Part III
Techniques
43
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_5, © Springer-Verlag Berlin Heidelberg 2013
5
Introduction
To appreciate how far we have gone to develop
the treatment of the prominent ear, we must
understand the historical development of oto-
plasty. Ear repair began with fl aps for repair of
injuries and distortions. Ultimately the repairs
extended to the prominent ear for cosmetic
improvement. Myriads of techniques and
modi fi cations have been reported.
History
Sushruta, in Sushruta Samhita, described various
reconstructive methods or different types of
defects like release of the skin for covering small
defects, rotation of the fl aps to make up for the
partial loss, and pedicle fl aps for covering com-
plete loss of skin from an area such as earlobe
reconstruction [ 1 ] . In 30 A.D., Aulus Cornelius
Celsus in De Medicina [ 2 ] referred to repair of
mutilated ears with advancement quadrangle fl aps
[ 3 ] . Gaspari Tagliacozzi (1597), in his treatise De
Curtorum Chirurgia per Institutionem, instructed
surgeons on how to reconstruct ears [ 4 ] .
Dieffenbach [ 5 ] attempted to correct the pro-
truding, or lop ear, deformity with postauricular
skin excision in the auriculocephalic sulcus with
conchomastoidal fi xation. The correction of
protruding (large) ears (macrotia) was by means
of triangular excisions taken from the auricle
described by de Martino in 1856 [ 6 ] . In 1968,
Rogers [ 7 ] claimed that the origins of otoplasty
for the prominent ear were by Eli [ 8 ] who
described prominent ear correction that con-
sisted of postauricular skin excision, concho-
mastoidal fi xation, and conchal strip excision.
Keen [ 9 ] removed a narrow, V-shaped section of
cartilage from the posterior surface of the auri-
cle after a large section of skin had been excised.
Monks [ 10 ] described removal of skin from the
back of the ear, but if the cartilage was stiff, then
excision of some cartilage. Cocheril [ 11 ]
modi fi ed the original techniques by adding inci-
sion and excision of various parts of the conchal
cartilage to improve the results. Haug [ 12 ]
reported removal of triangular wedges of carti-
lage along with excision of the skin on the pos-
terior surface of the auricle. In 1896, Joseph
[ 13 ] divided protruding ears into two types: the
soft and the hard cartilage types. For ears of the
soft cartilage type, he advised excision of skin at
the auriculomastoid angle. For the hard cartilage
type, he advised resection of cartilage from the
region along with excision of skin. The promi-
nent ear in children was corrected by
DeSchweinitz and Randall [ 14 ] by attaching the
auricle to the skull surface with glue or collo-
dion and bandaging it fi rmly union the union
was secure. In adults skin excisions were made
on the back of the ear and over the mastoid, but
no cartilage was excised.
M. A. Shiffman , M.D., J.D.
Section of Surgery , Newport Specialty Hospital ,
17501 Chatham Drive , 92780-2302 Tustin , CA , USA
e-mail: shiffmanmdjd@gmail.com
History of Otoplasty: Review
of Literature
Melvin A. Shiffman
44
M.A. Shiffman
Gersuny [ 15 ] sutured the perichondrium to the
mastoid periosteum. Morestin [ 16 ] bent the carti-
lage and held it in place with nonabsorbable
sutures. He believed that the incision through the
cartilage must extend well up to the upper and
lower borders of the cartilage. Payr [ 17 ] embed-
ded a cartilage fl ap under the periosteum. Miller
[ 18 ] described his experience in the correction of
various facial deformities including “outstand-
ing” ears. Goldstein [ 19 ] described an operation
similar to Morestin, but he sutured the cartilage
to the mastoid periosteum.
Luckett [ 20 ] (Fig. 5.1 ) resorted to a cartilage-
breaking technique consisting of crescent medial
skin and cartilage excision along the entire verti-
cal length of the antihelical fold to restore the
antihelical fold. However, this produced a sharp
outline to the antihelical fold in some cases.
Luckett attempted to alleviate this problem with
several horizontal mattress sutures, as adapted
from Lembert, that allowed the fl at surfaces of the
concha and the antihelix to be apposed, not the
edges of each, as the sutures were tied tightly.
Modi fi cations of Luckett’s technique include:
Barsky [ 21 ] beveled the borders and kept an
intact segment of cartilage over the cartilage
incisions by suturing the cut edges under a
bridge, Baxter [ 22 ] made parallel incisions of the
cartilage instead of a single one, Young [ 23 ] pro-
longed the cartilage incision to break the spring
and avoid suturing, Farina (Fig. 5.2 ) [ 24 ] varied
the skin incision and cartilage resection (Fig. 5.3 ),
Vidaurre [ 25 ] added an incision for the anterior
crus, and Seltzer [ 26 ] gave a lengthy description
Fig. 5.1 Luckett’s technique (1910) [ 20 ] . Excision of car-
tilage along predetermined site of the antihelix with sutures
in place. A to A ¢: Skin closure, B to B ¢: Cartilage closure
a
b
Fig. 5.2 Farina’s technique
(1951) [ 24 ] . ( a ) dabc :
Cutaneous incision. ab : Trunk
of antihelix. bx : Superior
ramus of antihelix. bz :
Inferior ramus of antihelix.
( b ) Elliptical cartilaginous
excision. a : Portion of scapha
removed. b : Portion of concha
removed. cc ¢ : Incision of
inferior ramus of antihelix
45
5 History of Otoplasty: Review of Literature
of his technique, including obliterating the post-
auricular sulcus, modifying Luckett’s technique.
Hatch [ 27 ] modi fi ed Luckett’s procedure by
removing three separate, though continuous,
crescent-shaped pieces of tissue: two of which
are cartilage, and one of which is cartilage and
fat in the lobule. This repositioning allowed the
ear to open out in three separate and opposing
directions simultaneously to produce anatomic
and aesthetic normality; Jones [ 28 ] excised a
wider cartilage strip in order to decrease the
sharpness of the antihelical ridge; Holmes [ 29 ]
used a special gouge to make fi sh-like scales up
and down the proposed antihelix (Fig. 5.3 );
Cloutier [ 30 ] divided the cartilage from the top
of the ear to the lobule and the skin overlying
the anterior surface of the cartilage dissected
off the cartilage approximately 3/8 in. on each
side. The upper and lower ends of one edge of
the cartilage are grasped with forceps and turned
back so that the anterior side of the cartilage
faces the operator. The edge of the cartilage is
beveled with a razor blade. The edge of the car-
tilage will curl, and the width of the curl will
depend on the width of the beveled edge. The
proper width should be made on the fi rst attempt.
A similar procedure is carried out on the other
edge of cartilage. The cartilage does not require
suturing; McDowell [ 31 ] made a precise place-
ment of the main cartilage incision from the pos-
terior surface while continuously observing the
marked line to follow on the anterior surface of
the ear (Fig. 5.4 ). The knife point goes through
the cartilage, and its continuing path is easily
seen under the anterior skin. This method allows
for a quicker and more accurate incision than
does the use of perforating needles.
Ruttin [ 32 ] anchored the cartilage with fascia
lata strips. Kolle [ 33 ] corrected protruding
( macrotia) ears with excision of skin and an
elongated ellipse of cartilage (Fig. 5.5 ).
Alexander [ 34 ] corrected ear prominence due to
a high concha by incising and overlapping the
posterior wall of the concha. Frühwald [ 35 ]
removed a wedge of tissue with scissors at the
junction of the upper and middle thirds of the
helix extending into the cavity of the concha.
This was then closed by approximating the edges
of the wound. Demel [ 36 ] advised the removal of
a large section of conchal cartilage to be turned
on itself and pedicled beneath a bridge of perios-
teum over the mastoid region. Eltner [ 37 ] tried
to eliminate the wrinkling of skin on the ante-
rior surface that occurred with the Joseph and
Morestin techniques, by excising two triangles
of cartilage with a common base from the region
of the concha. The skin and perichondrium were
incised horizontally and then undermined before
excision of the cartilage. Davis and Kitlowski
[ 38 ] described the use of needles passed through
and through the auricle to mark the antihelix.
They recommended dipping the needles in a
dye and then marked the cartilage with a series
of puncture points to assist in the incision
and remodeling of the auricular cartilage.
MacColumm [ 39 ] and Young [ 40 ] combined the
Luckett technique of antihelical correction with
earlier techniques of conchal reduction that now
forms the foundation for most of the modern oto-
plasty techniques for correcting the prominent
ear deformity.
New and Erich [ 41 ] described a technique of
external stay sutures that permitted an easy and
fl exible method of modeling the antihelix fold
and maintaining the infolding of the cartilage in
position during healing.
Fig. 5.3 Holmes’ technique (1959) [ 29 ] . A method of
breaking cartilage spring using a special gouge. Point of
blade should come just through the cartilage on the ante-
rior surface
46
M.A. Shiffman
a
b
c
d
e
Fig. 5.4 McDowell’s technique (1968) [ 31 ] . ( a ) Line of
main cartilage incision marked on anterior surface. Note
exaggerated curvature in line for new superior crus. ( b )
Shaded areas show approximate scope and location of carti-
lage excision as related to the initial cartilage incision. ( c )
Cross-hatched area shows skin marked for excision. An
elongated dumbbell pattern provides for 1–3 mm excision in
mid-portion but several mm at each end. ( d ) Corrected ear:
Distance from outer border of helix to mastoid skin should be
10–12 mm at top , 16–18 mm in mid-portion, and 20–22 mm
in lower third. ( e ) After main cartilage excision is completed,
the edges should be trimmed square or else beveled only in
the direction advocated by Cloutier. ( f ) Careful trimming of
cartilage edges does much toward avoiding sharpness of the
new antihelix. Slight subluxation of scaphal cartilage does
not spoil the antihelix crest and helps the overall correction
47
5 History of Otoplasty: Review of Literature
Fishman and Fishman [ 42 ] used a through-
and-through excision after premarking (Fig. 5.6 ).
The outer or lateral portion followed the curve
of the helix closely extending beyond the crural
of the antihelix at the upper end and into and
through the length of the fossa of the concha at
the lower end. The medial incision was in accor-
dance with the amount of skin and cartilage
required to be excised. Subsequent modi fi cations
were described by Pierce et al. [ 43 ] , Dufourmental
[ 44 ] , and Paletta et al. [ 45 ] .
Borges [ 46 ] felt that Young’s technique had
the disadvantage of the middle ridge and the
superior crus being too sharp and does not
conform to the normal ear. He modi fi ed the
technique by not excising the elliptical strip of
cartilage from the concha but just incising and
crisscrossing it while excising the inferior
and internal strip from the concha (Fig. 5.7 ) so
that it may give bulk and roundness to
the superior crus and medial part of the
antihelix.
a
b
Fig. 5.5 Kolle’s technique
(1911) [ 33 ] . ( a ) An incision is
made along the whole back of
the ear as far down as the
sulcus, where the retroaural
integument joins that of the
neck. The skin incision is ¾ to
½ in. from the outer border.
Oozing blood from the skin is
impressed on the skin by
pressing the ear backward on
the bare skin of the head,
leaving an imprint. A second
incision is made along this line,
fi ving the total heart-shaped
outline. ( b ) The skin is removed
and an elongated ellipse of
cartilage excised. Catgut sutures
are placed through the conchal
cartilage and deeper tissue back
of the ear. A continuous running
suture is used in the skin
f
Fig. 5.4 (continued)
48
M.A. Shiffman
McEvitt [ 47 ] used multiple parallel antihelical
incisions to soften the hard-edge contours of the
corrected antihelical fold (Fig. 5.8 ). He also
divided protruded ears into types:
Type 1: Ears of normal size with moderate pro-
trusion caused by underdevelopment of the
normal fold of the antihelix. The concha and
fossae are approximately normal size, and
their ratio to one another is correct. The anti-
tragus is not overprominent.
Type 2: Large ears usually with marked protru-
sion, underdevelopment of the fold of the anti-
helix, overprominence of the antitragus, and
wide scapha (fossa of the helix).
