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

94
A.F. Bhatti and A. Orlando
References
1. Barnett TA, Kapp DS. Reduction of pain and local
complications when buffered lidocaine solution is used
as a local anesthetic in conjunction with hyperthermia
treatments: results of a randomized trial. Int J Radiat
Oncol Biol Phys. 1992;23(3):585–91.
2. Masters JE. Randomised control trial of pH buffered
lignocaine with adrenaline in outpatient operations. Br
J Plast Surg. 1998;51(5):385–7.
Fig. 9.19 Front portion of the bandage is re fl ected and
secured in position by adhesive tape
Fig. 9.20 Final appearance of head bandage

95
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_10, © Springer-Verlag Berlin Heidelberg 2013
10
Introduction
The ear is a complementary but integral part of
one’s appearance. Because the ear is more later-
ally located compared to other facial structures, it
is often not the main focus when one examines
the face. However, when prominent or otherwise
abnormal, the ear can draw one’s attention from
the rest of the face, possibly resulting in social
stigma or ridicule, especially in childhood. In
1881, Ely [ 1 ] performed the fi rst truly cosmetic
otoplasty on a 12-year-old boy for this very rea-
son. Many variations of this operation have been
described since, leaving today’s practitioners
with a number of techniques from which to
choose.
In general, these techniques can be divided
into two categories: cartilage cutting and carti-
lage shaping. Cartilage-cutting techniques involve
scoring, incising, or excising cartilage to create
the desired shape, while cartilage-shaping tech-
niques involve suturing to bend cartilage into the
desired shape. Cartilage-cutting techniques can
result in unsightly irregularities, while cartilage-
shaping techniques are at risk for suture failure
and the ear springing back to its original position.
The authors prefer a cartilage-shaping technique
because the risk of cartilage irregularities is low,
and in the case of suture failure, revision is rela-
tively easily performed. Overall, however, excel-
lent results can be achieved from the vast majority
techniques that are available today as long as
appropriate attention is given to each patient’s
anatomy.
Preoperative Workup
Patient Selection
As with any potential surgical candidate, a detailed
history and physical exam is essential. Ear mal-
formations may be associated with syndromes
that include heart and kidney malformations or
other craniofacial malformations that may com-
plicate anesthesia, particularly airway manage-
ment, and an anesthesiologist should be consulted
preoperatively whenever appropriate. Although
these concerns should always be kept in one’s
mind, it is still relatively uncommon to encounter
such abnormalities in the otherwise healthy and
anatomically normal appearing patient. As part of
the exam, photographs should be taken for surgi-
cal planning. A series that includes full-face fron-
tal, lateral, and posterior images as well as
close-up frontal, lateral, oblique, and posterior
images of each ear are helpful in the initial con-
sultation (Fig. 10.1 ) [ 2 ] . These images assist in
preoperative planning as well as the management
of expectations and surgical goals.
N. T. N. Schreiber , M.D. • S. R. Mobley , M.D. (*)
Division of Otolaryngology-Head and Neck Surgery,
Department of Surgery ,
University of Utah School of Medicine ,
50 North Medical Dr. 3C120 , Salt Lake City ,
UT 84132 , USA
e-mail: ntschreiber@gmail.com ;
mobley@mobleymd.com
Nuances of Otoplasty
Nathan T. N. Schreiber and Steven R. Mobley

96
N.T.N. Schreiber and S.R. Mobley
Fig. 10.1 Typical full-face
images for otoplasty

97
10 Nuances of Otoplasty
Analysis of the patient’s ears should be care-
fully documented so that any preexisting asymme-
tries and irregularities can be addressed.
Measurements of the cephaloauricular angle,
helix-to-scalp distance, as well as hypoplastic por-
tions of the ear are often helpful in this regard.
Prominent ears are often the result of a poorly
formed antihelix and deep conchal bowl and have
been de fi ned alternatively as a cephaloauricular
angle greater than 40° or a helix-to-scalp distance
of 2 cm or greater (Fig. 10.2 ) [ 3, 4 ] . Regardless of
published standards, patients with prominent ears
will often present their own goals regarding ear
appearance, especially when older. In the experi-
ence of the senior author, adult patients are much
more likely to have contemplated otoplasty for
many years and will often present with a well-
de fi ned idea of how close they desire their ears to
be to their scalp. Individuals with longer hair, for
example, may tolerate a greater degree of ear
prominence compared to those with shorter hair,
while men with shaved heads may request that
their ears be quite close to the scalp, perhaps even
closer than might be considered a cosmetic norm.
As long as the request is reasonable, however,
more extreme setbacks can still be accomplished
with a high degree of patient satisfaction as long as
goals and expectations are clear preoperatively.
Younger patients, on the other hand, tend to have a
much less speci fi c idea of how close their ears
should be to their scalp and an otoplasty should be
performed with reasonable, standard goals in
mind. One study noted a discrepancy between sur-
geon and patient identi fi cation of prominent ears,
with surgeons labeling 10 % of patient ears as
prominent but only 2 % of patients labeling their
ears as prominent [ 5 ] . In other words, one may
consider an ear prominent when a patient says it is.
In this respect, goals regarding the ultimate appear-
ance of one’s ears are important to elicit.
Fig. 10.2 Normal anatomic
relationships of the ear (Image
used with permission from
[ 74 ] )

98
N.T.N. Schreiber and S.R. Mobley
Psychosocial concerns should also be acknowl-
edged and discussed in the initial consultation.
The social impact of having large protruding ears
can often be underestimated by society and facial
plastic surgeons. However, patients, and often
their parents, will be the ones to most clearly
understand this social stigma, particularly during
the more cruel years of adolescence and its asso-
ciated bullying and teasing. To further illustrate
these social stresses, one study compared chil-
dren with prominent ears to children with visible
facial port-wine stains. One might initially think
that a port-wine stain would prove to be a greater
social handicap than prominent ears. However,
this study suggested that self-esteem, social prob-
lems, and attention problems may be worse in the
group with prominent ears [ 6 ] . The authors
hypothesized that this difference may be due to a
tendency to treat prominent ears as an exaggera-
tion of normal rather than a true deformity, result-
ing in decreased social support for children with
prominent ears. Although further research is
needed regarding this subject, children with
prominent ears may have a greater degree of psy-
chosocial problems compared to children with
other facial deformities. The potential psychoso-
cial consequences of this condition are illustrated
in heartbreaking detail by the following excerpt
from a letter to the senior author written by the
mother of a 9-year-old boy with prominent ears:
…he recently had an incident on the school bus
where an older boy punched him in the stomach
and then mockingly asked, are you going to use
your bat ears to fl y away?… My son asks me on a
regular basis, why people make fun of his ears?…
It has gotten to the point where he is afraid to meet
new people , is becoming increasingly shy, and is
prone to hiding behind me or burying his face in
my side when I introduce him to new people.
Stories similar to this are told by the majority
of patients and families who are seen in consulta-
tion for an otoplasty and should be always be
acknowledged so that appropriate family and
social support can be encouraged.
Patient and family expectations regarding tim-
ing of surgery, potential complications, and abil-
ity to tolerate dressings and postoperative care
should be addressed, particularly with younger
patients. Traditionally, otoplasty in children is
delayed until around 5–6 years of age, a time at
which the ear has nearly reached its adult size
and before entering grade school when teasing
becomes a greater concern [ 7 ] . However, citing
concerns about development of self-image with
excessive family focus upon ear prominence prior
to 5 years of age, some surgeons have performed
otoplasty as early as 9 months without observing
any disturbance in cartilage growth [ 8, 9 ] .
Otoplasty much earlier than 5 years of age, how-
ever, remains controversial.
Molding Techniques
Neonates who have an auricular deformity, how-
ever, should be considered for ear molding. Ear
molding techniques usually involve placing a
splint along the contours of the ear to hold it in
a desired shape for approximately 2–12 weeks. If
started within the fi rst week of life, molding may
correct up to 90 % of auricular deformations, while
30 % may self-correct [ 10, 11 ] . Most authors advo-
cate ear molding for neonates only. Yotsuyanagi
[ 12, 13 ] , however, suggested that ear molding can
be performed in older children and even adults,
reporting 72 % success in achieving adequate cor-
rection with a variety of auricular deformities after
splinting from 2 weeks to 2 months depending on
the deformity, cartilage elasticity, and response. Of
these deformities, however, prominent ears were
the most resistant to treatment, only responding
54 % of the time. The most signi fi cant barrier to
ear molding, however, is tolerability of the splint.
Younger children who are most likely to bene fi t
from molding are less likely to tolerate prolonged,
consistent use of the splint.
In 2011, however, Leclere [ 14 ] reported a
4-year experience of laser-assisted cartilage
reshaping (LACR) for prominent ears. The
Er:Glass laser used in this study has a wavelength
of 1,540 nm, allowing penetration through the
entire ear cartilage. Once treated, the cartilage is
malleable and generates new cartilage that is
thought to be the cause of long-term shape stabil-
ity. In this study, 32 prominent ears of 17 patients
with an average age of 34.5 years were treated
with an Er:Glass laser, followed by placement of
a silicone elastomer splint to hold the helix in the

99
10 Nuances of Otoplasty
desired shape. The splint was worn at all times
for 2 weeks and then only at night for an addi-
tional 4 weeks. Overall, 2 patients developed
contact dermatitis thought to be related to the
splint, 2 patients noticed ear asymmetry, and 1
patient rated the result as unsatisfactory but would
have been willing to undergo the procedure again.
This technique appears to have promise and may
be more widely used in the future; however, at
this time, larger studies are needed to further
de fi ne indications and limitations for LACR.
Operative Techniques
Positioning
Traditionally, the patient is placed in the supine
position for otoplasty. If available, a May fi eld-
type head rest can be helpful to allow easier
access to the postauricular areas. Both ears should
remain visible within the operative fi eld, even if
only one ear is to be operated upon so that ear-to-
ear comparisons can be made during surgery.
Alternatively, Manushakian et al. [ 15 ] reported
performing otoplasty with the patient in the prone
position, citing superior ability to compare each
ear for symmetry without needing to turn the
head from side to side. However, while symmetry
can be appreciated from the prone position, it is
clearly not the posterior view about which patients
are usually concerned. Patients present to the
of fi ce almost universally disturbed by how their
ears look on frontal view. While operating on
someone in the prone position may allow for an
advantage visualizing posterior symmetry, this
position makes it nearly impossible to assess the
most important view to the patient, a seeming
mismatch of intraoperative planning and tech-
nique with ultimate surgical goals. In addition,
the prone position may expose the patient to an
increased risk of serious complication, including
accidental endotracheal extubation and corneal
injury [ 16 ] . Although the overall risk for such
complications may be low, any increased risk
along these lines in an elective procedure may be
unacceptable to the patient and surgeon.
Regardless of positioning, symmetry is of the
utmost importance, and for that reason the more
challenging ear should be addressed fi rst. It is
often helpful to keep the goals of otoplasty in
mind throughout surgery as a guide (Table 10.1 ).
Anesthesia
In general, conscious sedation with local anesthe-
sia has become increasingly recommended in
aesthetic surgery due to decreased postoperative
morbidity as compared to general anesthesia. In
one study of conscious sedation agents, remifen-
tanil compared to propofol and midazolam was
found to provide better perioperative pain control
in patients undergoing otoplasty and blepharo-
plasty [ 18 ] . Another study of ambulatory surgery
patients suggested signi fi cantly decreased post-
operative pain and time to discharge when local
anesthesia was injected intraoperatively [ 19 ] . For
younger children, general anesthesia is still the
safest and most practical option. For adults, these
options should be discussed as a part of preopera-
tive counseling. The senior author usually frames
the discussion that general anesthesia will have a
slightly higher incidence of postoperative nausea
and possibly a sore throat, while conscious seda-
tion has the advantage of a quicker wake-up and
quicker discharge from the surgical facility.
Overall, these are relatively minor decision
points, and excellent patient experiences can
usually be achieved with either general anesthe-
sia or conscious sedation depending on each indi-
vidual patient’s desires and concerns. Whether
conscious sedation or general anesthesia is used,
local anesthesia in fi ltration is a must.
Table 10.1 Goals of otoplasty [ 17 ]
1. Correct all upper third ear protrusion
2. The helix should be visible beyond the antihelix on
frontal view
3. The helix should have a smooth, regular contour
4. The postauricular sulcus should not be excessively
decreased or distorted
5. The helix-to-scalp distance should be:
(a) 10–12 mm at the upper third
(b) 16–18 mm at the middle third
(c) 20–22 mm at the lower third
6. The helix-to-scalp distance should match the
opposite side within 3 mm at any point

100
N.T.N. Schreiber and S.R. Mobley
Local Anesthesia Injection
Many surgeons will inject standard concentrations
of local anesthetic with epinephrine when per-
forming otoplasty. The most common epinephrine
concentration for this purpose is 1:100,000. One
must keep in mind, however, that a hypertensive
crisis may result from excessive epinephrine
injection in patients who are taking vasoactive
medications or who have cardiovascular disease,
uncontrolled hypertension, pheochromocytoma,
or hyperthyroidism [ 20, 21 ] . In patients with
severe cardiovascular disease, some advocate
maximum epinephrine doses of 0.04 mg (4 mL of
anesthetic with 1:100,000 epinephrine) that can be
administered up to every 30 min [ 22 ] . The major-
ity of patients selected for elective otoplasty are
in general healthy and without signi fi cant medi-
cal comorbidities. In our experience with such
patients, epinephrine concentrations of 1:50,000
can be injected along the anterior and posterior
ear without cardiovascular or ischemic complica-
tion. Under general anesthesia, 2–3 mL of a cus-
tom mixture of 0.25 % bupivacaine with 1:50,000
epinephrine will be injected along both sides of
each ear. When using conscious sedation, a cus-
tom mixture of 1 % lidocaine with 0.25 % bupiva-
caine and 1:50,000 epinephrine will be injected.
This dilution can be attained by combining 5 mL
of 2 % lidocaine with 5 mL of 0.5 % bupivacaine
and 0.2 mL of 1:1,000 epinephrine.
Incision
Most otoplasty techniques involve a postauricular
incision and skin excision in the shape of a dumb-
bell (Fig. 10.3 ). A skin excision of this shape will
help to avoid creating a telephone ear deformity
in which the upper and lower thirds of the ear are
not adequately corrected and remain excessively
prominent in the shape of a traditional telephone
(Fig. 10.4 ). Some surgeons, on the other hand,
advocate a simple postauricular skin incision with-
out skin excision [ 23, 24 ] . In either case, the inci-
sion should be designed based upon the amount
of correction that is needed as well as cartilage
access. For example, the incision may be extended
Fig. 10.3 Traditional dumbbell-shaped skin excision
Fig. 10.4 Telephone ear (Image used with permission
from [ 74 ] )

