set back by a single horizontal
mattress suture to the most inferior part of the concha
Fig. 44.4 Authors’ technique of cartilage folding and the
helical tail-concha suture in place to set back the lobule

479
44 Correction of the Protruding Lobule
The conchal excision which he believes is a key
point in prominent ear correction softens the
cartilage spring in the helical tail, allowing the
lobule to be more easily recessed. He addresses
lobule prominence only by varying the closure
of the posterior diamond-shaped inferior portion
of the excised skin to different positions until the
lobule setback is the desired one.
Siegert [ 12 ] uses one or multiple sutures from
the dermis to the most inferior portion of the con-
cha for lobule setback. The anchorage to the der-
mis should be strong enough but not too super fi cial
so as to produce tethering of the skin or suture vis-
ibility. The path of each arc of mattress suture
should be wide enough to allow strong anchorage
of the intervening fi brofatty tissue of the lobule
[ 1, 12 ] . A small anterior stab incision may be per-
formed in the lobule to facilitate passage of the
suture via an anterior or posterior approach [ 1 ] .
Spira [ 13 ] uses a single similar dermal-mastoid 5-0
PDS suture placed in the primary incision line.
Gosain uses a dermal-mastoid periosteum
suture to fi x the lobule [ 4 ] . The point of suture
placement is determined as the closest point on
the medial surface of the lobule to the retrolobu-
lar sulcus which controls the lobule position and
minimally alters the sulcus. Gosain uses a later-
ally extended small incision through the point of
control and passes a single 3-0 PDS suture from
the point of control to the mastoid fascia and the
medial aspect of the postauricular skin incision.
The main advantage of this technique is, as its
author states, the stable result in time with no
recurrence.
Thorne [ 14 ] excises a triangle of skin from the
medial surface of the lobule. When the defect is
closed, the suture incorporates the posterior sur-
face of the concha.
Some authors advocate weakening the carti-
lage by scoring the helix of the tail or incising
along its scaphal attachment prior to suturing [ 1 ] ,
while others prefer its excision [ 15 ] . Adamson
and Litner [ 1 ] states that by excising the tail of the
helix, we only forfeit suture control of the lobule.
Many authors also underlined the importance of
leaving the tail of the helix and its attachment to
the anterior skin intact as it is this attachment that
allows lobule reposition [ 4, 5, 16, 17 ] .
Helical tail fi xation to the concha by means of
sutures may be combined with posterior lobular
skin excision.
If the lobule is not adequately managed, a tele-
phone-ear or reverse telephone-ear deformity
results. On the other hand, excess resection of the
earlobule yields an either fl at or stretched lobule.
In addition to being prominent after the set-
back of the ear, the lobule may also appear too
long compared to the new shape of the auricle.
Rodriguez-Camps shortens the lobule in almost
every case with the use of a speci fi c design [ 18 ] .
Conclusions
Compared to the luxurious number of tech-
niques which address the antihelical fold rec-
reation and conchal setback published over
the years, surprisingly very few procedures
have been described for lobular protrusion.
This is even more astonishing as inadequate
lobule positioning may alter the result of an
otherwise perfectly performed otoplasty.
References
1. Adamson P, Litner J. Adjunctive procedures: man-
agement of the helix, scapha and lobule. In:
Adamson P, editor. Aesthetic otoplasty (Thomas
procedures in facial plastic surgery). Shelton:
People’s Medical Publishing House USA Ltd; 2011.
p. 45–53.
2. Beernink JH, Blocksma R, Moore WD. The role of
the helical tail in cosmetic otoplasty. Plast Reconstr
Surg. 1979;64(1):115–7.
3. Bauer B. Evolution and re fi nements in otoplasty tech-
niques. In: Nahai F, editor. The art of aesthetic sur-
gery- principles and techniques. St. Louis: Quality
Medical Publishing; 2005. p. 1463–95.
4. Gosain AK, Recinos RF. A novel approach to correc-
tion of the prominent lobule during otoplasty. Plast
Reconstr Surg. 2003;112(2):575–83.
5. Mustarde JC. The correction of prominent ears using
simple mattress sutures. Br J Plast Surg. 1963;16:
170–8.
6. Furnas DW. Correction of prominent ears by concho-
mastoid sutures. Plast Reconstr Surg. 1968;42:
189–93.
7. Karagoz H, Eren F, Ulkur E. A new skin excision pat-
tern to correct protruding earlobe deformity in promi-
nent ears. Aesthetic Plast Surg. 2012;36(1):215–7.
8. Goulian D, Conway H. Prevention of persistent defor-
mity of the tragus and lobule by modi fi cation of the

480
C. Isac and A. Isac
Luckett technique of otoplasty. Plast Reconstr Surg.
1960;26:399–404.
9. Caouette-Laberge L, Guay N, Bortoluzzi P, Belleville
C. Otoplasty: anterior scoring technique and results in
500 cases (review). Plast Reconstr Surg. 2000;105(2):
504–15.
10. Webster G. The tail of the helix as a key to otoplasty.
Plast Reconstr Surg. 1969;44(5):455–61.
11. Bauer B, Margulis A, Song DH. The importance of
conchal resection in correcting the prominent ear.
Aesthet Surg J. 2005;25(1):72–9.
12. Siegert R. Correction of the lobule. Facial Plast Surg.
2004;20(4):293–8.
13. Spira M. Otoplasty: what I do now-a 30-year
perspective. Plast Reconstr Surg. 1999;104(3):
834–42.
14. Thorne C. Otoplasty. Plast Reconstr Surg. 2008;122(1):
291–2.
15. Nachlas NE, Duncan D, Trail M. Otoplasty. Arch
Otolaryngol. 1970;91(1):44–9.
16. Elliot Jr RA. Otoplasty: a combined approach. Clin
Plast Surg. 1990;17(2):373–81.
17. McDowell AJ. Goals in otoplasty for protruding ears.
Plast Reconstr Surg. 1968;41(1):17–27.
18. Rodriguez-Camps S. Our procedure for integral aesthetic
otoplasty. Aesthetic Plast Surg. 1997;21(5):332–8.

481
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_45, © Springer-Verlag Berlin Heidelberg 2013
45
Introduction
The ear is one of the most visible facial feature
in a pro fi le view, and hence its cosmetic concerns
are frequently requested for correction. A torn
earlobe is by far the commonest cosmetic prob-
lem of the ear requiring surgery. Torn earlobes
result from various forms of trauma, includ-
ing babies pulling on earrings, entanglement in
telephone cords [ 1 ] , hairbrushes and clothing,
spousal abuse, and last but not the least by use of
heavy earrings over a period of time [ 2 ] . In many
Asian countries, especially India, ear piercing is
practiced as a ritual and is customary for all girls
to have their ears pierced at the age of 1 year.
This practice makes the human earlobe the most
used and albeit abused part of the body by metal
ornamentations.
Many techniques have been published for the
repair of earlobe tears [ 3– 10 ] . These techniques
consist of simple suturing of the tear, use of
fl ap for preservation of earhole besides descrip-
tion of many different types of fl aps to provide
strength to the earlobe below the repaired ear-
hole. All these surgical methods inadvertently
tend to add to further scarring and weakening
of the earlobe tissues, thus predisposing the ear-
lobe to recurrent tears.
The earlobe anatomically consists of skin
layer and subcutaneous tissue only with no inter-
nal architectural support of cartilage, muscle, or
fascial tissue. The soft structure of the earlobe is
hence not strong enough to withstand the con-
tinuous trauma associated with long-term earring
use with its attendant problems of superadded
incidental trauma due to inadvertent pulling of
earring or even surgical scarring which is unwit-
tingly contributed by repeated repairs of split
earlobe.
A new technique has been developed which
strengthens the earlobe with locally available
conchal cartilage and provides the necessary
reinforcement of earlobe tissues, preventing fur-
ther recurrence following surgery. This technique
also allows simultaneous creation of a centrally
located earhole, thus eliminating the waiting
period between earhole repair and reperforation.
A new classi fi cation scheme and anatomy of
acquired cleft earlobes is also described [ 11, 12 ] .
Technique
Anesthesia
The operation is performed under local anesthe-
sia as an outpatient procedure. The center of the
earlobe is marked and tattooed. The edges of the
split earlobe are fi rst in fi ltrated with 2 % xylo-
caine mixed with adrenaline solution. Thereafter,
R. Agarwal , M.D.
Department of Plastic Surgery ,
K.G Medical University ,
Lucknow , India
e-mail: drrajivagarwal@gmail.com
Repair of Split Earlobe with Free
Conchal Cartilage Sandwich Graft
Rajiv Agarwal

482
R. Agarwal
the same solution is in fi ltrated along a line located
between the auriculocephalic sulcus and the
helical border on the posterior surface of the ear.
The plane of injection is between the skin and the
conchal cartilage. Ten-minute time is allowed
after injection to take advantage of the vasocon-
strictor effect of the adrenaline and also for the
swelling of local anesthetic to subside.
Paring the Edges
A stay suture at the apex of the earlobe is used to
stabilize the lobe. Two stay sutures may be used
on each side if there is total cleft of the earlobe.
The cleft edges are pared using a #11 blade and
the intervening inrolled skin tissue is discarded
(Fig. 45.1 ). The same blade is used to create a
pocket in both the split halves of the earlobe. The
depth of the pocket should be two third of the
diameter of the respective split half of the ear-
lobe. Care is exercised so as not to unduly thin
any of the split halves, thus maintaining adequate
thickness of the tissue on all sides of the pocket.
Hemostasis is maintained.
Harvesting the Cartilage Graft
A curvilinear incision is made along a line
midway between the auriculocephalic sulcus
and the helical margin (Fig. 45.2 ). Skin fl aps
are re fl ected on both sides to expose the con-
chal cartilage. A disc of conchal cartilage of
size commensurate with the created pocket is
marked out and dissected out. The diameter
of the conchal cartilage graft should be two
thirds of the diameter of the repaired earlobe
and usually measures 1.5 cm. for one side
(Fig. 45.3 ). For bilateral cases, cartilage grafts
may be taken from both the sides. Adequate
care should be taken to not damage the skin of
the anterior aspect of the concha. The donor
site is closed after ensuring hemostasis. The
harvested conchal graft should be inspected for
Fig. 45.1 Marking (in red color ) for paring the edges in
a case of right-sided total split of the earlobe with fi brosis
and retraction of the earlobe halves
Fig. 45.2 Curvilinear incision located on a line between
the auriculocephalic sulcus and the helical margin. Length
of incision is usually 3–4 cm