Type 3: Long narrow ears with little or no evi-
dence of the antihelix. The structure seems
curled forward. The concha and fossae form a
continuous hollow giving the ear almost the
appearance of a shell. They tend to be wide at
the top and taper toward the lobule being
roughly triangular.
Weaver [ 48 ] modi fi ed the technique of New
and Erich (1940).
Becker [ 49 ] described a procedure with an
incision through the skin and perichondrium in
the postauricular region of the margin between
the scapha and the concha, in the fossa antiheli-
cis, and extended at the superior portion to the
junction of the ear and temporal region, while at
the inferior portion it is extended down to the
base of the antitragus close to the mastoid region
(Fig. 5.9 ). The skin and perichondrium are
undermined laterally almost to the mastoid
angle and to the beginning rim of the helix. The
ear is folded back against the head to show the
new antihelix. Skin and cartilage are pierced by
a needle and the posterior surface of the carti-
lage marked with methylene blue. The double
row of marks delineates the posterior and ante-
rior borders of the antihelix and superior crus.
Two incisions are made through the cartilage
along the markings and a section of cartilage
removed from the antihelix. The skin is under-
mined laterally for a few millimeters on the
anterior surface of the auricle. The sulcus anti-
helicis transversus is incised completely through
extending the incision into the previously incised
cartilage of the antihelix that breaks the spring
of the inferior crus. The cauda helicis is
completely removed and the superior crus cross-
cut by incisions to weaken the spring of the
cartilage. A small transverse section of cartilage
Crisscrossed
Excised
Fig. 5.7 Borges’ [ 46 ] technique. The superior and exter-
nal strip of cartilage from the scapha is incised and criss-
crossed while the inferior and internal strip from the
concha is excised
a
b
Fig. 5.6 Fishman and Fishman [ 42 ] technique. Lines of
incision. ( a ) Outer or lateral incision following the curve
of the antihelix extending beyond the crura of the antihe-
lix at the upper end and through the length of the fossa of
the concha at the lower end. ( b ) Second incision medial to
the fi rst in accordance with the amount of skin and carti-
lage required to be excised
49
5 History of Otoplasty: Review of Literature
Fig. 5.8 McEvitt’s technique (1947) [ 47 ] . ( a ) (1) Limit
of antihelix excision. (2) Limit of incisional weakening.
( b ) Transfer of outline to posterior surface by method of
Davis and Kitlowski. ( c ) Ellipse of skin excised showing
needle marks on the underlying cartilage. ( d ) Excision of
cartilage along antihelix line with projection for posterior
crus, wide inferior excision in antitragus, parallel weaken-
ing incision, and three sutures in position. ( e ) Sutures tied
forming antihelix. ( f ) Closure of skin with interrupted silk
sutures
a
b
c
d
e
A
B
f
50
M.A. Shiffman
Fig. 5.9 Becker’s technique (1949) [ 49 ] . ( a ) Incision
through skin and perichondrium on the posterior surface
of the auricle in the region of the fossa antihelicis. ( b )
Undermining of the skin and perichondrium almost to the
auriculmastoid angle. ( c ) Complete exposure of the poste-
rior surface of auricle, revealing all landmarks; undermin-
ing of the skin anteriorly to expose the cauda helicis and
fi ssure antitragohelicis. ( d ) Outlining of the new antihelix
a
b
c
d
e
f
51
5 History of Otoplasty: Review of Literature
and its posterior crus. When the ear is folded back, the
new antihelicis is noted on the anterior surface of the auri-
cle. The skin is punctured through from the anterior sur-
face with a fi ne needle along the outer and inner borders
of the new antihelix and superior crus. Each point is
marked on the posterior surface of the auricular cartilage
with methylene blue to delineate the cartilage incision. No
markings are necessary to outline the inferior crus since
the sulcus antihelicis transversus is usually visible. ( e )
Incision made along the markings down to the fi ssure
antitragohelicina. An incision is also made through the
sulcus antihelicis transversus to form the inferior crus. A
diamond-shaped section of cartilage is the outlined, which
extends up to the inferior crus. ( f ) Section of cartilage
removed. The width of the excision carries with the
amount of spring found in the cartilage. ( g ) Cauda helicis
exposed and removed. This procedure is necessary in the
majority of cases. An incision is made at the upper end of
the superior crus for removal of a section of cartilage.
This incision is located under the helix and is usually nec-
essary to break completely the spring of the cartilage. ( h )
The cartilage removed. ( i ) Partial crosscutting of the
remaining cartilage that forms the superior crus. These
incisions are made to weaken the spring of the cartilage
and must not pass completely through the cartilage. In
cases in which the cartilage is soft and pliable, crosscut-
ting is not necessary. In other cases, thinning of the carti-
lage by shaving is suf fi cient to weaken the spring.
A section of antitragus is removed in most cases of
extreme cupping of the lower portion of the ear. ( j ) Surgical
gut fi xation sutures inserted. The sutures are tied only
tight enough to form a smooth antihelix and superior crus.
External mattress sutures tied over cotton rolls, instead of
surgical gut sutures, have been used to good advantage in
many cases. If the cartilage is soft and pliable, allowing
the ear to fall back easily, no fi xation sutures are neces-
sary. Excess skin is trimmed, and black silk sutures are
used to close the incision
g
i
j
h
Fig. 5.9 (continued)
52
M.A. Shiffman
is removed from the upper end of the superior
crus to completely break the spring of the anti-
helix and superior crus. Three or four surgical
gut mattress sutures are inserted in the perichon-
drium along the margins of the original incisions
in the cartilage and tied to form the new
antihelical fold. Excess skin is excised and the
skin sutured closed.
Jayes and Dale [ 50 ] modi fi ed the Luckett tech-
nique by also using antihelical incisions. Also,
they classi fi ed the prominent ear into types:
Type 1: The antihelix is formed but is not folded
back as sharply as in a normal ear, and the
scapho-conchal angle is widened. The ear is
small and it will not be abnormally promi-
nent, but if large, it will de fi nitely “stick
out.”
Type 2: Superior crus of the antihelix is absent.
The upper part of the scapha looks abnor-
mally wide owing to the absence of the
dividing ridge. The whole upper part of the
ear turns forward and tends to droop as it
lacks the stiffening support of the superior
crus.
Type 3: The whole of the antihelix is poorly
formed, and the scapho-conchal angle is
widely obtuse. The superior crus is absent.
The inferior crus and the lower part of the
antihelix, though visible, are very much
fl attened. The ear stands sharply out from the
head at a right angle.
Type 4: The antihelix is totally absent. The ear is
of the fetal type curving smoothly outward
and forward from the head in the pane of the
concha. This type of deformity is sometimes
associated with microtia or relative shortness
of the helix.
Sercer [ 51 ] resected the anterior spine of the
helix, thinned the back of the conch, and excised
an ellipse or myrtle-leaf piece of the retroau-
ricular skin. Kristensen [ 52 ] devised variations
in skin resection and cartilage incisions
(Fig. 5.10 ). Becker [ 53 ] described parallel anti-
helical incisions held together by permanent
sutures to produce conical antihelical tubing in
order to soften the external contour of the cor-
rected prominent ear. This was re fi ned by
Converse et al. [ 54 ] and further elaborated by
Converse and Wood-Smith [ 55 ] (Fig. 5.11 ) and
Wood-Smith and Converse [ 56 ] .
Straith [ 57 ] corrected unpleasant effects of
otoplasty (Fig. 5.12 ) by (1) running a cutaneous
0000 nylon suture just back of the cut edges of the
concha and helix; (2) predetermining the correct
height of concha and antihelix by folding the ear
back and placing needles, after which the needles
are removed and the ear folded back to determine
the amount of cartilage to be determined and
excised accordingly; and (3) predetermining the
formation of a normal curve of the antihelix by
folding the ear back and placing the needles along
the edges of the concha and triangular fossa.
a
b
Fig. 5.10 Kristensen’s
technique (1952) [ 52 ] . ( a )
Postauricular skin excision.
( b ) Parallel incision in the
cartilage
53
5 History of Otoplasty: Review of Literature
Fig. 5.11 Converse and Wood-Smith technique is a carti-
lage-breaking technique applicable to severe prominent ear
deformities in all age groups. ( a ) Prominence of the ear
with conchal excess, lack of an antihelical fold, and oblique-
ness of the conchoscaphal angle. ( b ) While pressing medi-
ally on the prominent ear helix, several linear markings are
drawn on the anterior surface. These markings surround the
superior crus on three sides and include the superior rim of
the triangular fossa, the upper border of the superior crus,
and the junction of the scapha with the helix. The conchal
rim is marked by its full length. ( c ) Markings are visualized
on both anterior and posterior auricular surfaces. ( d ) By
passing a straight Keith cutting needle through the ear, the
exact location of the posterior auricular skin excision is
determined. The skin is excised down to the cartilage,
excising all soft tissue and perichondrium from the poste-
rior auricular cartilage. ( e ) The straight Keith needles are
passed through the previous anterior marking so that the
anterior cartilage markings can be transposed to the
posterior surface of the cartilage. ( f ) Transference of all
markings requires that the posterior skin and perichondrium
be dissected off the cartilage to the rim of the helix. Full-
thickness breaks in the cartilage can then be made with care
to preserve the anterior skin of the ear. ( g ) Tubing of the
antihelix is performed with several permanent white sutures
placed in mattress fashion. The sutures are tied simultane-
ously with enough tension to provide for the proper amount
of tubing of the antihelix. ( h ) The amount of conchal carti-
lage excess is estimated by pressing inward on the newly
folded antihelix. ( i ) The conchal excess is excised from the
conchal rim, usually performed in elliptical fashion.
Variations may be required depending on the deformity. ( j )
The edges of the newly formed antihelix and freshly con-
toured conchal rim are approximated with several well-
placed 4-0 permanent white sutures placed in mattress
fashion. The sutures are tied with enough tension to provide
the intended end result and are placed in such a fashion that
the edges of the cartilage do not evert
a
c
d
b
54
M.A. Shiffman
Usually a strip no more than 2 mm wide is excised
to give a normal appearance.
Surgical abrasion of the antihelix was
described by Stark and Saunders [ 58 ] . Mustarde
(1963 [ 59 ] , 1967 [ 60 ] , 1971 [ 61 ] ) simpli fi ed these
techniques by creating a conical antihelical tub-
ing with permanent conchoscaphal mattress
sutures (Fig. 5.13 ). These sutures, placed full
e
h
i
j
f
g
Fig. 5.11 (continued)
55
5 History of Otoplasty: Review of Literature
thickness through the cartilage of the concha and
scapha in mattress fashion without piercing the
lateral skin, are particularly successful to treat the
pliable cartilage of children. All cartilage tubing
techniques depend on scarring to fi ll the tube and
lock the sculpted framework into position.
Tamerin and Mirehouse [ 62 ] noted the ten-
dency of the auricular cartilage in the region of
the helix to curl backward when it is incised
near the free edge of the ear and when it is
separated from its anterior lining perichondrium.
Farrior [ 63 ] used the smallest dermabrader to
remove parallel concave troughs similar to the
full-thickness wedges removed in the current
technique. The strips that remain between the
troughs give body and resilience to the ear.
He used a method of three incisions and an over-
riding cartilage strip in the reconstruction
of the antihelix proper. He did not join the supe-
rior crus and conchal rim incisions but left an
a
c
b
Fig. 5.12 Straith’s technique (1953) [ 57 ] . ( a ) By normal
pressure the helix is forced back into a normal position
and the height and shape of the antihelix determined. The
ear is pierced by needles approximately 1 cm below the
desired antihelical rim (after the method of Davis and
Kitlowski). ( b ) An incision is made just above the needles
that are then removed, and the ear is folded back for
examination. The excess cartilage as seen anteriorly can
then be removed to the desired shape and height of the
antihelix and posterior crus. ( c ) A subcuticular suture is
started at one end. Four-millimeter bites are taken in
alternate edges of the under surface of the antihelix
approximately 1 mm back from the edges. At the center
of the antihelix, these sutures are brought out to the sur-
face to facilitate easy removal in two sections. The ear is
folded back, the sutures pulled taut, and the antihelix is
examined from the lateral side. If a sharp antihelix ridge
is present, the suture should be removed and placed closer
to the surface or farther away, as the case may be, to cor-
rect the deformity
56
M.A. Shiffman
isthmus of cartilage at the junction of the crura
as in Straith’s [ 57 ] method.
