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

519
50 Postoperative Care Using a Silicone-Based Occlusive Dressing
Fig. 50.1 Preoperative photo of a patient presenting for otoplasty
Fig. 50.2 Silicone-based occlusive dressing following otoplasty
Fig. 50.3 Five days postoperative
References
1. Michelow BJ, Varghai A, Movassaghi K, Guyuron B.
A new dressing for laser-treated areas. Plast Reconstr
Surg. 2002;110(4):1150–7.
2. Suarez M, Fulton Jr JE. A novel occlusive dressing for
skin resurfacing. Dermatol Surg. 1998;24(5):567–70.
3. Kannon GA, Gerrett AB. Moist wound healing with
occlusive dressings. A clinical review. Dermatol Surg.
1995;21(7):583–90.
4. Vogt PM, Andree C, Brueing K, Liu PY, Slama J, Helo
G, et al. Dry, moist, and wet skin wound repair. Ann
Plast Surg. 1995;34(5):493–9.
5. Tang CJ, Ponsky DC. Seal it and reveal it: postopera-
tive otoplasty care using a silicone-based occlusive
dressing. Otolaryngol Head Neck Surg. 2010;142(4):
621–3.

Part V
Complications of Otoplasty

523
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_51, © Springer-Verlag Berlin Heidelberg 2013
51
Introduction
Cosmetic otoplasty is a frequently performed
procedure. For the prominent ear, there are many
different approaches to correct the various prob-
lems, and this may lead to a variety of complica-
tions. There are other cosmetic problems that
may be treated including scars, especially keloid
scars, traumatic injuries, and resection of tumors.
Complications can arise from cosmetic otoplasty,
most of which are well known. The surgeon per-
forming otoplasty should be aware of the possible
complications, their cause, and their treatment.
Complications
Angulation of Incision
Farrior (2000) [ 1 ] reported angulation of the par-
tial incisions on the anterior surface resulting
from the incision having been carried too deep.
Asymmetry [ 2 ]
Asymmetry may exist before otoplasty is per-
formed. If asymmetry occurs postoperatively,
correction may be avoided if the asymmetry is
minor. Surgical correction would depend on the
cause of the asymmetry (i.e., too tight or too loose
a suture on one side, too much or too little skin
excision on one side).
Bleeding and Hematoma [ 1, 3, 4 ]
The cause of bleeding after otoplasty can be from
inadequate hemostasis, hypertension, rebound
vasodilatation from local anesthetics, postopera-
tive trauma, or preexisting coagulopathy. Surgical
intervention is necessary to control bleeding ves-
sels and evacuate blood clots. Failure to remove
an expanding hematoma in a timely fashion may
result in tissue necrosis or chondritis.
Cartilage Irregularities [ 5, 6 ]
Palpable and visible cartilage edges or irregulari-
ties of the cartilage can be caused by full-thickness
cartilage incisions (cartilage splitting) or some
sculpting techniques that weaken the cartilage.
Cartilage Necrosis [ 2 ]
This may occur from not draining a hematoma
early enough and the hematoma causing exces-
sive pressure on the cartilage. The necrotic area
should be excised. There will probably be a
deformity that will need fi lling.
M. A. Shiffman , M.D., J.D.
Section of Surgery , Newport Specialty Hospital ,
17501 Chatham Drive , Tustin , CA 92780-2302 , USA
e-mail: medicinepluslaw@yahoo.com ,
shiffmanmdjd@gmail.com
Otoplasty Complications
Melvin A. Shiffman

524
M.A. Shiffman
Chondritis and Perichondritis [ 6 ]
Typically, clinical signs of infection (i.e., pain
increasingly resistant to analgesics, swollen ery-
thematous ear) begin 3–5 days after surgery.
Chondritis may require drainage and debride-
ment of infected cartilage. Appropriate perioper-
ative antibiotics and drainage of any collection of
serum or blood can prevent chondritis.
Granulomas [ 4 ]
Braided nonabsorbable sutures are more likely to
cause granulomas than mono fi lament nonabsorb-
able sutures. Removal of the suture and granuloma
would be necessary. Mono fi lament nonabsorbable
sutures, nylon or polypropylene, may erode
through skin causing fi stulas or granuloma.
Grisel’s Syndrome [ 7– 12 ]
Grisel’s syndrome is a non-traumatic subluxation
of the atlanto-axial joint caused by in fl ammation
of the adjacent tissues found primarily in children.
This may occur in association with any condition
that results in hyperemia and pathological relax-
ation of the transverse ligament of the atlanto-axial
joint. Several common otolaryngeal conditions
have been associated with the syndrome: pharyn-
gitis, adenotonsillitis, tonsillar abscess, cervical
abscess, and otitis media. Moreover, the syndrome
has been observed after numerous otolaryngologic
procedures such as tonsillectomy, adenoidectomy,
and mastoidectomy. Non-traumatic subluxation
of the atlanto-axial joint should be suspected in
cases of persistent neck pain and stiffness
Early management, consisting of cervical
immobilization and medical treatment, is consid-
ered the key factor for a satisfactory outcome.
Hypersensitivity [ 2 ]
Postoperative hypersensitivity is the result of
nerve endings being irritated or cutaneous nerves
growing back. This will usually subside with
avoidance of pressure on the ear and mild pain
medication such as Tylenol.
Infection [ 2, 4, 13, 14 ]
Infection is usually diagnosed because of exces-
sive pain, erythema, fever, or purulent drainage.
The wound has to be opened, cultured, and thor-
oughly cleansed with antibiotic solution and oral
antibiotics then used for at least 7 days. Culture
and sensitivity (C&S) of the pus may take a few
days to be reported, and the antibiotics may have
to be changed depending on the results. Failure to
treat the infection early and adequately may result
in perichondritis, chondritis, and cartilage necro-
sis [ 2, 14 ] .
Overcorrection
The fl attened appearance of the ear after otoplasty
and the helix no longer visible from the frontal
view is due to overmedialization of the entire ear
leaving the auriculomastoid angle less than 30°
[ 3 ] . Overcorrection of the middle third of the ear
results in prominent inferior pole and contributes
to the “telephone deformity” [ 2, 14 ] .
Overcorrection of the superior and inferior
poles results in the “reverse telephone ear” defor-
mity [ 2, 3 ] .
Obliteration of the External
Ear Canal [ 3, 4, 15, 16 ]
Surgical deformity from anterior displacement of
the concha produces obliteration of the ear canal.
The origin is from setback of an extensively
hypertrophic concha with conchomastoid sutures
alone.
This can be prevented by careful preopera-
tive planning and sticking to the plan in excising
the concha. Treatment requires excision of the
undercorrected concha and lateral based con-
chal fl ap [ 15 ] .

525
51 Otoplasty Complications
Pain
Excessive postoperative pain may be a warning
sign of a developing hematoma. The dressing
should be removed and the wound examined for
swelling and fl uctuant mass indicating a hema-
toma. Treatment requires exploring the wound to
fi nd the source of bleeding for electrocoagulation
and evacuation of the hematoma. A drain may be
used for 24–48 h to detect further fresh bleeding
and to drain any residual blood.
Recurrent Deformity [ 3, 4, 14 ]
Recurrence of the initial ear deformity may be
caused by trauma, patient manipulation, insuf fi -
cient cartilage weakening, suture failure, or suture
insuf fi ciency. This may be the result of relying on
skin excision to retain correction.
Reverse Telephone Deformity [ 3, 4, 16 ]
This is produced by unequal setback of the auri-
cle where the concha is relatively prominent with
respect to the superior pole and inferior poles.
The deformity is caused by failure to address the
prominent concha while focusing on the defor-
mity of the antihelical fold. The conchal setback
is done too excessively, and the concha rolls in
the sagittal plane, pushing the tragus laterally and
narrowing the outer segment of the external audi-
tory canal.
Prevention requires conchal resection, if indi-
cated, and proper placement of the conchomastoid
suture. Treatment involves surgical replace ment
of the conchomastoid suture.
Scarring [ 4 ]
Baker and Converse (1979) [ 17 ] reported hyper-
trophic and keloid scars in 11 % of African
American ears and 2.1 % in Caucasian ears.
Hypertrophic or keloid scars occur in about 15 %
of blacks, Hispanics, and Asians [ 18, 19 ] .
The opening for earrings may be a source of
keloid scarring. Excess tension on the closure
may result in a widened scar. Careful and conser-
vative skin resection can help limit excessive scar
formation [ 6 ] .
About 80 % of hypertrophic scars will resolve
without treatment, but 80 % of keloid scars will
recur, although many times with some improve-
ment, with treatment. Treatment may include
intralesional steroid (triamcinolone) alone or in
combination with 5- fl uorouracil or bleomycin,
excision with or without irradiation, cryotherapy
with or without intralesional steroid, and com-
pression therapy.
Skin Necrosis
Necrosis of the skin is usually the result of post-
operative compression dressings being too tight
or by excessive electrocoagulation under the skin.
This may result in wound dehiscence.
Suture Extrusion [ 1, 2, 4, 14 ]
Extrusion of sutures may result from permanent
sutures being placed too close to the skin and
excessive tension of the cartilage. Infection can
cause sutures being extruded. If suture extrusion
is a late complication, probably no surgery will
need to be performed as long as the ear retains its
corrected shape.
Telephone Ear Deformity [ 3– 5, 16 ]
This deformity is created by unequal setback of
the auricle where the superior and inferior poles
of the ear are still protuberant in relationship to
the middle third of the ear.
The cause is attributed to inadequate correc-
tion of the superior pole; uncorrected prominent
helical root; excessive tightening of the concho-
mastoid sutures; excessive tightening of the con-
cho-scaphoid sutures (especially in the middle
third); excessive removal of skin, soft tissue, or

526
M.A. Shiffman
cartilage in the middle third of the ear; and uncor-
rected lobule.
Prevention includes tightening the middle
suture last to avoid potential overcorrection,
avoiding excess removal of cartilage, and deter-
mining if the lobule and helical tail have to be
corrected once the conchal and antihelix are
treated. Treatment requires replacement of the
Mustardé sutures and the Furnas conchomastoid
sutures to obtain the antihelical fold and conchal
position. If the lobule, helical root, or superior
pole has not been initially improved, then these
have to be corrected.
Undercorrection
Farrior (2000) [ 1 ] described a patient who
required opening of the superior third of the inci-
sion for placement of a horizontal mattress suture
near the superior crus because of the failure to
place a suture above the level of the junction of
the crus that is usually done to create a more nor-
mal contour.
Undercorrection of the superior helix and lob-
ule results in a relatively prominent superior third
of the ear called the “telephone deformity”
[ 2, 14 ] . Undercorrection of an overdeveloped con-
chal bowl can result in a “reverse telephone ear”
[ 2, 3 ] .
Unrealistic Expectations of Patient
Unrealistic expectations of the patient should be
detected by the surgeon before operating on the
ears. This requires listening to what the patients
have to say about what they want done and the
results they expect. A careful discussion of the
surgical procedure and the limitation of results
from any complications should be held.
Wound Dehiscence
Dehiscence may occur from loss of skin sutures
from trauma, too loosely tied sutures, skin necrosis,
or wound infection.
References
1. Farrior RT. A facial plastic surgeon’s perspective. In:
Romo III T, Millman AL, editors. Aesthetic facial
plastic surgery: a multidisciplinary approach. New
York: Thieme; 2000. p. 427–43.
2. Nachlas NE. Otoplasty. In: Papel ID, editor. Facial
plastic and reconstructive surgery. New York: Thieme;
2002. p. 309–21.
3. Adamson PA, Strecker HD. Otoplasty techniques.
Facial Plast Surg. 1995;11(4):284–300.
4. Owsley TG, Biggerstaff TG. Otoplasty complications.
Oral Maxillofac Surg Clin North Am. 2009;21(1):
105–18.
5. Walter C, Nolst-Trenite GJ. Revision otoplasty and spe-
cial problems. Facial Plast Surg. 1994;10(3):298–308.
6. Sclafani AP. Otoplasty. 2011. http:emedicine.co/arti-
cle839886-treatment#a17 . Accessed 26 Sept 2011.
7. Samuel D, Thomas DM, Tierney PA, Patel KS.
Atlanto-axial subluxation (Grisel’s syndrome) follow-
ing otolaryngological diseases and procedures.
J Laryngol Otol. 1995;109(10):1005–9.
8. Gourin CG, Kaper B, Abdu WA, Donegan JO.
Nontraumatic atlanto-axial subluxation after retro-
pharyngeal cellulitis: Grisel’s syndrome. Am J
Otolaryngol. 2002;23(1):60–5.
9. Bocciolini C, Dall’Olio D, Cunsolo E, Cavazzuti PP,
Laudadio P. Grisel’s syndrome: a rare complication
following adenoidectomy. Acta Otorhinolaryngol Ital.
2005;25(4):245–9.
10. Rinaldo A, Mondin V, Suárez C, Genden EM, Ferlito
A. Grisel’s syndrome in head and neck practice. Oral
Oncol. 2005;41(10):966–70.
11. Deichmueller CM, Welkoborsky HJ. Grisel’s syn-
drome–a rare complication following “small” opera-
tions and infections in the ENT region. Eur Arch
Otorhinolaryngol. 2010;267(9):1467–73.
12. Durst F, Staudenmaier R, Pilge H, Lauen J, Prodinger
P, Holzapfel K, et al. Grisel’s syndrome after oto-
plasty. HNO (Hals-, Nasen-, Ohren-Heilkunde). 2012;
60(2):135–40.
13. Elliott Jr RA. Complications in the treatment of prom-
inent ears. Clin Plast Surg. 1978;5(3):479–90.
14. Campbell
AC.
Otoplasty.
Facial
Plast
Surg.
2005;21(4):310–6.
15. Spira M, Stal S. The conchal fl ap as an adjunct in oto-
plasty. Ann Plast Surg. 1983;11(4):291–8.
16. Hoehn JG, Ashruf S. Otoplasty: sequencing the oper-
ation for improved results. Plast Reconstr Surg.
2005;15(1):5–16.
17. Baker DC, Converse M. Correction of protruding
ears: a 20-year retrospective. Aesthetic Plast Surg.
1979;3(1):29–39.
18. Shiffman MA. Causes of and treatment for hypertro-
phic and keloid scars with a new method of treating
steroid fat atrophy. Int J Cosmet Surg Aesthet
Dermatol. 2002;4(1):9–14.
19. Shiffman MA. Uncovering scars. Healthy Aging.
2007;3(2):23–6.