483
45 Repair of Split Earlobe with Free Conchal Cartilage Sandwich Graft
any thickenings, and if present, they should be
shaved off using a # 11 blade.
Placement of the Graft in the Earlobe
The posterior layer of the split earlobe is closed
fi rst using 5/0 PDS so as to create the bed for the
graft (Fig. 45.4 ). Next the harvested graft is
placed in the earlobe pocket with the concavity
facing anteriorly (Fig. 45.5 ). Care should be exer-
cised so that any signi fi cant contour curvatures of
the graft disc be corrected by scoring the graft on
the opposite side. The anterior layer of the ear-
lobe is then repaired in single layer using 6/0
PDS, taking care to maintain the shape of the ear-
lobe (Fig. 45.6 ).
Simultaneous Creation
of New Central Earhole
A new earhole is created at a central location
on the repaired split earlobe at the marked site.
Fig. 45.3 Harvested conchal cartilage disc measuring
approximately 1.5 cm in diameter
Fig. 45.4 Repaired posterior layer of the split earlobe in
preparation for making a “bed” for the conchal cartilage
graft
Fig. 45.5 Placement of the conchal cartilage graft over
the repaired posterior layer. The graft is placed snugly in
the pocket that is created in the earlobe on both the sides
of the cleft

484
R. Agarwal
A # 16 needle is taken and pierced from posterior
to anterior direction at the proposed site of ear-
lobe. The needle tip goes through posterior earlobe
skin, new conchal graft, and the anterior earlobe
skin. A stud type of gold ear jewelry presterilized
in Lysol solution is taken and is simply inserted
into the needle tip hole. The needle along with the
stud is now withdrawn toward the posterior side
and needle is taken out. The stud is now capped
easily, completing the procedure. Alternatively, an
intravenous cannula of 18 G is taken and passed
through the proposed site of earhole. The stilette
is removed and a ~5-mm length of distal sheath
is cut and left behind in the new hole. The sheath
can be even used for wearing arti fi cial jewelry
in those patients with positive history of metal
allergy. Subsequently, as the tract epithelializes,
the sheath is removed and the earhole can then be
used for wearing appropriate metal jewelry.
Postoperative Care
Postoperatively, the ear cavity is packed with
gauze soaked in antibiotic solution, and retroau-
ricular support dressing is also given for 48 h to
prevent auricular hematoma. An antibiotic oint-
ment is freely applied over the earlobe reperfora-
tion site, and free rotation of the stud bar is
checked. The patient is instructed to keep the
stitch line clean with dilute hydrogen peroxide
solution and Q tip along with twice daily applica-
tion of antibiotic ointment. Twice daily circular
motion of the stud is also recommended after
application of lubricating ointment.
Patients are instructed to continue wearing
light jewelry for at least 2 months after surgery.
Anatomy of the Split Earlobe
The pathological anatomy of the split of the ear-
lobe is unique and interesting. It has been
observed that the axis of the splitting of the ear-
lobe does not correspond to the anatomical cran-
iocaudal axis of the ear but is directed in a down
and out position starting from the original cen-
trally located earhole. This particular axis of tear
was found to be present in both incomplete and
complete splitting of the earlobes caused due to
constant pulling by the earrings (Fig. 45.7 ).
Fig. 45.6 The appearance after fi nal closure of the anterior
layer over the previously placed conchal cartilage graft
Fig. 45.7 Split right earlobe in a 42-year-old female
showing the unique axis of splitting of the earlobe.
The axis of splitting was 29° from the craniocaudal axis
of the ear

485
45 Repair of Split Earlobe with Free Conchal Cartilage Sandwich Graft
On analysis using clinical goniometry and
CAD measurements of these cases, the axis of
splitting is a function of the relative position in
which that individual holds the head while awake
and performing various tasks. The vertical axis
of the ear in normal head-holding position is
inclined at an angle of approximately 25° ± 5°,
and this fact determines the axis of the splitting
of the ear. It is clear that gravity combined with
weight of the earring contributes to the oblique
axis of the split [ 12 ] .
A New Classi fi cation for Split
Earlobe Deformity
The split earlobe deformity can present in a vari-
ety of combinations and degrees of split ranging
from an elongation of the earhole to total split of
the earlobe. Moreover, there are other variables
that also need to be taken into consideration while
planning repair for split earlobe, especially the
condition and volume of the soft tissues and also
multiplicity of the tears.
No formal classi fi cation for acquired split ear-
lobe exists currently in the literature. Boo-Chai
(1961) [ 3 ] described two types of acquired clefts:
complete and incomplete. This classi fi cation
however does not give enough details of the split
earlobe.
A new classi fi cation system for grading the
split earlobe based on its severity and also con-
dition of the soft tissues is described. This
classi fi cation system is helpful for planning the
type of surgical treatment (Table 45.1 ). All the
acquired split earlobes have been classi fi ed into
fi ve types with type I having minimal and type
V having maximum deformity (Figs. 45.8 , 45.9 ,
45.10 , 45.11 , and 45.12 ) [ 11 ] . The type of surgi-
cal repair for these grades of split ear should
Table 45.1 Classi fi cation of acquired split earlobe defor-
mity [ 11 ]
Type
Description
Type I
Stretched out hole of earlobe more than
twice the original diameter a
Type II
Near total split of earlobe. A thin rim
of soft tissue remaining
Type III
Total split of earlobe with preservation
of soft tissue
Type IV
Total split of earlobe with fi brosis and
retraction of earlobe halves
Type V
Single/multiple tears of earlobe with
fi brosis and loss of soft tissue
a A normal earhole would be de fi ned as one that is located
in a central aesthetic location on the earlobe, is horizon-
tally oriented, and allows snug fi tting of a regular earring
Fig. 45.8 Clinical photo-
graph of right ear of a
21-year-old woman with type
I classi fi cation of acquired
split earlobe deformity

486
R. Agarwal
take into account the various local factors
including the quality of soft tissues, number of
times the repair has been done previously, and
the extent of split. Traditional repairs may be
used for the treatment of types I to III, but we
recommend the conchal cartilage graft sandwich
technique for all the types of split earlobe except
type I, where any of the traditional techniques
may be used.
Discussion
The split earlobe deformity occurs primarily in
women as they are akin to wearing heavy jewelry
for a long duration. The splitting may be observed
in age group ranging from 18 to 62 years; the
average age of involvement is usually 35 years.
Both the sides of the ear may be involved by the
splitting forces. Majority of the women have had
Fig. 45.9 Clinical photo-
graph of right ear of a 45-year-
old woman with type II
classi fi cation of acquired split
earlobe deformity
Fig. 45.10 Right ear of a
42-year-old woman with type
III classi fi cation of acquired
split earlobe deformity

487
45 Repair of Split Earlobe with Free Conchal Cartilage Sandwich Graft
three constant predetermining factors for the torn
earlobe. Firstly, they have been using heavy jew-
elry for extended period of time. A positive his-
tory of acute pull on the earring was present in all
the cases at some point. A positive history of
metal allergy in the form of metal dermatitis of
the earlobe may also be present.
The results of the repair of split earlobe using
the conchal cartilage graft have been shown in a
representative patient in Fig. 45.13 . No recur-
rence of split was reported in the current series.
The diameter of the earhole has remained con-
stant over a follow-up period ranging from 1 to
3 years. The patients have been instructed to wear
Fig. 45.11 Right ear of a
40-year-old woman with type
IV classi fi cation of acquired
split earlobe deformity
Fig. 45.12 Right ear of a
42-year-old woman with type
V classi fi cation of acquired
split earlobe deformity

488
R. Agarwal
light jewelry routinely, but occasional usage of
heavy jewelry is also permissible with this
technique.
The cartilage graft has settled well in this
group of patients. The earlobe feels stiff for few
weeks after surgery but gradually softens over a
period of time. There has been no report of
cartilage exposure or extrusion in this series. The
conchal graft donor site has also healed well in
this series. The scars have matured well and there
has been no residual deformity of ear following
removal of conchal graft. A granuloma was
reported in one patient that healed completely
after local curettage.
a
d
e
b
c
Fig. 45.13 ( a ) Right ear of a 45-year-old woman with
type II classi fi cation of acquired split earlobe defor-
mity before surgery. The tissues are torn and loose. ( b )
Intraoperative showing harvesting of conchal cartilage.
( c ) Intraoperative showing insertion of conchal cartilage
disc into the earlobe. ( d ) Early postoperative showing
suture line with simultaneous reperforation in a central
location. ( e ) Follow-up showing well-healed suture line
with the new earhole. The earlobe looks rejuvenated due
to volume restoration, shape, and strength afforded by the
conchal graft

489
45 Repair of Split Earlobe with Free Conchal Cartilage Sandwich Graft
The patients have been followed up for a
period ranging from 6 months to 3 years. Six
patients complained of residual swelling and
hardness of the earlobe during the fi rst 2 weeks
after surgery. One patient developed a small
granuloma at the site of the new earhole. This
however responded with change in the earrings.
No other problems have been reported by the
patients in this series. The donor site has healed
well in all the patients without any problem or
deformity (Fig. 45.14 ).
The ears command a position of prominence
and contribute to key aesthetic beauty of the face.
The earlobe is one of the most visible parts of the
face and is also the commonest site of the body
which is used for metal ornamentations. Women
and men alike enjoy wearing ear jewelry to
enhance their appearance and to ful fi ll socioreli-
gious obligations. Rings, posts, studs and many
other trendy designs of earrings have adorned
ears since ancient times.
In India, earlobes are universally pierced as a
ritual before the age of 1 year among females of
all races and also in speci fi c castes of males too
in adolescent age. The earlobes consequently are
made to bear the brunt of metal ornaments very
early on in life. The initial ear ornament is com-
monly either a stud or a small ring, but later on
in adolescence and later years, there is a grad-
ual shift to “danglers” and often heavy earring
use. These types of earrings especially in young
mothers are prone to being yanked by children, or
they may suffer similar kind of acute severe pull
or entanglement due to other reasons [ 1 ] . This
acute event initiates a “tear” of the earhole which
becomes the starting point for a split earlobe.
The split earlobe is a troublesome problem to
the plastic surgeon because of high incidence of
recurrence after repair. Many different techniques
have been described in the literature for repair.
These techniques range from excision of skin of
the cleft edges and resuturing to fashioning dif-
ferent designs of fl aps of skin on the anterior and/
or posterior aspects of the earlobe. These tech-
niques may or may not be combined with preser-
vation of the original earhole repair [ 4 ] . There are
several disadvantages with these techniques.
Repair of split earlobe by either a straight line or
any form of Z-plasty closure [ 5– 10 ] introduces a
scar right across the central “aesthetic” axis of
the earlobe which constitutes an area of weak-
ness in the earlobe. When a reperforation is being
done, it has to be done on any one side of the scar,
thus making the new hole in a paracentric posi-
tion on the earlobe. These repairs subject the
patient to a 3–4-weeklong waiting period between
the repair and reperforation. The Z-plasty design
often leads to lengthening of the earlobe, thus
causing distortion of the shape of the lobe mak-
ing the earlobe pointed in shape. There is also a
possibility of an oblique retear as the upper limb
of the repaired Z lies directly below the hole
which slants downward. All in all, these Z-plasty
techniques aim at introducing tongue of tissue
below the repaired earhole for support, but given
the compromised, scarred, and ischemic condi-
tions of the soft tissues of the earlobe, these
repairs eventually give way leading to enlarged
earholes over time especially if the patient goes
back to wearing heavy earrings.
It is interesting to study the likely cause(s)
of elongation and splitting of the earlobe. Two
important reasons have emerged as the inciting
Fig. 45.14 Clinical photograph of a patient after conchal
cartilage graft procedure showing minimal donor site
deformity and scarring