Pitanguy and Rebello [ 64 ] used an island tech-
nique to cover visible cartilage ridges. Gibson
and Davis [ 65 ] , Chongchet [ 66 ] (Fig. 5.14 ), and
Stenströem [ 67 ] introduced lateral cartilage
weakening techniques to take advantage of the
unique ability of a sheet of cartilage to warp away
from the injured surface. In the Chongchet tech-
nique, the lateral scaphal cartilage is scored with
a scalpel to form an antihelix. In the Stenströem
technique, postauricular incision is used so that a
short-tined rasp could be used to “blindly” scar
the antihelix. Morcellation of the antihelix
through a direct lateral incision was advocated by
Ju et al. [ 68 ] .
Crikelair and Cosman [ 69 ] described a new
technique for the prominent ear with combined
concha and antihelix deformity (Fig. 5.15 ).
A postauricular incision parallel to the free border
a
d
f
e
b
c
Fig. 5.13 Mustarde’s cartilage molding technique. ( a )
Best used in children with a pliable nature of the cartilage.
( b ) While pressing medially on the helix of the ear, several
pairs of ink marks are made on the conchal and outer
aspect of the antihelix. These pairs of marks precisely
mimic the position of the mattress sutures to be used in the
repair. ( c ) Several 25-gauge needles dipped in ink are used
to transfer the pairs of ink marks to the postauricular skin.
A postauricular skin excision is marked between the rows
of transferred ink marks. ( d ) The skin excision is carried
down to the cartilage, excising all soft tissue and per-
ichondrium from the posterior auricular cartilage. Several
permanent white 4-0 sutures are placed through the full
thickness of cartilage, making certain that the perichon-
drium of the anterior auricular cartilage is pierced. ( e ) The
sutures are tied simultaneously, not under full tension. ( f )
A subcuticular or over-and-over running 4-0 nylon suture
is used for closure
57
5 History of Otoplasty: Review of Literature
of the helix and 1 cm from the border is extended
from the cephaloauricular angle superiorly to the
fl eshy lobule inferiorly. An ellipse of skin can be
excised using the incision line as the outer border.
Needles are passed posteriorly from the anterior
surface of the ear just beneath the helix overhang,
tipped with methylene blue and then withdrawn.
The wound edges are slightly undermined and
the methylene blue markings identi fi ed on the
cartilage. The auricular cartilage is cut through
along this line from superiorly at the cephaloau-
ricular angle inferiorly to where the tail of the
helix begins. This separates the rim of the ear
from the major ear cartilage. The auricular
cartilage is freed subchondrally on its anterior
surface and the anterior dissection carried for-
ward in the upper part of the ear until the inferior
crus of the helix is exposed. The middle and
lower portion of the ear, the edge of the cavum
concha, is similarly exposed. The anterior carti-
lage surface is lightly striated (not through the
full thickness of the cartilage) in at least three or
four directions. The cartilage will bend back on
itself forming the smooth roll of the antihelix.
The acuteness of the roll can be increased by
increasing the number and decreasing the spac-
ing of the striations. The redundant auricular
cartilage can be trimmed. The amount to be
Fold of antihelix
a
d
e
b
c
Fig. 5.14 Chongchet’s technique (1963) [ 66 ] . ( a ) Excision of skin. Undermining toward the free border. ( b ) Marking
of new antihelix. ( c ) Anterior scoring of the cartilage. ( d ) Curling of the cartilage. ( e ) Overlapping of cartilage
58
M.A. Shiffman
a
c
d
e
f
g
h
b
Fig. 5.15 Crikelair and Cosman technique (1964) [ 69 ] .
( a ) Prominent ear with combined concha and antihelix
deformity. The darkened ellipses indicate desirable reduc-
tions in size. The arrow indicates the antihelix with superior
crus to be constructed. ( b ) Posterior incision in dark dashes .
Possible elliptical skin excision in light dashes . ( c ) Auricular
cartilage cut through to anterior surface. ( d ) Subepichondrial
auricular cartilage dissection on the anterior surface. ( e )
Striation of anterior surface of cartilage. ( f ) Trimming of
auricular cartilage and concha edge to be carried out as
indicated by heavy dark lines . Tail of the helix excision is
also indicated. ( g ) Tail of helix excised. Tentative excisions
of superior helix, concha ellipse, and antitragus prominence
indicated by heavy dash line . ( h ) Pieces of cartilage excised
in maximum reduction. 1 through 3 are usual excisions,
4 through 6 are excisions dictated by the individual case.
1 Auricular cartilage edge. 2 Tail of helix. 3 Edge of concha.
4 Ellipse of concha. 5 Antitragal prominence. 6 Helix
wedge. ( i ) Cutaway view showing effect of cartilage exci-
sions with formation of free helix bucket handle
59
5 History of Otoplasty: Review of Literature
excised can be determined by replacing the helix
over the auricular cartilage and observing the
excess from behind. The width removed affects
the width of the new scaphoid fossa. The amount
trimmed from the superior pole affects the verti-
cal length of the ear. The edge of the cavum con-
cha is trimmed, and the tail of the helix is dissected
free and excised. The anterior skin fl ap is replaced
on the cartilage and molded into its new contours.
The postauricular incision is closed.
In 1966, Barnes and Morris [ 70 ] reported use
of the Stenströem technique by elevating the skin
from the postauricular skin excision site and free-
ing tail of the helix from the conchal cartilage
and the skin anteriorly. Half of a Brown-Adson
tissue forceps was introduced into the subcutane-
ous tunnel to make multiple super fi cial scratches
along the antihelix and its crura. The ear can then
be folded back quite easily and held in its new
position by simply closing the elliptical skin
defect. Kaye [ 71 ] developed a combination of the
Stenströem technique of antihelical rasping and
the Mustard concept of permanent mattress suture
fi xation to maintain the proper amount of antihe-
lical roll after a lateral rasp of the antihelix.
Permanent sutures are introduced through tiny
lateral incisions along the conchal crest, which
are carried across the antihelical fold and tied on
the lateral side.
Further contributions of the Ely technique
with conchomastoidal sutures include Owens
and Delgado [ 72 ] and Furnas [ 73 ] . Spira et al.
[ 74 ] combined conchomastoidal suturing with
conchoscaphal suturing with good results
(Fig. 5.16 ). Webster [ 75 ] stated that regardless of
the skill of the operator or the technique of the
operation, however, one falls short of the ideal
appearance in every case. Perfection is impossi-
ble of attainment. He used a combination of
ideas of many authors plus individual interpreta-
tion (Fig. 5.17 ). The essential concept is think-
ing of the concha as one entity and the rest of the
ear, including the helix and antihelix area, as
another unit. Wood-Smith [ 76 ] reported on cor-
rection of prominent lobules when the lower
third of the ear protrudes with a modi fi ed fi shtail
excision (Fig. 5.18 ).
Weerda [ 77 ] , in cases of thick auricular carti-
lage with low elasticity, used a diamond drill to
weaken the auricular cartilage immediately above
and below the intended new antihelical fold and
the antihelical crus through a retroauricular
access. Full-thickness mattress sutures of slowly
absorbable suture material are placed at the posi-
tions with the corresponding markings to fi x the
helix in the intended position.
Wegener [ 78 ] stated that the procedure that
combined correction of protruding ears with
reduction of hyperplastic auricles had been devel-
oped by the author more than 30 years previously.
During the postauricular removal of the promi-
nent cartilage in a layer-by-layer fashion, the
scalpel is used tangentially following the outline
of the individual crural curvature to the antihelix
margin and the auricle base. Falciform excision
of the cartilage of the superior helix is performed
starting from the anterior fold of the auricle
peripherally toward the scapha. After an anterior
skin sickle excision, a new helix margin is cre-
ated by eversion of the still intact skin of the pos-
terior helix wall. The operation is fi nished by a
wedge-shaped skin-cartilage excision of the
superior part of the helix.
Horlock et al. [ 79 ] described a postauricular
fascial fl ap in otoplasty. Scuderi et al. [ 80 ]
reported on a posterior auricular muscle fl ap in
otoplasty.
An excellent algorithm was developed by Stal
and Hatef [ 81 ] for the analysis and treatment of
the prominent ear.
i
Fig. 5.15 (continued)
60
M.A. Shiffman
Fig. 5.16 Spira’s technique (1969) [ 74 ] . ( a ) Creating
outline for insertion of sutures by depressing helix to cre-
ate normal contour. ( b ) Dye marks on posterior ear. Skin
excisions. ( c ) Cartilage exposed. ( d ) Concha setback when
needed. ( e ) Sutures forming antihelical fold inserted and
tied. ( f ) Sutures in position. ( g ) Internal closure complete.
( h ) Dermis to periosteum suture repositioning lobe. ( i )
Closure completed
Concha sel back
when needed
Mastoid
periosleum
a
b
c
f
e
d
g
h
i
Additional
excision for
setback of
lobule
61
5 History of Otoplasty: Review of Literature
Fig. 5.17 Webster’s technique (1969) [ 75 ] . ( a ) Outline
of slipper-shaped incision. ( b ) After resection of skin.
Note width of the skin resection is widest opposite the
superior and lower portions of the ear. ( c ) Undermining
skin and subcutaneous tissues. ( d ) Resection of redundant
concha continuing into strip resection at level of new
antihelical fold. ( e ) Replacement of the tail of the helix on
the concha. This 4-0 plan catgut suture is the only buried
suture used. ( f ) Skin closure with 4-0 silk (for easier
removal). ( g ) Completed everting closure. ( h ): Location
of through-and-through mattress sutures of 4-0 plain cat-
gut for fi xation of reconstructed antihelical fold. Base of
each arrow describing the structure
Helix
Tail of helix
a
c
e
g
f
d
b
Inf.crus
Site of sup.
crus
Incision
Concha
62
M.A. Shiffman
Conclusions
Otoplasty history shows the development of the
surgical treatment of the prominent ear with a
multitudinous variety of new and modi fi ed
techniques. When performing otoplasty, the
surgeon should be thoroughly informed of the
variety of procedures available.
a
b
c
d
Fig. 5.18 Wood-Smith technique. ( a ) The skin is excised
over the concha, and a V extension of the excision is
drawn on the posterior surface of the lobule. ( b ) While the
ink is wet, the lobule is pressed against mastoid skin. ( c )
The mirror impression of the V is transposed to the mas-
toid skin. Excision of all the skin within the borders of the
modi fi ed fi shtail design is carried out. ( d ) Closure is with
4-0 nylon suture
Superior crus (reconstructed)
Inferior crus
Telfa dressing
h
Fig. 5.17 (continued)
63
5 History of Otoplasty: Review of Literature
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65
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_6, © Springer-Verlag Berlin Heidelberg 2013
6
Introduction
The incidence of prominent ears is 5 % in the
Caucasian population, with the most common
abnormality being an unfurled antihelix, and the
second most common, a deep conchal bowl [ 1 ] .
Often, these abnormalities coexist and both must
be addressed. Over 200 techniques have been
described for the surgical correction of prominent
ears, suggesting that no single “best” technique
exists and that techniques and modi fi cations will
continue to evolve [ 2 ] . Otoplasty techniques can
typically be divided into two broad categories:
cartilage-cutting and cartilage-sparing. Cartilage-
cutting techniques aim to eliminate the inherent
elastic spring of the cartilage and improve the
longevity of surgical results; these include car-
tilaginous incisions, wedge excisions, scoring,
and abrasion of either the posterior or anterior
auricular surfaces. Cartilage-sparing techniques
emerged in an attempt to prevent anterior pinna
irregularities that can arise with cartilage-cutting
techniques. Suturing, rather than cutting, is used
to create the desired auricular contours, thereby
preserving cartilaginous support and minimiz-
ing contour irregularities. However, elements of
both categories are often used in conjunction.