101
10 Nuances of Otoplasty
superoanteriorly to the helical root and inferiorly
to the lobule and should be used to access the
planned antihelix and conchal cartilage.
Alternatively, some surgeons who prefer to
recreate an antihelix by scoring the anterior carti-
lage surface advocate an anterior skin incision
[ 25 ] . An anterior incision can allow easier access
to the anterior surface of the cartilage, but does
create a visible scar. Others have attempted to
reduce incision size as much as possible to mini-
mize risk of scar and keloid formation. One such
technique, endoscopic-assisted otoplasty, trades a
larger postauricular incision for a 2-cm temporal
scalp incision for placement of an endoscope and
a postauricular stab incision for placement of
instruments [ 26 ] . Importantly, endoscopic-assisted
otoplasty is not recommended for ears in which
the lobule requires reduction independent to that
of the helix or prominence is the result of a deep
conchal bowl only. An additional technique called
incisionless otoplasty avoids a traditional incision
through percutaneous suture placement [ 27 ] .
Conchal Bowl
Conchal setback involves securing the con-
chal cartilage closer to the mastoid periosteum
and can be performed in either a cartilage-cutting
or cartilage-shaping manner. Cartilage-shaping
techniques will work for the majority of ears.
Particularly deep conchal bowls or stiff carti-
lage, however, may be easier to address with a
cartilage-cutting technique.
Cartilage-Cutting Techniques
for the Conchal Bowl
The fi rst cosmetic otoplasty as described by Ely
involved a simple excision of skin and conchal
cartilage [ 1 ] . In descriptions of their modi fi ed
techniques, Converse and Farrior similarly
excised strips of conchal cartilage, resuspending
the cut edge of cartilage to the mastoid perios-
teum to decrease ear prominence [ 28, 29 ] . This
technique was the preeminent practice of the
early twentieth century and was noted to be long
lasting but carried with it the risk of creating a
noticeable cartilage irregularity.
Cartilage-Shaping Techniques
for the Conchal Bowl
In 1968, Furnas [ 30 ] described placing three per-
manent sutures from the conchal cartilage to the
mastoid periosteum to correct the excessively
deep conchal bowl without incising the cartilage.
This technique had been described previously, but
with frequent deformity recurrence. Furnas
achieved longer lasting results by emphasizing
the importance of sutures penetrating entirely
through the conchal cartilage as well as the mas-
toid periosteum. Ideal suture placement in this
technique is identi fi ed prior to making any inci-
sions by using a cotton-tipped applicator to press
the conchal cartilage against the mastoid and
marking the most aesthetically pleasing locations.
Placing sutures too far posteriorly at the conchal
cartilage or too far anteriorly at the mastoid
periosteum can rotate the conchal bowl anteriorly,
narrowing the entrance to the external auditory
canal. It is recommended that one removes a disk
of soft tissue above the mastoid periosteum to
allow for adequate ear medialization (Fig. 10.5 ).
Fritsch [ 27 ] described incisionless otoplasty in
1992, in which he reduced conchal bowl promi-
nence through a small incision up to a few milli-
meters in length directly in the postauricular
sulcus. Electrocautery is used to ablate soft tissue
above the mastoid periosteum, and a suture needle
is passed subcutaneously through a portion of dis-
tal conchal bowl cartilage until it passes through
the skin posteriorly. The suture needle is then
passed back through the same opening through
which it had just passed, through an adjacent por-
tion of distal conchal bowl cartilage, and out
through the small postauricular incision. The nee-
dle is then passed through mastoid periosteum and
tied in place to achieve the desired correction.
In 2001, Horlock [ 31 ] described a modi fi cation
of the conchal setback that involves creating a
posteriorly based fascial fl ap from tissue that is
initially left along the posterior surface of the
auricular cartilage. This fl ap is elevated off of the
mastoid to create adequate space for conchal
medialization and attached above the newly cre-
ated antihelix to provide additional coverage for
the permanent sutures in this location. This
modi fi cation is intended to provide additional

102
N.T.N. Schreiber and S.R. Mobley
stability and reduce postoperative ear lateraliza-
tion as well as suture extrusion and discomfort.
Antihelix
On average, an unfolded antihelix accounts for
73 % of ear prominence [ 5 ] . For this reason,
recreation of the antihelical fold is perhaps the
most important single factor in otoplasty and
may be performed without a conchal setback.
The antihelix can also be recreated with either
a cartilage-cutting or cartilage-shaping technique.
Again, cartilage-shaping techniques will work for
most ears, but cartilage-cutting techniques may
be better suited for very stiff cartilage.
Cartilage-Cutting Techniques
for the Antihelix
In 1910, Luckett [ 32 ] described a transcartilagi-
nous incision at the antihelix in order to create a
fold. This technique has also been described with
excision of a cartilage strip [ 17, 33 ] . The resulting
antihelix, however, may appear sharp and unnatu-
ral. Converse attempted to improve the appearance
of the new antihelix by folding the cartilage upon
itself after performing the transcartilaginous inci-
sion [ 28 ] . Other surgeons recognizing a persistent
irregular appearance then began partial thickness
cartilage incision or excision along the posterior
surface. Farrior [ 29 ] excised a series of partial
thickness cartilage wedges posteriorly at the
planned antihelix and then made two transcartilagi-
nous incisions at either side of the planned antihe-
lix, allowing this strip of cartilage to be positioned
anteriorly and curved slightly in a more natural
shape. One such method involves using monopolar
electrocautery in “cut” mode to create a “Y”-shaped
partial thickness trough along the antihelix and
superior and inferior crura after being marked with
methylene blue [ 34 ] . This trough weakens the car-
tilage, allowing easier creation of an antihelix with
horizontal mattress sutures. A similar technique of
cartilage ablation to create troughs using the CO 2
laser was described by Ragab in 2010 [ 35 ] , with
the idea that cartilage remodeling may be induced
to create a more stable cartilage shape.
Alternatively, some surgeons prefer to score
the antihelical cartilage along its anterior surface,
making use of cartilage’s tendency to bend aware
from a scored surface [ 36 ] . From a postauricular
approach, Chongchet [ 37 ] described a transcarti-
laginous incision between the helix and antihelix
to allow anterior cartilage access. Stenström and
Heftner [ 38 ] described access to the antihelix
from a postauricular incision, dissecting the
entire auricular cartilage from the overlying skin
to score the anterior cartilage surface. In varia-
tions of these techniques, the anterior cartilage
surface is weakened with partial thickness incisions
or scoring [ 23, 39 ] . These techniques, however,
a
b
c
Fig. 10.5 Steps of conchal setback. Removing disk of
soft tissue behind conchal cartilage ( a ), identifying ideal
suture placement at posterior concha ( b ), and placing con-
chal setback suture ( c )

103
10 Nuances of Otoplasty
involve a greater degree of skin undermining and
potentially a greater risk of hematoma if careful
attention is not given to hemostasis or dressing
application intraoperatively.
The anterior cartilage surface can be accessed
from an anterior auricular incision along the poste-
rior border of the conchal cartilage as well. From
this incision, the anterior cartilage surface can be
scored, abraded, or accessed endoscopically for
greater scoring precision [ 25 ] . An anterior incision
allows for decreased skin undermining, but does
create a scar in a visible location.
An alternative technique described by Fritsch
in 1992 [ 27 ] addresses both of these concerns.
This technique, incisionless otoplasty, involves
percutaneous scoring of the anterior cartilage
along the planned antihelix with a 20-gauge phle-
botomy needle followed by percutaneous place-
ment of permanent horizontal mattress sutures.
Cartilage-Shaping Techniques
for the Antihelix
In 1963, Mustarde [ 40 ] described placing a series
of permanent horizontal mattress sutures through
a postauricular incision without incising the car-
tilage to recreate the antihelix.
Some have noted that it can be dif fi cult to place
these sutures exactly from the posterior ear and
have advocated the use of transcutaneous silk
sutures placed intraoperatively as a guide for per-
manent suture placement [ 41 ] . In either case, it is
often helpful to manually bend the antihelix to the
desired natural shape and place markings where
horizontal mattress sutures will be most effective
(Fig. 10.6 ). Most surgeons will use 4-0 polyester
sutures in this technique. Horlock’s [ 31 ] postau-
ricular fascial fl ap is designed to provide additional
coverage of these permanent sutures and reduce
the risk of suture extrusion and discomfort.
Helical Root
Often, after performing a conchal setback and
recreating the antihelix, the helical root will pro-
trude laterally in a majority of cases. This problem
was addressed by Hatch in 1958 [ 42 ] , when he
described securing the helical root to the temporalis
fascia. This area can be accessed by extending the
postauricular incision superiorly and anteriorly
along a natural skin crease in front of the helical
root or creating a separate 5–10-mm incision. A
4-0 polyester suture can then be placed securely,
deep into the temporalis fascia and through the
inferior-most helical root cartilage. When this stitch
is tightened, the helical root should be brought into
a more natural position (Fig. 10.7 ). This technique
helps one avoid a telephone ear deformity [ 24 ] .
a
b
Fig. 10.6 Planning horizontal mattress sutures for anti-
helix using a 30 gauge needle to enter the cartilage through
the skin at the anterior surface marking ( a ) and marking the
posterior surface of the cartilage at the needle’s exit ( b )
Fig. 10.7 Helical root suture and incision placement

104
N.T.N. Schreiber and S.R. Mobley
Lobule
Traditionally, the lobule is addressed by excising
a vertical ellipse of skin along its posterior sur-
face (Fig. 10.8 ) [ 7, 30 ] . In Fritsch’s [ 27 ] incision-
less otoplasty, however, lobule projection can be
reduced by percutaneously dissecting the cauda
helicis from the helix with a 20-gauge phlebot-
omy needle and securing the fl ail segment of
cauda helicis cartilage to the posterior conchal
bowl. The lobule is important to address if needed
as it may also contribute to a postoperative tele-
phone ear deformity.
Closing the Incision
In traditional otoplasty with a postauricular inci-
sion, it is important to close the incision meticu-
lously to minimize the postoperative scar. Even
though it is hidden behind the ear, a poorly closed
incision may be bothersome to the patient. The
authors prefer to close this incision using 5-0
fast-absorbing catgut suture, leaving three small,
3–4-mm gaps to allow egress of blood and
decrease risk for hematoma. This modi fi cation of
leaving small, purposeful 3–4-mm gaps in the
closure has anecdotally reduced the senior
author’s rate of postoperative hematoma to zero
without compromising fi nal wound aesthetics or
risk of infection.
Postoperative Care
Dressing
The majority of surgeons who perform otoplasty
use some sort of compression dressing postoper-
atively to keep the ears in a fi xed position during
initial healing. Dressings used for this purpose
range from fl uffed gauze padding held in place
by circumferential gauze or Silastic foam to a
dust mask, a doorknob cover, or a wrestling head-
gear [ 43– 47 ] . These dressings, however, may
cause pressure necrosis of pinna and forehead or
reduce the likelihood that a hematoma or infec-
tion will be recognized at an earlier time. In addi-
tion, dressings that require frequent replacement
are coated with dried blood or have an odor may
cause embarrassment and limit an earlier return
to work or school [ 48, 49 ] . Because of these con-
cerns, some surgeons have questioned the dura-
tion and even need for dressings after otoplasty,
especially in cartilage-shaping techniques when
permanent sutures are holding the newly posi-
tioned cartilage in position. Ramkumar et al. [ 50 ]
randomized 80 children receiving otoplasty into
24-h versus 10-day dressing groups and found no
difference between them. Orabi et al. [ 51 ]
reviewed a series of 84 patients in which 23 did
not receive a postoperative dressing and did not
fi nd any difference in complication rate. Overall,
these studies suggest that postoperative dressings
may be kept in place for shorter amount of time
and may, perhaps, not even be necessary.
Currently, however, there are no clear evidence-
based recommendations, and, for this reason, the
traditional approach of using a compression
dressing is favored.
In our patients, a soft compression dressing is
used in every case. Petrolatum gauze is cut into
fi ve 5-mm strips and packed along the newly
shaped anterior and posterior ear surfaces. This
dressing is covered by fl uffed 4 × 4 in. gauze
sponges and either size seven or eight elastic net
bandage doubled over the face after twisting at
the top of the head. A gap is cut over the eyes,
nose, and mouth, while the inferior edge is pulled
Fig. 10.8 Lobule reduction with posterior wedge excision

105
10 Nuances of Otoplasty
under the chin for patient comfort (Fig. 10.9 ).
This dressing is left in place for 48 h and is
removed when the patient returns to clinic on
postoperative day 2.
Antibiotics
Many surgeons prescribe postoperative antibiot-
ics after otoplasty, and unfortunately there are no
studies speci fi c to this topic. One study found no
bene fi t for postoperative antibiotics in the setting
of middle ear surgery and tympanoplasty [ 52 ] .
Another study by Sylaidis et al. [ 53 ] suggests a
5 % wound infection rate for surgery near the ear
mostly involving local fl aps after oncologic resec-
tion. If antibiotics are to be used, one that covers
typical skin fl ora, such as cephalexin, should be
adequate.
Complications
Complications after otoplasty are uncommon,
but can be severe when they occur. Therefore,
any complications should be dealt with expedi-
tiously. Early postoperative complications include
bleeding, hematoma, skin necrosis, infection, and
chondritis, while late complications include
asymmetry inadequate correction, telephone ear
deformity, abnormal ear contours, suture granu-
lomas, extruded or broken sutures, and keloids.
Complication rates are summarized in Table 10.2
[ 3, 23, 31, 37, 54– 71 ] . Hematoma usually pres-
ents as sudden swelling at the surgical site and is
often caused by inadequate hemostasis or postop-
erative trauma. Hematomas should be drained to
prevent infection, calci fi cation, and cartilage loss.
Infection, on the other hand, will often present as
ear swelling and drainage with worsening pain
around postoperative day 3 or 4. In this situation,
fl uid collections should be drained, cultures
should be obtained, and antibiotics should be ini-
tiated. Oral antibiotics may be given at fi rst, but if
infection persists at 48–72 h, broad-spectrum
intravenous antibiotics that include pseudomonal
coverage should be started. Excessive pain can be
a sign of either of these complications but can
also indicate a hypersensitivity reaction or exces-
sive dressing tightness resulting in skin necrosis.
Overall, the most common complication of
otoplasty is inadequate correction, a situation that
may require revision surgery. The ear will often
lateralize with time as well, possibly resulting in
a late presentation. One type of inadequate cor-
rection is telephone ear deformity, a condition in
which there are a residual laterally protruding
helical root and lobule that give the ear the
appearance of a traditional telephone. Telephone
ear deformity can be prevented by performing a
helical root setback and lobule reduction in the
initial surgery. Overcorrection can also occur,
although much less frequently. When this does
occur, it can almost always be improved by plac-
ing a folded 2 × 2 in. gauze between the posterior
surface of the ear and the scalp to push the ear
laterally by 10–15°. This splint can be held in
place with an athletic sweatband placed above
and behind the ears and generally takes 2–6
weeks to achieve the desired amount of correc-
tion. This complication is very rare and has
occurred in only a few of the senior author’s
patients, but each was adequately resolved using
the aforementioned technique.
Abnormal ear contours can also result from
otoplasty, most commonly from cartilage-cutting
techniques in which sharp edges may cause an
unnatural appearance. Cartilage-shaping tech-
niques, however, are more susceptible to suture
Fig. 10.9 Elastic net bandage placement