490
R. Agarwal
causes of split earlobe. The usual inciting factor is
the acute tugging of the pendant earring by small
children. This event leads to a skin breach in the
lower part of the earhole which becomes a path for
subsequent tear of the lobe. Dibbell [ 13 ] has also
reported acute lacerations of the earlobes from
forcible traction causing their clefts, and these
fi ndings have also been reported by Boo-Chai [ 3 ] .
Raveendran and Amarasinghe [ 14 ] have
reported a new theory of splitting of the earlobe
as due to the allergy of metals used in the ear-
ring. We have also observed that earrings made
of arti fi cial metals lead to increased incidence of
infection, granuloma formation, or even keloid
formation at the local site. These factors found in
11 cases of this series lead to complete blockage
of the earlobe necessitating a later redo piercing
and leaving behind a potential weakness in the
soft tissues which is prone to subsequent split-
ting of the earlobe. We have henceforth advised
all of our patients to bring gold ear studs only
for the procedure of simultaneous repiercing at
the time of repair. Cornetta and Reiter [ 15 ] have
devised a novel technique for those having metal
hypersensitivity. They have described the use of
the distal shaft of an intravenous catheter as an
earring post sheath that allows hypersensitive
individuals to wear earrings in pierced ears on
a limited basis. McDonagh et al. [ 16 ] in a large
study of 612 consecutive patients undergoing
routine patch tests for suspected allergic contact
dermatitis found that many women who have
had their ears pierced gave a history of cutane-
ous reactions to metallic jewelry and almost one
third were sensitive to nickel. They were of the
opinion that ear piercing seems to induce nickel
allergy which may result in lifelong morbidity
and dif fi culty in employment. Jewelry suppliers
should be encouraged to provide nickel-free ear-
rings to reduce the frequency of this apparently
avoidable problem. In the current series, all the
women were preoperatively assessed for his-
tory of metal allergy, and those with suggestive
symptomatology were pierced using intravenous
catheter. Once the fi stula was well formed, these
women resumed earrings.
The human earlobe is composed of skin and
subcutaneous tissue which is predominantly fat.
There are no tough supporting tissues present in
the earlobe and it is devoid of any inherent struc-
tural support. It is clear that an acquired traumatic
split in the earlobe causes scarring, ischemia, and
weakening of the earlobe. Repeated attempts at
surgical repair further weaken and cause cicatri-
cial volume atrophy of the earlobe and predispose
to recurrent tears. Given such circumstances, we
have devised a new technique whereby a healthy
disc of conchal cartilage is harvested and placed
in the earlobe at the time of repair. This cartilage
disc has been found to provide many advantages
and overcomes the disadvantages found with the
traditional techniques.
The cartilage provides a buttress support to
the ear and prevents retear as the new hole is
done through the center of this disc. It restores
the soft tissue volume of the ear, thereby improv-
ing earlobe aesthetics. Thirdly, it allows the cre-
ation of a central aesthetic earhole. Fourthly, it
allows simultaneous reperforation at the time of
repair and cuts down the waiting period com-
pletely, leading to high degrees of patient satis-
faction and acceptability to this procedure. The
conchal cartilage is an ideal support tissue for
split earlobe repair as it is a standard donor
source of cartilage and is located in the same sur-
gical fi eld.
There has been no recurrence or enlargement
of the earhole following introduction of the con-
chal cartilage graft. Concha of one side is ade-
quate to provide enough tissue for repair of both
the earlobes, leaving behind the other concha for
future requirements. In the event of theoretical
possibility of enlargement of the earhole, a sec-
ond hole can be conveniently made through the
conchal graft at a nearby location, after repair of
the previous hole.
The use of a conchal cartilage “sandwich”
graft for repair of split earlobe seems justi fi able
as earlobe tears are limited to the area of the ear-
lobe and perforations of the cartilaginous part of
the ear by metal ornamentations is seldom seen.
This is attributable to the fact that the metal orna-
ment derives strong support of the cartilage that it
pierces. A further similarity is also found in case
of nose perforations which seldom tear. These
perforations too are transcending the alar carti-

491
45 Repair of Split Earlobe with Free Conchal Cartilage Sandwich Graft
lage which provides enough structural support to
resist tears.
Recently Mischkowski et al. [ 17 ] have also
recommended conchal grafts as ideal cartilage
graft material for reconstructive procedures. They
believe that no other biological or alloplastic
material approaches the qualities of fresh autog-
enous cartilage in terms of safety, durability, and
versatility.
The only disadvantage with this technique has
been a residual stiffness of the earlobe conse-
quent to the use of the cartilage graft. However,
only one patient complained about this and the
stiffness resolved with time. Secondly, this is
usually not a problem in majority of the cases as
the earlobes are already covered by the metal
ornaments and are hence inaccessible to the pal-
pating fi nger of the patient.
There have been no reports of recurrence of
splitting of earlobe following introduction of
conchal cartilage discs at the time of repair. The
earhole size also did not change over the fol-
low-up period of 3 years. Additionally, there have
been no reports of perichondritis in the earlobe in
the operated patients, and all of them have toler-
ated these cartilage grafts well under cover of
systemic perioperative antibiotics.
Conclusions
The conchal cartilage graft sandwich proce-
dure allows immediate reperforation of the
repaired earlobe at the time of repair in a cen-
tral aesthetic location along with providing
necessary strength to the earlobe, thus pre-
venting recurrence in primary and recurrent
split earlobe.
References
1. Niamtu J. Eleven pearls for cosmetic earlobe repair.
Dermatol Surg. 2002;28(2):180–5.
2. Altchek E. Tearing of an earlobe by weight of a tele-
phone earpiece on an earring. Plast Reconstr Surg.
1977;59(4):564.
3. Boo-Chai K. The cleft earlobe. Plast Reconstr Surg
Trans Bull. 1961;28:681–8.
4. Pardue AM. Repair of torn earlobe with preservation
of the perforation for an earring. Plast Reconstr Surg.
1973;51(4):472–3.
5. Hamilton R, LaRossa D. Method for repair of cleft
earlobes. Plast Reconstr Surg. 1975;55(1):99–101.
6. Abenavoli FM. Split earlobe: repair using a half Z-plasty
technique. Plast Reconstr Surg. 1996;98(2):372–3.
7. Agarwal R. Repair of cleft earlobe using double opposing
Z-plasty. Plast Reconstr Surg. 1998;102(5):1759–60.
8. Gajiwala K. Repair of the split earlobe using a half
Z-plasty. Plast Reconstr Surg. 1998;101(3):855–6.
9. Fatah MF. L-plasty technique in the repair of split ear
lobe. Br J Plast Surg. 1985;38(3):410–4.
10. Staiano JJ, Niranjan NS. Split earlobe repair using a
double- fl ap
technique.
Ann
Plast
Surg.
2001;47(1):89–91.
11. Agarwal R, Chandra R. A new technique for repair of
acquired split-ear-lobe deformity: the free conchal
cartilage sandwich graft. J Plast Reconstr Aesthet
Surg. 2010;63(3):499–505.
12. Agarwal R, Chandra R. The anatomy of split ear lobe.
J Plast Reconstr Aesthet Surg. 2008;61 Suppl 1:S114.
13. Dibbell DG. Split earlobe deformities. Plast Reconstr
Surg. 1970;45(1):77.
14. Raveendran SS, Amarasinghe L. The mystery of the
split earlobe. Plast Reconstr Surg. 2004;114(7):1903–9.
15. Cornetta AJ, Reiter D. Ear piercing for individuals
with metal hypersensitivity. Otolaryngol Head Neck
Surg. 2001;125(1):93–5.
16. McDonagh AJ, Wright AL, Cork MJ, Gawkrodger
DJ. Nickel sensitivity: the in fl uence of ear piercing
and atopy. Br J Dermatol. 1992;126(1):16–8.
17. Mischkowski
RA,
Domingos-Hadamitzky
C,
Siessegger M, Zinser MJ, Zoller JE. Donor-site mor-
bidity of ear cartilage autografts. Plast Reconstr Surg.
2008;121(1):79–87.