Here, historical techniques will be reviewed and
discussed, as well as more recent modi fi cations
and techniques found in the literature, paying
particular attention to the last 5 years.
Pertinent Anatomy
A thorough understanding of the anatomy of the
normal and prominent ear is essential for correct
analysis prior to surgical correction of the defect.
The pinna is composed of fi broelastic cartilage
that is covered by thin skin. The anterior skin is
quite adherent to the perichondrium, but on the
posterior aspect, there is a layer of loose areolar
tissue between the skin and cartilage. The pinna
is de fi ned by the contours of the lobule, the helix,
the antihelix, the superior and inferior crura, the
fossa triangularis, the scapha, and the helical crus
(Fig. 6.1 ). The conchal bowl is divided into two
concavities, the concha cavum inferiorly and the
concha cymba superiorly. Several intrinsic and
extrinsic muscles and ligaments stabilize the
auricular cartilage. The intrinsic muscles are the
helicis major, helicis minor, tragicus, antitragi-
cus, transversus auriculae, and obliquus auriculae
muscles; the extrinsic muscles are the anterior
auricular, superior auricular, and posterior auric-
ular muscles. Auricular blood supply is derived
from branches of the external carotid artery and
includes the super fi cial temporal, posterior auric-
ular, and occipital arteries. The posterior auricu-
lar, external jugular, super fi cial temporal, and
retromandibular veins provide venous drainage.
R. S. Petersson , M.D.
Division of Pediatric Otolaryngology,
Virginia Commonwealth University ,
1200 East Broad Street, West Hospital,
12th Floor, South Wing, Suite 313 ,
Richmond , VA 23298 , USA
e-mail: rajpetersson@gmail.com
Current Trends in Otoplasty
Rajanya S. Petersson
66
R.S. Petersson
Sensory innervation is through the auriculotem-
poral nerve (cranial nerve V3), the great auricular
nerve, and branches of cranial nerves VII (tempo-
ral and posterior auricular branches), IX, and X
(Arnold’s nerve).
Eighty- fi ve percent of auricular growth is com-
pleted by age 3, and 90–95 % of adult size is
achieved by age 5 [ 1 ] . Vertical length of the auri-
cle measures approximately 5–6 cm, and the
width should be approximately 55 % of the length.
The long axis of the ear should be inclined about
20° posteriorly. The helical rim usually protrudes
1–2 cm from the mastoid skin, and the angle of
protrusion should be between 21 and 30° [ 1, 3 ] .
Timing of Repair
Prominent ears can be surgically repaired when
children are aged 3–6 years, when most of
the growth of the ear has been completed [ 2 ] .
However, most surgeons seem to perform the
surgery at about 5 or 6 years of age, with the
hope of correcting the malformation prior to
socialization in school in order to minimize ridi-
cule by peers [ 4 ] . Signi fi cant psychosocial dis-
tress due to the deformity has been documented
in the literature, as have improvements in many
psychosocial parameters after otoplasty [ 5– 7 ] .
Performing otoplasty in children aged 5–8 years
old does not seem to affect further growth and
development of the ear [ 8 ] . In fact, Gosain et al.
showed that otoplasty could be performed safely,
without growth arrest or alteration, in children
younger than 4 years and as young as 9 months
[ 4, 9 ] . They assert that an important advantage
of performing otoplasty at these younger ages is
increased malleability of the auricular cartilage,
allowing for the effective use of cartilage-sparing
techniques and decreasing the need for cartilage-
cutting techniques.
Goals of Correction
The goals of otoplasty are to restore normal ana-
tomic features and anatomic position of the auri-
cle in a permanent and aesthetically acceptable
fashion. These were summarized by McDowell
in 1968 [ 10 ] , are still the guiding principles used
for otoplasty today, and are as follows:
1. All trace of protrusion in the upper 1/3 of the
ear must be corrected.
2. From front view, the helix of both ears should
be seen beyond the antihelix.
3. The helix should have a smooth and regular
line throughout.
4. The postauricular sulcus should not be mark-
edly decreased or distorted.
5. The ear should not be placed too close to the
head – posterior measurement from the outer
edge of the helix to the mastoid should be
10–12 mm at the top, 16–18 mm in the middle
1/3, and 20–22 mm in the lower 1/3.
6. The position of the two ears should match
fairly closely – to within 3 mm at any given
point.
Treatment
Treatment of prominent ears includes nonsurgi-
cal as well as surgical methods. Surgical methods
can be divided largely into two groups: cartilage-
cutting and cartilage-sparing. These techniques
are often utilized in combination.
Superior
and inferior
crura
Scapha
Helix
Antihelix
Lobule
Tragus
Concha
cavum
Concha
cymba
Fossa
triangularis
Fig. 6.1 Anatomy of the pinna
67
6 Current Trends in Otoplasty
Nonsurgical Correction
Several reports, mostly in the Japanese and British
literature in the 1980s and 1990s, have shown that
molding the deformed ear, especially if started
within the fi rst 3 days of birth, can lead to excel-
lent correction [ 11– 15 ] . Auricular molding has
been reported to be a simple, effective, and inex-
pensive treatment for correction of congenital
auricular deformities, particularly when initiated
within the fi rst 3 days of birth when the auricular
cartilage is soft and lacks elasticity [ 11 ] . High
maternal estrogen levels during this period cause
the auricular cartilage to be highly malleable by
external forces [ 12 ] . The author’s own experience
with these techniques has shown excellent results
[ 16 ] , especially for cup (Fig. 6.2 ) and Stahl’s ear
deformities (Fig. 6.3 ); results are variable for
prominent ears, especially if a deep conchal bowl
is present (Fig. 6.4 ). The author’s preference is to
fashion a splint by inserting 24-guage copper wire
through a small (6- or 8-Fr) silicone feeding tube
(Fig. 6.5 ). This is measured to fi t between the
helical rim and newly created antihelical fold and
is then secured in place with Steri-strips ®
(Fig. 6.5 ). Dermabond ® is then applied over the
entire taped area to allow for waterproo fi ng and
ease of care.
In early 2012, van Wijk et al. [ 17 ] prospectively
studied 209 ears in 132 babies treated with ear
splinting
using
the
commercially
available
Earbuddies ® system. They noted fair or good results
in 66.7 % of those who followed up if splinting was
started before 6 weeks of age. Older babies also had
longer splinting times required in addition to more
variable results. It should also be noted that these
techniques are best suited for reshaping the antiheli-
cal fold, but do not reliably treat a deep conchal
bowl. These molding techniques are worth consid-
ering, especially in the neonatal period, as they are
noninvasive, carry minimal morbidity, and surgical
correction may be prevented in many cases.
Fig. 6.2 Cup ears. The fi rst infant ( a – c ) underwent
1.5 weeks of splinting. ( a ) Before splinting, ( b ) 2 weeks
after splinting initiated, ( c ) 3 months after splinting initiated.
The second infant ( d – f ) underwent 2 weeks of splinting and
2 weeks of taping. ( d ) Before splinting, ( e ) 1 week after
splinting initiated, ( f ) 4 weeks after splinting initiated
68
R.S. Petersson
Cartilage-Cutting Techniques
The fi rst aesthetic otoplasties described by Ely in
1881 [ 18 ] and Luckett in 1910 [ 19 ] were exam-
ples of cartilage-cutting techniques. Luckett [ 19 ]
noted the importance of recreating an underde-
veloped antihelical fold in prominent ear surgery.
Cartilage-cutting techniques were advanced
in the 1950s and 1960s by surgeons including
Becker [ 20 ] , Converse [ 21, 22 ] , Farrior [ 23 ] ,
and Pitanguy [ 24 ] . These techniques are most
appropriate for stiff, thick cartilage that requires
disruption in its inherent elasticity to maintain
results. Cartilage may be incised either partial or
full thickness and either anteriorly or posteriorly.
Portions of cartilage may also be excised, scored,
or abraded in order to help reshape it. With any
cartilage-cutting technique, there is the risk of
creating visible contour irregularities and sharp
edges, which may limit the aesthetic acceptabil-
ity of the results.
The technique described by Converse is
an example of a classic, yet complicated,
cartilage-cutting technique [ 21, 22 ] . Parallel,
full-thickness cartilaginous incisions are made
along the conchal rim and the desired antiheli-
cal fold to form an island of cartilage, which
is then tubed and secured with sutures to cre-
ate the new antihelical fold. Becker’s technique
also involves incisions through the cartilage.
Fig. 6.3 Stahl’s ears. The fi rst infant ( a – c ) underwent
1 week of splinting. ( a ) Before splinting, ( b ) after 1 week
of splinting, ( c ) 2 weeks after splinting initiated. The second
infant ( d – f ) underwent 4 weeks of splinting. ( d ) Before
splinting, ( e ) after 2.5 weeks of splinting, ( f ) after 4 weeks
of splinting
69
6 Current Trends in Otoplasty
Farrior’s [ 23 ] technique involves removing lon-
gitudinal wedges of cartilage at the superior
crus without through-and-through cartilagi-
nous incisions and along the entire antihelix;
through-and-through incisions are then made at
the borders of the antihelical fold to create an
overriding island that widens from inferior to
superior, giving a gentle bend to the antihelix.
Pitanguy [ 24, 25 ] described a simpler technique
that involves the formation of a smaller carti-
lage island by parallel incisions in the region of
the desired antihelical fold; this island is then
projected forward to create an antihelical fold
by approximating the under-riding cartilage
with mattress sutures. This technique effec-
tively reconstructs the antihelix and forms a
new triangular fossa.
In 2007, Werdin et al. [ 26 ] reviewed their
results in 278 patients, who underwent 551 oto-
plasty operations from 1991 to 2006 using a
modi fi cation of Pitanguy’s island technique. The
original technique involved a conchal-mastoid
suture for conchal hyperplasia [ 25 ] , which is
known to risk posterior constriction of the exter-
nal auditory canal. The modi fi cation used by
Werdin et al. involves the resection of a rim of
conchal cartilage to avoid this complication [ 26 ] .
Complications were seen in 41 patients (7 %), of
whom 24 (4 %) required reoperation. In 2010,
Maricevich et al. [ 27 ] reviewed the experience
with the island technique at the Ivo Pitanguy
Clinic, where 111 patients underwent otoplasty
with this technique between 1990 and 2008.
These patients also underwent reconstruction of
Fig. 6.4 Prominent ears. The right ( a – c ) and left ( d – f )
ears of one infant with prominent ears are shown after
4 weeks of splinting. ( a and d ) Before splinting, ( b and e )
after 2 weeks of splinting, ( c and f ) after 4 weeks of splinting.
This infant is continuing with molding therapy, as full
correction has not been achieved after 4 weeks, although
there has been some improvement in recreating the
antihelical fold
70
R.S. Petersson
the concha with conchal-mastoid sutures with or
without excision of conchal cartilage as neces-
sary. Two patients experienced early complica-
tions, which were hematoma development in one
patient and wound dehiscence in another, for a
rate of 1.8 %. The total late complication rate was
10.8 % and included fi ve patients (4.5 %) whose
antihelical folds appeared “operated” on, three
patients (2.7 %) with asymmetry, one patient with
both of the above complications (0.9 %), and
three patients (2.7 %) with undercorrection. No
patient showed recurrence of the defect. Overall,
Pitanguy’s island technique seems to have good,
predictable aesthetic results in these authors’
hands.