106
N.T.N. Schreiber and S.R. Mobley
Table 10.2 Complications of otoplasty
Type of
otoplasty
Author
Year
Study size
Method
Early complications
Bleeding
(%)
Hematoma
(%)
Skin
necrosis (%)
Cartilage-
cutting
Chongchet
1962
21
Cartilage incising and
scoring
5
Tan
1986
101
Cartilage incising and
scoring
8
Calder and
Naasan
1994
562
Cartilage incising and
scoring
2
1.4
Jeffery
1999
118
Cartilage incising and
scoring
3.4
1.7
Caouette-
Laberge et al.
2000
500
Cartilage incising and
scoring
2.1
0.4
0.6
Peker et al.
2002
178
Cartilage incising and
scoring
5.6
2.2
0
Kompatscher
et al.
2004
50
Cartilage incising and
scoring
7.1
Kompatscher
et al
2004
14
Anterior cartilage
scoring and suturing
0
Panettier et al. 2004
33
Cartilage incising and
scoring
0
0
Panettier et al. 2004
30
Posterior cartilage
scoring and suturing
0
0
Bulstrode
et al.
2003
114
Anterior cartilage
scoring and suturing
0.9
0
0
Di Mascio
et al.
2003
40
Cartilage incising and
scoring +/– suturing
7.5
Rubino et al.
2005
10
Cartilage incising and
scoring
10
0
0
Mandal et al.
2006
68
Anterior cartilage
scoring and suturing
1.5
0.7
Salgarello
et al.
2007
135
Anterior cartilage
scoring and suturing
6.6
0
1.5
Olivier et al.
2009
104
Posterior cartilage
scoring and suturing
1
Cartilage-
shaping
Rigg
1979
101
Cartilage suturing
Minderjahn
et al.
1980
135
Cartilage suturing
Attwood and
Evans
1985
52
Cartilage suturing
2.2
Tan
1986
45
Cartilage suturing
33
Adamson
et al.
1991
55
Cartilage suturing
0.8
Foda
1999
39
Cartilage suturing
0
0
0
Horlock et al.
2001
51
Cartilage suturing with
fascial fl ap
2
0
0
Mandal et al.
2006
94
Cartilage suturing
5.3
Mandal et al.
2006
41
Cartilage suturing with
fascial fl ap
2.4
Schaverien
et al.
2010
30
Cartilage suturing with
fascial fl ap
3.3
Sinha
2012
227
Cartilage suturing with
fascial fl ap
0
a Recurrence and inadequate correction reported separately when possible as % + %
b Suture extrusion and granuloma reported separately when possible as % + %

107
10 Nuances of Otoplasty
Late complications
Infection (%)
Recurrence or
inadequate
correction (%) a
Asymmetry
(%)
Suture extrusion
or granuloma (%) b
Hypertrophic
scar (%)
Keloid
scar (%)
Dysaesthesia
(%)
10
0
9.9 + 4.4
5.2
8
0
3.3
12.7
0.8
0
4.1
0
4.4
5.6
1.6
9.6
0
0
50
14
4
0
2
0
0.9 + 5.3
0
5
0
0
1.5
11
1.4
0
3
1.5
0.7
11.3
4.9
4.8
1
2.9
2
11
12.3
40
0
4.6
24.4
15
6.6
8.4
0.8
0.8
5.1
12.8
11.8
0
1.1
8
1.1 + 2.1
2.1
0
4.8
1.1
4.5
10
0.4
3.7
2.6
1.3

108
N.T.N. Schreiber and S.R. Mobley
failure or extrusion and may require revision sur-
gery. Asymmetry can also result from failure to
adequately
address
preexisting
differences
between each ear as different techniques or
degrees of medialization may be required from
side to side. Suture granulomas can appear at any
time postoperatively and are often noticed as a
fi rm, subcutaneous irregularity that can be treated
with skin incision and suture removal. Finally,
scarring may occur at the skin incisions used in
otoplasty. Keloid scars are often the most dis-
tressing but can be treated with triamcinolone
injections, similar to keloid scar treatment at
other body sites. With any postoperative compli-
cation, the patient is often distressed, and more
frequent clinic visits can be very helpful in pro-
viding the reassurance necessary for long-term
patient satisfaction.
Long-Term Results
Overall, the vast majority of patients undergoing
otoplasty can expect to be satis fi ed with the result.
Over time, however, the ear can be expected to
lateralize to some degree. Schlegel-Wagner et al.
[ 72 ] performed otoplasty using an anterior carti-
lage scoring technique with suture fi xation and
found that 2 mm of lost medialization could be
expected at 6 years postoperatively, especially at
the superior third of the ear. Because of this,
excessive medialization is often performed ini-
tially, especially with cartilage-shaping tech-
niques in which a greater degree of lateralization
has been noted to occur. Messner and Crysdale
[ 73 ] performed a retrospective review of 31
patients 3.7 years after cartilage-sparing otoplasty
using the techniques described by Mustarde and
Furnas and found that 29 % of ears returned to
the original position, 28 % of ears stayed in the
initial postoperative position, and the remaining
43 % of ears ended up somewhere in between.
Overall, 0.9–5.8 mm of medialization was lost
1 year after surgery, with the majority of medial-
ization loss at the superior rim. Despite loss of
medialization, 90 % of families and patients in
Schlegel-Wagner’s [ 72 ] study reported “good” or
“very good” results, while 85 % of families and
patients in Messner and Crysdale’s [ 73 ] study
were happy with the results but only 73 % would
choose to undergo otoplasty again.
Conclusions
Otoplasty is a rewarding procedure with low
morbidity and high rates of surgical success
and patient satisfaction. Patient and family
satisfaction is also dependent on adequate pre-
operative counseling and the surgeon’s under-
standing
of
patient
expectations
and
psychosocial concerns. The psychosocial
impact of having prominent ears, particularly
in childhood and adolescence, should not be
underestimated, and bullying and teasing
should be addressed, particularly with younger
patients, in the initial otoplasty consultation.
In a newborn with an ear deformity, molding
techniques should be considered. In the future,
laser-assisted cartilage reshaping may be a
useful technique in older individuals, but
speci fi c indications and limitations are yet to
be de fi ned. At this time, surgery is the primary
modality for correction of prominent ears.
A large number of otoplasty techniques and
modi fi cations have been described since the
original report in 1881 and have been reviewed
in this chapter. A thorough understanding of
normal ear anatomy as well as a variety of the
otoplasty techniques described in this chapter
will allow one to tailor surgery to each indi-
vidual ear and achieve excellent results.
References
1. Lam SM. Edward Talbot Ely: father of aesthetic oto-
plasty. Arch Facial Plast Surg. 2004;6(1):64.
2. Nuara MJ, Mobley SR. Nuances of otoplasty: a com-
prehensive review of the past 20 years. Facial Plast
Surg Clin North Am. 2006;14(2):89–102.
3. Adamson PA, McGraw BL, Tropper GJ. Otoplasty:
critical review of clinical results. Laryngoscope.
1991;101(8):883–8.
4. Richards SD, Jebreel A, Capper R. Otoplasty: a review
of the surgical techniques. Clin Otolaryngol. 2005;
30(1):2–8.
5. Alexander KS, Stott DJ, Sivakumar B, Kang N.
A morphometric study of the human ear. J Plast
Reconstr Aesthet Surg. 2011;64(1):41–7.

109
10 Nuances of Otoplasty
6. Sheerin D, MacLeod M, Kusumakar V. Psychosocial
adjustment in children with port-wine stains and
prominent ears. J Am Acad Child Adolesc Psychiatry.
1995;34(12):1637–47.
7. Mobley SR, Vartanian AJ, Toriumi DM. Otoplasty:
surgical correction of the protruding ear. Oper Tech
Otolaryngol Head Neck Surg. 2002;13(1):29–35.
8. Songu M, Adibelli H. Otoplasty in children younger
than 5 years of age. Int J Pediatr Otorhinolaryngol.
2010;74(3):292–6.
9. Gosain AK, Kumar A, Huang G. Prominent ears in
children younger than 4 years of age: what is the
appropriate timing for otoplasty? Plast Reconstr Surg.
2004;114(5):1042–54.
10. Byrd HS, Langevin CJ, Ghidoni LA. Ear molding in
newborn infants with auricular deformities. Plast
Reconstr Surg. 2010;126(4):1191–200.
11. Ullmann Y, Blazer S, Ramon Y, Blumenfeld I, Peled
IJ. Early nonsurgical correction of congenital auricu-
lar
deformities.
Plast
Reconstr
Surg.
2002;109(3):907–13; discussion 914–5.
12. Yotsuyanagi T, Yokoi K, Urushidate S, Sawada Y.
Nonsurgical correction of congenital auricular defor-
mities in children older than early neonates. Plast
Reconstr Surg. 1998;101(4):907–14.
13. Yotsuyanagi T. Nonsurgical correction of congeni-
tal auricular deformities in children older than
early neonates. Plast Reconstr Surg. 2004;114(1):
190–1.
14. Leclère FM, Trelles M, Mordon SR. Cartilage reshap-
ing for protruding ears: a prospective long term fol-
low-up of 32 procedures. Lasers Surg Med. 2011;
43(9):875–80.
15. Manushakian HS, Wilson PA, De Souza BA,
McGrouther DA. The prone position in otoplasty.
Plast Reconstr Surg. 2005;115(3):963–4.
16. Mobley SR, Miller BT, Astor FC, Fine B, Halliday
NJ. Prone positioning for head and neck reconstruc-
tive surgery. Head Neck. 2007;2911:1041–5.
17. McDowell AJ. Goals in otoplasty for protruding ears.
Plast Reconstr Surg. 1968;41(1):17–27.
18. Ferraro GA, Corcione A, Nicoletti G, Rossano F,
Perrotta A, D’Andrea F. Blepharoplasty and oto-
plasty: comparative sedation with remifentanil,
propofol, and midazolam. Aesthetic Plast Surg.
2005;29(3):181–3.
19. Pavlin DJ, Chen C, Penaloza DA, Polissar NL,
Buckley FP. Pain as a factor complicating recovery
and discharge after ambulatory surgery. Anesth Analg.
2002;95:627–34.
20. Rizzi MD, Weil RJ, Lorenz RR. Severe transient
hypertension after greater palatine foramen block in a
patient taking midodrine. Am J Otolaryngol. 2010;
31(1):67–9.
21. Berbaum MW, Bredle DL, Futamara W. Absence of
signi fi cant adverse effects from low-dose subcutane-
ous epinephrine in dermatologic procedures. Arch
Dermatol. 1997;133(10):1318–9.
22. Becker DE, Reed KL. Essentials of local anesthetic
pharmacology. Anesth Prog. 2006;53(3):98–108.
23. Caouette-Laberge L, Guay N, Bortoluzzi P, Belleville
C. Otoplasty: anterior scoring technique and results in
500 cases. Plast Reconstr Surg. 2000;105(2):504–15.
24. Spira M. Otoplasty: what I do now – a 30-year per-
spective. Plast Reconstr Surg. 1999;104(3):834–40.
25. Erol OO. New modi fi cation in otoplasty: anterior
approach.
Plast
Reconstr
Surg.
2001;107(1):
193–202.
26. Graham KE, Gault DT. Endoscopic assisted otoplasty:
a preliminary report. Br J Plast Surg. 1997;50(1):
47–57.
27. Fritsch MH. Incisionless otoplasty. Otolaryngol Clin
North Am. 2009;42(6):1199–208.
28. Converse JM, Nigro A, Wilson FA, Johnson N.
A technique for surgical correction of lop ears. Plast
Reconstr Surg. 1955;15(5):411–8.
29. Farrior RT. A method of otoplasty; normal contour of
the antihelix and scaphoid fossa. AMA Arch
Otolaryngol. 1959;69(4):400–8.
30. Furnas DW. Correction of prominent ears by concha
mastoid
sutures.
Plast
Reconstr
Surg.
1968;
42(3):189–93.
31. Horlock N, Misra A, Gault DT. The postauricular fas-
cial fl ap as an adjunct to Mustardé and Furnas type
otoplasty. Plast Reconstr Surg. 2001;108(6):1487–90.
32. Rogers BO. The classic reprint. A new operation for
prominent ears based on the anatomy of the deformity
by William H. Luckett, M.D. (reprinted from Surg
Gynec. & Obst., 10: 635–7, 1910). Plast Reconstr
Surg. 1969;43(1):83–6.
33. Cloutier AM. Correction of outstanding ears. Plast
Reconstr Surg Transplant Bull. 1961;28:412–6.
34. Epstein JS, Kabaker SS, Swerdloff J. The ‘electric’
otoplasty. Arch Facial Plast Surg. 1999;1(3):204–7.
35. Ragab A. Carbon dioxide laser-assisted cartilage
reshaping otoplasty: a new technique for prominent
ears. Laryngoscope. 2010;120(7):1312–8.
36. Stenstroem SJ. A ‘natural’ technique for correction of
congenitally prominent ears. Plast Reconstr Surg.
1963;32:509–18.
37. Chongchet V. A method of antihelix reconstruction.
Br J Plast Surg. 1963;16:268–72.
38. Stenström SJ, Heftner J. The Stenström otoplasty.
Clin Plast Surg. 1978;5(3):465–70.
39. Tolhurst DE. The correction of prominent ears. Br
J Plast Surg. 1972;25(3):261–5.
40. Mustarde JC. The correction of prominent ears using
simple mattress sutures. Br J Plast Surg. 1963;16:
170–8.
41. de la Torre J, Tenenhaus M, Douglas BK, Swinburne
JK. A simpli fi ed technique of otoplasty: the tempo-
rary Kaye suture. Ann Plast Surg. 1998;41(1):94–6.
42. Hatch MD. Common problems of otoplasty. J Int Coll
Surg. 1958;30(2):171–8.
43. Converse JM, Wood-Smith D. Technical details in the
surgical correction of the lop ear deformity. Plast
Reconstr Surg. 1963;31:118–28.
44. Bandey SA, Atkins J, Neil WF. Silastic foam dress-
ing in pinnaplasty. J Laryngol Otol. 1986;100(2):
201–2.