493
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_46, © Springer-Verlag Berlin Heidelberg 2013
46
Introduction
Otoplasty for correction of prominent ear defor-
mity is well established despite the variety of
techniques. It is possible to obtain successful
results with alternate techniques based on sur-
geon preference or speci fi c needs of the patient
[ 1– 16 ] . Maybe one of the most common long-
term complications of the operation is an unnatu-
ral “operated” look of the ear. Intermingled
recesses and folds constitute the complex anat-
omy of the auricle as we know it. This seemingly
chaotic arrangement is in harmony and the human
eye is very quick to detect any alterations to it
[ 17 ] . Although most patients are satis fi ed as long
as their ears are less visible than before, an unnat-
ural looking ear will attract more attention than
before, leading to annoying inquiries. Our cur-
rent aim in otoplasty must be further re fi nement
of the surgical technique in order to address fi ner
details such as Stahl’s ear, prominent Darwin’s
tubercle, and lobule prominence.
Disharmony of the lobule with corrected carti-
lage framework of the auricle is one of the com-
mon reasons of an “operated” look. The lateral
surface of the lobule may be facing anteriorly as
part of a cup ear deformity, or the rest of the ear
may be normal as an isolated lobule deformity.
Careful assessment of the lobule position during
preoperative examination of an otoplasty patient
is essential. However, normal lobules may also
become relatively prominent after medialization
of the helix and related structures, leaving the
lobule in place. Therefore one should carefully
reassess the alignment of the lobule with rest of
the auricle after completion of the major steps of
any otoplasty technique. The above-mentioned
condition may result in a secondary lobule defor-
mity if left untouched.
Misalignment of the lobule may result in “tele-
phone ear” or “reverse telephone ear” deformi-
ties. If the lobule is readily movable together with
the cartilage framework, it is possible to correct it
together with no further intervention. However,
such medial movement as a whole is often inad-
equate and further correction of lobule position is
required.
Although earlobes are signi fi cant anatomic
structures with regard to normal facial appear-
ance, there are not many articles addressing this
issue [ 7– 10 ] . Review of the literature shows that
some surgeons prefer skin excisions and others
suggest correction of cartilage framework for
correction of the lobule deformity [ 2 ] .
Gosain prefers suturing of the tail of the helix to
the conchal rim to correct lobule position [ 2, 13 ] .
However, it is sometimes impossible to move the
Y. O. Tiftikcioglu , M.D. (*) • U. Bilkay , M.D.
Department of Plastic, Reconstructive and Aesthetic
Surgery , Ege University Medical School ,
Bornova-Izmir TR-35100 , Turkey
e-mail: drtiftikcioglu@yahoo.com ;
ubilkay@hotmail.com
Electronic supplementary material
The online version of this chapter (doi: 10.1007/978-3-
642-35431-1_46 ) contains supplementary material, which
is available to authorized users.
Prominent Lobule Correction
in Otoplasty: With Step-by-Step
Description of the “Y to V Setback”
Technique
Yigit Ozer Tiftikcioglu and Ufuk Bilkay

494
Y.O. Tiftikcioglu and U. Bilkay
lobule by manipulating the cartilage framework.
On the other hand, buckling of the cartilage
framework may cause unwanted irregularities
elsewhere.
Advocates of skin excision believe that the
prominence of the lobule is caused by skin excess
[ 2 ] . Postauricular skin excision may be extended
inferiorly to provide lobule setback, or a separate
wedge excision from the posterior surface of the
lobule may be performed [ 2, 3 ] . Although it may
sound simple, these excisions are tricky and over-
excision may cause iatrogenic lobule deformities.
It is usually dif fi cult to plan the amount of skin
excision beforehand.
Spira used a single dermomastoid suture to
medialize the lobule [ 2 ] . This is a very useful
trick but necessitates dissection of the mastoid
area that is prone to bleeding and hematoma
formation.
Authors’ Preferred Technique
The preferred technique is Y to V setback of
the lobule. It may be used as the last step of a
routine otoplasty operation or for correction of
isolated or secondary prominent lobule defor-
mities. This technique is simple and easy to
learn. The technique enables manipulation of
the lobule independent from the cartilage
framework. It enables sensitive calibration of
the amount of setback and skin excision. Deep
dissection that may lead to hematoma is unnec-
essary. Step-by-step illustration of the tech-
nique is as follows:
Step 1
In this case a routine otoplasty was fi rst per-
formed with Mustarde conchoscaphal sutures
and Furnas conchomastoid sutures. After the
completion of otoplasty, the lobule is still very
prominent despite proper medialization of carti-
lage framework (Fig. 46.1 ).
Step 2
A horizontal “Y” shape is marked on the poste-
rior surface of the lobule so that the arms of the
“Y” point the lateral edge of the lobule and the
foot points the planned direction of medialization
(Fig. 46.2 ).
Fig. 46.1 A routine otoplasty was fi rst performed with
Mustarde conchoscaphal sutures and Furnas conchomas-
toid sutures. After the completion of otoplasty, the lobule
is still very prominent despite proper medialization of car-
tilage framework
Fig. 46.2 A horizontal “Y” shape is marked on the pos-
terior surface of the lobule so that the arms of the “Y”
point the lateral edge of the lobule and the foot points the
planned direction of medialization

495
46 Prominent Lobule Correction in Otoplasty
Step 3
The “Y”-shaped incision is made. A triangular
skin fl ap is elevated from the area between the
arms of the “Y” (Fig. 46.3 ).
Step 4
The triangular fl ap is advanced medially toward
the mastoid to be anchored to the tip of the foot of
the “Y”-shaped incision. At this stage the new
position of the lobule is checked, and the incision
may be elongated medially if further medializa-
tion is necessary (Fig. 46.4 ).
Step 5
The base of the fl ap is fi xed with 3/0 polypropyl-
ene to the mastoid fascia. Excess skin at the sides
of foot of the y may be excised (Fig. 46.5 ).
a
b
Fig. 46.3 ( a ) The “Y”-shaped incision is made. ( b ) A triangular skin fl ap is elevated from the area between the arms
of the “Y”
Fig. 46.4 The triangular fl ap is advanced medially
toward the mastoid to be anchored to the tip of the foot of
the “Y”-shaped incision. At this stage the new position of
the lobule is checked, and the incision may be elongated
medially if further medialization is necessary
Fig. 46.5 The base of the fl ap is fi xed with 3/0 polypro-
pylene to the mastoid fascia. Excess skin at the sides of
foot of the “Y” may be excised

496
Y.O. Tiftikcioglu and U. Bilkay
Step 6
Remaining skin incisions are sutured with 4/0
polypropylene and the procedure is fi nished
(Fig. 46.6 ).
Conclusions
The procedure is easy to learn and the results
are excellent (Fig. 46.7 ).
Fig. 46.6 The fi nal result after the remaining skin inci-
sions are sutured with 4/0 polypropylene
a
b
Fig. 46.7 ( a ) Preoperative. ( b ) Postoperative

497
46 Prominent Lobule Correction in Otoplasty
References
1. Siegert R. Correction of the lobule. Facial Plast Surg.
2004;20(4):293–8.
2. Gosain AK, Recinos RF. A novel approach to correc-
tion of the prominent lobule during otoplasty. Plast
Reconstr Surg. 2003;112(2):575–83.
3. Ellis DA, Keohane JD. A simpli fi ed approach to oto-
plasty. J Otolaryngol. 1992;21(1):66–9.
4. Schwentner I, Schmutzhard J, Deibl M, Sprinzl GM.
Health-related quality of life outcome of adult
patients after otoplasty. J Craniofac Surg. 2006;
17(4):629–35.
5. Becker DG, Lai SS, Wise JB, Steiger JD. Analysis in
otoplasty. Facial Plast Surg Clin North Am. 2006;
14(2):63–71.
6. Nuara MJ, Mobley SR. Nuances of otoplasty: a com-
prehensive review of the past 20 years. Facial Plast
Surg Clin North Am. 2006;14(2):89–102.
7. Yuen A, Coombs CJ. Reduction otoplasty: correction
of the large or asymmetric ear. Aesthetic Plast Surg.
2006;30(6):675–8.
8. Mattheis S, Siegert R. Techniques in otoplasty. HNO.
2006;54(8):643–52.
9. Bajaj Y, Rokade A, De PR. Otoplasty: experience
with a modi fi cation using a drill, and literature review.
J Laryngol Otol. 2007;121(1):61–4.
10. Emery BE. Otoplasty. Facial Plast Surg Clin North
Am. 2001;9(1):147–57.
11. Sevin K, Sevin A. Otoplasty with Mustarde suture,
cartilage rasping, and scratching. Aesthetic Plast Surg.
2006;30(4):437–41.
12. Gosain AK, Recinos RF. Otoplasty in children less
than four years of age: surgical technique. J Craniofac
Surg. 2002;13(4):505–9.
13. Gomulinski L, Mauduy M, Saterre J. Our experience of oto-
plasty based on the study of the cartilaginous frame, espe-
cially the tail of the helix (about 244 cases and 22 anatomical
dissections). Ann Chir Plast Esthet. 2005;50(3):206–15.
14. Adamson PA, Litner JA. Otoplasty technique. Facial
Plast Surg Clin North Am. 2006;14(2):79–87.
15. Elliott Jr RA. Otoplasty: a combined approach. Clin
Plast Surg. 1990;17(2):373–81.
16. Furnas DW. Correction of prominent ears with multi-
ple sutures. Clin Plast Surg. 1978;5(3):491–5.
17. Bilkay U, Tiftikcioglu YO, Kapi E, Ozek C. Y-to-V
setback for prominent lobule correction in otoplasty.
Ann Plast Surg. 2011;66(6):623–6.

499
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_47, © Springer-Verlag Berlin Heidelberg 2013
47
Introduction
Keloids can develop after injuries, surgical inter-
ventions, or skin piercings at certain predilection
sites, such as neck, shoulders, breast, and ears.
Keloids are benign fi brous proliferations, histo-
logically characterized by excessive deposition
of dermal collagen in a frequently mucinous
matrix, due to increased collagen synthesis in
fi broblasts and decreased collagen degradation
[ 1 ] . Pathophysiologically keloid formation is still
not fully understood. Mitogens like the insulin-
like growth factor (IGF), the vascular endothelial
growth factor (VEGF), and the transforming
growth factor beta (TGF-beta) seem to play a dis-
tinct role in this process [ 2– 4 ] . Foreign-body
reactions, frequently observed after ear piercing,
wound infections, as well as continuous tension
on wounds after surgery or by heavy earrings,
also promote keloid formation. Besides, there
seems to be a genetic disposition for keloid for-
mation in persons with black skin, certain HLA-
types, and blood group A. Keloids may develop
at any age, but young persons are most frequently
affected [ 5 ] . Interestingly, after ear piercing, kel-
oids seem to occur mainly in patients who were
12 or older when the piercing was done [ 6 ] .
Although keloids are benign, they mean a sub-
stantial cosmetic dis fi gurement to the patients,
especially if they occur on the ears, leading to a
reduction of patients’ quality of life. In addition,
they can be itchy and painful. Treatment of ear kel-
oids is still a major challenge. Because of the high
recurrence rates of up to 80 %, surgical removal
should be performed only in combination with
other therapies [ 7 ] . Various postoperative treat-
ments, such as topical silicone gels, intralesional
corticosteroids with or without cryotherapy, radio-
therapy, or compression therapy, may be used [ 5 ] .
Although there is little evidence from controlled
clinical studies, the most promising proceeding
seems to be a combination of therapies [ 8 ] .
Topical application of silicone gel sheets is
intended to soften hypertrophic scars and reduce
pruritus by skin hyperhydration [ 9 ] . For most of
keloid formations, however, this therapy alone is
usually insuf fi cient. Injection of corticosteroids
intralesionally is another common keloid ther-
apy. Corticosteroids reduce collagen synthesis
and increase collagenase activity [ 10 ] . However,
in case of large keloids, particularly those devel-
oping on ears, this therapy is often unsuccessful,
J. C. Hassel , M.D. (*)
Department of Dermatology , National Center
for Tumor Diseases, University Hospital
Heidelberg , Im Neuenheimer Feld 460 ,
Heidelberg 69120 , Germany
e-mail: jessica.hassel@med.uni-heidelberg.de
A. Kreuter
Zahntechnik Alexander Kreuter (Dental Laboratory) ,
Reuenthaler Straße 7 , Weilbach 63937 , Germany
e-mail: alexander.kreuter@gmx.de
A. J. Hassel , M.D.
Department of Prosthodontics , Heidelberg
University Hospital , Im Neuenheimer Feld 400 ,
Heidelberg 69120 , Germany
e-mail: ahassel@gmx.net
Compression Treatment of Ear
Keloids by a Modi fi ed Oyster
Splint Technique
Jessica C. Hassel, Alexander Kreuter,
and Alexander J. Hassel