Cartilage-Sparing Techniques
Cartilage-sparing, or suture, techniques were
developed to address potential contour irregu-
larities that may develop with cartilage-cutting
techniques. Suture techniques are most appro-
priate for thin or pliable cartilage. No contour
irregularities are created, as the cartilage is not
incised. However, in cases of stiffer cartilage,
these techniques may not achieve adequate,
long-term correction, as the elastic spring of the
cartilage would remain intact. Mustardé fi rst
described the use of multiple horizontal mattress
sutures to recreate the antihelical fold in 1963
[ 28 ] . In 1968, Furnas [ 29 ] introduced the use of
conchal-mastoid mattress sutures to decrease the
projection of a deep conchal bowl. As a pediatric
otolaryngologist and facial plastic surgeon that
sees only pediatric patients, the author primarily
uses the following techniques.
Once the patient is prepped and draped, pre-
operative measurements are taken at three points:
the superior pole, the middle third, and the lob-
ule. A ruler is gently held against the scalp and
measurements taken to the lateral aspect of the
helical rim at each of the above points (Fig. 6.6 ).
These measurements are recorded. The helical
rim is then folded back towards the mastoid to
visualize the line of the new antihelix, which is
marked (Fig. 6.7 ). A dumbbell-shaped postauric-
ular skin excision is centered on the postauricular
Fig. 6.5 Ear splint. ( a ) Splint made from 6 French silicone feeding tube with 24-gauge copper wire core. ( b ) Splint
applied to newborn ear with Steri-Strips
71
6 Current Trends in Otoplasty
sulcus (Fig. 6.8 ). This may also be placed entirely
on the postauricular surface, which allows for
ease of dissection, but the author’s preference is
to center it on the postauricular sulcus to better
hide the incision. The purpose of the skin exci-
sion is to help support the cartilaginous recon-
struction in the healing phase and should not be
relied upon for enduring results, as the skin will
relax over time. The skin is incised with a 15
blade, and then curved iris scissors are used to
resect the skin and underlying subcutaneous tis-
sue (Fig. 6.9 ).
Following this, dissection of the postauricular
skin is carried to the helical rim in a subperichon-
drial plane, allowing for adequate exposure for
placement of Mustardé-type sutures to recre-
ate the antihelical fold. The ear is turned back
to visualize the location of the markings for the
antihelix. Using digital pressure, the antihelix
is created, and a 27-guage free needle is placed
through-and-through the newly created antihelix
in the middle portion, taking care not to catch the
elevated postauricular skin, which is held away
from the cartilage with a retractor (Fig. 6.10 ).
Digital pressure is removed, and the curvature
of the newly created antihelical fold at the nee-
dle site is maintained and observed. If deemed
acceptable, a Mustardé horizontal mattress suture
is placed. Either 4-0 Mersilene ® or 4-0 clear nylon
suture can be used. Each bite with the needle is
Fig. 6.6 Measurement of distance from mastoid scalp to
helical rim
Fig. 6.7 Digital manipulation to create antihelical fold,
which is marked along its apex
Fig. 6.8 Planned dumbbell-shaped postauricular skin
excision
Fig. 6.9 Postauricular skin excision
72
R.S. Petersson
placed perpendicular to the 27-guage hollow nee-
dle, and is through the cartilage, into the subcuta-
neous plane underlying the anterior skin, but not
through the anterior skin (Fig. 6.11 ). A fi nger is
placed on the anterior skin to feel for the needle,
and just before fully driving the needle through
posteriorly, the anterior ear is examined to ensure
the needle is not visualized. The more lateral bite
spans a slightly greater distance than the medial
to account for the curvature of the antihelical fold.
The suture is then tied down to appropriate ten-
sion to give a natural-appearing antihelical fold.
Mustardé sutures are placed superior and inferior
to this point as needed, following the above steps.
Usually three or four sutures are needed to ade-
quately create the antihelical fold, superior crus,
and de fi ne the fossa triangularis (Fig. 6.12 ). The
author’s preference is to tie each suture down to
appropriate tension as they are placed. However,
all sutures can be placed and then tied down in
succession.
The conchal bowl is addressed next, if nec-
essary, with conchal-mastoid setback sutures.
Dissection is carried posteriorly to the mastoid
periosteum. Typically, two horizontal mattress
sutures are placed through the conchal bowl
cartilage (again taking care not to penetrate
the anterior skin) and mastoid periosteum. The
more lateral the suture, the greater the setback.
However, placing the sutures too laterally may
cause narrowing of the external auditory canal,
which must be avoided. In very deep conchal
bowls with excess cartilage, it can be bene fi cial
to shave or partially resect conchal bowl cartilage
from the posterior aspect to ease the setback.
Once all of the cartilaginous work has been
completed, and prior to skin closure, measurements
Fig. 6.10 27-gauge-free needle used to mark suture
placement to create antihelical fold
Fig. 6.11 Placement of Mustardé sutures using 27-gauge
needle for guidance
Fig. 6.12 Creation of antihelical fold. ( a ) Preoperative
marking of antihelical fold with digital pressure released.
( b ) Newly created antihelical fold after Mustardé sutures
placed
73
6 Current Trends in Otoplasty
are repeated. It is these measurements that are
expected to be maintained long term. The skin
incision is then closed using 4-0 Vicryl in a deep,
inverted, interrupted manner in the subcuticular
plane. Steri-strips ® are then applied. Measurements
are then repeated, and there may be further setback
noted after skin closure, but this should be expected
to decrease over time as the skin relaxes.
In 2001, Horlock et al. [ 30 ] described a postau-
ricular fascial fl ap used in conjunction with the
traditional Mustardé and Furnas suture otoplasty
techniques. After performing a standard postau-
ricular dumbbell skin excision, dissection is car-
ried to the helical rim in the dermal subcutaneous
tissue junction plane. That is, the subcutaneous
tissue is left on the posterior aspect of the auricu-
lar cartilage. This subcutaneous tissue is then ele-
vated from the cartilage as a separate fascial fl ap,
and dissection carried to the mastoid. Mustardé
and Furnas sutures are then placed, taking care not
to catch the fascial fl ap. The fl ap is then advanced
back over the sutures and secured to the posterior
helical rim, and the skin closed. Complications of
suture erosion and irritation from buried sutures
are prevented by this technique. They did notice a
recurrence rate of 8 %, which is lower than most
described suture only techniques.
A study of the same technique by Schaverien
et al. in 2010 [ 31 ] reviewed 57 ears in 30 patients
(ages 4–14 years, mean 8.5 years) over a mean
3.9 year follow-up period. The recurrence rate
was 4.5 %, and six minor complications were
observed. These included wound dehiscence in
one, bleeding in one, suture extrusion in one,
and painful/palpable suture in three patients.
Compared to previously reported recurrence
rates with suture techniques alone, the recurrence
rate of 4.5 % is favorable. Sinha and Richard
[ 32 ] reviewed their experience with the tech-
nique in 227 patients over an 8-year period, with
a recurrence rate of 3.67 %. Ten complications
were observed, including suture extrusion in 6
(2.64 %), keloid formation in 3 (1.32 %), and
infection and anterior skin necrosis in 1 each
(0.44 %). They concluded that the postauricular
fascial fl ap seems to prevent suture extrusion and
reduces the risk of recurrence as evidenced by
their low complication rate.
Although cartilage-scoring techniques are
injurious to cartilage, they will be considered
here with the cartilage-sparing techniques as no
full-thickness cartilaginous incisions are per-
formed. After Gibson and Davis showed the abil-
ity of injured cartilage to bend away from the side
of injury in 1958 [ 33 ] , Stenströem [ 34 ] described
scoring of the anterior auricular cartilage to cre-
ate an antihelical fold. Through a postauricular
approach, he created a tunnel along the anterior
aspect of the planned antihelix and then scored
the anterior perichondrium and cartilage to allow
it to bend posteriorly, creating an antihelical fold.
Various instruments through various approaches
have been used for scoring, including scalpels,
rasps, abraders, diamond burr drills, Adson-
Brown forceps, and hypodermic needles [ 35 ] .
Scoring techniques are often combined with other
approaches.
Incisionless Otoplasty
and Cartilage Reshaping
The success of cartilage-sparing suturing tech-
niques has led to the development of incisionless
otoplasty, fi rst described by Fritsch in 2004 [ 36 ]
and then updated in 2009 [ 37 ] . The anterior sur-
face of the planned antihelical fold is fi rst scored
percutaneously using a 20-gauge hypodermic
needle. Three to four Mustardé-type sutures are
then placed percutaneously to create an antiheli-
cal fold. For successful placement of these
sutures, the needle must reenter the skin at exactly
the same point from where it exited to ensure that
no skin is buried subcutaneously. The needle
never emerges through the anterior skin. A deep
conchal bowl is addressed fi rst by removing soft
tissue between the conchal bowl and mastoid
using
needle-tip
monopolar
electrocautery
through a small postauricular sulcus incision and
then placing Furnas-type sutures percutaneously.
It is noted that this technique is not useful for
infants because their auricular cartilage is too
soft, and the sutures cause accordion-like fold-
ing, rather than smooth curving.
There has been recent interest in incisionless
ear reshaping using a 1,450-nm diode laser. In
74
R.S. Petersson
2009, Holden et al. [ 38 ] performed a controlled
animal study on rabbit ears in which nine right-
sided rabbit ears, which have similar skin and
cartilage thickness as human ears, underwent
laser treatment with a 1,450-nm diode laser with
cryogen skin cooling followed by splinting for 1,
3, or 4 weeks. The left ears served as controls
and were splinted only. Shape change was noted
in all nine laser-treated ears, with no change in
the splinted controls. Reshaped ears were stiff-
est after 4 weeks of splinting. There was no skin
injury or signs of postprocedural pain. Histologic
analysis showed an expanded chondrocyte pop-
ulation in the laser-treated area, as well as per-
ichondrial thickening and fi brosis of the deep
dermis. These results echoed a similar rabbit ear
study by Mordon et al. in 2004 [ 39 ] in which the
same laser was used.
Three clinical studies by Mordon’s group have
since been published between 2006 and 2011
[ 40– 42 ] . In all three studies, the entire helix and
concha were treated with a 1,540-nm Er:glass
laser with an integrated cooling device. The laser
was set at 12 J/cm 3 per pulse. Seven stacked pulses
(3 ms, 2 Hz-84/cm 2 cumulative fl uence) were
applied with a 4-mm spot size. Due to the inte-
grated cooling device, no anesthesia was required.
Immediately following treatment, a mold was
made using a silicone elastomer typically used for
dental impressions to stabilize the desired antihe-
lical contour. The mold was left in place for
15 days, and the patients followed up. In the 2006
study, Trelles and Mordon performed the proce-
dure on 12 ears in 8 patients [ 40 ] . Only one mild
recurrence was noted, with a follow-up period of
6 months. In this study, 3 mm punch biopsies were
performed at 1, 2, 3, and 4 weeks after the proce-
dure. At 1 week, an in fl ammatory reaction was
noted within the dermis. At 2 weeks, a thickening
of the perichondrium and cartilage was observed.
At 3 and 4 weeks, thickening was con fi rmed with
an intact matrix, and the chondrocytes were viable
and functional. The thickening appears to be
responsible for the permanent shape change.
In the latter two studies, no major complica-
tions were noted, and overall stable results
achieved [ 41, 42 ] . A few patients did suffer con-
tact dermatitis from the ear molds and did not see
improvement in the shape of their ears if the
molds were discontinued. Advantages of this
procedure are that no hypertrophic scars or kelo-
ids were observed, anesthesia was avoided, and
the procedure could be completed in 15–20 min
as an outpatient. However, the recurrence rate in
the 2010 study was relatively higher than for
other otoplasty techniques, with 3 out of 25 ears
showing severe recurrence and 6 out of 25 show-
ing moderate recurrence [ 41 ] .