527
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_52, © Springer-Verlag Berlin Heidelberg 2013
52
Introduction
It has been well documented in the literature that
ear deformities can result in signi fi cant psycho-
logical and emotional distress [ 1, 2 ] . Children
who have prominent ears are perceived as “nor-
mal” with a “minor cosmetic defect” yet are ridi-
culed far more often than children with more
signi fi cant craniofacial defects. This fi nding is
attributed to the belief that major craniofacial
anomalies evoke a sense of pity, and therefore,
teasing is not acceptable [ 3 ] . Therefore, patients
that undergo otoplasty have motivations for the
procedure which include improved cosmetic out-
come while seeking to stop all social stigmata of
their original defect. As such, a less than perfect
outcome is not tolerated. Any perceived postop-
erative deformity or asymmetry can render
patients angry and distrustful. When faced with
revision otoplasty, the surgeon should go to great
lengths to carefully analyze the post otoplasty
deformity and develop a well-organized plan for
the correction. Without a corrective strategy, one
is likely to encounter further complications and
unwanted outcomes.
Anatomy and Etiology
of the Prominent Ear
Anthropometric studies have been performed to
better de fi ne the anatomy of a normal ear [ 4 ] .
These measurements do not function as an abso-
lute guide but rather set guidelines for de fi ning
the ideal ear. Attempts for a clear de fi nition of
prominent ears using comparative anatomy have
revealed that perception of prominence is multi-
faceted and subjective [ 5 ] . Therefore, actual mea-
surements to de fi ne prominent ear are not
absolutely necessary, as recognition of promi-
nence is typically innate.
Two etiologies are commonly described for
prominent ear. The fi rst is effacement of the anti-
helical fold, with an obtuse scaphoconchal angle [ 6 ] .
This causes the upper third of the ear to project
outward (Fig. 52.1 ). The second, conchal hyper-
trophy, causes total displacement of the entire ear
from the head (Fig. 52.2 ) [ 7 ] . Additional etiolo-
gies include the presence of an abnormal skull
shape due to plagiocephaly (Fig. 52.3 ) or a heart-
shaped face with a broad intertemporal distance
tapering toward a narrow face and mandible
(Fig. 52.4 ). In each of the later two cases, the ear
A. K. Lentz , M.D. (*)
Division of Plastic and Reconstructive Surgery,
Department of Surgery ,
University of Florida College of Medicine ,
PO Box 100138 , Gainesville , FL 32610 , USA
e-mail: lentz@surgery.u fl .edu
B. S. Bauer , M.D.
Section of Pediatric Plastic Surgery,
Division of Plastic and Reconstructive Surgery ,
NorthShore University Health System,
University of Chicago Medical School ,
Chicago , IL , USA
Department of Surgery , University of Chicago,
Pritzker School of Medicine ,
501 Skokie Blvd , Northbrook , IL 60062 , USA
e-mail: bbauer@northshore.org
Understanding and Correcting
the Unfavorable Results After
Otoplasty
Ashley K. Lentz and Bruce S. Bauer

528
A.K. Lentz and B.S. Bauer
Fig. 52.2 Conchal hypertrophy causing total displace-
ment of the entire ear from the head
Fig. 52.3 Presence of an abnormal skull shape due to
plagiocephaly
Fig. 52.4 Heart-shaped face with a broad intertemporal
distance tapering toward a narrow face and mandible
Fig. 52.1 Effacement of the antihelical fold, with an
obtuse scaphoconchal angle causing the upper third of the
ear to project outward

529
52 Understanding and Correcting the Unfavorable Results After Otoplasty
sits on a sharply inclined cranial base, creating a
unilateral prominence in the former and bilateral
in the later.
Goals for Otoplasty
In 1968, McDowell [ 8 ] described six basic goals
for otoplasty. These include (1) complete correc-
tion of the upper third of the ear; (2) preservation
of the visualization of bilateral helices from the
front view; (3) smoothing and regularity of the
helical line; (4) avoidance of postauricular sulcus
distortion; (5) no creation of a plastering appear-
ance of the ear to the skull, meaning preservation
of the normal values of distance between the
mastoid and the helix; and (6) the position of
each ear should remain symmetrical within 3 mm
at any given point. Achievement of these goals is
not possible without a critical evaluation of the
ear anomaly and a well-thought-out plan for sur-
gical correction.
Dieffenbach [ 9 ] originally described the exci-
sion of postauricular skin and placement of con-
chomastoid sutures. Since that time, numerous
otoplasty techniques have been described to
address the effacement of the scaphoconchal
angle, the lack of an antihelical fold, the conchal
hypertrophy, and the lobular deformity. The cho-
sen surgical technique should address the under-
lying pathology in order to achieve the desired
outcome.
Etiology of Post Otoplasty Deformities
Post otoplasty deformities most typically present
as errors of overcorrection or undercorrection.
Most often, the deformity is of mixed origin.
Undercorrection is rather straightforward while
overcorrection can present one of the most chal-
lenging problems in surgery of the external ear.
Undercorrection often occurs when absorb-
able sutures are used for correction of ear posi-
tion and cartilage tension is no longer restrained
once the sutures absorb. Permanent sutures
should be used with full-thickness bites through
the cartilage including both surfaces of perichon-
drium so as to avoid sutures cutting through with
secondary loss of correction. Undercorrection
also occurs when cranial and skeletal asymmetry
goes unrecognized, and the repair fails to address
the need for asymmetrical correction of each ear.
If conchal hypertrophy is ignored and surgery
aims to correct only the antihelix and scaphocon-
chal effacement, then prominence will remain
with anatomic distortion. Finally, the lobule must
always be included in the preoperative analysis.
If there is lobular hypertrophy or inadequate posi-
tioning of the lobule, it requires correction at the
time of otoplasty. Release or resection of the car-
tilage at the antitragus-conchal junction is often
necessary in order to prevent the outward thrust
on the lower third of the ear. Skin resection alone
cannot reposition the lobule properly.
Over-resection of skin and cartilage damage
at varying degrees lead to overcorrection. Patients
will complain of a “pinned back” appearance, as
they lose the visibility of the helix from the front
view (Fig. 52.5 ). Most often, this tends to occur
when conchal hypertrophy is not addressed.
Fig. 52.5 Over-resection of skin and cartilage damage at
varying degrees lead to overcorrection with a “pinned
back” appearance, as there is loss of the visibility of the
helix from the frontal view

530
A.K. Lentz and B.S. Bauer
Balance and shape of the ear must be maintained,
and aggressive scoring of the cartilage to over-
compensate for conchal hypertrophy will cause
irregularities along the antihelix and crura.
A sharp, unnatural antihelical edge with disrup-
tion of the smooth cartilage results from fractur-
ing of the cartilage, and loss of smooth cartilage
contour is perhaps the greatest challenge in
repairing overcorrection (Fig. 52.6 ). The authors’
current otoplasty technique arose out of an
understanding of how this secondary deformity
could be avoided with a chondrocutaneous-con-
chal resection as the means of helping to “break
the spring” of the antihelix and allow the antihe-
lix to be reshaped without any disruption of
either surface. This technique of conchal resec-
tion allows for fi nal reshaping with the use of
suture placement alone.
The telephone deformity is the prime example
of post otoplasty complication of mixed origin
(Fig. 52.7 ). In these cases, there is overcorrection
of the middle third of the ear due to over-resection
of the skin. The skin resection should be carefully
tapered in this region to smoothly follow the line
of the upper-third correction. If lobular hypertro-
phy goes unrecognized and untreated, it creates a
prominent lower third of the ear as compared to
the middle third.
Algorithm-Based Approach
to Revision Otoplasty
Revision otoplasty requires attention and under-
standing of not only the original etiology of
prominent ear but also the state of the post oto-
plasty deformity. A logical and well-thought-out
surgical plan should be implemented in order to
achieve proper correction. First, the surgeon
must have a thorough discussion with the patient
Fig. 52.6 A sharp, unnatural antihelical edge with dis-
ruption of the smooth cartilage results from fracturing of
the cartilage and loss of smooth cartilage contour
Fig. 52.7 The telephone deformity

531
52 Understanding and Correcting the Unfavorable Results After Otoplasty
to determine expectations and willingness to
achieve optimal outcomes. Patients must have
realistic goals, as correction can be dif fi cult in
the case of overcorrection, and some cases may
require multiple revisions in order to achieve the
optimal outcome. The anatomy of the previously
operated antihelix and concha will dictate the
number of steps needed for correction of the
deformity. In simpler cases, placement or release
of sutures is all that is required to repair the
deformity. In contrast, cartilage grafting may be
required in more complex post otoplasty defor-
mities [ 10 ] .
Undercorrection is straightforward, and reop-
eration includes resection of residual conchal
hypertrophy, replacement of cartilage-shaping
sutures, resection of excess skin, and correction
of lobular excess (Fig. 52.8 ). In the case of con-
chal hypertrophy, we recommend an anterior
approach for resection as this allows the ear to
fall or “spring back” into the correct position.
A minimal amount of skin is removed during
conchal harvest. The concha and skin should be
sutured prior to proceeding to the next stage of
repair. Conchal excess exerts a posterior force on
the antihelix and creates a prominent sharpened
edge. For this reason, the conchal hypertrophy
should be addressed prior to cartilage reshaping.
Overcorrection requires greater thought and
technical expertise. The operative plan typically
requires a strategy to correct cartilage and skin
defects. Careful analysis will dictate your need
for cartilage grafting and need for skin grafts or
fl aps in order to modify shape and skin de fi ciency
(Fig. 52.9 ).
Skin shortage is classically seen in the mid-
dle third of the ear, and this defect requires skin
replacement. While in early approaches to cor-
rection of this deformity, we released scar and
adhesions holding the cartilage in its overcor-
rected position, followed by placement of a full-
thickness skin graft to the defect, the extent of
cartilage release was limited by needing to
maintain a vascular bed for the graft. With addi-
tional experience it became clear that a postau-
ricular transposition fl ap could be used to avoid
this potential limitation of the correction and
also allow placement of stenting cartilage grafts
when needed. The fl ap may be designed from an
area of relative skin excess above or below and
Deformity of undercorrection
Upper pole
Incorrect
suture
placement
Loss of key
suture integrity
Perform proper suture placement
Debulk the
lobule
Size and
thickness of
soft tissue was
not addressed
Incorrect
suture
placement
Failure to
release
underlying
cartilage
support in
concha
Place proper
sutures
Release the
underlying
cartilage of the
concha
Failure to
recognize
underlying
cranial
deformity
Lower pole/lobule
Fig. 52.8 Deformity of undercorrection

532
A.K. Lentz and B.S. Bauer
rotated 180° in the de fi cient middle third
(Fig. 52.10 ). It is important to maintain the
underlying fascia in these fl aps in order to pre-
serve the vascularity.
The sharp, unnatural appearance of an over-
corrected antihelix is the most dif fi cult defor-
mity to correct. The goal is to achieve a smooth
surface of the antihelix. Very few reports exist
to describe the correction of antihelical defor-
mities [ 11 ] . A posterior approach is designed to
allow wide access to release the sutures and
fi brous cartilage adhesions deforming the carti-
lage. Meticulous dissection in the loose plane
above the perichondrium by aligning the scis-
sors with the surface of the cartilage and the use
of cut/spread motions is necessary to expose the
cartilage (Fig. 52.11 ). This technique prevents
further damage of the remaining cartilage. The
cartilage should be carefully unfolded and
inspected for quality. At this point, harvested
cartilage grafts are added posteriorly to rein-
force the fracture sites and to stent open the col-
lapsed antihelical fold (Fig. 52.12 ). Clear nylon
sutures are used to secure the grafts in multiple
planes to avoid shifting of the grafts. On occa-
sion, the posterior cartilage grafts do not pro-
vide enough correction, and an anteriorly placed
graft is required to camou fl age severe distortion.
The skin in this area is densely adherent to the
scared cartilage, and special care must be given
to avoid disruption of the skin envelope. Costal
cartilage may be needed in cases of conchal car-
tilage shortage.
In severe cases, attempts for correction of
the skin de fi ciency and cartilage disruption
may be better tackled in a multistaged
approach. First, provide additional skin with
either a graft or a transposition fl ap. A second
stage is used to perform cartilage grafts and
suture reshaping.
Deformity of overcorrection
Skin deficiency
Mild
Moderate
Release skin and cartilage adhesions
Skin closure
Adjacent skin
advancement
± skin graft
Postauricular
flap closure
Release
sutures
Severe
Overtightened
sutures
Cartilage deformation
Cartilage
deformation/
fracture with
surface
irregularities
Conchal
excess
Conchal
reduction via
anterior or
posterior
approach
Release skin
and cartilage
adhesions
Conchal
cartilage graft
to support the
change of
contour
Overlying the
antihelix
(cemouflage)
Posterior to the
antihelix
(for support)
Postauricular flap closure
Fig. 52.9 Deformity of overcorrection

533
52 Understanding and Correcting the Unfavorable Results After Otoplasty
Conclusions
Patients seek otoplasty for cosmetic and emo-
tional reasons. When there is a less than per-
fect outcome, patients express dissatisfaction
and reconstruction. If the baseline ear anat-
omy goes unrecognized and the treatment
plan for repair incorrect, then post otoplasty
deformities will arise. Adequate analysis of
the ear will help determine the cause of the
deformity.
The common post otoplasty deformities
include the following: (1) loss of the postauricu-
lar sulcus, (2) loss of the helical rim visibility,
(3) irregular antihelical surface, (4) sharp anti-
helical fold, (5) residual prominence, (6) tele-
phone ear deformity, and (7) asymmetry. The
loss of the postauricular sulcus is due to aggres-
sive skin resection, thereby obliterating the
space between the posterior auricle and the mas-
toid. Overtightened sutures cause loss of helical
rim visibility. Cartilage disruption and fracture
create an irregular antihelical surface or, worse,
a sharp, unnatural appearance. Inadequate con-
chal reduction also causes a sharp unnatural
antihelix. Undercorrection of the superior
Fig. 52.10 The fl ap may be designed from an area of
relative skin excess above or below and rotated 180° in the
de fi cient middle third
Fig. 52.11 Dissection in the loose plane above the per-
ichondrium by aligning the scissors with the surface of the
cartilage and the use of cut/spread motions is necessary to
expose the cartilage
Fig. 52.12 Harvested cartilage grafts are added posteri-
orly to reinforce the fracture sites and to stent open the
collapsed antihelical fold

534
A.K. Lentz and B.S. Bauer
one-third of the ear results in residual promi-
nence. Mixed errors of over- and undercorrec-
tion lead to a telephone ear deformity and
asymmetry. A telephone ear deformity may
have excess middle-third ear skin excision or a
hypertrophied lobule, whereas asymmetry can
occur with overcorrection due to overtightened
sutures, or undercorrection may be present due
to an unrecognized skull base deformity.
An algorithm-based approach is helpful
when determining the best solution for recon-
struction. Careful attention to the underlying
pathology and a detailed approach to repair are
necessary. Patients must have a realistic under-
standing of the limitations for revision and the
possibility for multiple stages. Thorough pre-
operative discussion will empower the patient
to understand the complexities of repair and
ultimately result in an acceptable outcome.
References
1. Bradbury ET, Hewison J, Timmons MJ. Psychological
and social outcome of prominent ear correction in
children. Br J Plast Surg. 1992;45(2):97–100.
2. Cooper-Hobson G, Jaffe W. The bene fi ts of otoplasty
for children: further evidence to satisfy the modern
NHS. J Plast Reconstr Aesthet Surg. 2009;62(2):
190–4.
3. MacGregor FC. Ear deformities: social and psycho-
logical implications. Clin Plast Surg. 1978;5(3):
347–50.
4. Farkas LG. Anthropometry of normal and anomalous
ears. Clin Plast Surg. 1978;5(3):401–12.
5. Driessen JP, Borgstein JA, Vuyk HD. De fi ning the
protruding ear. J Craniofac Surg. 2011;22(6):
2102–8.
6. da Silva Freitas R, Sanchez ME, Manzotti MS, Baras
F, Ono MC, de Oliveira e Cruz GA. Comparing cepha-
loauricular and scaphaconchal angles in prominent
ears and control subjects. Aesthetic Plast Surg.
2008;32(4):620–3.
7. Bauer BS, Song DH, Aitken ME. Combined otoplasty
technique: chondrocutaneous conchal resection as the
cornerstone to correction of the prominent ear. Plast
Reconstr Surg. 2002;110(4):1033–40; discussion
1041.
8. McDowell AJ. Goals in otoplasty for protruding ears.
Plast Reconstr Surg. 1968;41(1):17–27.
9. Dieffenbach JF. Die operative Chirurgie. Leipzig: F.
A. Brockhause; 1845.
10. Lentz AK, Plikaitis CM, Bauer BS. Understanding
the unfavorable result after otoplasty: an integrated
approach to correction. Plast Reconstr Surg. 2011;
128(2):536–44.
11. Widgerow AD. Revision otoplasty: the contracted anti-
helical fold. Plast Reconstr Surg. 2002;110(3):827–30.