500
J.C. Hassel et al.
even if combined with cryotherapy [ 11, 12 ] .
Repeated cryosurgery alone may be an effec-
tive therapy of small keloids but often causes
hypopigmentation [ 5 ] . Immediate postoperative
irradiation of ear keloids can be successful [ 13 ] ,
probably by destruction of the fi broblasts. But
since there have been isolated reports of skin
tumor development after keloid irradiation [ 14,
15 ] , this option should be chosen only after care-
ful consideration and failure of other therapies,
especially in children [ 16 ] .
Pressure therapy can be a good postoperative
option [ 17 ] . The pressure applied should exceed
the capillary pressure to generate local hypoxia
which can be seen by blanching of the skin [ 18 ] .
This will reduce tissue metabolism and inhibit
fi broblast proliferation. Compression has also
been shown to increase collagenase activity
and stabilize mast cells, which leads to a reduc-
tion of pruritus. To treat earlobe keloids, a large
variety of compression splints, made of metal
or acrylic or equipped with magnets, have been
developed [ 17, 19, 20 ] . However, the auricle is
dif fi cult to treat by compression because of the
pressure sensitivity of the auricular cartilage.
Here, mainly techniques that are common in
dentistry and dental engineering are used [ 21– 23 ] .
The authors combined a modi fi ed “oyster splint”
technique with intraoperative corticosteroid
injec tion and topical application of a silicone
gel sheet.
Technique
Keloid Excision
To minimize trauma and prevent tension on the
wound, we prefer the shave excision of the keloid if
possible (Fig. 47.1 ). Aim of the excision should be
to restore the shape of the ear, not to excise the
keloid completely [ 24 ] . Shave excision has another
advantage, namely, to avoid sutures which could
promote keloid formation by a foreign-body reac-
tion. To optimize the aesthetic outcome, depending
on the location of the keloid, excision and wound
adaptation with sutures may be needed, however.
After excision we inject triamcinolone acetonide
intralesionally and place a hydrogel bandage on the
wound to promote secondary healing by moist
wound conditions [ 25 ] .
Taking the Impression
Within the fi rst week after surgery, the wound is pro-
tected by an adhesive fi lm dressing (e.g., Hydro fi lm®,
Hartmann), and the ear is isolated with Vaseline. To
protect the ear canal, a foam pellet is inserted. The
impression is then taken with a two-phase, addition-
cured silicone (e.g., Epiform®, Institut Schilling
GmbH). Use of silicones guarantees a detailed
impression and they are easy to remove from the
skin. First, a thin, mobile silicone phase is used to
Fig. 47.1 Operation and silicone impression. ( a ) A 16-year-old girl with ear keloid upon presentation. ( b ) Clinical
fi nding at 3 days postoperatively. ( c ) Silicone impression on ear after creation

501
47 Compression Treatment of Ear Keloids by a Modi fi ed Oyster Splint Technique
obtain a detailed impression, without deformation of
the ear, and covering approximately 1 cm of adja-
cent skin. A more viscous, yet still mobile, compo-
nent is then used to complete the impression. The
layer should be of suf fi cient thickness for stability
(Fig. 47.1 ). While taking the impression, it is impor-
tant to avoid air bubbles, to obtain an exact negative
model of the ear. After setting of the silicone, it can
be easily removed from the ear. The wound is cov-
ered with a silicone gel sheet (e.g., Cica-Care®,
Smith and Nephew) and fi xed with a bandage [ 25 ] .
Fabrication of the Oyster Splint
The silicone impression is given to a dental labo-
ratory to fabricate an accurate, true-to-scale stone
model. On this model the “oyster splint,” an
acrylic resin splint consisting of two shells, is
made. The splint is provided with nylon or metal
screws to be able to adjust the pressure exerted on
the patient’s ear. A detailed description of the
splint fabrication technique has been published
[ 26 ] . To obtain a good functional compressive
device, it is important to communicate with the
dental laboratory and give an exact drawing on
the parts of the ear which have to be covered. The
oyster shells cover the part of the ear which was
previously affected by the keloid, avoiding the
ear opening. Use of transparent acrylate enables
close observation of the underlying skin. If
desired, decorative features can be incorporated
[ 25 ] . With this technique very individual splints
are made (Fig. 47.2 ).
Fig. 47.2 Individual splints depending on ear shape and keloid location

502
J.C. Hassel et al.
Adjustment of the Oyster Splint
The pressure generated by the oyster splint is
adjusted in such a way that the underlying skin
turns pale, i.e., anemic, but the splint is not pain-
ful to wear. The method proposed by Mercer and
Studd [ 22 ] was modi fi ed in so far as a silicone gel
sheet is applied between the wound and the splint,
to protect the fresh wound or hydrate the fresh scar
and increase patient comfort. The splint should be
worn 23 h a day. It is recommended to remove
the splint for 1 h a day to enable care of the skin
and cleaning of the device. During the fi rst week,
the patient’s ear should be examined for pressure
lesions. If necessary, the respective splint areas are
abraded. If pressure seems to be too low (loosen-
ing of the splint, no blanching of the underlying
skin), acrylic material can be added to the region
of the splint corresponding to the keloid.
The duration of compressive therapy should at
least be 6–12 months. If patients are wearing the
splint regularly, no additional therapy is needed.
However, a wearing time of less than 20 h a day –
caused by incompliance or problems getting the
splint on – is not enough to prevent keloid forma-
tion [ 27 ] . Then additional steroid injections into
the developing keloid can be given to have time to
solve the problem. Treatment cannot be stopped
until there is no longer any activity in the scar.
Follow-Up of Patients
A group of 23 patients with a follow-up of at least
6 months have been treated with this technique
by the authors from 2007 to 2012. The fi rst
important step to be successful with this treat-
ment is to take time for detailed information
about treatment options, the elaborateness of this
method, and the importance of absolute compli-
ance to make sure that only very motivated
patients decide to take this treatment. Otherwise
compliance and success will be poor. Despite this
proceeding, six of the patients decided not to
wear the splint after fabrication and did not return
for recall visits. The median age of the 17 remain-
ing patients was 18 years at operation (age range –
14–37 years); 82.4 % of them were female
(Table 47.1 ). Two patients were not able to fi x the
splint properly to the ear and therapy had there-
fore to be stopped; both of them got a recurrence
(Table 47.1 ). Thus, 15 patients were treated with
Table 47.1 Patient follow-up (FU)
ID
Location of ear keloid
Duration of therapy
(months)
Compliance
Recurrence
FU/time of recurrence
(months)
1
Back of right ear
24
+
No
72
Top of left ear
12
+
No
26 (Fig. 47.3 )
2
Right lobulus
0
−
Yes
5
3
Right helix (3 in row)
22
−
Yes
24
4
Both lobuli
11
+
No
49
5
Right lobulus
0
−
Yes
8
6
Right lobulus
12
+
No
37
7
Right lobulus
24
−
Yes
25
8
Left lobulus
24
−
Yes
26
9
Left lobulus
24
−
Yes
25
10
Right lobules
3
−
Yes
3 (Fig. 47.4 )
11
Right lobulus
12
+
No
31 (Fig. 47.3 )
12
Right lobulus
>15
+
No
15
13
Right lobulus
>6
+
No
6
14
Left lobulus
>7
+
No
7
15
Left lobulus
2
−
Yes
4
16
Left lobulus
>13
−
Partially
13
17
Right lobulus
>7
+
No
7

503
47 Compression Treatment of Ear Keloids by a Modi fi ed Oyster Splint Technique
this pressure device. However, of those, only half
were compliant in wearing the splints for the sup-
posed times; the other half stopped therapy too
early or wore the splint in a kind of “on and off
strategy,” only applying the splint when they felt
the keloid started to develop again. This explains
times of 2 years followed by a recurrence; the
scar never had time to settle down. Importantly,
the incompliance of patients was never based on
pain during wearing [ 27 ] but on the elaborateness
of the method being always reminded of their
keloid. Of six patients with recurrences, four
decided not to do any treatment at that time. Two
patients were referred to radiation oncologists
because they had multiple local treatments
already before the pressure device was made and
felt not to be able to achieve compliance. They
received 20 Gy (6-MeV electrons, 5 × 4 Gy) to
the keloid area immediately after reexcision of
the keloid. However, even with this treatment, the
keloid recurred a few months after irradiation.
Some of the patients had additional corticos-
teroid injections into the developing keloid. But,
according to our experience, this should be lim-
ited to give the patient a second chance for com-
pliance when he realizes that the keloid will
de fi nitely recur. Otherwise it just prolongs time
for de fi nite recurrence. Our experience shows
that success of this treatment depends strongly on
compliance. By patient questionnaires we found
out that to prevent the keloid formation, the splint
has to be worn every day for at least 20 h for
between 6 and 12 months [ 27 ] . Prolongation of
therapy was always based on initial incompliance
or problems to get the splint on. However, patients
who managed to wear the splint appropriately
were very happy about the cosmetic outcome
(Fig. 47.3 ) [ 28 ] ; most of them had several unsuc-
cessful treatments before.
Discussion
Ear keloids continue to be a therapeutic chal-
lenge. The compression treatment by this
modi fi ed oyster splint technique can be a very
successful method to prevent the recurrence of
ear keloids after surgical removal. However, it
has to be taken into account that the duration of
this therapy is long and its success largely depends
on the daily wearing time of the splint, i.e., on
patient compliance. Of course patients in addi-
tion have to have a certain manual dexterity in
handling the splint screws. Putting the splint
together with magnets might be easier but would
not assure pressure adjustment. Figure 47.4
shows how the pressure is responsible for keloid
prevention. This 16-year-old girl had a recurrence
of the keloid just in an area where the splint did
not cover the scar suf fi ciently. Regular follow-up
examinations, allowing the clinician to check,
among other factors, whether or not the patient
properly applies the splint, are indispensable to
this treatment. However, only one of ten patients
considered the effort involved in this therapy
unjusti fi able [ 27 ] .
As compliance is so important, it appears sen-
sible to carefully select the patients for this ther-
apy and inform them about the effort involved, in
order to prevent a course of treatment that would
be frustrating for both patient and clinician. High
patient motivation is the basic prerequisite for a
successful treatment and for satisfaction with
both the method and the result. This technique
can easily be combined not only with the use of
silicone gel sheets but also with other therapy
options, such as intralesional injection of ste-
roids. This combination, however, was necessary
mainly in those patients who did not wear their
splints for more than 20 h/day [ 27 ] . If compli-
ance did not improve, it was not able to prevent
keloid formation.
Most of the patients had already undergone
several other therapies, including surgery, intral-
esional corticosteroid injection, and/or cryother-
apy. None of these therapies had prevented their
ear keloids from recurring, which suggests that
these ear keloid treatments may not be successful
without any compression therapy. Postoperative
irradiation is described to be successful with a
relapse rate of 16 % after 5 years [ 13 ] . The two
patients referred for radiation therapy suffered a
recurrence. However, they received fractionized
radiotherapy with doses of fi ve times 4 Gy instead
of a single 10-Gy dose 24 h after excision. But, in
our opinion radiation therapy should only be the