Combined Approaches
Many surgeons combine cartilage-cutting tech-
niques with cartilage-sparing techniques to
achieve the desired results. In 2007, Salgarello
et al. [ 43 ] performed a retrospective review of
such a technique, in which anterior auricular car-
tilage scoring with the Stenström otoabrader is
combined with the placement of Mustardé-type
horizontal mattress sutures through a posterior
approach; if a deep conchal bowl is present, it is
treated with a full-thickness conchal rim cartilage
excision. No skin excision is performed. One
hundred and thirty- fi ve patients who underwent
primary otoplasty between 1995 and 2005 were
included in the study. No major complications
were seen, and minor complications were
observed in 20 ears. Aesthetic results were
assessed by the surgeon, an independent plastic
surgeon observer, and the patient. A four-level
grading system was used: very good, good, satis-
factory, and poor. Ninety- fi ve percent of the cases
received grades of very good or good, while the
rest of the cases were graded satisfactory. It
appears that this technique results in a high suc-
cess rate with low morbidity.
Farrior’s technique [ 23, 44, 45 ] is an effective
approach to prominent ear surgery. The Farrior
technique, which has been updated from its origi-
nal description in 1959, combines elements of
cartilage sculpting, suturing, and conchal setback
techniques in a graduated approach that is based
on anatomical demand [ 45 ] . After proper evalua-
tion, the simplest methods are used fi rst to achieve
the desired contour. For example, a lack of an
antihelical fold in a patient with thin, pliable
75
6 Current Trends in Otoplasty
cartilage may be amenable to treatment with mat-
tress sutures alone. If a deep conchal bowl is the
only deformity, a conchal reduction is performed
with an elliptical excision of cartilage along the
conchal rim, with or without conchal-mastoid
sutures. Sometimes, the cartilage must be scored
to break its resilient spring, and this is performed
in conjunction with suturing. Farrior’s descrip-
tion of cartilage scoring for the creation of an
antihelical fold involves multiple incisions made
through the cartilage along the axis of the antihe-
lical fold placed perpendicularly to the direction
of the antihelical fold. Subsequently, longitudi-
nal, partial-thickness wedge excisions of cartilage
may be made at the level of the superior crus and
antihelical fold, with horizontal mattress sutures
placed for reinforcement. Trimming of the cauda
helicis may help reverse a protuberant lobule.
In 2007, Scharer et al. [ 45 ] published a retro-
spective analysis of the Farrior technique in 144
ears in 75 patients over a 15-year period. The
main outcome measures of the study were satis-
factory correction of the auricular deformity,
incidence of postoperative complications, and
degree of patient satisfaction. The most fre-
quently used operation was a combination of
conchal cartilage reduction, cartilage scoring,
and mattress suturing. No major complications
(large hematoma, tissue necrosis, gross defor-
mity, and signi fi cant infection) were documented.
Forty minor complications were observed in 29
patients. The most common were persistent
auricular protrusion and suture extrusion. Eleven
of the 75 patients underwent successful revision
surgery. Patient satisfaction was assessed with a
survey questionnaire consisting of ten questions,
which showed overall high satisfaction. The
authors conclude that the Farrior technique has
been successful and reliable in their hands.
In 2009, Valente [ 46 ] reported on another con-
cept in otoplasty in which the helix is separated
from the antihelix to break the cartilaginous
spring. A postauricular approach is used with a
dumbbell-shaped skin excision. The posterior
side of the cartilage is exposed, revealing the pre-
viously marked antihelical fold with methylene
blue. The auricular cartilage is then incised with
a 15 blade along the entire superior and posterior
border of the antihelical fold, beginning at the
fossa triangularis and extending to the tail of the
helix, thus disconnecting the helix from the anti-
helix. The antihelix is then dissected free from
the anterior skin and then shaped with horizontal
mattress sutures. Because the cartilaginous spring
is broken, no scoring is needed to mold the anti-
helical fold. The concha is then addressed if nec-
essary. During the 10-year study period, 6 of 60
(10 %) patients experienced complications: two
(3.3 %) small hematomas that did not require
drainage, epidermolysis in two cases (3.3 %),
hypertrophic scar in one case (1.7 %), and unnat-
ural appearance in one case (1.7 %). There were
discrete recurrences in the superior pole in six
ears (10 %) requiring reoperation, and no major
recurrences.
More recently in 2010, Ragab [ 47 ] described
the use of a carbon dioxide (CO 2 ) laser to assist in
reshaping the auricular cartilage into a well-
de fi ned antihelical fold. Thirty-two ears under-
went surgery on patients aged 4–7 years. Average
follow-up was 2.4 years, and no ears required
revision surgery. A postauricular approach was
used, and after a skin excision was performed on
the posterior auricle, supraperichondrial dissec-
tion was carried out to the helical rim to expose
the entire cartilaginous aspect. The posterior
(scaphal line) and anterior (conchal line) borders
of the planned antihelical fold were marked with
methylene blue after needles were placed from the
anterior surface through the cartilage posteriorly.
The CO 2 laser controlled by a micromanipulator
with a focal length of 200 mm, mounted on an
operating microscope, was used to evaporate per-
ichondrium and partial-thickness cartilage from
the posterior surface between the markings of the
planned antihelical fold. Defocused laser beam
settings for this were 5 W, 0.5 s pulse, and 2-mm
spot size. The beam was then focused to 0.8-mm
spot size, 8 W, 0.5 s pulse to incise the scaphal and
conchal lines. Pressure and cooling with wet gauze
allowed curling of the antihelical fold and supe-
rior crus. 4-0 Vicryl sutures were then placed in a
mattress fashion to stabilize the newly created
antihelical fold. Advantages cited for the use of a
laser in this application included the observation
that laser incisions can be healed by formation of
76
R.S. Petersson
fi brosis-free young cartilage yielding permanent
shape change; scalpel incision cartilaginous heal-
ing consists mostly of fi brosis.
Minimally invasive surgery is often appealing
for patients, and de la Fuente and Sordo [ 48 ]
reviewed their results with minimally invasive
otoplasty in 2011. They reviewed 100 otoplasties
between 2005 and 2009, and techniques used
included conchal-mastoid sutures (in 81 % of
patients), scapha reduction (76 %), antihelical
folding (70 %), conchal reduction (53 %), and
earlobe correction (19 %). Average follow-up
was 12.4 months, and 84 % of patients were very
satis fi ed, while 15 % were satis fi ed. Three patients
experienced partial recurrence requiring revision,
one patient experienced partial upper pole pres-
sure necrosis from the dressing, and three experi-
enced mild skin discoloration and epidermolysis
lasting less than 10 days. Preoperative evaluation
determined the needs to be addressed and included
conchal cartilage hypertrophy, lack of antihelical
fold, auriculocephalic angle, hypertrophic scapha,
and hypertrophic lobule. They developed a
speci fi c surgical order by which to address these
needs, but only operated on the relevant needs. If
all of the above require surgery, scaphal reduction
is addressed fi rst via an incision placed at the
most superior aspect of the anterior surface of the
scapha at the junction of the helix. Subperichondrial
dissection is performed, and the soft tissues are
released inferiorly. This leaves a crescent-shaped
segment of scaphal cartilage that extends beyond
the cutaneous junction and guides the amount to
be resected. The skin is then reapproximated. The
hypertrophic concha is addressed next through a
curved incision at the most superior aspect of the
anterior concha at the border of the antihelical
fold, where the incision will be camou fl aged.
Again, subperichondrial dissection is performed,
and the cartilage incised. The ear is then set back
to its desired location, causing the cartilage to
overlap, which guides a crescent-shaped excision.
The skin is then reapproximated. The antihelix is
then address via a stab incision at the antihelical
root, and a subperichondrial tunnel overlying the
desired antihelical fold is made. An ophthalmic
knife is then inserted and passed downwards sev-
eral times to score the cartilage. That incision is
then closed. A narrow 3–5 mm ellipse of skin is
then removed from the postauricular sulcus, and
tunnels are bluntly dissected to the mastoid
periosteum at the superior, middle, and inferior
aspects. Subcutaneous tissue and perichondrium
that form the posterior auricle are then sutured to
the mastoid periosteum through the tunnels, thus
maintaining the desired position of the ear. If the
lobule is hypertrophic, reduction is performed via
a wedge excision and primary closure. The post-
auricular incision is then closed.
Thus far, only techniques that address the
auricular cartilage itself for correction have been
discussed. Smith and Takashima [ 49 ] postulated
that a displaced insertion of the posterior auricu-
lar muscle lengthens its effective movement, thus
leading to protrusion of the ear. In addition,
Guyuron and DeLuca [ 50 ] demonstrated that a
proximally displaced insertion of the posterior
auricular muscle would lead to greater projection
of the auricle. In 2007, Scuderi et al. [ 51 ] described
repositioning of the posterior auricular muscle to
reduce the increased cephaloauricular angle. The
technique is appropriate only for cases of mild or
moderate conchal projection. Essentially, the pos-
terior auricular muscle is raised as a chondro-
muscular fl ap and then advanced and secured
more peripherally, thus narrowing the cephaloau-
ricular angle. The antihelix is addressed with car-
tilage scoring and suturing for mild to moderate
antihelical hypoplasia, and with a cartilage-
cutting island technique for severe defects. This
technique was performed in 103 ears in 55
patients, with no skin necrosis or suture extrusion
observed. Three ears in two patients required a
further procedure to improve symmetry. Overall,
the correction of the cephaloauricular angle was
satisfactory, although pre- and postoperative mea-
surements were not discussed.
There are many techniques utilized in oto-
plasty, all to accomplish similar goals. It appears
from a review of the most current literature that
most surgeons employ a combination of tech-
niques to achieve the desired results. The training
and experience of the surgeon, as well as patient
factors (the particular deformity, nature of the
cartilage, patient expectations), drive the choice
of techniques used.
77
6 Current Trends in Otoplasty
Postoperative Dressings
Various head bandages are commonly used after
otoplasty, but the type and duration of these vary
greatly depending on surgeon preference [ 52 ] .
There have been no studies directly comparing
the type of dressings used. A formal mastoid-
type dressing is typically applied at the end of
surgery and kept in place from 1 to 10 days, fol-
lowed by various protocols for wearing an elastic
headband over the ears. Some surgeons advocate
wearing the headband day and night for a period
of time (e.g., 2–3 weeks), followed by nighttime-
only protection for another variable period of
time (up to 6 months) [ 52 ] . Ramkumar et al. [ 52 ]
addressed the length of time the bandage should
be worn in a randomized controlled trial in chil-
dren following otoplasty. Their previous protocol
had been to leave the head bandage in place for
10 days postoperatively, but they noted an aver-
age of 1.5 unscheduled of fi ce visits per patient
due to a slipped bandage. There previous proto-
col had been to leave the postoperative bandage
in place for 10 days. This study randomized chil-
dren undergoing anterior scoring technique oto-
plasty into two groups; the control group wore
the head bandage for 10 days postoperatively,
while the trial group wore it for 24 h postop-
eratively. All children wore a tubigrip headband
at night for 4–6 weeks after the bandage was
removed. Outcome measures (lateral ear pro-
jection, complications, unscheduled visits, and
patient satisfaction) were recorded during sched-
uled follow-up visits at 10 days and 2 months
postoperatively. There were no statistical differ-
ences in any of the outcome measures recorded,
and the authors concluded it is safe to remove the
head bandage after 24 h.
A few studies have questioned the need for
any head bandage after otoplasty. Powell [ 53 ] ,
using an anterior scoring technique, and Wong
and Sylaidis [ 54 ] , using posterior scoring and
suturing techniques, showed no increased risk of
hematoma formation or early recurrence in
patients in whom a head bandage was not used.
In fact, it has been noted that a padded head
dressing may contribute to anterior skin necrosis,
especially if applied incorrectly [ 53, 55 ] . The
tendency for head dressings to slip or fall off
often eliminates its potential utility [ 52, 56 ] .
Recent studies have looked at the use of cyano-
acrylate tissue glues as an alternative to the head
bandage. In 2008, Shokrollahi and Tanner [ 57 ]
reported on 15 patients in whom tissue glue was
used over the suture line and to hold the pinna
against the mastoid scalp. They noted that the glue
released after approximately 3 weeks in children
and that the ears did not require extra protection
during this period. No complications were noted.