535
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_53, © Springer-Verlag Berlin Heidelberg 2013
53
Introduction
Prominent ear deformity is the most common ear
malformation. The incidence in Caucasian popula-
tion is 5 % with 8 % of those having a positive fam-
ily history [ 1 ] . When correcting the deformity, the
surgeon must have a thorough knowledge of the
normal anatomy to achieve an acceptable result [ 2 ] .
The most common auricular deformities are poorly
developed antihelical fold and the formation of
excessive conchal cartilage. Such deformities elim-
inate the distinction between the conchal cavity and
scapha, resulting in the lateral projection of the ear
[ 3 ] . Various surgical techniques (more than 200)
have been proposed for the treatment of this deformity
[ 3 ] . Some studies have presented techniques using
a total cartilage incision to treat the prominent ear
and avoid its recurrence [ 4, 5 ] . Pitanguy described
a technique in which an island of cartilage is created
on the anterior surface of the ear that is pushed for-
ward to resemble a smooth antihelical fold by
suturing of edges of the wound after resection of a
generous ellipse of skin from the posterior surface
[ 6 ] . Other surgeons have published studies present-
ing their successful experience with this technique
[ 7 ] . The authors, however, have seen several cases
of secondary deformities utilizing this technique,
presenting with a good antihelical fold, but with
excessive sharpness evident, providing a deformed
antihelix due the cartilage island. A novel solution
for correction of this deformity is described by the
authors.
Technique
A posterior incision along the previous scar was
performed until the cartilaginous surface, and
then undermine over the perichondrium. After a
complete releasing of the posterior skin, the ante-
rior surface was carefully undermined, with care
taken to avoid skin laceration. The cartilage
island was identi fi ed and kept untouched on the
surface. A diamond drill with pineapple shape
point was utilized to trim the sharp borders
(Fig. 53.1 ). After careful hemostasia, the skin
envelope was draped over the cartilage and
sutured. A compressive dressing associated to
four sutures crossing all the layers are used to
redrape the skin and avoid hematoma. Follow-up
of these patients demonstrated great improve-
ment of the ear contours (Figs. 53.2 and 53.3 ).
R. da Silva Freitas , M.D. (*)
Department of Plastic Surgery,
Federal University of Parana ,
Rua General Carneiro 181 9o. Andar ,
Curitiba , PR 80000-000 , Brazil
Universidade Federal do Paraná
Livre-Docente pela USP , Curitiba , PR , Brazil
e-mail: dr.renato.freitas@gmail.com
M. C. C. Ono , M.D.
Rua Rosa Kaint Nadolny, 190, ap 701 , Campo
Comprido, Curitiba , PR CEP 81200-525 , Brazil
e-mail: mccono@gmail.com
N. Alonso , M.D.
Av Pavao 130, apto 162 , Moema, São
Paulo , SP 04516-010 , Brazil
e-mail: nivalonso@gmail.com
Solving Sharp Edges of the Antihelix
After Otoplasty
Renato da Silva Freitas, Maria Cecilia Closs Ono,
and Nivaldo Alonso

536
R. da Silva Freitas et al.
Discussion
Among the surgical goals in the otoplasty is to
produce a smooth, rounded, and adequate promi-
nent antihelical fold. The majority of the patients
presenting for otoplasty are happy with decreased
projection of the helix. But some patients do not
wish stigmata of the procedure. Many techniques
have been published, using sutures, transection, or
scoring for antihelical fold reconstruction. When
a complete incision is performed on the ear carti-
lage, it is possible to achieve sharp borders of the
antihelix, a potentially undesirable result [ 5 ] .
Luckett was the fi rst to describe the cartilage inci-
sion [ 4 ] . He described a crescent-shaped segment of
skin and cartilage and sutured the edges to create a
new antihelical fold. Pitanguy [ 6 ] presented his tech-
nique using an island of cartilage that is pushed for-
ward to create the new antihelix. Balogh and Millesi
[ 5 ] have used a sutured 2-mm strip of cartilage
behind the cartilage edge to avoid sharpness of the
new antihelix. However, they presented the same
complication presented in this chapter in 9 cases out
of a total 77 cases operated. Recently, a new study was
published using this island technique in 278 patients,
but the authors did not mention the occurrence of
sharping edges of the new antihelical fold [ 7 ] .
Antihelical fold deformity can follow various
techniques. The severity of the deformity guides
the treatment. The procedure we have described
can repair this complication after ear cartilage
incision, especially when the main problem is the
acute and unnatural borders of the antihelical
fold. However, there are more severe cases in
Fig. 53.1 Utilizing the drill to trim the borders of
cartilage
a
b
Fig. 53.2 ( a ) Preoperative
patient who had otoplasty
2 years before and now
complains about the
appearance of her ears.
( b ) Six months postoperative

537
53 Solving Sharp Edges of the Antihelix After Otoplasty
which it is necessary to consider the use of a
conchal or costal cartilage frame to substitute the
antihelical fold deformity [ 2 ] .
The authors believe that the surgeon should
avoid complete cartilage incision, primarily on
the antihelix, to prevent the occurrence of an
unnatural and unpleasant result.
References
1. Kelley P, Hollier L, Stal S. Otoplasty: evaluation, tech-
nique, and review. J Craniofac Surg. 2003;14(5):643–53.
2. Firmin F, Sanger C, O’Toole G. Ear reconstruction fol-
lowing severe complications of otoplasty. J Plast
Reconstr Aesthet Surg. 2008;61 Suppl 1:S13–20.
3. Panettiere P, Marchetti L, Accorsi D, Del Gaudio GA.
Otoplasty: a comparison of techniques for antihelical
defects treatment. Aesthetic Plast Surg. 2004;27(6):
462–5.
4. Rogers BO. The classic reprint. A new operation for
prominent ears based on the anatomy of the deformity
by William H. Luckett, M.D. (Reprinted from Surg
Gynec & Obst, 10:635–7, 1910). Plast Reconstr Surg.
1969;43(1):83–6.
5. Balogh B, Millesi H. Are growth alterations a conse-
quence of surgery for prominent ears? Plast Reconstr
Surg. 1992;90(2):192–9.
6. Pitanguy I, Müller P, Piccolo N, Ramalho E, Solinas R.
The treatment of prominent ears: a 25-year survey of
the island technique. Aesthetic Plast Surg. 1987;11(2):
87–93.
7. Werdin F, Wolters M, Lampe H. Pitanguy’s otoplasty:
report of 551 operations. Scand J Plast Reconstr Surg
Hand Surg. 2007;41(6):283–7.
a
b
Fig. 53.3 ( a ) Preoperative
patient. ( b ) Postoperative
following Pitanguy
technique otoplasty

539
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_54, © Springer-Verlag Berlin Heidelberg 2013
54
Introduction
Wedge excision is a popular and a well-
documented surgical procedure of removing a
wide range of skin lesions and cancers of the ear.
It is a simple and an effective treatment. But not
too infrequently, notch deformity of the helical
rim is noted postoperatively (Fig. 54.1 ). Such
deformity is well accepted in majority of cases
and can be hidden behind the longer hair, but in
some cases, it leads to patient dissatisfaction.
Application of Z-plasty [ 1 ] in these instances can
effectively prevent helical rim notch deformity,
and this chapter will illustrate this technique.
Technique
Basal cell carcinoma (BCC) of the ear was
excised using Mohs surgery to enable maximum
amount of soft tissue for the ear reconstruction
(Fig. 54.2 ). The ear was wedge excised, and
when the surgical margins of the wedged ear
were approximated, the “notch” deformity of
the helical rim was noted. If the ear was to be
approximated in its current state, a postoperative
ear with a notch deformity can be predicted. In
order to prevent this complication, Z-plasty was
fashioned prophylactically. A 60° Z-plasty inci-
sion was made; the two triangular fl aps were ele-
vated and transposed and then sutured. Sutures
were removed after 1 week, and a 3-month post-
operative outcome was satisfactory with no notch
deformity.
Discussion
The ear is an important aspect of facial aesthetics.
One of the cosmetically pleasing aspects of a nat-
ural ear is an ear with a smooth and uninterrupted
helical contour. Disturbances in this contour, such
as the notch deformity following a wedge exci-
sion, can produce cosmetic concerns and patient
dissatisfaction. A major cause of notch deformity
of the helical rim appears to be related to excess
closure tension on the rim [ 2 ] . This produces tis-
sue ischemia in short term (dehiscence) which
can manifest as a contour defects both immedi-
ately at the time of surgery as well as gradually
over the longer term as the result of distensae
striae.
Z-plasty was initially described by Fricke in
1829 and William Horner in 1837 [ 3 ] , and
Z-plasty is one of the oldest and most recog-
nized form of skin fl ap surgery. In Z-plasty,
Z-shaped skin incision is made to allow the two
triangular fl aps to be elevated and interdigitated
(transposed) as to produce a change in the direc-
tion of the central limb (Fig. 54.3 ). When this
principle is applied in the skin surgery of the
P. Kim , M.D., MBBS
Simply Beautiful Cosmetic Surgery & Laser Clinic ,
4 Farnell Street , West Ryde, Sidney ,
NSW 2114 , Australia
e-mail: dr.peterkim@yahoo.com.au
Prophylactic Z-Plasty to Prevent
the Notch Deformity of the Helical
Rim Following the Wedge Excision
of the Ear
Peter Kim

540
P. Kim
Fig. 54.1 a ) Notch
deformity of the helical rim.
b ) Following a wedge
excision
Fig. 54.2 Application of Z-plasty prophylactically to
prevent notch deformity of the helical rim. ( a ) Basal cell
carcinoma (BCC) of the ear. ( b ) BCC excised using Mohs
surgery to enable maximum amount of soft tissue for the
ear reconstruction. The ear was wedge excised. ( c ) When
the surgical margins of the wedged ear were approximated,
the “notch” deformity of the helical rim was noted.
( d ) Z-plasty was fashioned prophylactically. Z-plasty
incision, 60°, was made. ( e ) Two triangular fl aps were
elevated and transposed. ( f ) Sutured. ( g ) Sutures removed
after 1 week. ( h ) Three months’ postoperative outcome
was satisfactory with no notch deformity
ear, an effective correction of the scars and heli-
cal rim contour deformities can be achieved by
changing the direction of scar (from transverse
to parallel Z-plasty). This is one of the oldest
and most recognized forms of skin fl ap surgery.
1. Tissue lengthening along the rim
2. Interrupting scar linearity (zigzag scars are
less perceptible)
3. Producing a smooth and continuous helical
rim curvature

541
54 Prophylactic Z-Plasty to Prevent the Notch Deformity of the Helical Rim
a
b
a
a
b
60º
60º
b
b’
b’
a’
a’
Fig. 54.3 ( a , b ) Standard
60° Z-plasty when applied in
ear
In the ear, Z-plasty is commonly used to treat
the postoperative depressed scar or a preexisting
dermatological deformity [ 4 ] . However, where
the postoperative notch deformity can be intra-
operatively predicted, such as in this case fol-
lowing a wedge excision, prophylactic Z-plasty
can prevent such deformity and in turn produce
a more cosmetically satisfying outcome, with-
out signi fi cantly increasing the morbidity.
Conclusions
Prophylactic Z-plasty following a wedge exci-
sion of the ear lesion offers a surgeon a simple
and an effective one-stage procedure that can
prevent the unsightly notch deformity of the
helical rim.
References
1. Kim P. Prophylactic Z-plasty – correcting helical rim
deformity from wedge excision. Aust Fam Physician.
2010;39(9):649–50.
2. Holzmann RD, Guldbakke KK, Schanbacher CF.
Bilateral advancement fl aps with helical rim Z-plasty.
Modi fi cation for management of ear defects. Dermatol
Surg. 2008;34(3):374–7.
3. Hodges A. Z-plasty.A-Z of plastic surgery. Oxford:
Oxford University Press; 2009.
4. Lee PK, Ju HS, Rhie JW, Ahn ST. Two fl aps and
Z-plasty technique for correction of longitudinal ear
lobe cleft. Br J Plast Surg. 2005;58(4):573–6.