110
N.T.N. Schreiber and S.R. Mobley
45. Mitsukawa N. Auricular protection after ear surgery
using a dust mask. J Craniofac Surg. 2008;
19(6):1639–40.
46. Mitsukawa N. Auricular protection after ear surgery
using a door knob cover. J Craniofac Surg.
2007;18(6):1416–8.
47. McIntire MR, Morgan RF, Kenney JG, Edgerton MT.
Postoperative protection for the external ear. Ann
Plast Surg. 1983;11(3):261–2.
48. Bartley J. How long should ears be bandaged after
otoplasty? J Laryngol Otol. 1998;112(6):531–2.
49. Bradbury ET, Hewison J, Timmons MJ. Psychological
and social outcome of prominent ear correction in
children. Br J Plast Surg. 1992;45(2):97–100.
50. Ramkumar S, Narayanan V, Laing JH. Twenty-four
hours or 10 days? A prospective randomised con-
trolled trial in children comparing head bandages fol-
lowing pinnaplasty. J Plast Reconstr Aesthet Surg.
2006;59(9):969–74.
51. Orabi AA, Chintamani BH, Timms MS. Is a head
bandage useful after otoplasty? A quasi-random-
ized controlled study of complications and patient
satisfaction. Ear Nose Throat J. 2009;88(10):
E17–22.
52. Jackson CG. Antimicrobial prophylaxis in ear sur-
gery. Laryngoscope. 1988;98(10):1116–23.
53. Sylaidis P, Wood S, Murray DS. Postoperative infec-
tion following clean facial surgery. Ann Plast Surg.
1997;39(4):342–6.
54. Tan KH. Long-term survey of prominent ear surgery:
a comparison of two methods. Br J Plast Surg.
1986;39(2):270–3.
55. Calder JC, Naasan A. Morbidity of otoplasty: a review
of 562 consecutive cases. Br J Plast Surg.
1994;47(3):170–4.
56. Jeffery SL. Complications following correction of
prominent ears: an audit review of 122 cases. Br J
Plast Surg. 1999;52(7):588–90.
57. Peker F, Celiköz B. Otoplasty: anterior scoring and
posterior rolling technique in adults. Aesthetic Plast
Surg. 2002;26(4):267–73.
58. Kompatscher P, Schuler CH, Clemens S, Seifert B,
Beer GM. The cartilage-sparing versus the cartilage-
cutting technique: a retrospective quality control
comparison of the Francesconi and Converse oto-
plasties. Aesthetic Plast Surg. 2003;27(6):446–53.
59. Panettiere P, Marchetti L, Accorsi D, Del Gaudio GA.
Otoplasty: a comparison of techniques for antihelical
defects treatment. Aesthetic Plast Surg. 2003;
27(6):462–5.
60. Bulstrode NW, Huang S, Martin DL. Otoplasty by
percutaneous anterior scoring. Another twist to the
story: a long-term study of 114 patients. Br J Plast
Surg. 2003;56(2):145–9.
61. Di Cio D, Castagnetti F, Baldassarre S. Otoplasty:
anterior abrasion of ear cartilage with dermabrader.
Aesthetic Plast Surg. 2003;27(6):466–71.
62. Rubino C, Farace F, Figus A, Masia DR. Anterior
scoring of the upper helical cartilage as a re fi nement
in
aesthetic
otoplasty.
Aesthetic
Plast
Surg.
2005;29:88–93.
63. Mandal A, Bahia H, Ahmad T, Stewart KJ. Comparison
of cartilage scoring and cartilage sparing otoplasty – a
study of 203 cases. J Plast Reconstr Aesthet Surg.
2006;59(11):1170–6.
64. Salgarello M, Gasperoni C, Montagnese A, Farallo E.
Otoplasty for prominent ears: a versatile combined
technique to master the shape of the ear. Otolaryngol
Head Neck Surg. 2007;137(2):224–7.
65. Olivier B, Mohammad H, Christian A, Akram R.
Retrospective study of the long-term results of oto-
plasty using a modi fi ed Mustardé (cartilage-sparing)
technique.
J
Otolaryngol
Head
Neck
Surg.
2009;38(3):340–7.
66. Rigg BM. Suture materials in otoplasty. Plast Reconstr
Surg. 1979;63(3):409–10.
67. Minderjahn A, Hüttl WR, Hildmann H. Mustardé’s
otoplasty – evaluation of correlation between clinical
and statistical fi ndings. J Maxillofac Surg. 1980;
8(3):241–50.
68. Attwood AI, Evans DM. Correction of prominent ears
using Mustardé’s technique: an out-patient procedure
under local anaesthetic in children and adults. Br
J Plast Surg. 1985;38(2):252–8.
69. Foda HM. Otoplasty: a graduated approach. Aesthetic
Plast Surg. 1999;23(6):407–12.
70. Schaverien MV, Al-Busaidi S, Stewart KJ. Long-term
results of posterior suturing with postauricular fascial
fl ap otoplasty. J Plast Reconstr Aesthet Surg.
2010;63(9):1447–51.
71. Sinha M, Richard B. Postauricular fascial fl ap and
suture otoplasty: a prospective outcome study of 227
patients. J Plast Reconstr Aesthet Surg. 2012;
65(3):367–71.
72. Schlegel-Wagner C, Pabst G, Müller W, Linder T.
Otoplasty using a modi fi ed anterior scoring technique:
standardized measurements of long-term results. Arch
Facial Plast Surg. 2010;12(3):143–8.
73. Messner AH, Crysdale WS. Otoplasty. Clinical proto-
col and long-term results. Arch Otolaryngol Head
Neck Surg. 1996;122(7):773–7.
74. Schreiber NTN, Mobley SR. Advanced Cosmetic
Otoplasty. In: Johnson J. Head and Neck Surgery:
Otolaryngology. 5th Ed. 2013. In press.

111
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_11, © Springer-Verlag Berlin Heidelberg 2013
11
Introduction
Prominent ear (lop ear) is a common birth defect,
occurring in 5 % of the white population [ 1 ] . This
malformation is inherited in an autosomal domi-
nant pattern with variable penetrance [ 2 ] . In most
patients, two deformities usually coexist, deter-
mining the greatest separation of the auricles: an
inadequate development of the antihelix fold and
an overdevelopment of the concha [ 3 ] .
More than 200 surgical techniques have been
described for its correction, indicating the lack of
an ideal technique [ 4 ] . These can be classi fi ed
into two categories: with conservation of carti-
lage or with cartilage section. Section methods
attempt to eliminate the inherent memory of the
cartilage so that the shape of the auricle can be
modi fi ed. These techniques may leave signi fi cant
asymmetries. In contrast, methods designed to
reshape the cartilage are based on the Mustardé
technique, which consists of placing three or four
horizontal mattress sutures with permanent suture
material along the ridge of the helix, to create an
antihelix fold. These techniques have higher rates
of relapse and require surgical revisions more
frequently due to failure of correction, compared
with section techniques [ 5 ] .
Moreover, it is still unclear which approach
should be used. The posterior or retroauricular
approach was described initially [ 1, 4, 5 ] , but sub-
sequently, anterior [ 6– 9 ] or combined approaches
were recommended or even those without any
incision whatsoever, so-called incisionless oto-
plasty [ 10 ] .
The aim of this chapter is to review the useful-
ness and advantages of the anterior approach, in
comparison with the retroauricular approach,
after review of our own experience on a consecu-
tive series of suture-based otoplasties without
cartilage section, which have been recently pub-
lished [ 11 ] .
Surgical Technique
An individual evaluation of the auricles of every
patient should be our fi rst step while planning
surgery. Pictures should be obtained of every case
to measure sizes and distances between the lat-
eral helical rim and the mastoid surface and to
discuss possible surgical procedures and results
with the patients and their families.
The authors have been performing otoplasties
for more than 15 years. The technique has evolved
into one that is similar to the recently described
Lucerne technique, which follows fi ve basic
surgical steps [ 12 ] :
R. M. Echarri , M.D. (*) • M. Hernando , M.D.
G. Plaza , M.D., Ph.D.
Servicio de Otorrinolaringología ,
Hospital Universitario de Fuenlabrada,
Universidad Rey Juan Carlos ,
Cº del Molino, 2 , Fuenlabrada, Madrid 28942 , Spain
e-mail: recharri.h fl r@salud.madrid.org ;
monica.hernando@salud.madrid.org ;
gplaza.h fl r@salud.madrid.org
Anterior Versus Posterior
Approach to Otoplasty
Rosa Maria Echarri , Mónica Hernando ,
and Guillermo Plaza

112
R.M. Echarri et al.
1. Skin incision, which may be anterior or
retroauricular
2. Anterior scoring to reshape antihelical
cartilage
3. Contouring of the antihelical fold by postau-
ricular fi xation sutures
4. Correction of auricular position, usually with-
out cartilage excision
5. Re fi nements, specially lobuloplasty
Anterior Approach
Local in fi ltration of a combination of 1 % lido-
caine and epinephrine 1:100,000 on both sides of
the auricle is used. An incision of 1–2 cm is made,
following the ridge of the helix, to prevent it being
seen later. Using a Freer elevator, the skin is sepa-
rated from the anterior cartilage, and the area is
then scraped with a rasp (Fig. 11.1 ) to remove the
anterior perichondrium. Three hypodermic nee-
dles are passed through the anterior skin and car-
tilage to serve as a guide for the creation of the
new antihelical fold. Small incisions are made in
the skin in the entry and exit areas of the needles.
Nonabsorbable, ivory-colored sutures (Lorca-
Marin ® , Supramid, ref 65343, white polyamide,
Tb-15, 3/0) are passed through these incisions and
back through the posterior auricular part to create
the new antihelical fold (Fig. 11.1 ). In case of pro-
lapsed concha, an ellipse of skin and cartilage is
removed in the area where the concha joins the
antihelix, below the antitragus. This is completed
with 4/0 silk suture of the incisions, which is
removed after 7 days. Compression is done with
cotton soaked in soap solution on the concha and
the antihelical fold, covered with loose gauze and
bandage for 1 week.
Posterior Approach
This approach also begins with in fi ltration of a
combination of 1 % lidocaine and epinephrine
1:100,000 on both sides of the auricle. A poste-
rior skin incision is carried out in an elliptical
Fig. 11.1 Otoplasty by anterior approach. ( a ) Rasping
the anterior perichondrium. ( b ) Nonabsorbable, ivory-
colored stitches, through the incisions and passing through
the posterior part of the auricular pavilion, to create the
new antihelical fold

113
11 Anterior Versus Posterior Approach to Otoplasty
shape, approximately 1 cm from the edge of the
helix, and the skin is resected to the level of the
perichondrium (Fig. 11.2 ). Dissection is per-
formed up to the proximity of the retroauricular
sulcus, and in a cranial direction, it should reach
the proximity of the edge of the helix. Using the
Freer elevator, the skin is separated from the
anterior cartilage, and a rasp (Fig. 11.2 ) is then
used to remove the anterior perichondrium. If it is
necessary to reduce the height of the concha, a
half-moon of cartilage of approximately 6 mm is
resected at the junction of the antihelical fold and
the root. Careful design of the new antihelical
fold is planned, passing needles several times
until the desired result is achieved (Fig. 11.3 ).
Hypodermic needles are placed through the skin
Fig. 11.2 Otoplasty by posterior approach. ( a ) Posterior elliptical skin incision, resection of a strip of skin to the level
of the perichondrium. ( b ) Rasping from the retroauricular incision
Fig. 11.3 Careful design of the new antihelical fold,
passing needles several times until the desired result is
achieved ( a ). Hypodermic needles are placed through the
skin and cartilage to serve as a guide for the creation of a
new antihelical fold ( b )

114
R.M. Echarri et al.
and cartilage to serve as a guide for the creation
of a new antihelical fold (Fig. 11.3 ). Mattress
sutures are applied, passing above and below the
fold created through the anterior cartilage and
perichondrium but not the skin, with three or four
nonabsorbable ivory-colored sutures (identical to
those used in the anterior approach). In adults
with tough cartilage, before suturing, it is neces-
sary to detach the anterior skin and thin the carti-
lage to facilitate the creation of the new fold. In
patients with highly prolapsing conchas, a suture
from the concha to the mastoid periosteum has to
be done to approximate the concha to it. Lastly,
the retroauricular skin is sutured with 4/0 silk.
Swabs soaked in soap are used to model the new
auricular shape, and dressing is maintained for
4–5 days.
Surgical Tips
The goal of surgery in the treatment of prominent
ears is to obtain symmetrical and natural ears,
with no signs of being operated on [ 13 ] . The vari-
ants of otoplasty can be classi fi ed into techniques
which remodel the cartilage, as advocated by
Mustardé [ 14 ] , Furnas [ 15, 16 ] , and Farrior et al.
[ 17 ] ; techniques which weaken it, as advocated
by Stenstrom and Heftner [ 18, 19 ] ; and tech-
niques which section it, as advocated by
Chongchet [ 20 ] and Converse et al. [ 21 ] . Some of
these techniques also include the excision of an
ellipse of retroauricular skin and other fi xation of
the cartilage to the mastoid.
Obtaining a good antihelical fold is crucial in
every case [ 22 ] , and this can be attempted with a
Fig. 11.4 Results after
otoplasty. Anterior approach:
( a ) preoperative. ( b ) Control
at 12 months. Posterior
approach: ( c ) preoperative.
( d ) Control at 12 months

115
11 Anterior Versus Posterior Approach to Otoplasty
multitude of surgical techniques, such as hori-
zontal sutures which fold the cartilage backward,
through the weakening of the anterior side of the
cartilage by fi ling, by multiple incisions in the
back of antihelix to make the cartilage more
fl exible, etc.
The authors’ technique includes a combination
of these techniques through thinning of the ante-
rior side of the antihelix to obtain a new antihelical
fold which look harmonious and natural, as
described by other authors [ 23, 24 ] , and creating at
least three Mustardé-type sutures that have to be
correctly designed [ 25, 26 ] . The cosmetic results
and patient satisfaction are good when using these
techniques (Figs. 11.4 , 11.5 , and 11.6 ).
Regarding the approach, both the anterior and
the posterior allow creating a new antihelical fold,
without the need to make cuts through the carti-
lage. However, the use of sutures is related to the
most common complication in our series, which
was extrusion of the sutures. This occurred
primarily when using an anterior approach (four
times more frequently than in the posterior). It has
been described by other authors in 10 % of patients
[ 27 ] , although it may be more frequent with some
sutures that with others [ 28 ] . When suture extru-
sion appears, it is sometimes manifested as a con-
tinuous discharge at a particular point of the skin
before the suture is exposed. Its early detection is
important to avoid the possibility of triggering
chondritis and because the tension effect of the
stitches may disappear, favoring the recurrence of
detachment of the operated ear, thus relapsing
the prominent ear. In fact, in our series, this was
the main cause of secondary operations, which
were also more frequent in the anterior approach
than in the posterior (28 % vs. 7 %).
The
remaining
complications
described
[ 29– 31 ] were less frequent; they did not repre-
sent major problems in our series. There may be
infection of the skin, cartilage, or both. The
importance of sequelae varies, with chondritis
Fig. 11.5 Results after
otoplasty. Anterior approach:
( a ) preoperative. ( b ) Control
at 12 months. Posterior
approach: ( c ) preoperative.
( d ) Control at 12 months