In 2009, Bovill et al. [ 58 ] retrospectively com-
pared the use of a conventional head dressing to
Dermabond ® . Twenty consecutive patients had
conventional head dressings placed, and the next
17 had Dermabond ® placed to seal the postauricu-
lar wound. The Dermabond ® group was given an
elastic headband to wear 24 h a day for the fi rst
week and then at night only for the second week.
Of the head-dressing group, 30 % (12/40 ears)
experienced complications, including a 10 %
recurrence rate that required reoperation. They
noted three patients in this group had unscheduled
visit for problems with the dressing, two with
suture granulomas, one with mild asymmetry, and
two with formation. The Dermabond ® group had
a 9 % (3/33 ears) complication rate with a single
recurrence, one super fi cial infection that responded
to antibiotics, and one hypertrophic scar. No
hematomas were reported in either group.
In 2010, Vetter et al. [ 59 ] described their
method of applying cyanoacrylate tissue glue in a
similar manner. They also place a fl at piece of
cotton wool padding over the ear and secured it
with adhesive tape to give some compression to
prevent hematoma formation. The cotton wool
dressing is removed after 4–6 days, and the bond-
ing removed after 10–14 days. They found this
dressing to be convenient and comfortable for the
patients and without adverse effects.
Also in 2010, Tang and Ponsky [ 60 ] described
dressing three patients’ ears that have undergone
otoplasty with a silicone-based occlusive dressing
(DiamondSeal ® ). After the procedure, wet cotton is
placed in the external auditory canal to protect it
from the silicone-based dressing; this is removed at
the end. A bolster cotton piece is placed in the con-
chal bowl to eliminate any dead space and secured
78
R.S. Petersson
with a single dissolvable suture. The DiamondSeal ® ,
a medical-grade silicone and a catalyst mixed into
a single delivery tube, is then applied to the ear and
spread evenly, and the ear is molded into the desired
contour. The product is delivered as a gel that
solidi fi es to a fl exible membrane within 5–10 min.
The authors leave the dressing on for 5 days, after
which is easily removed by peeling. None of the
three patients had any complications.
The traditional mastoid-style head dressing is
bulky and dif fi cult to keep in place, especially in
the pediatric population. The above-described
options seem to be an effective replacement of the
traditional head dressing. At the very least, if a tra-
ditional head dressing is placed, there appears to be
equal bene fi t to keeping the dressing in place for
24 h instead of a longer period of time.
Complications
Complications of otoplasty have been well
described in the literature and can be divided into
early and late categories [ 1, 61– 63 ] . Early com-
plications occur within hours to days and include
hematoma, infection, and skin and cartilage
necrosis. Late complications manifest themselves
in weeks to months and include patient dissatis-
faction, suture complications (e.g., extrusion,
granuloma), recurrence or residual deformity,
unacceptable scarring (e.g., keloid, hypertrophic
scar), and hypoesthesia. Fortunately, overall com-
plication rates are low, and when they do occur,
tend to be minor. Devastating major complica-
tions, such as chondritis, necrosis, and large
hematomas, are rarely seen today. Limandjaja
[ 64 ] performed a literature review of 20 articles
published between 2000 and 2007 to assess the
complication rates associated with otoplasty.
Though they could not directly compare the
included articles, given variable reporting means,
overall they noted early complication rates of
0–8.4 % and late complication rates of 0–47.3 %.
However, late complication rates at the higher
end of the spectrum did not necessarily correlate
with reoperation rates of the same magnitude.
Complications vary depending on the technique
used and the experience of the surgeon.
Conclusions
Without good studies that directly compare car-
tilage-cutting and cartilage-sparing techniques,
it is dif fi cult to ascertain which methods are
superior, and it may be that there is no one supe-
rior method. With several techniques to choose
from, satisfactory and reliable results with low
complication rates can be achieved, as long as
the surgeon is pro fi cient with the chosen tech-
niques. It seems that an approach that utilizes a
combination of techniques, based on careful pre-
operative evaluation and the anatomical needs of
the patient, leads to optimal results. Techniques
are constantly being re fi ned, and large stud-
ies are important in identifying shortcomings,
allowing otoplasty surgeons to make appropriate
modi fi cations. In addition, the future may hold a
greater role for nonsurgical correction if effec-
tive screening programs can be implemented
for early identi fi cation and treatment, especially
during the immediate neonatal period.
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6 Current Trends in Otoplasty
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16. Petersson RS, Recker CA, Martin JR, Driscoll CL,
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47. Ragab A. Carbon dioxide laser-assisted cartilage
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201–4.
52. Ramkumar S, Narayanan V, Laing JH. Twenty-four
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operative management of the prominent ear. Br J Plast
Surg. 1989;42(6):692–4.
54. Wong MC, Syladis P. Head dressing for pinnaplasty:
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55. Patel AJ, Price RD. The use of tissue glue in promi-
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as a dressing for prominent ear correction: a sound
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59. Vetter M, Foehn M, Wedler V. A new postoperative
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19–27.
81
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_7, © Springer-Verlag Berlin Heidelberg 2013
7
Introduction
The perpetual problem of hair interference in
ear and scalp surgery is a particular menace
during otoplasty. In spite of traditional surgical
drapes or stockinet [ 1 ] , hair is easily caught in
Mustarde and postauricular skin sutures, caus-
ing intraoperative aggravation and risking infec-
tion. Heden [ 2 ] fi rst described the use of elastic
bands in hair restraint, similar to the recent utili-
zation of hemorrhoid bands during facelift pro-
cedures [ 3 ] . Long hair may be simply braided to
keep the bulk out of the operative fi eld [ 4 ] , but
it is the fi ne periauricular hair that often evades
such restraint. Antibacterial gels, or prep agents,
applied by hand or comb, may be used to both
control and improve the sterility of hair in the
immediate vicinity, but are messy and leave a
sticky residue unacceptable to many patients,
compounding frustration at being unable to
wash the hair and contributing to sub-bandage
itch. None of these techniques fully seals the
operative fi eld allowing blood to seep onto the
hair-bearing scalp, which is dif fi cult and time
consuming to remove.
For use where the incisions are limited to the
postauricular region, such as during otoplasty,
the use of a swimming hat has been described as
a quick and cost-effective solution [ 5 ] . The
patient is helped to put on a latex or silicone
swimming hat in the anaesthetic room. Hair is
tucked into the hat behind the ears. Any area of
hat that may be exposed at the edge of the drapes
is prepped alongside the ears as normal. As good
hair retention is inherent to the design and mate-
rial of a swimming hat, ears are kept free of hair
interference for the duration of the procedure,
while the hair is kept completely clean from
blood or prepping agent. The hat is easily
removed at the end of the procedure allowing the
surgeons choice of dressing to be applied. Such
swimming hats are available commercially for
less than $1.
The application of a swimming hat, however,
is easier with awake-patient contribution and may
not be appropriate for younger children. This
illustrates the fact that while there is no single
panacea for hair preparation in otoplasty, a solu-
tion usually exists for a particular patient and
their hair type. Preoperative discussion with the
patient regarding putative methods of preparation
will often yield greater participation and accep-
tance, saving time in the operating room (Figs. 7.1
and 7.2 ).
E. S. Bovill , M.D., MBBS, Ph.D.
Department of Plastic and Reconstructive Surgery ,
Royal Devon & Exeter Hospital ,
Exeter EX2 5DW , UK
e-mail: ebovill@doctors.net.uk
Hair Preparation in Otoplasty
Esta S. Bovill
82
E.S. Bovill
Fig. 7.1 ( a ) Preoperative
appearance: routine otoplasty.
( b ) Prior to skin preparation.
Hair is kept clean and free
from gel, preparatory agent,
and blood
Fig. 7.2 Immediate postoperative appearance. Hair is
clean, dry, and away from sutures
References
1. Burningham AR, Stucker FJ. Otoplasty technique: how
I do it. Facial Plast Surg Clin North Am. 2006;14:
73–7.
2. Heden P. A new and simple way to clear the hair from
operating fi elds in the scalp. Plast Reconstr Surg.
1992;89:144–6.
3. O’Neill JK, Stone CA. A novel method of hair control
during face-lift surgery – haemorrhoid bands. Br J Plast
Surg. 2005;58(5):741–2.
4. Knight RJ, Majumder S. A helpful adjunct to otoplasty
surgery. Plast Reconstr Surg. 2005;116(6):1819.
5. Bovill ES, Wharton S. Not a hair out of place: a neat
method of otoplasty preparation. J Plast Reconstr
Aesthet Surg. 2009;62(12):e627–8.
83
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_8, © Springer-Verlag Berlin Heidelberg 2013
8
Introduction
This chapter aims to provide practical advice
on the more subtle aspects of preparing your
patient for otoplasty in the perioperative set-
ting. These tips have been used in clinical
practice and provide a range of solutions to
problems encountered during patient position-
ing, application of drapes, hair preparation, and
marking. The intention is to equip you with
various techniques to tackle these issues and
allow you to fi nd the methods that work best
in your hands.
Positioning
Traditionally patients are positioned supine on the
operating table. Varying amounts of “head-up”
are used depending on surgeon preference, and it
is uncommon to position patients completely fl at.
The use of a gel- fi lled head ring permits better
access to the postauricular region and allows the
head to be turned more easily than with a stan-
dard pillow.
Alternatively, the prone position has been
suggested by Manushakian et al. [ 1 ] . In this
method, the patient is lying face down on
the operating table with a pillow supporting
the patient’s chest (Fig. 8.1 ). This method allows the
operator to visualize both posterior sulci simulta-
neously and eliminates the need to turn the head
intraoperatively. Figure 8.2 demonstrates the ease
of access using this alternative method.
Draping
Following appropriate skin preparation, the stan-
dard method for draping involves a turban-style
head drape held in place with towel clips
(Fig. 8.3 ). This provides a sterile environment for
the procedure and attempts to keep stray hairs
from entering the operative fi eld. A modi fi cation
R. A. J. Wain , MBChB, MRCS(Eng), MSc(Res)
Department of Plastic & Reconstructive Surgery ,
Royal Preston Hospital, Lancashire Teaching
Hospitals NHS Foundation Trust ,
Sharoe Green Lane, Fulwood, Preston ,
Lancashire PR2 9HT , UK
e-mail: richwain@doctors.org.uk
Practical Perioperative Otoplasty
Preparation
Richard A. J. Wain
Fig. 8.1 Prone positioning of the patient prior to draping
84
R.A.J. Wain
of this technique has been proposed by Masud
and Gilbert [ 2 ] , which involves securing the drape
with sterile gauze and adhesive tape in the post-
auricular region (Fig. 8.4 ). It helps to prevent
slippage during movement of the head, however,
in the author’s experience, is quite bulky and lim-
its surgical access.
Drape slippage can be a problem during head
movement. As well as being an inconvenience,
it also can potentially lead to contamination of
the surgical site. Georgeu [ 3 ] describes the use
of 3½ in steri-strips (3M Healthcare, Neuss,
Germany) to aid in the security of the head
drape. The steri-strip positioning, above each eye
and above the nose, is shown in Fig. 8.5 and is
excellent at preventing slippage.
Hair Preparation
One of the common obstacles in otoplasty sur-
gery is that of stray hairs entering the surgical
fi eld. They can interfere with dissection, become
entwined with sutures, and also contaminate the
sterile operative area. Many techniques exist to
prevent this, and several are detailed in this
section.
The most traditional methods include simply
wetting the hair, applying a water-based lubricant,
or using surgical skin preparation solution to hold
the hair in place. A straightforward alternative
Fig. 8.2 Prone position demonstrating the ease of access
Fig. 8.3 The traditional turban-style head drape in position
Fig. 8.4 Secure head drape using sterile gauze and
adhesive tape
Fig. 8.5 Steri-strips in position to prevent drape slipping
85
8 Practical Perioperative Otoplasty Preparation
employs parallel helical plaiting to prevent long
hairs from obstructing the visual fi eld (Fig. 8.6 )
[ 4 ] . This simple and economical technique, how-
ever, is only applicable to patients with hair of
suf fi cient length and must be carried out prior to
the patient arriving in the operating room.