543
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_55, © Springer-Verlag Berlin Heidelberg 2013
55
Introduction
Perhaps the most important point to emphasize
when discussing the topic of revisional surgery
for otoplasty is prevention. It is much more com-
plicated to revise an unwanted result than getting
it right the fi rst time around. Of course, that prin-
ciple can likely be applied to all aspects of sur-
gery. But, this chapter would be amiss if it did not
mention some important points about prevention.
Importantly, the goal in otoplasty is to pin back
the ears to the degree that the patient desires. This
could be variable based on for whom you are per-
forming the otoplasty. So a generous discussion
with your patient is paramount in deciding just
how much setback they are wanting. If you do not
talk to your patients, it does not matter how well
you do the otoplasty; you might still be wrong if
you do not achieve what they want. So our dis-
cussion again goes back to prevention. Find out
what your patient wants and document it. You
will then have a better chance of making them
happy. There are ideals in the literature, however.
This is likely going to be covered in other chap-
ters. But based on the author’s theory on aesthet-
ics [ 1 ] , the ears should protrude about one iris
width from the side of the head. One and a half
iris widths of ear protrusion is probably the upper
extreme of normal; anything more than that
would be interpreted by the viewer as excessive.
Most people like their ears protruding about an
iris width without them knowing how the author’s
theory applies to ear aesthetics. In addition, if
there is any way that you would choose to skew
whether the upper, middle, or lower third is more
protruding, it is always better to allow the upper
third to protrude the most then middle and then
lower in that order (Fig. 55.1 ).
This chapter is based strongly on the author’s
experience but is undoubtedly in fl uenced by
a gestalt created by extensive background read-
ing. In the video case a speci fi c case will be illus-
trated that carries with it some of the more
extreme techniques that are needed in an otoplasty
revisional case.
General Prevention and Personal
Thoughts on Otoplasty and the
Revisional Approach
The upper third of the ear is the area that is
most likely to recur following an otoplasty.
It has been found that the relapse of this area
is most likely due to loosening of the sutures.
There may not be something that can be done
about recurrence in this area, but these are some
points that can be suggested. A 4-0 Mersilene
is likely the most common suture to be used
in Mustarde-type sutures (Fig. 55.2 ) [ 2, 3 ] for
reconstruction of the superior crus of the anti-
helix. The bene fi t of this suture is the braided,
P. A. Young , M.D.
1810 116th Ave NE #102 ,
Bellevue , WA 98004 , USA
e-mail: dryoung@drphilipyoung.com ,
payoung88@gmail.com
Otoplasty Revision
Philip A. Young

544
P.A. Young
nonabsorbable qualities that prevent pull-through
and absorption of the suture. This suture has a
long history of success among surgeons who per-
form otoplasty. Because braided sutures are more
likely to get infected, 4-0 clear nylon is used as
do many surgeons currently. Although this suture
is more likely to pull through, the author concen-
trates on getting full-thickness bites including
the perichondrium when performing Mustarde
sutures. With 4-0 Mersilene, the closer you are
to the skin surface, the greater is the possibility
of issues such as infection, suture abscesses, and
rejection of the suture. An erroneous approach
to the upper third is to depend on the Mustarde
sutures to do most of the pinning back of the ears.
The fault here is that when Mustarde sutures are
relied on more than other techniques, one often
tends to set back the helical rim so that the anti-
helix covers the helix on frontal view. This situ-
ation does not represent the ideal. This can be a
telltale sign of a poor and unthoughtful otoplasty.
It is much better to rely more on the conchal set-
back (Fig. 55.3 ) [ 4 ] to mostly pin back the ears
and more of a subtle bend and creation of the
antihelix that can give a more natural look. With
that approach, the recreated antihelix has less
pressure placed on it by the sutures and is thus
less likely to be affected by pull-through of the
sutures and recurrence of the prominent upper
third. Also you are more likely to have a better
result where the helix is positioned more laterally
than the antihelix.
Fig. 55.1 Overcorrected ear. The ear is barely visible. In
the middle and lower thirds, only 2–4 mm of ear is show-
ing lateral to the side of the face. The superior third is
showing approximately 8–9 mm. From the frontal view,
you should be able to see the helix, and the antihelix
should be more medial than the helix
Fig. 55.2 The Mustarde sutures. The markings for the
Mustarde sutures are 16 mm apart across the width of the
superior crus of the antihelix. They are 10 mm apart
lengthwise. The next horizontal mattress sutures are set
2 mm from the previous one. These numbers can vary
depending on the person and the shape that you want to
achieve

545
55 Otoplasty Revision
Conchal Setback and Mustarde
Sutures Speci fi cs
Start out the otoplasty with the conchal setback
[ 4 ] , then shave the back of the concha with the 15
blade to weaken the concha. This is done from
upper third to lower third. Most of the setback is
achieved when the 15 blade is concentrated over
the struts that actually protrude the ear. Wide
exposure is key to allow you to weaken the upper
and lower third, not just the middle third. In
Fig. 55.3 , the blue and yellow areas indicate the
areas that require more exposure to approach the
upper and lower third supporting struts of the con-
cha that need to be weakened to medialize these
quadrants. This is done in a gradual manner to
achieve just the right amount of total ear setback
with the goal being the patient’s desired amount
of setback. In Fig. 55.3 , the green arrow shows the
area that has been shaved. In actuality, the shaving
of the concha need not be so extensive that the
other soft tissue is exposed on the other side of the
cartilage. This fi gure is meant to illustrate this
point. Doing this may weaken the concha to such
a degree that you have bunching in the conchal
bowl which is undesirable. It is much better to
gradually thin the concha carefully so that a large
expanse of cartilage is thinned evenly and
suf fi ciently to medialize the ear without much
pressure placed when assessing the ear intraoper-
atively. If you do encounter areas of bunching,
tacking sutures can be done with 5-0 fast gut to
allow these areas of soft tissue to adhere to the
adjacent underlying postauricular areas. Another
reason for recurrence is an overdependence on the
conchal mastoid sutures and less on the conchal
shaving. I believe conchal shaving is essential in
getting more long results with medialization. If
there is little antihelical bend, I might be conser-
vative in the conchal setback superiorly in order to
allow the Mustarde sutures to medialize the upper
third and create the antihelix bend to the desired
amount. But I always have in mind that the less
dependence on the Mustarde sutures, the better it
is for more long-term results. After each round of
shaving, the frontal view is checked to make sure
that the concha is not over weakened and to get
just the right amount of setback. This is perhaps
the key to the best results. The concha is set back
with 4-0 clear nylon placed sequentially and
incrementally in number. The antihelical bend is
created with the Mustarde sutures. The Mustarde
sutures are placed through stab incisions from the
anterior side with an 11 blade. This makes it eas-
ier to judge the amount of bend that would be cre-
ated. This approach puts both less strain on the
Mustarde sutures and allows me to get more accu-
rate and aesthetic results. It also allows less strain
on the conchal mastoid sutures and the possibility
of weakening the cartilage that is used for these
sutures when you put the sutures from behind.
In Fig. 55.2 , the yellow dots show where the
Mustarde sutures will be placed. Sixteen millime-
ters is the distance across the width of the antihelix.
The sutures are placed 10 mm apart in the vertical
dimension, lengthwise along the antihelix, as
shown. The next horizontal mattress suture is 2 mm
apart. These measurements are more the classical
approach. In reality, you can determine where you
want the antihelical bend by bending the helix and
mapping the light re fl ex that you see. The bend will
usually also create a highlight, and the edge of the
highlight is where you can make the sutures enter.
The classical measurements are just a guideline,
and they can be quite variable depending on the
person. As you move more inferiorly, the width of
the horizontal mattress sutures also gets closer than
Fig. 55.3 Conchal setback. The 15 blade can be directed
at the concha and speci fi cally address each quadrant of the
ear. This is done incrementally and reassessed to assure
the most perfect amount of setback. The green arrow indi-
cates the area that has been shaved. The blue arrow shows
the direction and exposure that you must approach and
achieve to medialize the superior third. The yellow arrow
indicates the exposure you need to achieve to treat the
inferior strut of the conchal bowl to medialize this area

546
P.A. Young
16 mm. Instead of 16 mm, the author often fi nds
that 14 and 13 mm are for the fi rst Mustarde hori-
zontal suture and 12 and 10–9 mm are for the sec-
ond Mustarde sutures. At times, the author fi nds,
however, that only the fi rst suture and second one
are needed for support.
Undercorrection: General Thoughts
Undercorrection of the otoplasty is a much easier
situation in an otoplasty revision [ 5 ] case than the
overcorrected ear from otoplasty. Undercorrection
is revised most of the time by redoing the proce-
dures [ 6, 7 ] that were done in the original surgery.
Some general personal thoughts on undercorrec-
tion in the revision setting and the use of Mustarde
sutures and conchal setback will be presented here.
Most of the time, undercorrection can be corrected
by further conchal setback and conchal weakening
in the particular section of the ear where the under-
correction is located. You can reference the above
pointers on how to achieve that. Removal of more
mastoid fascia can also be done in the superior,
middle, or lower third to further medialize the ear
in each of these areas prior to the conchal setback.
This is not necessary in most situations and that
the conchal setback with shaving is more than
effective. There are many instances when after the
conchal setback and the Mustarde sutures are
done, the superior and anterior attachment of the
helix can assume an odd appearance in that portion
of the ear. A bowed and protruding helix is some-
times the result near the anterior attachment of the
helix. Tacking of the superior and anterior helix to
the deep temporal fascia can be done with a 4-0
nylon to address this issue (Fig. 55.4 ). Locating
where to place the nylon sutures is paramount.
You have to test different areas in this location to
achieve the desired results. The more anteriorly
the suture is placed, the more tension is created,
and you can actually get some lateralization to the
helix. Whereas a more posterior and superior
suture will more medialize the ear at the superior
third. Also carrying out the Mustarde sutures again
and tying these sutures more aggressively can fur-
ther medialize the upper third if this is the cause.
You can determine if you need Mustarde sutures
when you have no signi fi cant antihelical fold and
the concha appears to be set back enough already.
Again, the details on the Mustarde sutures and the
conchal setback were explained earlier and in other
chapters.
Undercorrected Upper Third
Further setback of the upper third can be accom-
plished by more aggressive Mustarde sutures
being careful not to hide the upper helical rim
behind the antihelix on frontal view. Also, as
mentioned earlier the anterior and superior attach-
ment of the helix can be set back through a sepa-
rate incision or an extension of the original
incision (Fig. 55.4 ). The goal here is to tack the
helix in this area to the temporal fascia. If you
want to avoid suture failure this time and would
like to support your revised Mustarde suture, one
Fig. 55.4 Tacking the superior anterior attachment of the
helix (Green arrow). This is a common area to create an
odd bowing effect after Mustarde sutures and conchal set-
back. Tacking this down will get an even better result for
your patient

547
55 Otoplasty Revision
option is to stagger the Mustarde suture and have
them overlap with each set of horizontal mattress
sutures separated by 5 mm (Fig. 55.5 ).
If the undercorrection of the upper third is
not due to the lack of the antihelical bend, treat-
ment of the conchal bowl may be what will be
needed. As discussed earlier, most conchal set-
backs are concentrated on the projection of the
middle third. The lack of exposure and treatment
of the upper third strut within the conchal bowl
during the original procedure could be the cause
of the excessive lateral position that persists in
the otoplasty revision. So one needs to prudently
decide if it is the Mustarde sutures or the conchal
setback or both that are needed. The key to this
decision is whether there is present an adequate
bend in the antihelix. If there is a de fi ciency, you
will need to determine if Mustarde sutures will be
enough to medialize the upper third to the ideal
degree without hiding the helix behind the anti-
helix. If this is not enough, it may still require
conchal bowl shaping. Further conchal setback,
when required, necessitates aggressive expo-
sure of the upper thirds conchal strut and further
incremental shaving and conchal mastoid sutures
to create the ideal position of this section.
Undercorrected Middle Third
The undercorrected middle third will require
more conchal shaving, setback, and possible
removal of soft tissue beneath the conchal bowl.
Thoughtful and incremental changes will achieve
the best results based on preoperative patient
counseling. Conchal shaving and setback should
be more than enough to medialize any section of
the ear, and the removal of soft tissue is not really
necessary. It is important to make sure that it is
truly an undercorrected middle third and not an
overcorrected upper and lower third. In this situ-
ation, further medialization of the middle third
will lead to an overcorrected ear as a whole. This
would be the worst situation and the most dif fi cult
to reverse depending on the maneuvers that were
used to achieve this state.
Undercorrected Lower Third
For the undercorrected lower third, further con-
chal setback requires aggressive exposure of the
conchal bowl inferiorly. Further shaving of the
inferior strut of the concha with mastoid conchal
sutures will be the most effective move to medial-
ize the lower third. In addition to more aggressive
conchal setback, removing the cauda helicis can
help medialize the lower third. Although this is
often suggested in reality, the removal of the
cauda helicis has less effect on lower third than
concentrating on the inferior strut of the concha
for more medialization. More aggressive skin
removal is another adjunct to medialize the lower
third but less accurate and reliable. There are
many variations in drawing the skin resection to
help medialize the lower third. The dumbbell
excision of skin is often done in the original oto-
plasty to help medialize the upper and lower
third. This can be done again during the revision
in a more aggressive manner. Another consider-
ation is to tack the earlobe in a more medial posi-
tion by extending the incision inferiorly and
Fig. 55.5 If you want to avoid suture failure this time and
would like to support your revised Mustarde suture, one
option is to stagger the Mustarde suture and have them
overlap with each set of horizontal mattress sutures sepa-
rated by 5 mm. The yellow dots represent the fi rst Mustarde
suture, and the green dots represent the second set

548
P.A. Young
tacking the earlobe to the deep soft tissue in this
area. Aesthetic judgment will determine where
and how the incision is extended to achieve the
results you want. The inferior incision starts at
the inferior end of the original postauricular inci-
sion but is located just under the lobule. You have
to determine where you want the earlobe to be
more medialized, and this will guide you on how
you place your incision. However, all of these
other options are inferior to the thoughtful treat-
ment of the inferior conchal strut with shaving
and sutures. These adjunctive maneuvers can
optimize the conchal setback revision of the
lower third but are not necessary in my opinion.
Overcorrection of the Upper Third
Reversing the Mustarde Sutures
Overcorrection after otoplasty is the much more
complicated situation. In the upper third, it can
entail over tightening of the Mustarde sutures. In
this situation it may be that the helix is not visible
on frontal view or contributing to the overmedial-
ized state. The approach entails loosening the
bend of the antihelix by cutting through sutures
and scar tissue. Through the postauricular inci-
sion, the iris scissors is used to incrementally
incise and spread through the scar tissue just
under the antihelix. A cartilage bar that is straight
or bent less than the current bend in the antihelix
is an important consideration in supporting the
reversal of the overly aggressive Mustarde
sutures. Strong sutures to hold these grafts in
place are necessary to resist recontracture of this
area (Fig. 55.6 ). Through-and-through sutures to
tack these support grafts are also a consideration
to strengthen the position of these grafts with 4-0
fast gut. Reverse Mustarde sutures are also an
option or can be done in conjunction with these
other maneuvers with the goal of bending the
antihelix in the opposite way. These sutures can
be done in an analogous way that lateral crural
horizontal mattress sutures are done to support
the lateral crural from a convex to straight shape.
One could choose to place these support sutures
for additional support even with cartilage graft-
ing and the other methods mentioned.
Reversing the Conchal Setback
in the Upper Third
Less commonly, an overcorrected upper third is
due to an aggressive setback of the concha in this
area. Because the conchal setback is mostly
directed towards the middle third, I often fi nd that
this is not the reason that the upper third is over-
corrected. As I will explain in more detail below
in the overcorrection of the middle third, release
of adhesions of the conchal bowl will precede the
use of cartilage batten-type grafts to the concha.
The goal is grafting cartilage to support the strut
that usually holds the upper third in a more lateral
position within the concha. To support this, more
grafting in the middle third can be used to sup-
port the upper third cartilage strut grafts. This is
done in much the same way as in Fig. 55.6 . The
difference is that these grafts are placed where
the struts were originally and some overlap is
helpful for support. Other options exist when car-
tilage is scarce. Rotating mastoid and postauricu-
lar tissue based anteriorly can be done to lateralize
the upper third. If this tissue is not enough, you
can rotate a super fi cial temporal fascial fl ap based
on the super fi cial temporal artery. Medpor or rib
cartilage can also be carved to lateralize the upper
Fig. 55.6 Antihelix with grafts in place. Dissection is
required with scissors to spread and cut through scar tis-
sue holding the overly aggressive antihelical bend.
Cartilage grafts are in place (as indicated by the green
arrows ) to maintain the correction for the long term