116
R.M. Echarri et al.
being one of the worst because it can make the
pavilion disappear [ 32 ] . Treatment is carried out
with
broad-spectrum
antibiotics
to
cover
Staphylococcus and Pseudomonas, along with
drainage of any collections that may appear.
Another important complication are hemato-
mas. It is very important to monitor the possible
formation of hematomas in the immediate postop-
erative period. Early symptoms include skin tight-
ness, pain, and sensation of fullness. Patients should
learn to recognize this rare complication, which has
been described in 2 % of cases [ 33, 34 ] .
As for aesthetic results (Figs. 11.3 and 11.4 ),
there may be a late relapse in which the auricles
become unstuck months after being operated on,
which takes place in 2–13 % of cases according
to the series, depending on the technique [ 33, 35,
36 ] . The authors observed more relapses with the
anterior approach, probably due to the increased
extrusion of sutures, decreasing tension.
Conclusions
Otoplasty allows for good cosmetic results in the
treatment of protruding ears. The most common
complication is the extrusion of stitches. The ret-
roauricular approach to create a new antihelix
without cartilage section allows achieving good
results with fewer complications.
Fig. 11.6 Results after
otoplasty. Anterior approach:
( a ) preoperative. ( b ) Control
at 12 months. Posterior
approach: ( c ) preoperative.
( d ) Control at 12 months

117
11 Anterior Versus Posterior Approach to Otoplasty
References
1. Mang WL. Otoplasty. In: Mang WL, editor. Manual
of aesthetic surgery. Heidelberg: Georg Thieme
Verlag; 2002. p. 191–223.
2. Weerda H. Classi fi cation and surgery of auricular
defects. In: Weerda H, editor. Surgery of the auricle.
Stuttgart: Georg Thieme Verlag; 2007. p. 43–233.
3. Barberan MT, Til G. Orejas en asa. In: Barberan MT,
Sprekelsen MB, editors. Sociedad Española de
Otorrinolaringología y Patología Cérvico-Facial.
Girona: Grà fi ques Alzamora; 2000. p. 151–6.
4. Adamson PA, Litner JA. Otoplasty technique.
Otolaryngol Clin North Am. 2007;40(2):305–18.
5. Mandal A, Bahia H, Ahmad T, Stewart KJ. Comparison
of cartilage scoring and cartilage sparing otoplasty – a
study of 203 cases. J Plast Reconstr Aesthet Surg.
2006;59(11):1170–6.
6. Bassot DJ. The anterior approach to otoplasty. Plast
Reconstr Surg. 2001;108(6):1823.
7. Burres S. The anterior-posterior otoplasty. Arch
Otolaryngol Head Neck Surg. 1998;124(2):181–5.
8. Zambudio G, Ruiz JI, Guirao MJ, Sánchez JM, Girón
O, Gutiérrez MA. Otoplastia por vía anterior para el
tratamiento de las orejas prominentes. Una técnica
mínimamente invasiva. Cir Pediatr. 2007;20(2):
119–21.
9. Erol OO. New modi fi cation in otoplasty: anterior
approach. Plast Reconstr Surg. 2001;107(1):193–203.
10. Fritsch MH. Incisionless otoplasty. Otolaryngol Clin
North Am. 2009;42(6):1199–208.
11. Echarri R, Hernando M, Montojo J, Plaza G. Otoplasty:
results after anterior versus posterior approach. Acta
Otorrinolaringol Esp. 2011;62:188–93.
12. Schlegel-Wagner C, Pabst G, Müller W, Linder T.
Otoplasty using a modi fi ed anterior scoring technique:
standardized measurements of long-term results. Arch
Facial Plast Surg. 2010;12(3):143–8.
13. Petersson RS, Friedman O. Current trends in oto-
plasty. Curr Opin Otolaryngol Head Neck Surg.
2008;16(4):352–8.
14. Mustarde JC. The correction of prominent eras using
simple mattress sutures. Br J Plast Surg. 1963;16:170–8.
15. Furnas DW. Correction of prominent ears by con-
chamastoid sutures. Plast Reconstr Surg. 1968;
42(3):189–93.
16. Janz BA, Cole P, Hollier Jr LH, Stal S. Treatment of
prominent and constricted ear anomalies. Plast
Reconstr Surg. 2009;124(1 Suppl):27e–37.
17. Scharer SA, Farrior EH, Farrior RT. Retrospective
analysis of the Farrior technique for otoplasty. Arch
Facial Plast Surg. 2007;9(3):167–73.
18. Stenstroem SJ. A “natural” technique for correction of
congenitally prominent ears. Plast Reconstr Surg.
1963;32:509–18.
19. Stenstrom SJ, Heftner J. The stenstrom otoplasty. Clin
Plast Surg. 1978;5(3):465–70.
20. Chongchet V. A method of antihelix reconstruction.
Br J Plast Surg. 1963;16:268–72.
21. Converse JM, Nigro A, Wilson FA, Johnson N. A
technique for surgical correction of lop ears. Plast
Reconstr Surg. 1955;15(5):411–8.
22. Becker DG, Lai SS, Wise JB, Steiger JD. Analysis in
otoplasty. Facial Plast Surg Clin North Am. 2006;
14(2):63–71.
23. Salgarello M, Gasperoni C, Montagnese A, Farallo E.
Otoplasty for prominent ears: a versatile combined
technique to master the shape of the ear. Otolaryngol
Head Neck Surg. 2007;137(2):224–7.
24. Nolst Trenité GJ. Otoplasty: a modi fi ed anterior scor-
ing technique. Facial Plast Surg. 2004;20(4):277–85.
25. Olivier B, Mohammad H, Christian A, Akram R.
Retrospective study of the long-term results of oto-
plasty using a modi fi ed Mustardé (cartilage-sparing)
technique. J Otolaryngol Head Neck Surg. 2009;
38(3):340–7.
26. Yugueros P, Friedland JA. Otoplasty: the experience
of 100 consecutive patients. Plast Reconstr Surg.
2001;108(4):1045–51.
27. Barberán MT. Complicaciones en la otoplastia. In:
Sprekelsen MB, Gomez JG, Ramos AM, Tomás MB,
editors. Riesgos y Complicaciones en la Cirugía Oral
y de Cabeza y Cuello. Kenilworth: Schering-Plough;
2008. p. 237–44.
28. Maslauskas
K,
Astrauskas
T,
Viksraitis
S,
Samsanavidius D. Comparison of otoplasty outcomes
using different types of suture materials. Int Surg.
2010;95(1):88–93.
29. Limandjaja GC, Breugem CC, van der Mink Molen
AB, Kon M. Complications of otoplasty: a literature
review. J Plast Reconstr Aesthet Surg. 2009;62(1):
19–27.
30. Owsley TG, Biggerstaff TG. Otoplasty complications.
Oral Maxillofac Surg Clin North Am. 2009;21(1):
105–18.
31. Bermúdez Polonio R. Acerca de ciertos fracasos esté-
ticos menores en las otoplastias de las orejas en asa.
An Otorrinolaringol Ibero Am. 1982;9(1):5–40.
32. Firmin F, Sanger C, O’Toole G. Ear reconstruction
following severe complications of otoplasty. J Plast
Reconstr Aesthet Surg. 2008;61(1 Suppl):S13–20.
33. Caouette-Laberge L, Guay N, Bortoluzzi P, Belleville
C. Otoplasty: anterior scoring technique and results in
500 cases. Plast Reconstr Surg. 2000;105(2):504–15.
34. Messner AH, Crysdale WS. Otoplasty: clinical proto-
col and long-term results. Arch Otolaryngol Head
Neck Surg. 1996;122(7):773–7.
35. Mompó L, Pastor G, Carrasco M, Cuesta MA, Dalmau
J. Otoplasty without cartilage section using the
Mustardé technique. Presentation of our experience.
Acta Otorrinolaringol Esp. 2011;62(3):181–7.
36. de la Fuente A, Sordo G. Minimally invasive oto-
plasty: technical details and long-term results.
Aesthetic Plast Surg. 2012;36(1):77–82.

119
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_12, © Springer-Verlag Berlin Heidelberg 2013
12
Introduction
Correction of protruding ears remains a challenge.
The literature describes a wide spectrum of tech-
niques, ranging from incision-suture techniques
[ 1 ] , suture-only techniques [ 2 ] , cartilage-scoring
techniques [ 3– 5 ] , and others that combine some
of the aforementioned procedures [ 6 ] . This wide
variety of techniques suggests that no ideal method
exists for the correction of protruding ears.
Pleasant results have been obtained with the
aforementioned techniques. Nevertheless, they
imply permanent buried sutures, extensive inci-
sions, and ample dissections, which might increase
the risk of complications such as bacterial con-
tamination or intolerance of the sutures, visibility
or palpability of foreign material, and skin and
cartilage vascular compromise, to name a few.
Since 1992, the authors have been using a
simpli fi ed and easily performed method for oto-
plasty that avoids the use of permanent sutures
and wide dissection and addresses each aes-
thetic issue of the ear independently by separate
incisions. This original technique was called
“ minimally invasive otoplasty,” and a technical
description of the procedure was published in
1998 [ 7 ] .
Preoperative Evaluation
Thorough analysis and diagnosis of each auricle
was performed preoperatively, thus identifying
every aesthetic deformity. Subsequently, surgical
actions to be applied in each particular case were
speci fi ed. The following algorithm was put into
practice for each type of deformity:
1. Conchal cartilage hypertrophy: crescent-
shaped conchal resection through a curved
anterior incision
2. Lack of antihelical fold de fi nition: anterior
scoring with an ophthalmic knife through a
stab wound at the root of the antihelical fold
3. Obtuse
auriculomastoid
angle:
concho-
mastoid sutures through a posterior incision
over the auricular sulcus on separate tunnels
4. Hypertrophic scapha: crescent-shaped scaphal
resection through an anterior curved incision
5. Hypertrophic lobule: wedge excision
Surgical Technique
Marking of the desired antihelical fold, excess
conchal or scaphal cartilage, or lobule reduction
is performed before surgery (Fig. 12.1 ).
With the patient under intravenous sedation
and local anesthesia using 1 % lidocaine and
A. de la Fuente , M.D., Ph.D.
Plastic, Aesthetic, and Reconstructive Surgery Unit ,
Hospital Rúber Internacional , Madrid , Spain
e-mail: secretaria@clinicadelafuente.es
G. Sordo , M.D. (*)
Servicio de Cirugía Plástica,
Hospital Central de la Cruz Roja/Private Practice ,
Madrid , Spain
e-mail: drgustavosordo@gmail.com
Minimally Invasive Otoplasty:
Technical Details and Long-Term
Results
Antonio de la Fuente and Gustavo Sordo

120
A. de la Fuente and G. Sordo
epinephrine 1:10,000, separate incisions are per-
formed for independent treatment of the areas to
be corrected.
Scaphal reduction is performed fi rst. An inci-
sion is placed at the superior-most part of the
anterior surface of the scapha where it meets the
helix. Subperichondrial dissection is performed,
releasing the soft tissues downward over the car-
tilage. This maneuver leaves a crescent-shaped
scaphal cartilage exceeding the cutaneous border,
which guides in calculating how much resection
is needed (Fig. 12.2 ). Once this amount has been
estimated, resection is performed, and skin is
reapproximated with 6-0 absorbable sutures. No
skin is removed.
Scaphal reduction has proved to be a powerful
tool for solving the excess of cartilage height that
con fl icts with a short skin envelope at the upper
pole. This type of deformity appears to be par-
ticularly frequent. It often is underestimated and
may be the cause for an excessively projected
upper pole of the auricle (Fig. 12.3 ).
Next, hypertrophic concha is addressed by a
curved incision on the superior-most part of the
concha’s anterior aspect, where the scar will be
hidden by the antihelical fold. A crescent-shaped
Fig. 12.1 Surgical markings
including scaphal hypertro-
phy (crescent-shaped) and
desired antihelical fold
Fig. 12.2 Crescent-shaped
excess scaphal cartilage

121
12 Minimally Invasive Otoplasty: Technical Details and Long-Term Results
portion of cartilage is subperichondrially dis-
sected and then incised (Fig. 12.4 ). With the ear
set back in its ideal position, conchal cartilage
overlaps, and the amount of resection is estimated
(Fig. 12.5 ). Skin is not resected to avoid undue
tension and is approximated with 6-0 absorbable
suture.
At this stage, the tendency to anteroposition of
the ear is corrected, and deep sutures are used to
set back and maintain the auricle. A narrow
ellipse of skin (3–5 mm) is excised at the auricu-
lomastoid sulcus, so the incision can be closed
without undue tension. Two to three tunnels are
bluntly dissected in the superior, medial, and
inferior parts to expose the mastoid fascia, with
no tissue removal (Fig. 12.6 ). The subcutaneous
tissue and perichondrium of the ear’s posterior
surface is grasped with a 4-0 or 3-0 absorbable
suture. The needle is passed all the way down
through a tunnel, and a strong bite of mastoid fas-
cia then is anchored (Fig. 12.7 ). The sutures are
left untied, and the tension is estimated, espe-
cially at the central part of the ear, so as not to
obliterate the postauricular sulcus.
Once the tension has been estimated, the
sutures are tied at the same time to control the
a
b
Fig. 12.3 ( a ) Preoperative.
This patient was concerned
about the height of her ears
and requested to have her
upper pole reduced.
Hypertrophic scaphal
cartilage is present. ( b ) One
year postoperatively. Surgery
included scaphal hypertrophy
reduction and conchal-mas-
toid sutures. Note scaphal
reduction and reduction of
upper pole fullness. The
antihelical fold was not
modi fi ed by any means
Fig. 12.4 Crescent-shaped
excess conchal cartilage

122
A. de la Fuente and G. Sordo
tension and to produce a natural setback as well
as a pleasant bending of the previously scored
antihelix. A running 4-0 suture is used to close
the posterior incision. If a hypertrophic lobule is
found, reduction generally is performed by means
of a wedge-shaped excision and direct closure.
Discussion
Minimally invasive otoplasty (96 bilateral and
4 unilateral) was performed for 100 patients
(68 women and 32 men) with a mean age of
22.4 years. The respective surgical steps and their
frequency are listed in Table 12.1 . The complica-
tions are listed in Table 12.2 .
All cases with mild discoloration or epidermoly-
sis healed uneventfully. Partial recurrence took place
in three cases, which was managed by reoperation
6 months postoperatively with very satisfactory
results. One patient experienced partial upper pole
necrosis, with tissue loss after application of undue
tension to his bandage for 1 week. Scar revision and
fat grafting were needed to improve the outcome.
Most of the patients were very satis fi ed (81 %)
or satis fi ed (17 %) with the procedure. Two
Fig. 12.5 Ophthalmic knife
anteriorly scoring the
antihelical fold
Fig. 12.6 Posterior tunnels
exposing the mastoid fascia