504
J.C. Hassel et al.
Fig. 47.4 Case of recurrence: ( a ) A 16-year-old girl at
presentation. ( b ) Three days after operation. ( c ) Wearing
the splint. ( d ) Three months later with a recurrence where
the splint did not cover suf fi ciently. This case demon-
strates how important suf fi cient pressure is to prevent a
recurrence
Fig. 47.3 Outcome of patients: ( top ) An 18-year-old man at presentation ( a ), wearing the splint ( b ), and 2 years after
operation ( c ). ( Bottom ) A 22-year-old woman at presentation ( d ), wearing the splint ( e ), and 2 years after operation ( f )

505
47 Compression Treatment of Ear Keloids by a Modi fi ed Oyster Splint Technique
last resort when treating ear keloid patients, who
are usually very young, because it may involve
the risk of causing skin cancer [ 14, 15 ] .
Conclusions
Although it requires considerable time and
effort, the modi fi ed oyster splint technique
seems to be a promising keloid therapy with
only minimal side effects. However, it is not
suitable for any patient. The keloids have to be
limited to the ears, i.e., a region on which
pressure can be exerted by the compression
splint, and the patients have to be highly com-
pliant and show a certain manual dexterity in
applying the splint.
References
1. Abergel RP, Pizurro D, Meeker CA, Lask G, Matsuoka
LY, Minor RR, et al. Biochemical composition of the
connective tissue in keloids and analysis of collagen
metabolism in keloid fi broblast cultures. J Invest
Dermatol. 1985;84(5):384–90.
2. Phan TT, Lim IJ, Bay BH, Qi R, Longaker MT, Lee
ST, et al. Role of IGF system of mitogens in the
induction of fi broblast proliferation by keloid-derived
keratinocytes in vitro. Am J Physiol Cell Physiol.
2003;284(4):C860–9.
3. Le AD, Zhang Q, Wu Y, Messadi DV, Akhondzadeh
A, Nguyen AL, et al. Elevated vascular endothelial
growth factor in keloids: relevance to tissue fi brosis.
Cells Tissues Organs. 2004;176(1–3):87–94.
4. Liu W, Wang DR, Cao YL. TGF-beta: a fi brotic factor
in wound scarring and a potential target for anti-scar-
ring gene therapy. Curr Gene Ther. 2004;4(1):123–36.
5. Olabanji JK, Onayemi O, Olasode OA, Lawal OA.
Keloids: an old problem still searching for a solution.
Surg Pract. 2005;9:2–7.
6. Mall JW, Pollmann C, Müller JM, Büttemeyer R.
Keloidbildung des Ohrläppchens nach Ohrlochstechen.
Chirurg. 2002;73(5):514–6.
7. Berman B, Bieley HC. Adjunct therapies to surgical
management of keloids. Dermatol Surg. 1996;22(2):
126–30.
8. Hackert I, Aschoff R, Sebastian G. The treatment of
keloids. Hautarzt. 2003;54(10):1003–15.
9. Gold MH, Foster TD, Adair MA, Burlison K, Lewis
T. Prevention of hypertrophic scars and keloids by the
prophylactic use of topical silicone gel sheets follow-
ing a surgical procedure in an of fi ce setting. Dermatol
Surg. 2001;27(7):641–4.
10. Diegelmann RF, Bryant CP, Cohen IK. Tissue alpha
globulins in keloid formation. Plast Reconstr Surg.
1977;59(3):418–23.
11. Grif fi th B, Monroe CW, McKinney P. A follow-up
study on the treatment of keloids with triamcinolone
acetonide. Plast Reconstr Surg. 1970;46(2):145–50.
12. Sclafani AP, Gordon L, Chadha M, Romo 3rd T.
Prevention of earlobe keloid recurrence with postop-
erative corticosteroid injections versus radiation ther-
apy: a randomized, prospective study and review of
the literature. Dermatol Surg. 1996;22(6):569–74.
13. Ragoowansi R, Cornes PG, Glees JP, Powell BW,
Moss AL. Ear-lobe keloids: treatment by a protocol
of surgical excision and immediate postoperative
adjuvant radiotherapy. Br J Plast Surg. 2001;54(6):
505–7.
14. Botwood N, Lewanski C, Lowdell C. The risks of treat-
ing keloids with radiotherapy. Br J Radiol. 1999;72(864):
1222–4.
15. Epstein R, Hanham I, Dale R. Radiotherapy induced
second cancers: are we doing enough to protect young
patients? Eur J Cancer. 1997;33(4):526–30.
16. Saladi RN, Persoud AN. The causes of skin cancer: a
comprehensive review. Drugs Today (Barc). 2005;41(1):
37–53.
17. Brent B. The role of pressure therapy in management
of earlobe keloids: preliminary report of a controlled
study. Ann Plast Surg. 1978;1(6):579–81.
18. Rockwell WB, Cohen EK, Ehrlich HP. Keloids and
hypertrophic scars: a comprehensive review. Plast
Reconstr Surg. 1989;84(5):827–37.
19. Chang CH, Song JY, Park JH, Seo SW. The ef fi cacy
of magnetic disks for the treatment of earlobe hyper-
trophic scar. Ann Plast Surg. 2005;54(5):566–9.
20. Snyder GB. Button compression for keloids of the
lobule. Br J Plast Surg. 1974;27(2):186–7.
21. Sela M, Taicher S. Prosthetic treatment of earlobe
keloids. J Prosthet Dent. 1984;52(3):417–8.
22. Mercer DM, Studd DM. “Oyster splint”: a new com-
pression device for the treatment of keloid scars of the
ear. Br J Plast Surg. 1983;36(1):75–8.
23. Bahmer FA, Scheicher S, Zilz W. Treatment of earlobe
keloids by the “oyster-splint technique” according to
Mercer and Studd. Akt Dermatol. 1993;19:64–6.
24. Cosman B, Wolff M. Correlation of keloid recurrence
with completeness of local excision. Plast Reconstr
Surg. 1972;50(2):163–6.
25. Hassel JC, Löser C, Voigtländer V, Rammelsberg P,
Hassel AJ. Treatment of ear keloids by the oyster
splint technique. Cosmet Med. 2007;6:269–73. No
additional issue number.
26. Kreuter A, Hassel JC, Voigtländer V, Rammelsberg P,
Hassel AJ. Interdisziplinäre Behandlung von Ohrkeloiden –
die “Austernschalentechnik”. Quintessenz Zahntech. 2006;
32(4):394–8.
27. Hassel JC, Löser C, Koenen W, Kreuter A, Hassel AJ.
Promising results from a pilot study on compression
treatment of ear keloids. J Cutan Med Surg. 2011;15(3):
130–6.
28. Hassel JC, Roberg B, Kreuter A, Voigtländer V,
Rammelsberg P, Hassel AJ. Treatment of ear keloids
by compression, using a modi fi ed oyster splint technique –
a case report. Dermatol Surg. 2007;33(2):208–12.

Part IV
Postoperative

509
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_48, © Springer-Verlag Berlin Heidelberg 2013
48
Introduction
Otoplasty is a commonly performed operation in
plastic surgery. The obvious goal of cosmetic sur-
gery of prominent ears is to normalize the shape and
position of both ears with maximal symmetry [ 1 ] .
Usually both ears have to undergo a surgical proce-
dure, but sometimes, a unilateral procedure is per-
formed. In general, otoplasty surgery patients are
children; however, in the authors’ department, most
patients are adults. It is technically dif fi cult to apply
a postoperative dressing because of its tendency to
slip. The dressings for adults are different than those
for children. An attractive appearance in public and
for the possibility of returning to work is important.
The aim of the dressing is to maintain the desired
shape and position postoperatively. Another goal is
to prevent hematoma or loosening of the dressing.
Classic otoplasty dressings have been described as
variants on a cotton wool pad placed over either a
dry dressing or a Vaseline gauze securing each ear
in position. Usually an elastic bandage is bonded
around the head. Problems and complications of
postoperative ear dressings are loosening, especially
during the night; postoperative discomfort; and even
skin necrosis because of the wrapping being too
tight [ 2– 6 ] .
Technique
After the surgical procedure, the authors use the
cyanoacrylate tissue adhesives for closing the skin.
It is necessary to clean the wound thoroughly and
then apply the bonding in thin layers with a light,
brushing stroke while holding the edges of the
wound together. After that, we fi xate the concha at
the mastoid also using the bonding (Fig. 48.1 ). It is
V. Wedler , M.D. (*)
Department of Plastic, Reconstructive and Aesthetic
Surgery , Kantonsspital Frauenfeld/Münsterlingen ,
Waldeckstrasse, Frauenfeld CH-8500 , Switzerland
e-mail: volker.wedler@stgag.ch , info@wedler.ch
M. Vetter , M.D.
Department of Plastic, Reconstructive and Aesthetic
Surgery , Kantonsspital Frauenfeld , Pfaffenholzstrasse 4 ,
Frauenfeld 8501 , Switzerland
e-mail: dr.miriam.vetter@web.de
M. Foehn , M.D.
Department of Plastic and Hand Surgery ,
University Hospital Centre Freiburg ,
Hugstetter Strasse 55 , Freiburg im.
Breisgau D-79106 , Germany
e-mail: matthias.foehn@uniklinik-freiburg.de
A New Postoperative Otoplasty
Dressing Technique Using
Cyanoacrylate Tissue Adhesives
Volker Wedler, Miriam Vetter, and Matthias Foehn
Fig. 48.1 Fixing the concha with adhesive at the mastoid