549
55 Otoplasty Revision
third but are second choices and should be dis-
cussed with your patients in greater details.
Cartilage Grafts
The lack of cartilage may become an issue in this
situation. Obvious possible sources include nasal
septum, rib, or the other ear. You can also con-
sider the ipsilateral or contralateral tragal carti-
lage, caudal helicis cartilage, or conchal bowl
that is not contributing to the ultimate shape of
the ear. In regard to the tragal cartilage, preserv-
ing the portion of this cartilage that immediately
protrudes laterally to the external auditory canal
is prudent to maintain the shape of the tragus. For
conchal bowl cartilage sources, taking the parts
of the cartilage that are not part of the struts that
are protruding the ear is important to maintain the
amount of protrusion that you would like to main-
tain. This usually limits conchal cartilage that is
at the base of the bowl.
Skin Component
One of the biggest issues with overcorrection in
any section of the ear is the loss of skin. Without
the outer lining, all other attempts to revise the
overcorrected ear will not be effective. The
extremely strong pressures from the contracture
will ultimately destroy any scar release, cartilage
grafting, and other measures that are done. There
are many possibilities for correction. A V-Y
advancement is a possible way to recruit skin to
the postauricular area directed to the area of the
ear that needs the most skin. This can be designed
from behind the ear to recruit skin from the post-
auricular area (Fig. 55.7 ). The width of the V
should approximate the area that is in need of lat-
eralizing the most. If at all possible, it is desirable
to have the Y limb close along the hairline.
Another option is the use of two separate fusi-
form shapes that can be recruited from different
sections of the ear (upper, middle, lower third)
based on a subcutaneous pedicle to augment the
skin where it is needed. Figure 55.7 shows these
fl aps that were used to augment the middle third
in this particular patient. A variation of this can
be done for the upper and lower third as well. You
must plan the fl aps so that when they are advanced,
the widest portion is at the most medialized loca-
tion that you are trying to correct and the advance-
ment and the width of the fl aps will also support
the parts of the ear that also need to be lateral-
ized. A posterior hairline incision can be used to
advance a rotational fl ap of skin to this area as
well. The length of the hairline incision will
depend on the amount of skin that will need to be
recruited. A transposition fl ap from the preauric-
ular area can be considered if the patient is agree-
able to an incision in this area. Full-thickness
skin grafts from the opposite ear or other areas
are other possibilities if regional skin fl aps are
not enough. With full-thickness skin grafts, the
revision otoplasty could be approached in a
staged fashion. The full-thickness skin graft is
done a few weeks to months in advance before
cartilage grafting, and other maneuvers are done
to revise the otoplasty. If done in one stage, rotat-
ing mastoid fascia or super fi cial temporal fascia
based on the super fi cial temporal artery should
be considered to support the skin graft. Others
have suggested recruiting skin from one of the
Fig. 55.7 Options for skin replacement. This is an exam-
ple of skin fl aps that can help augment the middle third.
The fusiform shapes denote options for subcutaneous
pedicled fl aps that can be advanced into the middle third.
Additional skin can also be recruited through a V-Y
advancement with the superior limb oriented along the
postauricular hairline as shown. Variations of this can be
tailored for the upper and lower third of the ear

550
P.A. Young
other sections of the ear (upper, middle, or lower
third) to supply skin from an area that is overcor-
rected to the area of de fi ciency [ 5 ] through trans-
position fl aps.
Overcorrection of the Middle Third
With the middle third an overcorrection can lead
to a telephone ear deformity where the middle
third is brought in more relative to the upper and
lower thirds of the ear. The main cause of this is
too much of a conchal setback in the middle third
area or not enough conchal setback in the upper
and lower thirds. For the upper third, overly
aggressive Mustarde sutures are also a consider-
ation. Thinking about these points is an important
determination before deciding to revise any oto-
plasty. An adequate discussion with your patient
is paramount to fi nd out what they would like.
Computer imaging is helpful to fi nd an agreement
of a shape that you are both trying to achieve and
that improvement and not perfection is the goal. If
the overcorrection is due to an over aggressive
conchal setback, augmentation is necessary.
Reversal of the Conchal Setback
and Element of the Conchal Bowl
Knowledge of how each section of the ear is
affected by the conchal bowl is important in
understanding how to revise the overcorrected or
undercorrected state. The superior third support-
ing strut is rather straight and perpendicular to the
surface of the head compared to the middle strut.
The middle third is more curved to the bowl’s
base, while the inferior third can be in between
the two. Variations exist. Most of the time there
will be remnant cartilage in the concha that when
supported by stronger cartilage grafts will allow
the concha to resume a shape more like the con-
chal’s original shape. Release of scar tissue caus-
ing the concha to adhere to deeper tissues is a
necessary fi rst step. The new grafts that are sup-
porting the struts should have adjacent grafts in
the location of the other struts for support or col-
lapse is a likely possibility. Depending on which
section of the ear is overcorrected, the grafts will
need to be done in the upper, middle, or lower
third. The overcorrected ear and how it is related
to the conchal setback procedure in the section of
the middle ear is most often overcorrected by the
conchal setback. Supporting soft tissue around
the grafts that will fi ll in possible dead space and
also support the cartilage grafts holding the ear
laterally can be helpful to add additional support.
If the struts are not able to recreate the strength of
the original struts holding the ear in a more lateral
position, a rib cartilage graft carved to fi t may be
necessary using Burt Brent’s microtia approach.
An alternative is the rotation of mastoid fascia to
lateralize the ear in the right amount or rotating
super fi cial temporal fascia with the same intent as
mentioned previously. Medpor blocks are another
option that can be carved to emulate the original
conchal shape also through incorporating Burt
Brent’s microtia approach (Fig. 55.8 ). A vascu-
lar bed is necessary when contemplating Medpor
or complications could arise. With any of these
approaches, a prerequisite is suf fi cient outer lin-
ing. Many times, it is the lack of skin from overly
aggressive skin resection that has caused the ear
to become too medialized. Hence, replacing the
skin component is likely the fi rst objective to get-
ting a suf fi cient result as discussed previously.
If this is not accomplished, it is my experience
that other procedural steps like cartilage grafting,
Fig. 55.8 Medpor in place to help lateralize the ear. The
green arrow and Adson forceps are pointing to the Medpor
in the postauricular space to help lateralize the ear.
Mastoid fascia anteriorly based and fl ipped to cover the
Medpor implant is shown just below. There is another
rotated fl ap based on an inferior pedicle that is also being
rotated upwards to the Medpor

551
55 Otoplasty Revision
release of scar tissue, reversing sutures, and all
other maneuvers will be done in vain.
Telephone Ear Deformity
Again, when considering the overcorrection of
the middle third, you need to determine if the
middle third is actually ideally set back and the
upper and lower thirds are more protruding or if
the middle third is really overcorrected. If the
middle third is ideal and the upper and lower
thirds are protruding more than ideal (telephone
ear deformity), then you may need to set back the
upper and lower third. This is done by getting
wide exposure of the upper and lower thirds to
further weaken the concha bowl and the struts that
are holding these areas in a more protruding man-
ner (Fig. 55.3 ). Most of the time, the conchal
weakening was concentrated on the middle third
in the original procedure because surgeons are
less likely to get the wider exposure to approach
these superior and inferior areas to set back the
upper and lower thirds. So in the revision, you
must adequately expose the struts that are holding
the upper and lower thirds more laterally than the
middle third. Following this, further weakening
and mastoid conchal sutures will allow you to set
back the upper and lower third into a more ideal
position. If the middle third is the section that is
overcorrected, augmentation and reversal of the
conchal setback is required as explained above.
Overcorrection of the Lower Third
For the lower third, the discussion will repeat
some of the same issues discussed above. In
regard to the speci fi cs of the lower third, it is more
natural that the lower third is more medial than
the middle and upper third. The upper third can
tolerate the most lateral position. This subcon-
sciously emulates the desired shape of the face,
with the width of the face at the level of eyes being
more attractive when it is wider than the lower
third of the face. If you are in a position where the
upper and lower thirds are medialized more than
the middle third, it is a better option to concentrate
on lateralizing the upper third before the lower
third for this reason. A medialized lower third is
much more easily tolerated from an aesthetic
standpoint than a medialized upper third.
Reversing the Conchal Setback in the
Lower Third
For an overcorrected lower third, cartilage graft-
ing the inferior struts of the conchal bowl is one
option. A single strut is likely to bend one way or
the other. One should support the strut with
another strut, most likely in the area of the middle
third to support the strut holding the lower third
in a more lateral position. If these struts are not
strong enough to hold the ear laterally, a total
graft with a strut carved out for the inferior and
middle third may be needed. This can be done
with a rib graft or Medpor block carved to emu-
late the conchal bowl in these areas. As men-
tioned before, rotating a mastoid fascial graft
based anteriorly can be an option. The super fi cial
temporal parietal fascia is complicated because
this rotated fl ap will likely also lateralize the
superior and middle third and you will have to
determine if this is what you want to achieve.
Also this fl ap has a longer distance to reach for
the inferior third and is a second choice after the
mastoid fl ap and other options.
Reversing Overcorrection
of the Lower Third Created
by Overly Aggressive Skin Resection
Support for the skin lining is essential as described
in the other sections. Over-resection of skin in the
lower third is more a common situation than in the
upper and lower third because resection of skin has
been taught to be one of the main ways to medialize
the lower third. In addition to the V-Y advancement,
full-thickness skin graft, and posterior hairline inci-
sion and rotation, a preauricular rotation fl ap could
be considered (at the expense of an incision in the
preauricular area) as a source of skin. A preauricu-
lar skin fl ap is perhaps best used to replace skin in
the lower third as compared to the middle and upper

552
P.A. Young
third. Another option is a tissue expander prior to
the otoplasty revision. This option, in my experi-
ence, is the most unpopular of all the options. In the
situation where the upper or middle third has a sur-
plus of skin, a rotation fl ap from this location can be
swung inferiorly to allow the lower third to become
more lateralized. But as stated earlier, cartilage
grafting is essential in holding any section of the ear
in a more lateral position, whether it is upper, mid-
dle, or lower third of the ear, for the long term.
Sharp Edges and Irregularities
The Mustarde sutures and conchal setback when
done right should have the least risk of having
these issues. Many other techniques require inci-
sions through the antihelix and helix that can lead
to sharp edges and irregularities that people often
seek remedy. Also rasping, burring, and other
forms of abrasion to weaken the front portion of
the ear to allow bending can lead to irregularities.
Prevention is also a key here as well, and the
author uses Mustarde sutures, conchal setback,
and the suture at the anterior superior helix attach-
ment for most all otoplasty prominent ear situa-
tions. Figure 55.9 shows an antihelix irregularity
that the patient said looked “broken.” This was
repaired by excising the depressed area and con-
necting the two edges. To further soften the ear, a
mastoid fascial graft was incorporated over the
repaired area and minced cartilage added to add
structure and shape to the antihelix. This case
illustrates how you can approach sharp edges and
irregularities. Most sharp edges can be excised
and shaped to blend in with the surrounding carti-
lage. The use of scissors, rasps, and power burs
can aid in achieving this. If augmentation is nec-
essary, cartilage grafts can be used to help shape
different portions of the ear. Morselizing the edges
of the grafts can help them blend in with the native
cartilage. Minced cartilage can give you some
ability to mold the shape that you want. Because
the skin in this area is so thin, a fascial graft is a
necessity to help your corrections and grafts blend
in. The fascial graft can also allow you to contain
minced cartilage in the location you want and help
you mold them into the shape you want as well.
References
1. Young PA, Sinha U, Rice D, Stucker F. Circles of
prominence: a new theory on facial aesthetics. Arch
Facial Plast Surg. 2006;8(4):263–7.
2. Mustarde JC. The correction of prominent ears using
simple mattress sutures. Br J Plast Surg. 1963;16:170–8.
a
b
Fig. 55.9 Antihelix
irregularity. ( a ) The area of
depression was excised and
the two halves connected.
With a mastoid facial graft,
minced cartilage was used to
further shape this area (Green
arrow). ( b ) Immediately
postoperative after correction
of antihelix irregularity. The
irregularity was corrected by
excising the depression
reconnecting the antihelix
and then shaped further with
a mastoid fascia and minced
cartilage underneath

553
55 Otoplasty Revision
3. Pearl CB, Wallace RD. New technique for marking the
location of Mustardé horizontal mattress sutures. Plast
Reconstr Surg. 2009;123(5):1468–70.
4. Furnas DW. Correction of prominent ears by conchamas-
toid sutures. Plast Reconstr Surg. 1968;42(3):189–93.
5. Lentz AK, Plikaitis CM, Bauer BS. Understanding
the unfavorable result after otoplasty: an integrated
approach to correction. Plast Reconstr Surg. 2011;
128(2):536–44.
6. Janz BA, Cole P, Hollier LH, Stal S. Treatment of
prominent and constricted ear anomalies. Plast
Reconstr Surg. 2009;124(1 Suppl):27e–37.
7. Thorne CH. Otoplasty. Plast Reconstr Surg. 2008;
122(1):291–2.

Part VI
Outcomes

557
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_56, © Springer-Verlag Berlin Heidelberg 2013
56
Introduction
Prominent ear is a common congenital deformity
of the ear, an incidence of about 5 % in Caucasian
population. There is inadequate formation of the
antihelix fold as well as conchal hypertrophy,
scaphoconchal angle greater than 90°, and for-
ward lobule. Prominent ears may cause psycho-
logical disorder, emotional stress, behavioral
disturbance, and restriction of social interaction
in children, adolescents, and adults. The treat-
ment of prominent ears involves reshaping of the
antihelical fold, correction of the conchal defect,
and lobule repositioning, the primary responsi-
bilities for the anatomical defects [ 1, 2 ] . Usually
a combination of techniques is used based on
each particular case and each degree of ear defor-
mity [ 3, 4 ] .
Tactile sensibility of the ear skin is from
branches of the cervical plexus and branches of
V, VII, IX, and X cranial nerves [ 1, 2 ] . The pos-
terior surface of the ear receives sensory innerva-
tion from the cervical plexus: the greater auricular
nerve (branches of C2 and C3) and the minor
occipital nerve (branch of C2). The anterior sur-
face (helix, antihelix, tragus, and lobule) is inner-
vated by the greater auricular and auriculotemporal
nerve (branch of mandibular division of trigemi-
nal nerve). Concha and external auditory canal
receive sensory innervation from the posterior
auricular nerve (branch of the facial nerve), the
Arnold’s nerve (auricular branch of the vagus
nerve), and the Jacobson’s nerve (branch tym-
panic of the glossopharyngeal nerve) (Fig. 56.1 ).
Assessment of cutaneous tactile sensibility
may be carried out by some neurosensory tests,
based on the knowledge of skin innervation [ 5 ] .
The group A-beta nerve fi bers are responsible
for conducting touch stimuli including both
those from slow- and fast-adaptative sensory
receptors. The slow-adaptative fi bers conduct
pressure perception, constant touch, and texture
and their skin receptors are the Merkel and
Ruf fi ni cells. The fast-adaptative fi bers provide
motion and vibration perception and their cuta-
neous receptors are the Meissner and Pacini cells
[ 6 ] . The best approach for measurement of cuta-
neous tactile sensibility should include both
static pressure sensation (slow-adaptative fi bers)
and motion sensation thresholds (fast-adaptative
fi bers), allowing monitoring before and after sur-
gical treatment [ 7, 8 ] .
The Semmes-Weinstein mono fi laments are
known as a test to evaluate touch sensibility of
the skin. It examines only the slow-adaptative
sensory fi bers and their peripheral receptors. The
fast-adaptative fi bers can be evaluated by another
P. S. Coltro , M.D. (*)
Division of Plastic Surgery, Faculty of Medicine ,
University of São Paulo , Alameda Jauaperi 943 apto 172 ,
Indianópolis, São Paulo , SP 04523-014 , Brazil
e-mail: pscoltro@hotmail.com
M. C. Ferreira , M.D., Ph.D.
Division of Plastic Surgery , University of São Paulo ,
Avenida Doutor Arnaldo 455 , Cerqueira César,
São Paulo , SP 01246-903 , Brazil
e-mail: mcastroferreira@uol.com.br
Sensibility of the Ear After Otoplasty
Pedro Soler Coltro and Marcus Castro Ferreira