123
12 Minimally Invasive Otoplasty: Technical Details and Long-Term Results
patients were dissatis fi ed, but no patient reported
great dissatisfaction with the outcome.
Like many techniques in otoplasty, the authors’
procedure is based on the papers published by
Stenstroem [ 3 ] , Ju and Crikelair [ 4 ] , and
Chongchet [ 5 ] , all of them inspired by Gibson
and Davis’s [ 8 ] interlocked stresses of cartilage.
Following Stenström, we con fi ne our dissection
to a tunnel beneath the perichondrium, scoring
blindly with an ophthalmic knife. This allows a
natural, soft warping of the antihelix, with no
permanent sutures (Fig. 12.8 ).
In addition to this, special attention is paid to
the management of scaphal cartilage. Statistics
show that a considerable number of patients seek-
ing otoplasty (76 %) also would bene fi t from
scaphal reduction. Thorough analysis of the upper
pole shows a relatively constant combination of a
lack of antihelical de fi nition, with discrepancy
between cartilage height and the skin envelope.
Skin shortage produces a bending effect on a
hypertrophic scapha, thus making the pinna look
more separated from the head at the upper pole
(Fig. 12.9 ).
Apart from de fi ning the antihelix, we strongly
recommend resizing the excess scaphal cartilage,
adapting it to the amount of available skin. The
anterior approach with downward release of skin
leaves a crescent-shaped excess cartilage that
eases the estimation of the resection. The poste-
rior approach also is feasible but makes this
maneuver more dif fi cult due to the lack of guid-
ance that the anterior skin release provides.
The size and overall appearance of the ear also
can bene fi t from this action, especially in cases of
patients concerned about excessive height of the
ears (Fig. 12.3 ). Hypertrophic concha also is
managed anteriorly. The principles of scaphal
cartilage apply in such cases because anterior
undermining leaves a crescent shape that guides
the amount of resection needed in each case.
Three different incisions can be performed at
the anterior surface, each aimed at solving a sin-
gle problem. In addition to this, a posterior inci-
sion is performed when the ear must be set back.
Although other techniques advocate a single
posterior incision for all the surgery, several
objections could arise concerning the amount of
Fig. 12.7 A 3-0 absorbable
suture passed all the way
down the tunnel anchoring
the ear to the mastoid fascia
Table 12.1 Techniques
Concho-mastoid sutures
81 %
Scaphal reduction
76 %
Antihelical folding
70 %
Conchal reduction
53 %
Earlobe reduction
19 %
Table 12.2 Complications
Discoloration/epidermolysis
5 %
Partial recurrence
2 %
Partial upper pole necrosis
1 %

124
A. de la Fuente and G. Sordo
dissection needed to access the anterior aspect
of the ear [ 5 ] or the need for permanent sutures
to fold the antihelix [ 2 ] . In our experience, a
combination of limited anterior and posterior
approaches has proved to be safe in terms of tissue
viability. All auricles have healed uneventfully.
Patients with some mild discoloration and
cyanosis (5 %) have been treated with topical
antibiotic ointments and eventually have healed
in 10–15 days.
Partial upper pole necrosis was found in one
case that had continuous undue tension applied
on the bandage for 1 week. Further corrections
consisting of scar revisions, fat grafting, and the
like were needed to achieve a satisfactory
result.
Regarding incision visibility, inconspicuous
scars on the anterior surface generally are
obtained if the scars are hidden under the natural
folds of the pinna. Careful manipulation of skin
and perichondrium together with excellent skin
edge approximation is mandatory.
Finally, concho-mastoid sutures are performed
through two or three tunnels to minimize the
amount of dissection needed. Absorbable sutures
are preferred because we have observed that
despite suture degradation, the ear maintains its
position.
In conclusion, minimally invasive otoplasty
provides long-term satisfactory results with an
aesthetically pleasant pinna and a natural crease
of the antihelical fold. The advantages of the
technique are its simplicity, reliability, and safety.
It avoids the use of permanent sutures and wide
dissection and results in low complication, seque-
lae, and recurrence rates.
Fig. 12.8 Final aspect of
the ear
a
b
Fig. 12.9 ( a ) Preoperative. ( b ) One year postoperatively.
Surgery included scaphal and conchal hypertrophy cor-
rection, anterior antihelical scoring, and conchal-mastoid
sutures. Note the proper antihelical bending achieved

125
12 Minimally Invasive Otoplasty: Technical Details and Long-Term Results
References
1. Converse JM, Nigro A, Wilson FA, Johnson N. A tech-
nique for surgical correction of lop ears. Plast Reconstr
Surg. 1955;15(5):411–8.
2. Mustarde JC. The correction of prominent ears using
simple mattress sutures. Br J Plast Surg. 1963;16:170–8.
3. Stenstroem SJ. A “natural” technique for correction
of congenitally prominent ears. Plast Reconstr Surg.
1963;32:509–18.
4. Ju DM, Li C, Crikelair GF. The surgical correction of
protruding ears. Plast Reconstr Surg. 1963;32:283–93.
5. Chongchet V. A method of antihelix reconstruction. Br
J Plast Surg. 1963;16:268–72.
6. Schlegel-Wagner C, Pabst G, Müller W, Linder T.
Otoplasty using a modi fi ed anterior scoring technique:
standardized measurements of long-term results. Arch
Facial Plast Surg. 2010;12(3):143–8.
7. de la Fuente A, Santamaría B. Minimally invasive oto-
plasty. Eur J Plast Surg. 1998;5:249–53.
8. Gibson T, Davis WB. The distortion of autogenous car-
tilage grafts: its cause and prevention. Br J Plast Surg.
1958;10:257–74.

127
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_13, © Springer-Verlag Berlin Heidelberg 2013
13
Introduction
Prominent ear occurs in 5 % of the Caucasian
population and is the most common congenital
auricular deformity [ 1 ] . While it is a mild con-
genital defect within the spectrum of ear anoma-
lies, its aesthetic and psychological impacts
should not be neglected. Two-thirds of the promi-
nent ear cases result from an underdeveloped
antihelical fold, while one-third of the cases result
from an excess of conchal bowl cartilage [ 2 ] .
Associated secondary anomalies include exces-
sive helical root protrusion, overprojected lobule,
excessive antitragal protrusion, insuf fi cient heli-
cal curling, cup ear deformity, and macrotia [ 3 ] .
Studies have shown that prominent ear exhibits
autosomal dominant inheritance [ 1 ] .
The ultimate goal of surgery is to produce
symmetrical, normal-appearing ears. Although
quantitative measures to evaluate auricular
dimensions serve as a useful guide when de fi ning
a deformity, prominence should be viewed in the
context of the individual’s face and patient’s or
family’s perception. This chapter is intended to
review the normal development and anatomy of
the ear and the treatment options available for
prominent ear otoplasty.
Development and Anatomy of the Ear
The external ear is composed of a tightly adher-
ent skin over a cartilaginous framework. The
posterior skin surface has a unique layer of adi-
pose tissue. This layer extends anteroinferiorly to
form the helical rim [ 4 ] . The average mature
auricle is 6 cm in height and 3–4 cm in width (or
50–60 % of the height) [ 5 ] . The root of the helix
is 6–7 cm posterior to the lateral canthus. The
superior and inferior points align with the supe-
rior orbital rim and subnasales, respectively.
The longitudinal axis is 15–20° off the sagittal
plane, and the ear protrudes 1.5–2.0 cm from the
postauricular skin [ 6 ] (Fig. 13.1 ).
The abnormal projection of the prominent ear
results from variations in two basic anatomical
structures: underdevelopment of the antihelix
(Fig. 13.2 ) and/or overdevelopment of the con-
chal bowl. An obtuse conchoscaphal angle (>90°)
is indicative of poor antihelical development
leading to perception of prominence, while an
enlarged or deepened conchal bowl (>1.5 cm)
further lateralizes the ear, thereby exaggerating
this prominence [ 3 ] .
Embryologically, the ear arises from six hill-
ocks of the fi rst and second branchial arches dur-
ing the second to fourth month of gestation [ 7 ] .
Hillocks 1–3, from the fi rst arch, form the antero-
medial aspects of the auricle – tragus, helical
crus, and helix, respectively. Hillocks 4–6, from
the second arch, develop into the posterolateral
aspects of the ear – the antihelix and antitragus,
respectively [ 8 ] . Congenital ear deformities result
A. S. Xue , B.S. • E. I. Lee , M.D.
S. Izaddoost , M.D., Ph.D. (*) • S. Stal , M.D.
Division of Plastic Surgery, Michael E. DeBakey
Department of Surgery , Baylor College of Medicine ,
6701 Fannin St , CC 610.00 , Houston , TX 77030 , USA
e-mail: xue@bcm.edu; eilee@bcm.edu;
shayani@bcm.edu; sstal@bcm.edu
Treatment of Prominent Ear
Anomalies
Amy S. Xue , Edward I. Lee , Shayan Izaddoost ,
and Samuel Stal

128
A.S. Xue et al.
from disruption of one or more of the auricular
hillocks during embryogenesis.
Postnatally, the ear develops rapidly over the
fi rst decade of life. By age 10, the ear reaches
97–99 % of expected adult width and 93 % of
adult length [ 3 ] . The fi brofatty lobule, however,
continues to lengthen throughout adulthood. The
auriculocephalic angle increases from 16 to 22°
from age 1 to 10 years and retracts over the third
decade before reaching an eventual plateau [ 9 ] .
The ear is supplied by the branches from the
super fi cial temporal artery anteriorly and the
posterior auricular and occipital arteries posteri-
orly. The super fi cial temporal, posterior auricu-
lar, and retromandibular veins provide venous
drainage. The lymphatic drainage of the anterior
three hillocks is mainly to the anterior triangle of
the neck while the posterior three hillocks ulti-
mately drain into the posterior triangle of the
neck. The ear is supplied by the great auricular
nerve, lesser occipital nerve, and the auriculotem-
poral nerve. The concha is supplied by Arnold’s
nerve which is a branch of the vagus nerve.
Timing
Evaluation and treatment of auricular defects in
children is similar to treating adults, with a few
exceptions. First, the ear framework continues to
grow during the fi rst decade of life; therefore, any
operative correction before this age must take into
consideration its growth potential. Furthermore,
children younger than 3 months old have very
pliable ear cartilage due to maternal estrogen.
For this reason, most ear deformities in young
children can be treated with molding devices
and do not require surgery. Expectedly, molding
devices (using combination of tapes, glues, and
stents) are most effective if implemented within
10 days of birth [ 10 ] and become less effective
as the ear cartilage matures. For practical pur-
poses, the ear is fully developed by 6–7 years
of age, and correction can be performed at this
time. Moreover, this age corresponds with age of
school matriculation, which can have signi fi cant
social rami fi cations for a child with prominent
ears. Optimum results can be achieved only when
both the parents and the child are motivated to
undergo the procedure. Postoperative compliance
with dressings is an integral part of prominent ear
correction.
Surgical Principles
The primary goal of auricular reconstruction
is to preserve function and restore form in
the anterior and lateral views. Speci fi cally,
McDowell described the following reconstruc-
tive principles: (1) eliminate the protrusion in
the superior third of the ear, (2) both helices
should be visible lateral to the antihelix from the
frontal view, (3) create a smooth and regular
helical contour, (4) minimize distortion to the
postauricular sulcus, (5) avoid placement of the
5.5–6.5 cm
50–60 % of the height
20–22 mm
16–18 mm
10–12 mm
Fig. 13.1 Dimensions of the
normal mature ear. The ears
typically reach maturity by
10 years of age. Notice that
the upper third of the helical
rim typically projects
1.0–1.2 cm from the scalp,
the middle third 1.6–1.8 cm,
and the lobule 2.0–2.2 cm
from the mastoid region. An
underdeveloped antihelix
leads to excessive projection
of the upper third, while an
overdeveloped conchal bowl
results in lateralization of the
middle third

129
13 Treatment of Prominent Ear Anomalies
ear too close to the head, and (6) contours and
positions of the two ears should be matched
closely but not necessarily symmetric [ 11 ] .
Since the lateral surface of the ear is rarely seen
along with the contralateral ear, subtle varia-
tions can be tolerated. Therefore, corrective
a
b
d
c
Fig. 13.2 ( a , b ) Anterior and posterior views of patient
with bilateral prominent ears. Notice the underdeveloped
antihelical fold and superior crus ( c ), leading to an obtuse
conchoscaphal angle. ( d ) Twelve-month outcome after
correction using Mustarde sutures

130
A.S. Xue et al.
treatment should concentrate on the frontal view,
which will allow for direct comparison of posi-
tion, protrusion, and height.
Many techniques have been used to correct
the underdeveloped antihelix. Initially, Ely
described a technique where both skin and con-
chal cartilage were resected in two stages [ 12 ] .
In 1910, Luckett described setback of the ear by
excision of the postauricular skin, after realizing
that the auricular prominence results from an
underdeveloped antihelical fold. He also incised
the ear cartilage leading to a sharp antihelix dem-
onstrating a “surgically altered” ear [ 13 ] . In
1963, Mustarde [ 14 ] described a suture tech-
nique that creates a smooth and more natural
fold. In his technique, permanent sutures are
placed in the posterior surface of the ear carti-
lage and tied under enough tension to create the
desired bend in the cartilage. While this allows
great control in formation of the fold, suture fail-
ure can occur especially in adult males where the
cartilage can be thick. These patients can bene fi t
from Stenstroem’s technique [ 15 ] , where the fold
is created by simply scoring the anterior surface
of the auricular cartilage. Gibson and Davis [ 16 ]
fi rst noted this phenomenon in which the carti-
lage naturally curves away from the scored
surface.
Several techniques have been described to
address the conchal bowl hypertrophy. The
Furnas technique [ 17 ] involves placement of con-
chal-mastoid sutures after removal of the poste-
rior auricularis muscle and fi brofatty tissue from
the postauricular groove. The Elliott technique
[ 18 ] resects the excess cartilage through an ante-
rior incision made at the conchal margin. Webster
[ 19 ] described repositioning of the ear lobule
using medial repositioning of the “tail” of the
helix after posterior dissection. Current auricular
reconstruction typically involves a combination
of these techniques to optimize outcome. A thor-
ough preoperative assessment, including history
and physical, photography, and measurement, is
necessary to determine the best surgical methods.
In addition, it is particularly important to evaluate
patient maturity and motivation for surgery, espe-
cially in the pediatric population.
Preferred Surgical Management
Preoperative
The fi rst step in treatment of a prominent ear is
preoperative assessment and creation of a surgi-
cal plan. Once the level of motivation of the
patient and parents have been assessed and
deemed to be appropriate for surgery, the helix,
the concha, and the pliability of the cartilage need
to be assessed. This will allow the surgeon to
choose from the armamentarium of techniques
described above. The patient should shower and
shampoo his/her hair the night prior to surgery.
The surgery can be performed using a “Diamond
Block” around the ear with 1 % Xylocaine with
1/100,000 epinephrine in adults or under general
anesthesia in children. The patient is draped in the
supine position such that both ears are visualized.
Ophthalmic adhesive tape or 1010 drape can be
used for sequestration of hair from the operative
fi eld. The ear should be prepped, including the
external auditory canal, which should be occluded
using a cotton plug. Lastly, digital pressure is
exerted over the ear cartilage, thereby allowing
visualization of the fi nal results.
Operative
The goal of surgery is to produce perceptibly nor-
mal and symmetrical ears that are less noticeable.
As discussed above, there is a large variety of
existing corrective techniques available for
prominent ears, which can be categorized into
cartilage-scoring, cartilage-breaking, or carti-
lage-molding techniques [ 12, 17, 18, 20 ] . In gen-
eral, a successful repair involves a combination
of these techniques addressing the concha fi rst,
followed by the antihelix, and then, if needed, the
lobule.
The conchal hypertrophy should be addressed
fi rst to minimize the risk of excessive Mustarde
suture tightening [ 3 ] . For conchal depths of less
than 2.5 cm, Furnas technique is suf fi cient
whereby three to four conchomastoid sutures are
placed to correct conchal excess (Fig. 13.3 ).