510
V. Wedler et al.
essential to press the concha to the head area until
the liquid adhesive is dried (Fig. 48.2 ). Then a fl at
piece of cotton wool pad and a piece of adhesive
tape or plaster in the required size is placed over the
ear. This causes compression to avoid postoperative
hematomas. No huge dressing is needed, and no
around the head taping is necessary (Fig. 48.3 ).
Four to 6 days after the surgical procedure, we
remove the plaster or cotton wool pad. The bonding
scab usually is removed after 10–14 days, some-
times earlier.
Discussion
This otoplasty dressing technique is simple, eco-
nomical, and very convenient and comfortable for
the patients. There are no further costs because of
the use of the cyanoacrylate tissue adhesive that is
used for skin closure in the same surgical proce-
dure. The cyanoacrylate tissue adhesive is a liquid
bonding agent that holds many cuts, wounds, and
incisions together as effectively as sutures [ 7, 8 ] . It
is especially desirable for the sensitive skin of the
face [ 9 ] . It is waterproof, so patients can shower
immediately after removing the plaster [ 9 ] . We
have not noticed any allergic reaction after using
the bonding. In case of emergency or if examina-
tion is required, it can be easily removed. It is rare
to not be possible to apply the tissue adhesive, even
in very hairy patients with deep hairlines.
References
1. Aygit AC. Molding the ears after anterior scoring and con-
cha repositioning: a combined approach for protruding ear
correction. Aesthetic Plast Surg. 2003;27(1):77–81.
2. Bartley J. How long should ears be bandaged after oto-
plasty? J Laryngol Otol. 1998;112(6):531–2.
3. Bhatti AF, Chapman TW, Orlando A. Practical tips for
otoplasty. Plast Reconstr Surg. 2006;117(1):329–30.
4. Krupp S, Asse N’Dri H. Otoplasty without a conformer
dressing. Ann Plast Surg. 1991;26(4):407–12.
5. McIntire MR, Morgan RF, Kenney JG, Edgerton MT.
Postoperative protection for the external ear. Ann Plast
Surg. 1983;11(3):261–2.
6. Simo R, Jones NS. Head bandaging following otoplasty—
how we do it. J Laryngol Otol. 1994;108(5):410–2.
7. Shapiro AJ, Dinsmore RC, North Jr JH. Tensile strength
of wound closure with cyanoacrylate glue. Am Surg.
2001;67(11):1113–5.
8. Toriumi DM, O’Grady K, Desai D, Bagal A. Use of
octy-2-cyanoacrylate for skin closure in facial
plastic surgery. Plast Reconstr Surg. 1998;102(6):
2209–19.
9. Maw JL, Quinn JV, Wells GA, Ducic Y, Odell PF, Lamothe
A, et al. A prospective comparison of octylcyanoacrylate
tissue adhesive and suture for the closure of head and neck
incisions. J Otolaryngol. 1997;26(1):26–30.
Fig. 48.2 Pressing the concha to the head area until the
liquid adhesive is dried
Fig. 48.3 Plaster in the required size is placed over the
ear

511
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_49, © Springer-Verlag Berlin Heidelberg 2013
49
Background and Rationale
Whatever the otoplasty technique followed,
surgeons usually advocate or even necessitate
applying a well-molded padded head bandage
following otoplasty [ 1, 2 ] . However, the purpose
of postoperative head bandage is controversial,
and many have persuasively argued against their
use. Suggested bene fi ts [ 3– 8 ] included hema-
toma prevention and absorption of blood trick-
ling, splinting, and protection:
1. Prevention of hematoma, reduction of postop-
erative bleeding, and absorption of blood trick-
ling [ 1, 6, 9 ] . Hematoma is one of the most
feared sequelae in the early phase of postop-
erative period [ 10 ] . The usual culprits leading
to this complication are insuf fi cient intraop-
erative hemostasis or other errors in surgical
technique. Less commonly, rebound vasodi-
latation from local anesthetics, hypertension,
preexisting coagulopathy, and postoperative
trauma can be involved [ 10, 11 ] . There is no
evidence to support the view that the head
dressing has a hemostatic role [ 12 ] , and some
feel that a head bandage could not be tied so
tight as to prevent hematoma without causing
a pressure sore to the forehead or pinna [ 13 ] .
Previous studies suggested no increase in the
incidence of hematoma when head dressings
were not used [ 1, 6, 13, 14 ] .
Postoperative bleeding is a warning sign
for possible hematoma. Indeed, both share the
same etiology. Again, it has to be also noted as
a general surgical principle that early postop-
erative bleeding is prevented by meticulous
intraoperative hemostasis and not by dressings
[ 6 ] . Bleeding is classi fi ed as such signi fi cant, if
it necessitates a bandage change [ 10 ] or return
to the hospital for advice [ 1 ] . Studies in which
head bandages were not used did not report
comparatively higher incidence of signi fi cant
postoperative bleeding [ 1, 6, 13, 14 ] . Powell
[ 1 ] stated that the padded bandage absorbs any
trickle of blood and the patient might inconve-
niently return to hospital with a minor bleed-
ing. However, the majority of his patients
managed to mop this satisfactorily with a tis-
sue, and if the parents and patients are warned
and reassured at the time of discharge, this
problem would not be serious.
2. Splinting and help to mold the newly shaped
ear [ 7, 9, 15 ] . Interestingly, it was Stenstrom
[ 3 ] himself who alluded to the fact that no
special care needs to be taken to consolidate
or preserve the shape and position of the ears.
In Powell study [ 1 ] as well as recent studies
[ 6, 13, 14 ] , there were no reported increase
in early recurrence of ear prominence where
no head bandage was used and regardless of
the technique used, i.e., suture or cartilage
sculpting techniques. The follow-up in most
of these studies was too short to comment
A. A. Orabi , M.D., MSc, FRCSEd (Oto), FRCSEd
(ORL-HNS)
Director, Otolaryngology-Head and Neck Surgery ,
Anas Consultancy Ltd for Specialized Medical Services ,
2 Thistle close , NR5 9HR, Norwich , United Kingdom
e-mail: aaorabi@doctors.org.uk
Head Bandage After Otoplasty
Ahmad A. Orabi

512
A.A. Orabi
on late recurrences or long-term satisfaction.
However, in one quasi-randomized controlled
study [ 13 ] , there was no difference in long-
term satisfaction scores (median: 38 months).
Therefore, some doubt is casted on the sug-
gestion that a head bandage promotes the con-
touring of the re-draped skin, and it is stated if
the result achieved at surgery is good, it will
remain so. Furthermore, wound strength is still
minimal after a week, and healing takes at least
6 weeks before scarring has matured enough. If
the bandage does act as a splint, then it should
be kept on for up to 6 weeks [ 16 ] .
3. Protection of the ear from potential injury in
the immediate postoperative period, thereby
preventing early recurrence [ 1, 12 ] . However,
using a removable elastic sports headband or
crepe bandage especially at night for
3–8 weeks to prevent inadvertent folding of
the ear was suggested [ 1, 12, 14, 17– 20 ] .
Shokrollahi and Tanner [ 21 ] described how
the ears do not require extra protection dur-
ing the initial postoperative period, thus
negating the need to have the traditional head
bandage. In at least 3 of the – no head ban-
dage – studies [ 6, 13, 14 ] , none of their
patients was reported to suffer postoperative
injury to the pinna. The ears are usually sen-
sitive and uncomfortable postoperatively if
manipulated and therefore likely to provide
suf fi cient disincentive to patients tempted to
touch them or allow siblings pulling at them
[ 6, 14 ] . It does appear that using a head ban-
dage for the protection of the ear has been
overestimated.
Types of Head Dressings/
Bandages (Fig. 49.1 )
The type of head bandage used depends on sur-
geon’s choice. It may be fl uff gauze supportive
dressing with a circumferential gauze [ 22 ] or
crepe bandage, a silicone foam ear dressing with
a protector [ 23 ] , a custom-made ear guard con-
structed with Orthoplast sheet and leather straps
[ 24 ] , a wrestling head gear [ 2 ] , or kraft paper [ 3 ] .
The presence of different types of head dressings
indicates that no single type has been found
universally ideal. Some are considerably more
complicated and dif fi cult to apply or dif fi cult to
remove and reapply if needs be, and some are
uncomfortable to wear at night especially in hot
weather. On the other hand, some can slip off eas-
ily and may allow the ear to be folded in an unfa-
vorable position during sleep [ 2 ] .
Duration of Head Bandage
Application
Stenstrom [ 3 ] stated that early removal of dressing
did not endanger the surgical outcome. Reported
duration of head bandage application varies from a
few hours to 10 days [ 1, 11, 18, 19, 25, 26 ] and
even 2 weeks [ 20 ] following surgery followed by a
further period of night protection for a variable
length of time up to 6 months [ 12 ] . The duration
for which they are applied depends on the set pro-
tocol in an institution or the personal preference of
the surgeon [ 12 ] . Bartley [ 16 ] suggested the use of
a head bandage for no more than 24 h. Ramkumar
et al. [ 12 ] study, limited to 2 months follow-up,
showed no bene fi t from the application of a formal
head bandage for any longer than 1 day.
Possible Problems and Complications
Use of head bandage itself can lead to many
complications:
1. Slippage and frequent need to re-bandaging
[ 17 ] . This is the most frequently encountered
problem [ 16, 17, 23, 27, 28 ] (ranging from
40 to 67 % within a week of the operation),
and in many cases, it would appear to migrate
placing unexpected tensions on the ear [ 16 ] .
This can be troublesome leading to recur-
rent visits to hospital, inconvenience, and
distress. Furthermore, in one audit [ 28 ] , ban-
dage redressing was found to correlate heav-
ily to a higher complication rate although it
was dif fi cult to ascertain the unidirectionality
of such correlation. Various modi fi cations to
the technique and type of head bandaging and
some tips have been suggested to reduce such
slippage particularly at night [ 29, 30 ] , but
none has been substantiated.