558
P.S. Coltro and M.C. Ferreira
test using vibration producing instruments, as
diapasons [ 6 ] . In 1989, Dellon et al. [ 9, 10 ] intro-
duced a new test using the Pressure Speci fi ed
Sensory Device™, PSSD, a device that quanti fi es
the level of pressure from 0 to 100 g/mm 2 applied
by metal prongs to the skin. The thresholds of
pressure necessary for the patient to feel the stim-
ulus, both statically and in moving, assess both
the slow- and fast-adaptative fi bers.
Plastic surgeons from the University of São
Paulo, Brazil, have employed this device in order
to better study changes in sensibility that occur in
the postoperative period of a number of condi-
tions treated by plastic surgery, including trauma,
aesthetic procedures, but mostly importantly, dia-
betic neuropathy [ 11– 15 ] .
Temporary or permanent changes on skin sen-
sibility may occur in the postoperative period
after plastic surgery procedures, especially when
there is extensive skin and subcutaneous tissue
dissection. The surgery of prominent ear involves
dissection of its cutaneous posterior surface and
we supposed that otoplasty might cause some
impairment in the ear sensibility of the skin.
The authors could not fi nd studies that objec-
tively compare the sensibility of the skin of the
ear before and after surgery for prominent ears
and, therefore, studied the tactile sensibility on
the skin of the ear before and after otoplasty for
prominent ears measuring the cutaneous pressure
thresholds with the Pressure Speci fi ed Sensory
Device™ (PSSD). Furthermore, vibration and
hot/cold sensibility were also evaluated [ 16 ] .
Study of Sensibility of the Ear’s Skin
A prospective study was conducted with 15
patients presenting bilateral prominent ears [ 16 ] .
They were submitted to bilateral otoplasty by the
same surgeon and in all of them the following
anatomical deformities were observed: conchal
hypertrophy, scaphoconchal angle greater than
90°, absence of the antihelical fold, and forward
lobe. Exclusion criteria included previous ear and
other surgery on the periauricular region and sys-
temic comorbidities that could alter the sensibil-
ity, such as diabetes or neurological disorders.
Occipital nerve
Greater auricular
nerve
Jacobson’s nerve
Arnold’s nerve
Posterior auricular
nerve
Auriculotemporal
nerve
Fig. 56.1 Innervation of the
skin of the external ear

559
56 Sensibility of the Ear After Otoplasty
Local anesthesia was used, blocking the main
nerve branches of the ear, the mastoid region, and
the posterior auricular surface. Retroauricular
incision was followed by extensive dissection of a
cutaneous fl ap at the posterior surface of the ear
reaching the perichondrium plan and dissection of
the mastoid in the ear projection. Hemostasis was
provided by direct cauterization of blood vessels.
The excess of the concha was treated by a par-
tial conchal resection and the scaphoconchal angle
was reduced using two conchomastoid nonab-
sorbable sutures. Restoration of the antihelical
fold was obtained using three scaphoconchal non-
absorbable sutures. The lobule was repositioned
using a dermoconchal suture, joining the lobule
dermis to the lower portion of the concha. The ret-
roauricular skin incision was closed with a con-
tinuous suture. After bandage was removed on the
second day, the patient was asked to continuously
use an elastic band during the fi rst month and just
during the night in the second month.
The same examiner tested the sensibility of
ear preoperatively and 6 and 12 months after sur-
gery using the PSSD. This unit consists of a
transducer of force coupled to a computer and
software capable of encoding an electrical signal
into pressure, expressed in grams per squared
millimeter (g/mm 2 ).
The examination with the PSSD consisted of
the touch of one metal rod to the skin of ear
(Fig. 56.2 ), anterior and posterior. The patient
was in possession of a bell and was instructed to
squeeze it when he/she felt the touch of the metal
rod. Thus, the software recorded the perceived
value of the pressure when the bell is activated
(electrical signal). The test was repeated fi ve
times in each area and the average obtained cor-
responded to the cutaneous pressure threshold of
that area (g/mm 2 ).
For the patient to understand the exam, a prior
test was conducted on the dominant hand of the
patient. During the test, the individuals remained
comfortably in supine position on the examina-
tion table, in a quiet and isolated room. As a pre-
liminary instruction, the patient was oriented to
keep eyes closed to avoid confusion with visual
sensation.
Each ear was tested in seven areas (Fig. 56.3 ),
fi ve on the anterior surface, root of the helix (area
1), medium helix (area 2), antihelix (area 3), con-
cha (area 4), and lobule (area 5), and two on the
posterior surface: retroauricular sulcus (area 6)
and scaphoconchal sulcus (area 7). The distribu-
tion of sensory innervation over the ear was taken
as a basis for choosing these areas, given by
branches of the cervical plexus and the branches
of V, VII, IX, and X cranial nerves.
On each area, the static one-point test was fi rst
performed, obtained by only one prong of the
transducer, and then the dynamic one-point test,
obtained by moving and pressing the transducer
(one prong) on the ear skin. Statistical analysis of
pressure measurements was performed by
Wilcoxon signed-rank test.
Fig. 56.2 Performing the test: a metal rod transducer of PSSD touching the ear

560
P.S. Coltro and M.C. Ferreira
Tests of vibratory sensibility were made by a
diapason of 128 Hz. Patients were tested with
closed eyes and the vibrating diapason was
touched on the same seven areas above for 5 s.
Vibratory sensibility was considered preserved if
patient felt the vibration in overtime. Study of
hot/cold sensibility was performed by the contact
of a test tube fi lled by hot water (40 °C) and
another by cold water (5 °C). Hot/cold sensibility
was considered preserved if patient felt the hot
tube as a “hot sensation” and the cold tube as a
“cold sensation.”
The comparison and the evolution of the cuta-
neous pressure thresholds measurements on the
preoperative and 6 and 12 months postoperative
for the one point static and moving tests are rep-
resented in Figs. 56.4 and 56.5 . The mean (M) of
cutaneous pressure thresholds (g/mm 2 ) in the
seven areas studied as well as the standard devia-
tion (SD) and “ p value” are described in
Tables 56.1 and 56.2 .
Vibratory and hot/cold sensibilities were con-
sidered preserved bilaterally in all 15 patients,
without difference between preoperative and 6 or
12 months postoperative.
Tests to detect changes in sensibility of the
skin were developed to assess and quantify sen-
sory function in patients with neurological dis-
ease complaints or in potential risk to develop it
[ 17– 19 ] . They can be used to evaluate skin sensi-
bility in many anatomical sites such as breast,
abdomen, face, and members, including the hands
and feet [ 11– 15, 20, 21 ] . Such studies compare
changes in skin sensibility before and after a
medical or surgical intervention, and severity of
some known diseases. For example, previous
tests have evaluated the sensibility of the skin,
breast, and nipple areola complex before and
after mammaplasty and others studied the sever-
ity of neuropathy in the diabetic lower extremity
[ 6, 11, 12 ] .
Over time, there was a change in the instru-
ments used to perform these sensitive tests [ 5 ] . In
1905, von Frey [ 22 ] developed an evaluation
method through the use of horsehair attached to a
stem, being very inaccurate and only with histori-
cal importance.
Semmes and Weinstein, in 1962 [ 23 ] , created
an indirect sensitive quantifying method for using
nylon mono fi laments with progressive diameters
a
b
2
3
1
4
5
7
6
Fig. 56.3 Areas of the ear
tested by PSSD. Anterior
( a ) 1 root of the helix,
2 medium helix, 3 anti-helix,
4 concha, 5 lobule. Posterior
( b ) 6 retro-auricular sulcus,
7 scaphoconchal sulcus

561
56 Sensibility of the Ear After Otoplasty
and attached to plastic rods, being widely dis-
seminated for loss of sensibility assessment due
to its simplicity, rapidity, and low cost. However,
several criticisms have been made to the use of
the Semmes-Weinstein mono fi lament. Since this
is a discontinuous test, it provides only an esti-
mate of the skin pressure thresholds, limiting the
statistical analysis [ 5, 24, 25 ] .
The objective tests to assess skin sensibility
were used in plastic surgery by Dellon in 1983,
by quantitative vibrometer, which also had some
controversy [ 5, 26 ] . In 1989, Dellon et al. [ 9 ]
developed a new method for skin sensibility
quanti fi cation, the Pressure Speci fi ed Sensory
Device™ (PSSD). The data obtained with the
PSSD represent the true pressure threshold, pro-
vided directly in grams per millimeter squared
(g/mm 2 ), which allows objective comparisons
and statistical analysis tests. This method is
more accurate than the Semmes-Weinstein
mono fi lament because it is a continuous and
direct measure and allows the study of slow and
fast to adaptative fi bers, being more complete
for skin sensibility evaluation [ 5, 10 ] .
Area 1
0
0.1
0.2
0.3
0.4
0.5
Area 2
Area 3
Area 4
Area 5
Area 6
Area 7
Pre operative
6 months post operative
12 months post operative
Fig. 56.4 Mean of the
cutaneous pressure
thresholds (g/mm 2 ) of
the static one-point test
(preoperative, 6 and
12 months postoperative)
Area 1
0
0.1
0.2
0.3
0.4
0.5
Area 2
Area 3
Area 4
Area 5
Area 6
Area 7
Pre operative
6 months post operative
12 months post operative
Fig. 56.5 Mean of the
cutaneous pressure
thresholds (g/mm 2 ) of the
moving one-point test
(preoperative, 6 and
12 months postoperative)

562
P.S. Coltro and M.C. Ferreira
Evaluation of Cutaneous Sensibility
of the Ear Before and After Otoplasty
During otoplasty, the dissection on the posterior
ear skin and surroundings may cause many kinds
of nerve injury. Injury to the sensory nerve fi bers
can lead to two patterns of chronic sequel: a
decrease in sensibility or hypoesthesia (the patient
feels less sensibility at the site) and increased
sensibility or hyperesthesia (the perception is
excessive or there is exaggerated sensibility in
response to the stimuli).
Knowledge of normal sensibility is important
for effective evaluation and treatment of sensi-
tive disorders [ 7 ] . The objective registration of
skin sensibility in various areas of the body –
including breast, abdomen, face, hands, and feet –
increases the scienti fi c data and contributes to
surgical techniques improvement, reducing nerve
injuries to minimize nerve sensory loss. Many
postoperative sensory de fi cits can be observed
when strict analysis is made [ 11, 13, 14, 20 ] .
Studies regarding ear sensibility are scarce in
the medical literature. In 1990, Posnick et al.
[ 27 ] assessed the skin sensibility in facial areas
of healthy subjects innervated by supraorbital,
infraorbital, mental, and greater auricular
nerves, including the distal helix and ear lobule.
Table 56.1 Static
and moving
one-point
test – mean (M) of
the cutaneous
pressure thresholds
(g/mm 2 ), standard
deviation (SD), and
“ p ” value
(preoperative and
6 months
postoperative)
Area
Preoperative
6 months postoperative
p
M
SD
M
SD
Area 1
Static
0.3767
0.06244
0.3987
0.05958
0.043
Moving
0.3653
0.05218
0.3947
0.056
0.0112
Area 2
Static
0.374
0.04854
0.4053
0.0545
0.0007
Moving
0.3547
0.04091
0.3813
0.03989
0.0041
Area 3
Static
0.37
0.04955
0.3893
0.05051
0.0138
Moving
0.382
0.0572
0.4007
0.04127
0.0402
Area 4
Static
0.388
0.05592
0.41
0.0393
0.0335
Moving
0.3827
0.05317
0.414
0.05184
0.0002
Area 5
Static
0.3373
0.03542
0.372
0.03498
0.0002
Moving
0.3393
0.04601
0.368
0.05102
0.0009
Area 6
Static
0.383
0.05676
0.40
0.04835
0.1
Moving
0.38
0.06384
0.402
0.04715
0.0273
Area 7
Static
0.382
0.05524
0.4013
0.05722
0.0465
Moving
0.3887
0.04637
0.4207
0.04193
0.0003
Table 56.2 Static
and moving
one-point test –
mean (M) of the
cutaneous pressure
thresholds (g/mm 2 ),
standard deviation
(SD), and “ p ” value
(preoperative and
12 months
postoperative)
Area
Preoperative
12 months postoperative
p
M
SD
M
SD
Area 1
Static
0.3767
0.06244
0.3567
0.04589
0.335
Moving
0.3653
0.05218
0.3527
0.0469
0.1928
Area 2
Static
0.374
0.04854
0.3653
0.04569
0.114
Moving
0.3547
0.04091
0.3473
0.03352
0.4561
Area 3
Static
0.37
0.04955
0.3635
0.04478
0.2359
Moving
0.382
0.0572
0.3673
0.05324
0.0916
Area 4
Static
0.388
0.05592
0.378
0.04944
0.3271
Moving
0.3827
0.05317
0.356
0.03114
0.0626
Area 5
Static
0.3373
0.03542
0.3313
0.01655
0.6456
Moving
0.3393
0.04601
0.3253
0.01456
0.4718
Area 6
Static
0.383
0.05676
0.3747
0.04776
0.2353
Moving
0.38
0.06384
0.362
0.05189
0.1967
Area 7
Static
0.382
0.05524
0.358
0.03263
0.1177
Moving
0.3887
0.04637
0.3747
0.04257
0.1409