131
13 Treatment of Prominent Ear Anomalies
Fig. 13.3 Furnas concho-
mastoid sutures. ( a ) Access
is established via a posterior
skin incision. ( b ) The
conchomastoid suture. ( c , d )
Horizontal mattress sutures
are placed in a anteroposte-
rior direction through the
conchal and mastoid
cartilages, respectively, to
minimize narrowing of the
external auditory canal

132
A.S. Xue et al.
A vertical incision is made in the posterior con-
chal skin lateral to the sulcus. Anterior and poste-
rior skin fl aps are elevated to access the helical
rim, scapha, and mastoid fascia. All skin fl aps
should be preserved, particularly the posterior
fl ap, to maintain the posterior sulcus and decrease
the incidence of suture granuloma formation [ 3 ] .
The postauricular muscle and ligament are divided
bluntly until the ponticulus is visualized and the
soft tissue elevated. The ear is then drawn back-
ward with nonabsorbable suture (4-0 Mersilene,
Ethicon, Inc., Somerville, NJ) until desired shape
is reached. The contact areas between the conchal
cartilage and the mastoid fascia are marked and
approximated with three to four mattress sutures
(Fig. 13.4 ). The sutures must contain both the
anterior and posterior perichondrium and must be
placed in an anteroposterior direction to avoid
forward rotation of the ear or narrowing of the
external ear canal [ 3 ] . A Spira posterior conchal
fl ap can be used to limit stenosis of the canal if
narrowing is observed after Furnas sutures [ 21 ] .
In the event of an overly deep concha, an anterior
incision can be made over the shallow area of the
concha, the cartilage incised, and excess cartilage
resected, as described by Elliott [ 18 ] .
The poorly de fi ned antihelical fold is addressed
next. The Mustarde technique (Fig. 13.5 ) places
four to fi ve scaphoconchal mattress sutures to
reshape the ear and to decrease the perceived
prominence [ 14 ] . A methylene-blue-dipped-25-
gauge needle can be useful by marking the outline
of suture placement on the concha and the outer
aspect of the antihelix. Otherwise, temporary nylon
sutures can be placed at 4-mm intervals to fold the
scapha and create the neohelix prior to permanent
suture placement (Fig. 13.4 ). When satisfactory
antihelical de fi nition is achieved, nonabsorbable
mattress sutures (4-0 Mersilene) are placed incor-
porating the anterior and posterior perichondrium
(Fig. 13.4 ). Sutures should be placed obliquely to
maintain the anatomical curvature of the ear. The
middle suture should be tied last to prevent tele-
phone ear deformity (Fig. 13.6 ).
Anterior cartilage scoring is commonly required
in case of rigid cartilage, such as in children older
than 6 years of age [ 15 ] . Cartilage-scoring tech-
niques are based on the observation that cartilage
curls away from a cut surface, a phenomenon
attributed to release of the interlocked stresses when
the perichondrium is scored (Gibson’s phenome-
non) [ 16 ] . In this technique, a Dingman otoabrader
is used to etch the anterior cartilage until the desired
curvature is achieved. Access to the anterior ear can
be achieved via a tunnel from the posterior incision
or an anterior incision. A pocket is initially made
between the skin and the cartilage to allow the
introduction of the otoabrader (Fig. 13.7 ).
Prominent ear can also be associated with
excessively large lobule. Moreover, excessive
Mustarde sutures may inadvertently accentuate
this fi nding, leading to telephone ear deformity
(Fig. 13.7 ). Prominent lobule is addressed last
with a simple full-thickness wedge excision or a
modi fi ed fi shtail excision [ 22 ] . A laterally posi-
tioned lobule is typically caused by a prominent
cauda helicis that can be corrected by suturing it
back to the concha, medial placement of the tail
of the helix, or direct excision [ 2 ] .
In more severe deformities or those involving
stiffer cartilages, cartilage-breaking rather than car-
tilage-molding technique may be required [ 13, 22 ] .
This is a powerful technique, the bene fi ts of which
must be weighed against the potential for second-
ary sharp ridging and contour irregularities.
Although cartilage-sparing techniques are
preferred, cartilage-cutting ones may be useful in
more severe prominent ear deformities. In cases
of severe conchal hypertrophy, excision of the
excess cartilage of the ascending conchal bowl
may be necessary. In addition, excising the post-
auricular muscle and soft tissue can be useful to
accentuate the setback [ 3 ] . Lastly, strict adher-
ence to skin preservation cannot be overempha-
sized. None of the skin, even if appearing to be
excessive after setback, should be excised.
A well-padded mastoid and auricular dressing
is critical in the immediate postoperative period.
Upon dressing removal, an elastic headband
should be worn continuously for 3 weeks and at
nighttime for 4–6 weeks.
Complications
The type of postoperative complication depends
on the surgical technique. Hematoma is the
most immediate and pressing postoperative

133
13 Treatment of Prominent Ear Anomalies
Fig. 13.4 Prominent ear otoplasty. ( a ) Temporary nylon
sutures placed to fold the scapha and create neohelix. ( b )
Posterior auricular incision. Note that no skin was excised.
( c ) Placement of scaphaconchal mattress sutures with the
aid of the temporary suture markers. ( d ) Placement of
Furnas conchomastoid sutures. ( e ) End result intraopera-
tively. ( f ) Long-term follow-up results
a
c
b
d
e

134
A.S. Xue et al.
complication which may require reoperation if
not amenable to local measures [ 23 ] . Insuf fi cient
hemostasis during surgery is the typical cause.
Cartilage-scoring techniques are particularly
more prone for hematoma formation [ 24 ] . Its
development is heralded by disproportionate uni-
lateral pain shortly after surgery [ 25 ] . Untreated
hematomas can result in cauli fl ower deformi-
ties and elevate the risk of infection [ 25, 26 ] .
Infection and chondritis are rare but may require
re-exploration and removal of necrotic cartilage.
A recent prospective study showed infection and
cartilage necrosis rate at 0.44 % [ 24 ] . Suture
protrusions on the other hand are quite common,
particularly the nylon Mustarde sutures through
the posterior skin. This complication may occur
within the fi rst few weeks postoperatively but
usually years later [ 27 ] . Patients should be
informed of this complication preoperatively
and encouraged to return for follow-up. These
sutures can usually be trimmed safely without
endangering the reconstruction. If suture extru-
sion occurs several months postoperatively, the
sutures can be removed.
The most common long-term complication is
recurrence of the deformity, and patients need
to be counseled preoperatively about this pos-
sibility. The surgical management discussed
above minimizes the more serious complica-
tions, such as overcorrection, unnatural sharp
contours, uneven setback, and telephone defor-
mity. These typically manifest 6 months post-
operatively and usually involve technical error.
Telephone deformity results from uneven set-
back, leading to a C-shaped or telephone-
shaped, helical contour with excessive protrusion
of the lobule (Fig. 13.7 ). Fortunately, these
more severe complications are preventable with
f
Fig. 13.4 (continued)

135
13 Treatment of Prominent Ear Anomalies
good preoperative planning and careful technical
execution.
Conclusions
Due to the large variety of available tech-
niques, reconstruction of prominent ears is
both highly versatile and also one of the more
debated topics. Although the functional
effects of the ear deformity are negligible, the
psychological impact on a patient, particu-
larly a child, can be profound and long last-
ing. The subjective nature of the perceived
auricular projections makes “normalcy”
dif fi cult to de fi ne, despite quantitative
measurements. Ultimately, the ears must be
evaluated within the context of the face, while
taking into consideration cultural and familial
perceptions.
Prominence typically derives from varying
degrees of antihelical hypoplasia or conchal
bowl hyperplasia and is often associated with
secondary auricular anomalies. A solid under-
standing of the anatomy of the ear is essential
when choosing among the myriad of correc-
tive techniques. A thoughtful and logical
approach to reconstruction with careful surgi-
cal planning will provide consistent, optimized
outcomes in form and symmetry.
Fig. 13.5 Mustarde
scaphoconchal sutures.
( a – d ) Five or six permanent,
horizontal mattress sutures
are typically needed to create
the antihelix. The middle
suture is tied last to prevent
telephone ear deformity

136
A.S. Xue et al.
References
1. Songu M, Adibelli H. Otoplasty in children younger
than 5 years of age. Int J Pediatr Otorhinolaryngol.
2010;74(3):292–6.
2. Ambro BT, Lebeau J. Pediatric otoplasty. Oper Tech
Otolaryngol Head Neck Surg. 2009;20:206–9.
3. Janz BA, Cole P, Hollier Jr LH, et al. Treatment of
prominent and constricted ear anomalies. Plast
Reconstr Surg. 2009;124(1 Suppl):27e–37.
4. Shonka Jr DC, Park SS. Ear defects. Facial Plast Surg
Clin North Am. 2009;17(3):429–43.
5. Shaye D, Sykes JM. Reconstruction of acquired auric-
ular deformity. Oper Tech Otolaryngol Head Neck
Surg. 2011;22:47–52.
6. Tolleth H. Artistic anatomy, dimensions, and propor-
tions of the external ear. Clin Plast Surg. 1978;5(3):
337–45.
7. Kösling S, Omenzetter M, Bartel-Friedrich S.
Congenital malformations of the external and middle
ear. Eur J Radiol. 2009;69(2):269–79.
8. Klockars T, Rautio J. Embryology and epidemiology
of microtia. Facial Plast Surg. 2009;25(3):145–8.
9. Kelley P, Hollier L, Stal S. Otoplasty: evaluation,
technique, and review. J Craniofac Surg. 2003;14(5):
643–53.
10. Byrd HS, Langevin CJ, Ghidoni LA. Ear molding in
newborn infants with auricular deformities. Plast
Reconstr Surg. 2010;126(4):1191–200.
11. McDowell AJ. Goals in otoplasty for protruding ears.
Plast Reconstr Surg. 1968;41(1):17–27.
12. Ely ET. A classic reprint: an operation for prominence
of the auricles (with two wood-cuts). Aesthetic Plast
Surg. 1987;11(2):73–4.
13. Rogers BO. The classic reprint. A new operation for
prominent ears based on the anatomy of the deformity
by William H. Luckett, M.D. (reprinted from Surg
Gynec Obst. 1910;10:635–7). Plast Reconstr Surg.
1969;43(1):83–6.
14. Mustardé JC. The correction of prominent ears using
simple mattress sutures. Br J Plast Surg. 1963;16:
170–8.
15. Stenstroem SJ. A “natural” technique for correction
of congenitally. Plast Reconstr Surg. 1963;32:
509–18.
16. Gibson T, Davis WB. The distortion of autogenous
cartilage grafts: its cause and prevention. Br J Plast
Surg. 1957;10:257–74.
17. Furnas DW. Correction of prominent ears by con-
chamastoid sutures. Plast Reconstr Surg. 1968;42(3):
189–93.
18. Elliott RA. Otoplasty: a combined approach. Clin
Plast Surg. 1990;17(2):373–81.
19. Webster GV. The tail of the helix as a key to otoplasty.
Plast Reconstr Surg. 1969;44(5):455–61.
20. Mustardé JC. The treatment of prominent ears by bur-
ied mattress sutures: a ten-year survey. Plast Reconstr
Surg. 1967;39(4):382–6.
Fig. 13.6 Telephone ear deformity, marked by excessive
projection of the lobule. The ear appears C-shaped from
the lateral view. It can result from overtightening of
Mustarde sutures
Fig. 13.7 Anterior cartilage scoring is necessary in more
dif fi cult cases with stiffer cartilage. A pocket is created to
accommodate the otoabrader

137
13 Treatment of Prominent Ear Anomalies
21. Spira M, Stal S. The conchal fl ap: an adjunct in oto-
plasty. Ann Plast Surg. 1983;11(4):291–8.
22. Wood-Smith D. Aesthetic plastic surgery. Philadelphia:
Saunders; 1980.
23. Hoehn JG, Ashruf S. Otoplasty: sequencing the oper-
ation for improved results. Plast Reconstr Surg.
2005;115(1):5e–16.
24. Sinha M, Richard B. Postauricular fascial fl ap and
suture otoplasty: a prospective outcome study of 227
patients. J Plast Reconstr Aesthet Surg. 2012;65(3):
367–71.
25. Limandjaja GC, Breugem CC, van der Molen AB M,
Kon M. Complications of otoplasty: a literature review.
J Plast Reconstr Aesthet Surg. 2009;62:19–27.
26. Campbell
AC.
Otoplasty.
Facial
Plast
Surg.
2005;21(4):310–6.
27. Thorne CH, Wilkes G. Ear deformities, otoplasty, and ear
reconstruction. Plast Reconstr Surg. 2012;129(4):701e–16.