Clear adhesive dressings are another option and
can be applied directly to the ear to keep hairs out
(Fig. 8.7 ) [ 5 ] . A longitudinal slit is cut into the sheet
and the entire pinna passed through it. The dressing
is then secured to the pre- and postauricular skin.
The use of a swimming cap has also been
described to aid the surgeon in the quest for a
hairless operating fi eld [ 6 ] . The latex or silicone
cap is applied prior to skin preparation and stray
hairs tucked beneath it (Fig. 8.8 ). The advantage
of this system is that all of the patient’s hair is
protected from skin preparation agents and any
blood. A potential disadvantage though is that
you rely on the patient bringing the cap to hospi-
tal or the theater having an available supply.
The author’s preferred technique reduces con-
tamination and obstruction by stray hairs in the
operative fi eld while maintaining adequate access,
at no added cost. Sterile paraf fi n gauze, such as
Jelonet (Smith & Nephew UK Ltd., London), is
often used in postoperative otoplasty dressings.
The author utilizes the otherwise wasted protec-
tive paper sheets to create a clean and hairless sur-
gical site [ 7 ] . A curve is cut across one of the
corners of the dressing to fi t the contour of the
postauricular region. The protective paper sheet is
removed and applied behind the ear on top of any
loose hairs, paraf fi n side down, and slid 1–2 cm
posteriorly. The remaining paraf fi n on the paper
helps to hold it in position while preventing hairs
from entering the surgical site. A sterile linen
drape then is applied in a traditional turban style
and secured with towel clips (Figs. 8.9 and 8.10 ).
The shape and orientation of the cutout section of
the paper can be modi fi ed to cover troublesome
hairs anterior to the tragus if required. The patient
now has a sterile, unobstructed operative fi eld
with a clear white background, making the proce-
dure cleaner and wound closure less challenging.
The second protective paper sheet can be used for
the contralateral procedure if necessary.
Fig. 8.6 Parallel helical plaiting of the hair
Fig. 8.7 Application of a clear adherent dressing to the
pinna
Fig. 8.8 Use of a latex swimming cap to prevent loose
hair
86
R.A.J. Wain
Marking
It is common practice during otoplasty to tattoo
the ear cartilage at the position of the antiheli-
cal fold to aid orientation of the correction.
A 23-gauge hypodermic needle along with blue dye
is the usual means of creating this tattoo. Removal
of the silicone coating on the needle has been
described to improve the capacity of the needle to
hold the blue dye [ 5 ] . The needle is dipped in the
dye, passed through the pinna at the desired point,
re-dipped in the dye, and then withdrawn through
the same point. Dye can be applied to the needle
tip in a number of ways, but a particularly versa-
tile method is using the needle sheath or cap fi lled
with dye (Fig. 8.11 ). A potential drawback of this
technique of course is the risk of needle stick
injury. O’Neill et al. have proposed a safer
variation on this with the use of a plastic suture
packet [ 8 ] . The needle sheath is still used, but is
held by the plastic suture packet, thereby reduc-
ing the risk of a needle stick injury (Fig. 8.12 ).
The author’s preferred technique is to apply dye
to the needle tip using a sterile cotton bud dipped
in the dye.
Conclusions
Otoplasty can be a challenging procedure,
even for the most accomplished surgeons. The
technical tips in this chapter aim to provide
useful, practical advice on the preparation of
your patient in the perioperative setting. Issues
Fig. 8.10 Patient fully draped, with paper sheet in posi-
tion demonstrating a clear unobstructed operative fi eld
Fig. 8.11 Use of the needle sheath to apply dye when
tattooing
Fig. 8.9 Paraf fi n dressing cut to shape with protective
sheet being removed
Fig. 8.12 Demonstrating the needle sheath held by the
suture packet
87
8 Practical Perioperative Otoplasty Preparation
such as patient positioning, application of
drapes, hair preparation, and marking tech-
niques have been addressed. It is the author’s
intention to demonstrate the variety of methods
available and allow the reader to choose those
that will bene fi t their individual practice.
References
1. Manushakian HS, Wilson PA, De Souza BA,
McGrouther DA. The prone position in otoplasty. Plast
Reconstr Surg. 2005;115(3):963–4.
2. Masud D, Gilbert P. Secure sterile head drape for head
and neck surgery. J Plast Reconstr Aesthet Surg. 2009;
62(1):143–4.
3. Georgeu GA. Stopping surgical drapes from slipping
during pinnaplasty using steri-strips. Aesthetic Plast
Surg. 2007;31(5):604–5.
4. Knight RJW, Majumder S. A helpful adjunct to otoplasty
surgery. Plast Reconstr Surg. 2005;116(6):1819.
5. Bhatti AF, Chapman TWP, Orlando A. Practical tips for
otoplasty. Plast Reconstr Surg. 2006;117(1):329–30.
6. Bovill ES, Wharton S. Not a hair out of place: a neat
method of otoplasty preparation. J Plast Reconstr
Aesthet Surg. 2009;62(12):e627–8.
7. Wain RAJ, Shah SHA. Practical perioperative pinna-
plasty preparation. Aesthetic Plast Surg. 2011;35(2):
281–2.
8. O’Neill JK, Gnanajebamani A, Beach R, Khandwala
AR. A safer method for inking the tattoo needle for
pinnaplasty. Clin Otolaryngol. 2006;31(6):564–5.
89
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_9, © Springer-Verlag Berlin Heidelberg 2013
9
Introduction
Otoplasty is a commonly performed operation
both in adults and children by a variety of surgi-
cal specialists. There are minor technical
dif fi culties encountered while performing this
procedure which are more of a nuisance than
anything else. These include intrusion of hair into
the operative fi eld, disappearance of ink marks
after tattooing the cartilage, and dif fi culty in
application of the dressing with its tendency to
slip postoperatively to name the most common
ones.
Although quite minor, these dif fi culties are
frequently associated with increased operating
time and may compromise the end results. The
authors describe a few simple tips that have help
in our practice to overcome these dif fi culties and
have helped to improve our outcome.
Tips
Local Anesthetics
Otoplasty is frequently done in adult patients
under local anesthesia, and in older children it
may be an option. Unbuffered lidocaine 1 % with
adrenaline 1: 200,000 (pH = 6.5) is commonly
employed as a local anesthetic solution. The
acidic nature of local anesthetic is at least par-
tially responsible for the stinging or burning sen-
sation at the injection site. A reduction in the pain
associated with the in fi ltration of lidocaine has
been reported by the use of alkalinized (buffered)
local anesthetic solutions [ 1, 2 ] . This effect can
be very easily achieved by adding 10 % of 8.4 %
sodium bicarbonate into the local anesthetic solu-
tion. This will neutralize the acidic effect, result-
ing in less stinging and a more comfortable
experience for the patient. If more than 10 % of
sodium bicarbonate is added, then the excess will
precipitate and appear as a cloudy solution.
Intrusion of Hair
To address the problem of hair intrusion into the
operative fi eld, we take various preemptive steps.
In patients who have long hair, the hair is twisted
into a single lock, and we tie this lock on top of
the head with cotton gauze (Figs. 9.1 and 9.2 ).
Even in patients with shorter hair, a copious
amount of chlorhexidine scrubbing solution is
applied to the hair around both ears. This not only
A. F. Bhatti , M.D. (*)
Department of Plastic and Reconstructive Surgery ,
Frenchay Hospital , Bristol , UK
e-mail: afbhatti1@yahoo.co.uk
A. Orlando , M.D.
Department of Plastic and Reconstructive Surgery,
Frenchay Hospital , Bristol , UK
e-mail: antonio.orlando@nbt.nhs.uk
Practical Tips for Otoplasty
Ahmad F. Bhatti and Antonio Orlando
90
A.F. Bhatti and A. Orlando
cleanses and decontaminates the scalp but also
matts the hair, and as it dries it hardens to stick
hair onto the scalp away from the surgical inci-
sion (Fig. 9.3 ).
Regardless of the length of hair and after the
head drapes have been applied, a medium-sized
clear adherent sheet dressing such as Tegaderm™
or Opsite™ is used. This adherent but transparent
layer further isolates the ear from the rest of the
face/scalp/neck. Cutting a longitudinal slit in
the sheet or taking a 1–2-cm-wide ellipse out of the
adherent dressing helps to facilitate application.
The ear is passed through this fenestration, and the
sticky portion of the dressings is placed over the
hair (Figs. 9.4 , 9.5 , and 9.6 ). This maneuver will
control even short hair on the dressing, resulting
Fig. 9.1 Long hair placed together cranially
Fig. 9.2 Hair tied with cotton gauze
Fig. 9.3 Hair is being soaked with chlorhexidine scrub-
bing solution
Fig. 9.4 Medium-sized Tegaderm™ with an ellipse cut
out in the center
Fig. 9.5 Application of Tegaderm™ around the ear
91
9 Practical Tips for Otoplasty
in no hair intruding into the operative fi eld. Care
must be taken to dry the whole of the operative
fi eld before application of the dressings, other-
wise it will not stick properly.
Tattooing the Cartilage
For tattooing the cartilage, we use a hypodermic
needle with its silicone surface roughened for
better holding of ink. This can be achieved by
running the back of a scalpel blade along its
length (Fig. 9.7 ).
The sheath of the needle itself can be used as
an ink container. The usage of the sheath is supe-
rior to having ink in a pot. The sheath will allow
ink to bath the whole length of needle as com-
pared to only tip encounter with ink in a pot.
This technique should result in more loading of
ink to the surface of needle and better tattooing.
The needle sheath can easily be fi lled by drawing
ink into a 2-mL syringe and then injecting with
the same needle into the sheath (Fig. 9.8 ).
The needle is dipped into the ink before punc-
ture and again prior to its withdrawal through the
cartilage. This has proven in our practice to be a
reliable method of tattooing both sides of the
cartilage (Figs. 9.9 , 9.10 , and 9.11 ). Care must be
Fig. 9.6 Tegaderm™ in place
Fig. 9.7 Removing silicon coating from hypodermic
needle
Fig. 9.8 Injecting ink into the needle sheath
Fig. 9.9 Dipping needle into the ink container
92
A.F. Bhatti and A. Orlando
taken not to puncture your fi nger with the sharp
needle tip before it is dipped into the sheath.
Alternatively, the sheath can be held in a hemo-
stat or forceps.
Ear Dressings
Application of dressings to the operated ear can
also be challenging. A small length of a plain or
pro fl avin-impregnated cotton is used and rolled
into a 6–8 cm long strip. A small piece of Jelonet
is further rolled over it to enhance its malleability
and is placed from the newly formed scaphoid
fossa to the concha of the ear (Figs. 9.12 , 9.13 ,
and 9.14 ). This placement will keep the gentle
pressure over the dissected area to keep in shape
and reduce any ooze from the deep surface of the
ear skin.
An oval dressing pad is cut in a spiral man-
ner and in a comma shape. An eye-pad dressing
is ideal for this purpose. The central portion is
applied on the conchal area, and the peripheral
portion is hooked over the upper pole, and rest
is placed behind the ear (Figs. 9.15 and 9.16 ).
This maneuver is excellent for holding the
dressing in position. Moreover, it provides a
soft cushion to both outer and inner surfaces of
the ear, dispersing any pressure and thus pre-
venting necrosis. This can be reinforced further
by placing small piece of cotton wool secured
in position by a head dressing if required
(Fig. 9.17 ).
Fig. 9.10 Dipping needle into the ink container after its
passage through the cartilage
Fig. 9.11 Visible intraoperative cartilage marks
Fig. 9.12 Pro fl avin-soaked wool strings wrapped in Jelonet
along with cutout eye pads
Fig. 9.13 Spiral cutting of an eye-pad dressing