563
56 Sensibility of the Ear After Otoplasty
The cutaneous pressure thresholds in this study
were measured using the Semmes-Weinstein
mono fi lament, a nonquantitative method.
In 1994, Costas et al. [ 28 ] studied the sensibil-
ity on 13 regions of the face and neck of volun-
teers with no history of neuropathy, diabetes,
trauma, or surgery on the face. The tested areas
corresponded to the main sensory branches of the
head and neck, including the greater auricular
nerve (anterior and posterior branch), minor
occipital nerve, and auriculotemporal nerve, but
not directly evaluating the ear. Moreover, the cuta-
neous pressure thresholds measurements were
also obtained with the Semmes-Weinstein
mono fi lament. No study could be found assessing
ear sensibility using a quantitative method like the
PSSD or that compares objectively cutaneous
pressure thresholds before and after otoplasty.
The authors’ study compared preoperative
and 6 months’ postoperative sensibilities [ 16 ] .
A higher cutaneous pressure thresholds (partial
loss of sensation) related to slow adaptative fi bers
was observed (static one-point test), with statisti-
cally signi fi cant differences in six of seven areas
tested, the exception being the static test on area
6 (posterior: retroauricular sulcus). Regarding to
the dynamic point test (fast-adaptative fi bers), the
measurements demonstrated a higher thresholds,
the difference being statistically signi fi cant on all
areas tested. Therefore, there was reduction in ear
tactile sensibility 6 months after otoplasty.
When
comparing
the
preoperative
and
12 months postoperative results, the cutaneous
static pressure and the motion were similar. There
were no statistically signi fi cant differences in all
seven areas tested, for both tests. Thus, the sensory
thresholds indicated that the ear tactile sensibility
12 months after otoplasty returned to levels similar
to preoperative level, but not exactly identical.
Furthermore, vibratory and hot/cold sensibil-
ity was preserved bilaterally, without difference
between preoperative level and at 6 or 12 months
postoperative. Thus, the fi bers responsible for
conducting such sensibility were not affected by
the otoplasty.
The best approach for assessment of cutaneous
tactile sensibility should include the static pres-
sure and motion sensation thresholds [ 7, 8 ] and
this was observed in our study, reduction in ear
tactile sensibility at 6 months after otoplasty, fol-
lowed by return at 12 months after surgery [ 16 ] .
These data can be used for the preparation of a
more consistent informed consent term for oto-
plasty adding this information about change on
postoperative level of ear sensibility, based on more
scienti fi c criteria. Also it is shown that the reduc-
tion in the ear sensibility after surgery is temporary
and it is expected to return to similar levels to the
preoperative, though not exactly identical ones.
Further studies are needed to assess techniques
used for otoplasty, such as scraping the anterior
cartilage and others with lesser extensive dissec-
tion of fl aps, and see the impact on the pre- and
postoperative sensation levels. It is possible to
compare changes in ear sensibility among vari-
ous otoplasty surgical techniques.
This study represented the fi rst evaluation of
ear tactile sensibility using a quantitative method
that compared objectively cutaneous pressure
thresholds before and after otoplasty. After oto-
plasty, there was initially a reduction on the ear
tactile sensibility, followed by a return to similar
levels to the preoperative. Documentation and
assessment of auricular sensibility are important
for clinical and surgical knowledge, and it helps
accurate orientation to the patient on the postop-
erative follow-up.
References
1. Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast
Reconstr Surg. 2005;115(4):60e–72e.
2. Hoehn JG, Ashruf S. Otoplasty: sequencing the opera-
tion for improved results. Plast Reconstr Surg. 2005;
115(1):5e–16e.
3. Kelley P, Hollier L, Stal S. Otoplasty: evaluation, tech-
nique, and review. J Craniofac Surg. 2003;14(5):
643–53.
4. Peker F, Celiköz B. Otoplasty: anterior scoring and
posterior rolling technique in adults. Aesthetic Plast
Surg. 2002;26(4):267–73.
5. Dellon AL. Invited discussion: sensibility of the breast
following reduction mammaplasty. Ann Plast Surg.
2003;51(1):6–9.
6. Carvalho VF, Ferreira MC, Vieira SA, Ueda T.
Cutaneous sensibility threshold in the feet of diabetic
patients with pressure speci fi ed sensory device: an
assessment of the neuropathy. Rev Assoc Med Bras.
2009;55(1):29–34.

564
P.S. Coltro and M.C. Ferreira
7. Dellon AL. Evaluation of sensibility and re-education
of sensation in the hand. Baltimore: Lippincott
Williams & Wilkins; 2000.
8. Dellon AL. Somatosensory testing and rehabilitation.
Baltimore: Lippincott Williams & Wilkins; 2000.
9. Dellon ES, Mourey MS, Dellon AL. Human pressure
perception values of constant and moving one and
two-point discrimination. Plast Reconstr Surg. 1992;
90(1):112–7.
10. Dellon ES, Crone S, Mourey R, Dellon AL.
Comparison of the Semmes-Weinstein mono fi laments
with the pressure speci fi ed sensory device. Restor
Neurol Neurosci. 1993;5(5):323–6.
11. Ferreira MC, Costa MP, Cunha MS, Sakae E, Fels
KW. Sensibility of the breast after reduction mamma-
plasty. Ann Plast Surg. 2003;51(1):1–5.
12. Ferreira MC, Rodrigues L, Fels KW. New method for
evaluation of cutaneous sensibility in diabetic feet:
preliminary report. Rev Hosp Clin Fac Med Sao
Paulo. 2004;59(5):286–90.
13. Fels KW, Cunha MS, Sturtz GP, Gemperli R, Ferreira
MC. Evaluation of cutaneous abdominal wall sensi-
bility after abdominoplasty. Aesthetic Plast Surg.
2005;29(2):78–82.
14. Fogaça WC, Ferreira MC, Dellon AL. Infraorbital
nerve injury associated with zygoma fractures: docu-
mentation with neurosensory testing. Plast Reconstr
Surg. 2004;113(3):834–8.
15. Fogaça WC, Sturtz GP, Surjan RC, Ferreira MC.
Evaluation of cutaneous sensibility on infraorbital
nerve area. J Craniofac Surg. 2005;16(6):953–6.
16. Coltro PS, Alves HR, Gallafrio ST, Busnardo FF,
Ferreira MC. Sensibility of ear after otoplasty. Ann
Plast Surg. 2011;68(2):120–4.
17. Yarnitsky D. Quantitative sensory testing. Muscle
Nerve. 1997;20(2):198–204.
18. Dellon AL. From there to here: a personal viewpoint
after three decades of neuropathy research. Clin
Podiatr Med Surg. 2006;23(3):497–508.
19. Soomekh D. Quantitative sensory testing. Clin Podiatr
Med Surg. 2006;23(3):545–57.
20. Mo fi d MM, Dellon AL, Elias JJ, Nahabedian MY.
Quantitation of breast sensibility following reduction
mammaplasty: a comparison of inferior and medial
pedicle techniques. Plast Reconstr Surg. 2002;109(7):
2283–8.
21. Grime PD. A pilot study to determine the potential
application of the pressure speci fi ed sensory device in
the maxillofacial region. Br J Oral Maxillofac Surg.
1996;34(6):500–3.
22. Levin S, Pearsall G, Ruderman RJ. Von Frey’s method
of measuring pressure sensibility in the hand: an
engineering analysis of the Weinstein-Semmes pres-
sure aesthesiometer. J Hand Surg Am. 1978;3(3):
211–6.
23. Malgrange D, Richard JL, Leymarie F. Screening dia-
betic patients at risk for foot ulceration. A multi- centre
hospital-based study in France. Diabetes Metab.
2003;29(3):261–8.
24. Dellon AL. Testing for facial sensibility. Plast
Reconstr Surg. 1991;87(6):1140–1.
25. Posnick JC, Grossman JA. Facial sensibility testing: a
clinical update. Plast Reconstr Surg. 2000;106(4):
892–4.
26. Dellon AL. The vibrometer. Plast Reconstr Surg.
1983;71(3):427–31.
27. Posnick JC, Zimbler AG, Grossman JA. Normal cuta-
neous sensibility of the face. Plast Reconstr Surg.
1990;86(3):429–33.
28. Costas PD, Heatley G, Seckel BR. Normal sensation
of the human face and neck. Plast Reconstr Surg.
1994;93(6):1141–5.

565
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_57, © Springer-Verlag Berlin Heidelberg 2013
57
Introduction
Measurement of human proportions was most
famously described by Leonardo da Vinci. His
drawing of the Vitruvian man has been repro-
duced countless times. Vitruvian man was da
Vinci’s interpretation of the observations of
Marcus Vitruvius Pollio (born c70–80 BC), a
Roman writer and architect. He likened the sym-
metry of man to architecture in his book De
architectura. Da Vinci further studied the human
form, and in his drawing entitled “The facial pro-
portions of a man in pro fi le; study of soldiers and
horses c1490-95 – 1503,” Leonardo describes the
relationship of the proportions of the ear. In his
own words, “…The hollow of the cheek-bone
occurs half-way between the tip of the nose and
the top of the jaw-bone, which is the lower angle
of the setting on of the ear…from the angle of the
eye socket to the ear is as far as the length of the
ear, or the third of the face.”
The human ear grows throughout life. Eighty-
fi ve percent of growth takes place before the age of
three with a further steady growth throughout life
up to the seventh decade [ 1 ] . Adamson et al. mea-
sured the conchomastoid distance in 2,300 ears in
children from birth to aged 16 and adults from 60
to 80. The conchomastoid distance increased up
to an average of 2 cm at age ten, but changes little
after this. Farkas [ 2 ] produced numerous papers
on the anthropometry of the ear. Farkas found
the average protrusion of the ear from the head if
measured as an angle was around 20°.
Many authors have described measurement of
the distance between the pinna and the cranium
to measure postoperative outcome from otoplasty.
Few authors have measured the projection of the
ear as an angle, probably due to the ease of mea-
suring distance versus angulation. The author
would recommend measurement of the concho-
mastoid distance as the optimum method of
de fi ning outcome for the simple reason that it is
the most commonly published method and there-
fore allows authors to compare their work.
The most widely quoted description of con-
chomastoid measurement was by McDowell in
1968 [ 3 ] . He measured the projection at three lev-
els: the top of the helix, the Frankfort line, and
the tail of the helix. Messner and Crysdale [ 4 ]
added a fourth point, the superior line in 1996
(Fig. 57.1 ): The measurement of both ear projec-
tion and size requires the subject to be positioned
in a standardized way. This is best done by ensur-
ing the head is positioned so that the Frankfort
horizontal is parallel to the fl oor. The Frankfort
horizontal is a reference line that is primarily
used for cephalometric analysis. It is drawn from
the superior margin of the external auditory canal
on lateral radiographs to the inferior border of the
infraorbital rim and is familiar to medical pho-
tographers. They use this line to ensure correct
orientation of the head before taking lateral views
S. D. Richards , M.D., FRCSEd (ORL-HNS)
Department of Otorhinolaryngology, ENT Department ,
Rotherham NHS Foundation Trust ,
Moorgate Road , Rotherham , S60 2UD , UK
e-mail: stuart.richards@rothgen.nhs.uk
Measurement of Postoperative
Cephaloauricular Distance to
Evaluate and Compare Results
of Otoplasty
Stuart D. Richards

566
S.D. Richards
of the head [ 5 ] . Interestingly, Farkas [ 2 ] found
that the Frankfort horizontal is not always at the
same level on both sides; the left side is most
commonly lower than the right by 4°.
Documentation through photography should
be performed preoperatively for evaluation of
postoperative results and for medicolegal rea-
sons, with appropriate consent. Anterior-posterior
and lateral views are recommended with care to
ensure that the Frankfort horizontal is maintained
in the horizontal plane.
McDowell proposed normal values for the
three measurement points, which are consistent
with the measurements taken by Adamson et al.
(Table 57.1 ). Pilz et al. [ 6 ] and Messner and
Crysdale [ 4 ] have both published data on
postoperative outcome as measured by the con-
chomastoid distance.
Articles describing the objective assessment of
postoperative results also compare the results by
application of the McDowell and Wright criteria
[ 3, 7– 9 ] . These criteria are not truly objective, but
do bear mention as they are so commonly quoted
for comparing results. These criteria list six items
S
t
SL
FL
FL
CL
SL
S
CL
or
FH
FH
or
CL
FL
FL
CL
S
S
a
b
t
Fig. 57.1 Points for
measurement of cephaloau-
ricular distance. ( a )
Four-point measurement after
Anna H. Messner: S superior
point, SL superior line, FL
Frankfort line, CL conchal
line. ( b ) Three-point
measurement after Allyn J.
McDowell: top of the helix
( S ), Frankfort line ( FL ), tail
of the helix ( CL )
Table 57.1 Normal measurements of cephaloauricular
distances
Position on pinna
Measurement (mm)
Top of the helix
10–12
Frankfort line
16–18
Tail of the helix
20–22

567
57 Measurement of Postoperative Cephaloauricular Distance to Evaluate and Compare Results of Otoplasty
against which the outcome can be measured. They
consist of a mixture of subjective assessment and
measurement of ear proportions (Table 57.2 ).
It is a fact that most articles on the postopera-
tive results of otoplasty do not use consistent
objective measurement. The author published a
review of surgical outcomes in 2005 in which the
use of the measurement of the cephaloauricular
distance at the Frankfort horizontal [ 10 ] was
advocated. The most scienti fi cally useful method
is to utilize the three-point measurement described
by McDowell; however, to allow comparison to
the available literature, measurement at the
Frankfort horizontal is all that is required.
References
1. Adamson JE, Horton CE, Crawford HH. The growth
pattern of the external ear. Plast Reconstr Surg.
1965;36(4):466–70.
2. Davis J. Aesthetic and reconstructive otoplasty. New
York: Springer; 1987.
3. McDowell AJ. Goals in otoplasty for protruding ears.
Plast Reconstr Surg. 1968;41(1):17–27.
4. Messner AH, Crysdale WS. Otoplasty. Clinical proto-
col and long-term results. Arch Otolaryngol Head
Neck Surg. 1996;122(7):773–7.
5. Sorribes MM, Tos M. Nonsurgical treatment of
prominent ears with the Auri method. Arch
Otolaryngol Head Neck Surg. 2002;128(112):
1369–76.
6. Pilz S, Hintringer T, Bauer M. Otoplasty using a
spherical metal head dermabrader to form a retroau-
ricular furrow: fi ve-year results. Aesthetic Plast Surg.
1995;19(1):83–91.
7. Wright WK. Otoplasty goals and principles. Arch
Otolaryngol. 1970;92(12):568–72.
8. Lee D, Bluestone CD. The Becker technique for oto-
plasty: modi fi ed and revisited with long-term out-
comes. Laryngoscope. 2000;110(6):949–54.
9. Vital V, Printza A. Cartilage-sparing otoplasty: our
experience. J Laryngol Otol. 2002;116(9):682–5.
10. Richards SD, Jebreel A, Capper R. Otoplasty: a review
of the surgical techniques. Clin Otolaryngol.
2005;30(1):2–8.
Table 57.2 Goals of otoplasty according to McDowell and Wright
1. All trace of protrusion in the upper one third of the ear must be corrected (Some remaining protrusion in the
middle third or lower portions may be acceptable, provided the superior aspect is thoroughly corrected; however,
the reverse does not hold true)
2. From the front view, the helix of both ears should be seen beyond the antihelix (at least down to the mid-ear and
preferably all the way)
3. The helix should have a smooth and regular line throughout
4. The postauricular sulcus should not be markedly decreased or distorted
5. Protrusion should measure between 15 and 20 mm from the helix to the head
6. Position of the two ears (i.e., distance from the lateral border to the head) should be within 3 mm at any given
point