513
49 Head Bandage After Otoplasty
2. Pressure necrosis of the anterior skin and car-
tilage of the pinna and skin of forehead [ 1, 10,
14 ] . It is the result of obstruction of the venous
circulation in the subdermal plexus caused by
excessive pressure from inappropriately tight
dressings [ 10 ] . Necrosis can also occur sec-
ondary to an expanding hematoma or infec-
tion as well as technical errors such as excess
diathermy. Anterior cartilage scoring tech-
niques pose a particular danger as anterior dis-
section can cause anterior hematoma, which
in turn may lead to anterior skin necrosis fol-
lowed by chondritis and eventually resulting
in permanent cartilage irregularities. Further
factors include the potential development of a
sharp antihelical fold as well as excessive dia-
thermy on the undersurface of the anterior
skin resulting in a compromise of what is
already thin fragile skin [ 10, 15 ] .
3. Potential
for
obscuring
early
recogni-
tion of complications such as infection and
hematoma.
4. Conductive deafness due to packing of the ear
with pro fl avin or cotton wool blocking the
external auditory meatus [ 6, 12 ] .
5. Postoperative nausea and vomiting from pack-
ing of the concha [ 6, 12, 14, 31 ] by stimulat-
ing a branch of the vagus supplying the concha
and the posterior wall of the external auditory
meatus (Arnold’s nerve).
6. Smell of coagulated blood in the hair [ 16 ] .
7. Discomfort and itching due to sweating pro-
voking an attempt to scratch the ear under the
dressings [ 6 , 12 ].
8. Health economic-related issues such as increase
theater time, reduced cost-effectiveness for
both hospital and parents/patients that is associ-
ated with unscheduled related visits, as well as
Fig. 49.1 Examples of Head
dressings: Top : Silicone foam
mould secured in the ear
protector ( left ) and the ear
protector ( right ) [ 23 ].
Bottom : Westling head gear
device showing the
cup-shaped protective
aluminum supports [ 2 ]

514
A.A. Orabi
increased return time to normal activity [ 16, 17,
28 ] . Patients are more willing to return to work
or school if they do not have embarrassing head
dressings on [ 6 ] .
Some of these problems are considered trivial
and are usually not mentioned in the patient
record. However, they can cause signi fi cant prob-
lems and embarrassment to patients [ 1, 16 ] .
Practical disadvantages might therefore outweigh
the theoretical advantages of head bandage.
Alternatives to Head Dressings
and Bandages
Alternative methods have been introduced to
avoid the use of the head bandage such as use of
tulle gras [ 1 ] , Steri-Strips [ 6 ] , and 2-octyl-
cyanoacrylate (Dermabond®, Ethicon, Inc.,
Somerville, NJ) skin adhesive [ 9, 14, 21 ] . The
advantages of the latter besides comfort and accept-
ability include the ability to form a sealed, fl exible
membrane with antimicrobial properties over the
incision and strong adherence to skin edges provid-
ing additional support [ 14 ] . It can be used for skin
closure [ 9, 14, 21, 32 ] and as a glue dressing to hold
back the posterior pinna against the postauricular
mastoid area [ 9, 21, 32 ] . There were no complica-
tions attributable to such use of current tissue glues
with longer chain molecule [ 15 ] .
Level of Evidence
Advocates for using head bandages following
otoplasty claim theoretical bene fi ts that have
never been substantiated. The level of evidence
in studies arguing against its use is not high
either. Powell [ 1 ] using the anterior scoring
technique in his prospective study suggested
that a postoperative padded head dressing is not
required in a well-motivated patient. However,
he considered all his patients as homogenous
non-head bandage group despite using a head
protective bandage in 33 out of 40 patients for
a varying duration ranging from the period
of recovery from general anesthesia to the
next postoperative day. Furthermore, he fol-
lowed up his patients for 30 days only. Orabi
et al. [ 13 ] in their quasi-randomized controlled
study concluded that patients’ satisfaction and
complications following otoplasty were not
in fl uenced by omitting head bandage use, par-
ticularly when cartilage plication technique
was used. Wong and Sylaidis [ 6 ] in a prospec-
tive study using posterior cartilage scoring
and/or posterior suture conchoplasty found no
increased risk of hematoma or of early recur-
rence in their patients where they used a single
Steri-Strip only to dress the wound. They have
used, however, historical controls from other
studies. Bovill et al. [ 14 ] retrospective com-
parative study using modi fi ed Mustarde tech-
nique has the same conclusion. However, their
Dermabond group still used a headband for 24 h
a day for the fi rst week and then at night for the
subsequent week; therefore, it was not purely
a non-head bandage group. The follow-up for
these studies was variable and ranged from 1 to
38 months.
Recommendations for Future Studies
Therefore, there remains a need for large pro-
spective single-blinded randomized controlled
structured trials with large comparative sample
size where a head bandage is not used. Study
designs with self-controls are particularly rele-
vant here. The outcome measures should include
the long-term satisfaction and objective cosmetic
measurements (e.g., using McDowell’s basic
goals of otoplasty [ 33 ] ), complications (includ-
ing delayed), as well as unscheduled visits. The
trials should ideally include strati fi cation for dif-
ferent operative techniques as well as degree and
type of deformity. Limandjaja et al. [ 10 ] also
recommended, when calculating complication
incidence, a minimum follow-up period of
2 years, considering each operated ear as an inde-
pendent variable and only including bilateral
primary procedures.

515
49 Head Bandage After Otoplasty
References
1. Powell BW. The value of head dressings in the post-
operative management of the prominent ear. Br J Plast
Surg. 1989;42(6):692–4.
2. McIntire MR. Postoperative protection for the exter-
nal ear. Ann Plast Surg. 1983;11(3):261–2.
3. Stenstrom SJ, McIntire MR, Morgan RF, Kenney JG,
Edgerton MT. A simple operation for prominent ears.
Acta Otolaryngol. 1967;63(S224):393–402.
4. Mustarde JC. The correction of prominent ears using
simple mattress sutures. Br J Plast Surg. 1963;16:170–8.
5. Stark RB. Otoplasty. Aesthetic plastic surgery. 1st ed.
Boston: Little and Brown; 1980. p. 345–61.
6. Wong MC, Sylaidis P. Head dressings for pinnaplasty:
a tradition not supported by evidence. Br J Plast Surg.
2001;54(1):81–2.
7. Georgiade GS, Riefkohl R, Georgiade NG. Prominent
ears and their correction: a forty-year experience.
Aesthetic Plast Surg. 1995;19(5):439–43.
8. Spira M. Otoplasty: what I do now- a 30-year perspec-
tive. Plast Reconstr Surg. 1999;104(3):834–40.
9. Vetter M, Foehn M, Wedler V. A new postoperative
otoplasty dressing technique using cyanoacrylate
tissue adhesives. Aesthetic Plast Surg. 2010;34(2):
212–3.
10. Limandjaja GC, Breugem CC, Mink van der Molen AB,
Kon M. Complications of otoplasty: a literature review.
J Plast Reconstr Aesthet Surg. 2009;62(1):19–27.
11. Adamson PA, McGraw BL, Tropper GJ. Otoplasty:
critical review of clinical results. Laryngoscope.
1991;101(8):883–8.
12. Ramkumar S, Narayanan V, Laing JH. Twenty-four
hours or 10 days? A prospective randomised con-
trolled trial in children comparing head bandages fol-
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DOI 10.1007/978-3-642-35431-1_50, © Springer-Verlag Berlin Heidelberg 2013
50
Introduction
As our understanding of the healing process
evolves, we continue to search for the optimal
dressing to apply in the immediate postoperative
setting. The recent utilization of occlusive dress-
ings has improved results of some facial plastic
surgery procedures such as facial laser resurfac-
ing [ 1 ] . Dermatologists have found a signi fi cant
reduction in pain, erythema, and edema with the
use of silicone occlusive dressings [ 2 ] . The curves
and contours of the ear, however, present a unique
obstacle and preclude application of most occlu-
sive dressings. A malleable silicone-based occlu-
sive dressing has many properties that make it a
superior postoperative dressing in otoplasty, as
will be discussed in this chapter.
There are several requirements that must be
considered in choosing an appropriate otoplasty
dressing. In any surgical procedure, the dressing
must keep the wound clean, as protection from
bacteria decreases the risk of infection and promotes
healing. Secondly, surgical dressings that main-
tain a moist environment increase the rate of epi-
thelialization by preventing wound desiccation
and subsequent necrosis [ 3, 4 ] . Furthermore, it is
important that the dressing provides protection
from physical trauma. A physical barrier will help
prevent alteration of the cosmetic results achieved
by the surgeon’s meticulous work. Without ade-
quate protection, the surgical site risks distortion
from a postsurgical hematoma, increased scarring
from trauma-induced in fl ammation, disruption of
the suture line, or necrosis caused by trauma to
the auricular vascular supply.
The traditional non-occlusive dressing, con-
sisting of a plastic hard cup with a padded base
(Glasscock, Otomed, Lake Havasu City, AZ), pro-
vides protection from trauma but does not ade-
quately meet the aforementioned requirements of
an effective otoplasty dressing. The nonremov-
able, customized occlusive dressing is a superior
protective barrier as compared to the Glasscock
and also enhances healing by maintaining a moist,
virtually bacteria-free environment.
A silicone-based occlusive dressing (Diamond
Seal, Snowden-Pencer, Genzyme Biosurgery,
Cambridge, MA) has proven to be an excellent
option for otoplasty with no documented dress-
ing-related complications [ 5 ] . It is composed
of nontoxic semitransparent silicone, which
solidi fi es when mixed with the enzymatic cata-
lyst. This easily moldable dressing takes approxi-
mately 5–10 min to solidify after the catalyst is
introduced. The silicone dressing presents several
bene fi ts to the patient and surgeon and should be
J. K. Frankel , M.D.
Department of Otolaryngology ,
University Hospitals, Case Western
Medical Center , Cleveland , OH 44106 , USA
e-mail: jkfrankel@gmail.com
D. C. Ponsky , M.D. (*)
Department of Otolaryngology-Facial Plastic
and Reconstructive Surgery , University Hospitals,
Case Medical Center , 11100 Euclid Avenue,
Mailstop LK5045 , Cleveland , OH 44106 , USA
e-mail: dianaponsky@yahoo.com
Postoperative Care Using
a Silicone-Based Occlusive Dressing
Jonathan K. Frankel and Diana C. Ponsky