569
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_58, © Springer-Verlag Berlin Heidelberg 2013
58
The Subjective Point of View
in Aesthetic Surgery
Unarguably, the main aim of every aesthetic
surgery is to produce a subjective bene fi t for
the patient. However, most publications about
certain surgical procedures in aesthetic surgery
focus on details of the operative technique from
the surgeon’s point of view and on the occurrence
of complications, while the aesthetic outcome is
usually graded by the surgeons themselves. From
our own experience in surgery of the auricle,
sometimes there is a huge discrepancy between
the subjective perception of the surgical results
by the patient and the evaluation by medical
professionals. In a study performed in a large
collective of patients having received auricular
reconstruction [ 1 ] , it was striking how patients
with mediocre or even poor results from the sur-
geon’s point of view were nonetheless absolutely
satis fi ed, while on the other hand patients with
excellent results did not experience a relevant
subjective bene fi t from auricular reconstruction.
A subgroup analysis revealed that patients with
acquired auricular defects were twice more likely
to be not satis fi ed with the results compared to
patients with congenital deformities [ 1 ] . The
authors have found it helpful to indicate this fact
in preoperative counseling to prevent the devel-
opment of false expectations in certain patients;
this is an example how studies focusing on the
patients’ subjective point of view can have an
impact on clinical practice.
However, it seems obvious that assessing
satisfaction rates only is a too simple method.
Recently,
“health-related
quality
of
life”
(HRQOL) has established itself as a reasonable
construct to measure subjective bene fi t from inter-
ventions in a standardized approach [ 2, 3 ] . Today,
HRQOL is considered by many authors even to
be the most important parameter in the evaluation
of a therapy regime [ 3 ] . Measuring HRQOL is
a valuable approach particularly in aesthetic sur-
gery with its main aim being to produce a subjec-
tive bene fi t for the patient and with the dif fi culty
to collect objective data that are often restricted
to anthropometric variables. Although there is no
gold standard for measuring HRQOL, it is gener-
ally agreed that HRQOL is a multidimensional
item, which includes physical, psychological,
and social aspects [ 3 ] . A still growing number
of validated questionnaires have been developed
to measure HRQOL. However, not all of them
seem to be appropriate for the evaluation of aes-
thetic surgery, since they predominantly cover
T. Braun , M.D. (*) • A. Berghaus , M.D.
J. M. Hempel , M.D.
Department of Otorhinolaryngology,
Head and Neck Surgery ,
Ludwig Maximilian University ,
Munich , Germany
Klinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde
der Ludwig-Maximilians-Universität München ,
Marchioninistraße 15 , Munich , D-81377 , Germany
e-mail: thomas.braun@med.uni-muenchen.de ;
alexander.berghaus@med.uni-muenchen.de ;
john-martin.hempel@med.uni-muenchen.de
Otoplasty : Focusing on Patient
Bene fi t and Health-Related
Quality of Life
Thomas Braun , Alexander Berghaus ,
and John Martin Hempel

570
T. Braun et al.
too general aspects of an individual’s health, like
the ability to perform daily activities autono-
mously (e.g., The Short Form 36 Health Survey
Questionnaire, SF-36 [ 4 ] ). The authors have
made good experiences with the Glasgow Bene fi t
Inventory (GBI) developed by Stuart Gatehouse
[ 5 ] , a questionnaire which is well validated for
otorhinolaryngological interventions and particu-
larly for plastic surgery [ 6 ] . Another advantage
is that also a validated version for children exists
(Glasgow Children’s Bene fi t Inventory, GCBI)
[ 7 ] . Both questionnaires are sensitive tools for
changes in health status following an interven-
tion. The GBI consists of 18 questions covering
different aspects of health-related quality of life.
Answers are selected from a Likert scale rang-
ing from 1 to 5. Raw data are processed into total
GBI scores, which can range from −100 (maximal
adverse effect of the operation) over 0 (no effect)
to +100 (maximal positive effect). Additionally,
subscores can be calculated: a general subscore,
a social support score, and a physical health score
[ 5, 6 ] . The GCBI is constructed as an analogue
to the GBI but consists of 24 questions and is
answered by the patient’s parents; in addition to
a total score (ranging from −100 to +100), the
subscores emotion, physical health, learning, and
vitality can be calculated [ 7 ] .
Effects of Otoplasty on Patients’
Health-Related Quality of Life
Prominent ears do not have any physiological
disadvantages and are considered to be a minor
auricular deformity. However, several studies
show that the emotional stress caused by teasing
due to an ear deformity leads to a decline in the
patient’s HRQOL, resulting in loss of self-
con fi dence, social avoidance, and poor school or
job performance [ 8– 10 ] . Attractive individuals
are judged to be socially more desirable and are
expected to have better prospects for social and
professional lives [ 11 ] . Accordingly, negative
evaluation of personal attractiveness in children
is associated with dysphoria [ 12 ] . Thus, since
about 5 % of the population suffer from promi-
nent ears, otoplasty is the most common aesthetic
surgery in children and adolescents [ 13, 14 ] .
Several studies using validated questionnaires
show that otoplasty leads to improvements in
self-esteem and behavior as well as reduced
psychological anxiety or depression [ 15– 18 ] .
Bradbury et al. analyzed a collective of 30 chil-
dren suffering from protruding ears (without
using validated tools): 63 % reported an increase
in happiness and con fi dence after otoplasty; 13 %
reported improvement in social experience in
terms of better integration with other children;
53 % reported teasing and bullying to have
stopped postoperatively [ 19 ] . An analogous study
by Cooper-Hobson and Jaffe yielded even more
promising results: 97 % reported an increase in
happiness and 92 % in self-con fi dence, 79 %
noted improved social experience, and 100 %
reported bullying reduced or stopped [ 20 ] .
As pointed out above, HRQOL with its holistic
approach is one of the most important parameters
in the evaluation of a therapy regime. Remarkably,
only few studies evaluating the effect of otoplasty
on HRQOL using validated tools are available in
the current medical literature.
Studies Using SF-36 to Measure HRQOL
The Short Form 36 Health Survey Questionnaire
(SF-36) is a well-validated tool that measures
eight aspects of health status: physical function,
role limitations due to physical problems, role
limitations due to emotional problems, social
function, mental health, energy, pain, and health
perception [ 4 ] . Klassen et al. [ 16 ] have been able
to show that patients undergoing otoplasty
( n = 41) had reduced social functioning and men-
tal health scores compared to normative data;
after otoplasty, patients ( n = 31) reached values of
the general population.
Studies Using GBI/GCBI
to Measure HRQOL
Schwentner et al. conducted a study using the
GBI in an adult population of fi ve men and nine
women having received otoplasty with modi fi ed
techniques according to Stenström et al. [ 21 ] .
A median GBI total score of 37.5 and a general

571
58 Otoplasty : Focusing on Patient Bene fi t and Health-Related Quality of Life
subscale score of 58.3 were found, while the medi-
ans of the social support and the physical health
score were 0.0. No differences were found between
male and female patients in total GBI scores or
any subscores. Furthermore, no statistical differ-
ences were found between short (<3 years) and
long (>3 years) follow-up periods. Schwentner
et al. therefore conclude that otoplasty leads to a
long-lasting improvement in patients’ HRQOL.
Since analogous data in the main patient
group, children and adolescents, were missing,
we initiated a study to analyze the HRQOL after
otoplasty in our own patients [ 22 ] . We almost
invariably perform suture techniques for reasons
stated later in this chapter. Sixty-two patients (27
men, 35 women) were assessed with the GBI. For
the adults’ cohort ( n = 21), the mean total GBI
score was 30.6 and the mean general subscore
43.0, indicating a bene fi t from the operation. The
social support and the physical health score were
only marginally elevated (mean 7.9 and 9.5,
respectively). The HRQOL was raised in 95.2 %
of the adult patients (indicated by total GBI
scores >0). Negative GBI scores or subscores
were not found in a single case. As in the study
by Schwentner et al. [ 21 ] , statistical analysis
showed no signi fi cant differences in the scores
and subscores of male and female patients.
100.0 % of the adults were satis fi ed with the aes-
thetical result. 90.5 % would again decide in
favor of the operation. For the children’s cohort,
the mean total GCBI score was 24.1. All GCBI
subscores (emotion, physical health, learning,
and vitality) were raised (mean 31.8, 16.5, 19.9,
and 24.6, respectively). The HRQOL was raised
in 95.1 % of the children (indicated by total GCBI
scores >0). Same as in the adults’ collective, no
negative GCBI scores or subscores and no differ-
ences between male and female patients were found.
95.1 % of the parents and 95.1 % of the children
were satis fi ed with the aesthetical result. 97.6 % of
the parents and 92.7 % of the children would again
decide in favor of the operation. GBI and GCBI
scores of patients with short-term (<6 months) and
long-term (>2 years) follow-up times did not show
statistical differences. Therefore, the fi ndings of
Schwentner et al. were con fi rmed saying that sub-
jective bene fi t from otoplasty seems to be stable
over the time.
To put it in a nutshell, otoplasty can signi fi cantly
increase the HRQOL of children and adults suf-
fering from protruding ears, and it leads to a high
rate of patient satisfaction. An advantage of stan-
dardized measurement of HRQOL after aesthetic
surgery is that a comparison with other operative
techniques or other fi elds of aesthetic surgery is
possible. Table 58.1 shows that the extent of the
effect of otoplasty on HRQOL is comparable to
other purely aesthetic operations, like ear recon-
struction or rhinoplasty, but lower than for opera-
tions with both a functional and aesthetic aim in
the head and neck area.
When Should Otoplasty Be
Performed?
Songu and Adibelli [ 26 ] conducted a survey in
ten patients with a median age of 51.5 months
and found that nine out of ten parents were
“very” or “completely” satis fi ed with the result of
otoplasty in their children; from their results, the
Table 58.1 GCI and GCBI total scores after otoplasty as published to the present date in comparison with selected
data from other aesthetic operations in the head and neck area
Operation
Authors
Mean GBI/GCBI total score
Collective
Otoplasty
Schwentner et al. 2006 [ 21 ]
37.5 (median)
Adults
Braun et al. 2010 [ 22 ]
30.6 (mean and median)
Adults
Braun et al. 2010 [ 22 ]
24.1
Children
Auricular reconstruction
Braun et al. 2010 [ 1 ]
21.1
Adults
Braun et al. 2010 [ 1 ]
27.7
Children
Cosmetic (septo)rhinoplasty
Robinson et al. 1996 [ 6 ]
24.0
Adults
Draper et al. 2007 [ 23 ]
20.0
Adults
Cosmetic and functional
(septo)rhinoplasty
McKiernan et al. 2001 [ 24 ]
58.3
Adults
Chauhan et al. 2010 [ 25 ]
53.8
Adolescents

572
T. Braun et al.
authors recommend to perform otoplasty before
the age of fi ve, since they think that there may
be signi fi cant bene fi t from an early intervention
after the child has expressed some concern about
the deformity.
From the authors’ data, it can be concluded
that children seem to take a larger bene fi t from
otoplasty than adults: Whereas in the children’s
cohort all GCBI scores and subscores were
signi fi cantly elevated, social support and physical
health scores in the adults’ cohort were affected
insigni fi cantly only [ 22 ] . It can be speculated
that problems with participating in social life
due to reduced self-con fi dence because of the
protruding ears remain constant with increasing
age and that physical health in adults is usually
not affected by aesthetic operations. Also, with
increasing age at the time of otoplasty, patients
state that the timing of the operation was too late,
most probably due to an increased period of time
during which they are teased for the protruding
ears. Patients who stated that the operation was
performed too late had received surgery at the
median age of 15.5, while the patients stating that
the operation was performed at the right age had
received surgery more than 5 years earlier.
Therefore, the recommendation can be given
to operate before the beginning of puberty, if pos-
sible, and in cases of need as early as in the age
around fi ve.
Otoplasty: Patient Bene fi t
Guaranteed?
The positive fi ndings for the effect of otoplasty
discussed above have to be attenuated for several
reasons. Of course, neither subjective bene fi t
from the operation nor satisfaction with the result
can be guaranteed as for every aesthetic opera-
tion. Also, complications can occur to a consider-
able extent (e.g., [ 27, 28 ] ). While minor
complications like postoperative pain and hyper-
sensitivity, relapse or asymmetry, thread granu-
loma, othematoma, or scar and small keloid
formation, if handled adequately by the experi-
enced surgeon, do not threaten the bene fi cial
effect of otoplasty [ 22 ] , auricular deformities
after failed otoplasty often result in an appear-
ance which is more annoying than the preopera-
tive state of prominent ears.
The huge number of different techniques
for correcting protruding ears can be grouped
into three basic concepts: the cutting technique
described by Converse [ 7 ] , the scoring tech-
nique according to Stenström [ 29 ] , and the pure
suture techniques introduced by Mustardé [ 30 ] .
Compared to all cutting or scoring techniques,
the risk of undesired edges, defects, or deformi-
ties dif fi cult to correct is lower with cartilage-
sparing, suture techniques [ 14, 31, 32 ] . The
authors therefore think otoplasty using suture
technique is especially recommendable when
focusing on patient bene fi t. In our own patients,
we use to fold the antihelix with sutures accord-
ing to Mustardé [ 30 ] and, if necessary, approxi-
mate the cavum conchae to the skull as described
by Furnas [ 33 ] and Goldstein [ 34 ] and correct the
earlobe position by a suspension suture follow-
ing the recommendations of Crikelair, Siegert,
and Weerda [ 35 ] .
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575
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_59, © Springer-Verlag Berlin Heidelberg 2013
59
Introduction
Nowadays, physical appearances are of major
importance because of the beauty ideal that con-
stantly appears in the media and that has been
increased by social networking in the Internet
era. Better socioeconomic statuses allow the use
of plastic surgery as an affordable method to
improve physical appearances to achieve our
society’s ideal of beauty.
Surgical treatment of prominent ears is
more than a simple cosmetic correction. On
one hand, it is a plastic surgery, which implies
that there should be a con fi dence-based physi-
cian-patient relationship. In this situation, the
surgeon and the patient can reach an agree-
ment about the preoperative expectations and
the best postoperative results that can be
achieved. This is important because in plastic
surgery it is all about a “results contract.” It is
also very important to determine if there is a
body dysmorphic disorder underlying patient’s
problem, because it is known that such patients
will not feel better after the surgery even with
the best technical results, so they may also need
a psychiatric evaluation. But, on the other hand,
in the case of protruding ears, as in other kinds
of physical anomalies, there is an important
psychosocial component that has to be
considered.
It is dif fi cult to establish a clear differentia-
tion between the objective physical and subjec-
tive aspects, and although prominent ears are
considered a minor defect with no physiological
disadvantages, this defect is a frequent source of
severe social and psychological problems. The
aim of this chapter is to describe these factors and
their relationships with otoplasty.
Otoplasty
Prominent Ears
Prominent ears are the most frequent congenital
craniofacial malformation, with an incidence of
near 5 % in the Caucasian population and both
sexes affected equally [ 1, 2 ] . It is transmitted
by an autosomal dominant pattern with vari-
able penetrance. Eight percent of the patients
[ 1 ] have familial antecedents. Environmental
factors have also been implicated in its
R. A. Cuesta , M.D. (*)
Department of Pediatrics and Pediatric Surgery ,
Hospital Clínico Universitario de Valladolid ,
C/Ramón y Cajal, 3 , 47003 Valladolid , Spain
e-mail: raquelnita@gmail.com,
C. S. Beauregard , M.D., Ph.D.
Department of Pediatric Surgery ,
Hospital Clínico San Carlos ,
C/Prof. Martín Lagos s/n , 28040 Madrid , Spain
e-mail: cirped.hcsc@salud.madrid.org
Psychosocial, Behavioral,
and Emotional Effects Following
Otoplasty
Raquel Aguilar Cuesta and Carmen Soto Beauregard