139
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_14, © Springer-Verlag Berlin Heidelberg 2013
14
Introduction
The ultimate goal in otoplasty is to achieve a
natural result. While symmetry is important, the
other crucial aspect is a natural shape to the ear.
Many surgeons in the past have dismissed suture
otoplasty as a technique that gives unnatural
results. This is undoubtedly the case in the hands
of an inexperienced surgeon or one whom has not
understood the dynamics of the ear and its manip-
ulation with sutures to create a natural result.
However, the author believes that the most
consistent and natural results are achieved with
variations on suture techniques. My otoplasty
practice has been based on the goal of a “virgin
ear,” whereby the ears have settled into a natural
and symmetrical shape as soon as possible after
surgery such that they do not look operated upon.
This is very simple to achieve when following the
recommendations below.
Suture Techniques Versus
Anterior Scoring
Many surgeons routinely use anterior scoring
methods that require degloving of the ear and get
very good results. However, when complications
do occur, these can be severe and potentially
uncorrectable. Complications aside, a more holis-
tic approach to surgery can be undertaken
whereby patients have less bruising and are in
less discomfort as their ear has not been degloved,
they do not need head bandages, and they can
shower the next day [ 1, 2 ] . These additional and
important positive patient outcomes are dif fi cult
to achieve with cartilage scoring methods. The
general techniques the author concentrates on are
scar positioning, positioning and tying of
Mustarde sutures, use of Furnas (concha-mas-
toid) sutures, and use of fascial fl aps.
Preoperative Counseling
and Managing Patient Expectations
Even more important than these surgical tech-
niques is an in-depth discussion with the patient
to realize their expectations. Some may not be
happy unless they are slightly overcorrected, and
others may have speci fi c issues with parts of their
ears that seem unusual to the surgeon. On many
occasions the author has stood with a mirror with
patients and bargained with them regarding their
ear position. The author often suggests a position
which is natural and that surgical colleagues
would approve of, but the patient will adjust their
ears to the position they want. In about 15 % of
cases, this position will be slight overcorrection
and 5 % very overcorrected. The author will
slightly overcorrect both these groups, fi rstly
because the patient will not be happy otherwise
K. Shokrollahi , M.D., BSc, MB, ChB, MSc, LLM,
MRCS(Eng), FRCS(Plast)
Mersey Regional Burns and Plastic Surgery Unit,
Ward 4D , Whiston Hospital , Warrington Rd ,
Liverpool L35 5DR , UK
e-mail: kshokrollahi@hotmail.com
Precision and Suture Positioning
in Otoplasty: Aspiring
to the “Virgin” Ear
Kayvan Shokrollahi

140
K. Shokrollahi
and secondly because what we perceive to be
“overcorrected ears” actually occur naturally in
many individuals if one cares to observe pass-
ersby. Nevertheless, the majority of patients will
agree with my recommendation of a natural cor-
rected position for their ears.
Scar Position
Where to position a skin incision or excision?
Using the posterior approach is undoubtedly
superior as it is hidden both as a scar and as a
potential keloid scar complication. The general
principles of scar positioning relate to visibility
and surgical access. There is no question that
placing the skin incision anterior/lateral to that
described “traditionally” is of great bene fi t. The
incision is best placed in the posterior groove
of the helix and where the helix casts a shadow
over the posterior of the ear. This scar is less
visible when stood behind a patient, whereas
scars in the center of the posterior ear or in the
auriculocephalic sulcus are more visible.
Secondly, access to the superior pole of the
ear and the outer aspect of the ear is simpler.
This allows for very accurate suture positioning
to create speci fi c and gentle corrections of parts
of the ear, especially the tip. A “lop” ear is often
encountered when using suture correction.
When the tip of the ear droops downward, good
access to the tip of the helical cartilage and
positioning of a speci fi c trajectory of suture
downward will correct this problem very easily
with a gentle and subtle suture tie. Raising a
substantial fascial fl ap based on the helix is
facilitated that can be used for a number of
purposes.
Positioning and Tying of Mustarde
Sutures
The most crucial element to a good result in
suture otoplasty is the positioning of the Mustarde
sutures. This will be the difference between an
unnatural angulated and overcorrected appear-
ance and an ear that is natural and appropriately
corrected. I now undertake these suture positions
by eye intraoperatively, but one technique that
can be used is to create and then skewer the cor-
rect antihelical fold using a fi ne gauge syringe
needle (Fig. 14.1 ) [ 3 ] . These can be left in or sub-
sequently marked with ink as per the surgeons’
preference. Three Mustarde sutures are usually
suf fi cient, but if required, there should be no hes-
itation to using additional ones.
To achieve the most natural correction, the
author recommends positioning and then tying
the Mustarde sutures from inferior to superior.
The reason is that the crucial superior pole of the
ear should be a subtle and gentle “ fi nal correc-
tion” after all other sutures are positioned and
tied. The sharp angular and overcorrected look is
in my opinion most commonly seen because the
superior pole was tied fi rst. In addition to angu-
larity, this means that the superior pole is always
overcorrected because when both the central and
inferior sutures are tied, they will cause further
posterior movement of the superior pole, even if
slight. By tying the inferior suture fi rst, which
gives only a very slight correction initially, and
then the central suture, the fi nal correction
Fig. 14.1 Orange needles used to create and maintain
antihelix, providing accurate localization for positioning
of Mustarde sutures

141
14 Precision and Suture Positioning in Otoplasty: Aspiring to the “Virgin” Ear
required at the superior pole is much milder,
without angularity, and can be judged with milli-
meter precision in comparison to the scalp.
4/0 Ticron or 4/0 Ethibond sutures are recom-
mended. These can be found on suitably curved
semicircular needles that are less easily lost in the
tissues. These braided sutures anecdotally appear
to form less rigid/crystalline knots that are less
likely to extrude and are more resistant to frac-
ture if weakened by stray needle damage. An
anteriorly based fascial fl ap sutured to the mas-
toid combined with skin glue as postoperative
splint will ensure almost no tension remains on
these suture knots by the end of surgery [ 1, 2 ] .
Furnas/Concha-Mastoid Sutures
Since using a fascial fl ap, which itself rotates the ear
when sutured to the mastoid, there is reduced need
for these sutures. However, their use to rotate the ear
before positioning and tying Mustarde sutures is
important for those ears with large and deep conchal
bowls. When used to give gentle rotation, it ensures
that the effect of subsequent Mustarde sutures is
more reserved and gentle, ensuring a more natural
contour with less angularity. Only in the most severe
cases is the excision of cartilage ellipse required
from the conchal bowl. I avoid this technique.
Fascial Flap
The author would encourage any surgeon under-
taking suture otoplasty to raise a fascial fl ap [ 2 ] .
This is simple and does not impact on differing
techniques. However, raising and manipulating
the fl ap when based on the helix allow the surgeon
to experiment without changing their usual oper-
ative strategy.
References
1. Shokrollahi K, Cooper MA, Hiew LY. A new strategy
for otoplasty. J Plast Reconstr Aesthet Surg.
2009;62(6):774–81.
2. Shokrollahi K, Tanner B. “Glue Ear”: beginning of
the end for head bandages after prominent ear correc-
tion? J Plast Reconstr Aesthet Surg. 2008;61(9):
1077.
3. Mathur BS, Shokrollahi K. Precision and suture posi-
tioning in otoplasty. Experience with 380 cases. J Plast
Reconstr Aesthet Surg. 2010;63(3):571–2.

143
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_15, © Springer-Verlag Berlin Heidelberg 2013
15
Introduction
Otoplasty is performed by different surgical speci-
alities including otorhinolaryngology, plastic sur-
gery, and maxillofacial surgery. As a result many
papers have been published describing different
techniques. However, the best technique may be
the one that is fl exible, simple, and versatile.
Correction of prominent ears was fi rst successfully
conducted by Dieffenbach [ 1 ] to correct a post-
traumatic prominent auricle in a patient. He
excised retroauricular skin and used a conchomas-
toidal suture for the fi xation of the ear. In 1910,
Luckett [ 2 ] combined a skin-cartilage excision
along the antihelical fold with horizontal mattress
sutures to achieve a better formation of the scapha.
Since then more than 200 surgical techniques have
been described for this condition indicating that no
single ideal technique has been universally
adopted. Modern otoplasty techniques are based
on two main surgical categories, cartilage sparing
and cartilage cutting, along with many nuances.
The anterior scoring methods, as described by
Stenstrom [ 3 ] and Chongchet [ 4 ] , are the most
commonly performed cartilage-scoring proce-
dures. However, these methods have been criti-
cized for their complications, such as hematoma,
anterior skin necrosis, chondritis, and irreparable
cartilage damage [ 5 ] . Conchoscaphoid suturing to
create the antihelical fold [ 6 ] and conchomastoid
suturing to rotate the conchal angle [ 7 ] are com-
monly described cartilage sparing methods.
Renewed interest in suture-based techniques
evolved through advances led by Horlock et al.
[ 6 ] whom introduced the idea of using a proxi-
mally based fascial fl ap beneath which permanent
sutures could be buried to prevent extrusion.
Schaverien [ 8 ] stated good results using a proxi-
mally based fascial fl ap to cover the internal per-
manent sutures and reduce the risk of suture
extrusion. Shokrollahi et al. [ 9 ] went further
using a distally based fascial fl ap successfully.
Conchal reduction has been performed using
various techniques. However, the use of concho-
mastoidal suturing was popularized by Furnas [ 10 ]
and later modi fi ed by Spira et al. [ 11 ] . Becker [ 12 ]
introduced the method involving a combination of
cartilage incisions and suture techniques to soften
the contour of the corrected prominent ear. This
technique was re fi ned later by Converse and
Wood-Smith [ 13 ] in 1963. Mustarde’ s [ 14 ]
approach to the creation of antihelical tubing was
to use permanent conchoscaphal mattress sutures.
K. Sevin , M.D. (*)
Plastic Reconstructive and Aesthetic Surgery
Department, Faculty of Medicine , Ankara University ,
435. Cadde 72/53 , Cankaya, Ankara 06550 , Turkey
e-mail: ksevin@gmail.com
A. Sevin , M.D.
Plastic Reconstructive and Aesthetic
Surgery Department ,
Ankara Numune Training and Research Hospital ,
435. Cadde 72/53 , Cankaya, Ankara 06550 , Turkey
e-mail: basevin@gmail.com
Otoplasty with Mustarde Suture
Cartilage Scratching and Rasping
Kutlu Sevin and Asuman Sevin

144
K. Sevin and A. Sevin
Technique
The patient is prepared and draped. Subcutaneous
injection of 1 % lidocaine with 1 in 100,000 epi-
nephrine is used for local anesthesia along the
posterior portion of the pinna. Using a no. 15
blade scalpel, an ellipse of postauricular skin is
excised in the subdermal plane to optimize expo-
sure. The amount of skin removed is determined
by folding the pinna back and marking the supe-
rior and inferior fi xation points needed to hold
the antihelical roll. A vertical postauricular skin
ellipse is excised 2–2.5 cm lateral to the sulcus.
Skin fl aps are elevated for access to the helical
rim, scapha, and mastoid fascia. The perichon-
drium is cut along the antihelix line carefully
sparing the cartilage, and then the perichondrium
is fi rst elevated by eye scissors and then by an
elevator. After hemostasis, the antihelix line is
softened with rasping and scratching. The carti-
lage is thinned to about 30 % of its thickness by
the use of a surgical blade. Three Mustarde
sutures are placed, superior, middle, and inferior,
using 4-0 white polyester material. Two concho-
mastoidal sutures are placed superior and infe-
rior. The sutures must contain both the anterior
and posterior perichondrium, although great care
must be taken to avoid inclusion of the anterior
auricular skin. The inferior sutures are tied fi rst,
leaving the superior suture until last, to provide
the best correction because the upper-pole suture
should be tied to position the ear fi nally at appro-
priate distance from the side of the head. This
distance cannot be correctly de fi ned if the upper-
most suture is tied fi rst, as the distance will
change when the lower sutures are tied. In case of
protruding earlobe, a single lobule deep dermis-
to-scalp periosteum suture is placed without
wedge excision. The skin is closed with 4-0
absorbable sutures in continuous fashion.
Following skin closure, the auricle is packed with
moist cotton to maintain skin fl exibility and the
shape of the new auricle. A bolster of cotton is
applied to prevent pressure ischemia or necrosis,
followed by an external bandage. On the fi rst
postoperative day, the dressing is removed for
evaluation and replaced again with a light
dressing. The auricle is packed anteriorly and
posteriorly to avoid maceration. A protective
bandage is worn for 4 days, and patients are
advised to continue wearing it at night for another
2 weeks. Prophylactic oral antibiotics are rou-
tinely continued for 1 week postoperatively.
Results
The authors performed a retrospective study of
patients who underwent otoplasty from 2002 to
2009, using Mustarde suturing and cartilage soft-
ening by scalpel scratching and rasping. All of
the patients have undergone the same procedure
under local anesthesia. Only bilaterally affected
patients were included. Of the 132 patients (264
primary otoplasties), 83 (63 %) were female and
49 (37 %) were male (Fig. 15.1 ). For nine patients,
a secondary revision was performed for recur-
rence (Table 15.1 ). Postauricular keloid was
found around the scar area after 1 year in two
cases. The lesions were excised and treated with
intralesional injection of triamcinolone acetonide
successfully. Wound infection occurred in one
patient. Suture extrusion was found in fi ve cases.
The remaining patients were satis fi ed with the
outcome.
Discussion
The goals of otoplasty as described by McDowell
[ 15 ] include (1) the helix should be just visible
beyond the antihelix when the patient is viewed
from the front, (2) protrusion of the upper one-
third of the ear must be corrected, (3) the helix
should have a smooth and regular line through-
out, (4) the postauricular sulcus should not be
markedly decreased or distorted, (5) the ear
should not be inset too close to the head, and (6)
the ear position should be within 3 mm between
both ears. Modern otoplasty techniques are
mainly based on two surgical categories, carti-
lage sparing and cartilage cutting along with dif-
ferent variations. The common aim of these
methods is to create an ear that appears normal
with acceptable protrusion, symmetry, and form.
A good understanding of the anatomic features

145
15 Otoplasty with Mustarde Suture Cartilage Scratching and Rasping
allows the surgeon to treat the patients effectively.
Techniques that are based on scoring can be sub-
divided further into those that only super fi cially
score the cartilage and those that score deeply
enough to cut through the newly created antihe-
lix. The scoring can be accomplished on either
the anterior or posterior surface of the ear carti-
lage. In general, however, full-thickness penetra-
tion of the cartilage usually results in a sharper
antihelical fold, which is not desirable [ 11, 16 ] .
Scoring techniques are mainly based on the
studies of Gibson and Davis [ 17 ] that the carti-
lage tends to warp away from an injured surface.
Stenstrom [ 3 ] and Chongchet [ 4 ] applied this
theory to otoplasty. Stenstrom’s initial techni-
que scored the anterior scapha to produce an
antihelical fold and later modi fi ed his technique
by adding a posterior approach [ 18 ] . Fry [ 19 ]
studied human nasal septal cartilage and pro-
posed that interlocked stresses released by par-
tial-thickness incisions on one side of in vitro
septal cartilage strips result in bending away from
the side incised due to unopposed tensile stresses
on the intact side. Later, however, in vitro studies
in 1982 by Murakami et al. [ 20 ] on human septal
cartilage strips found inconsistent results with
partial-thickness cuts. Today, the exact mecha-
nism for the observed warping behavior of carti-
lage is still a matter of debate.
Many different instruments have been used
within different centers to warp the cartilage.
Stenstrom and Heftner [ 18 ] scratched the cartilage
surface anteriorly with razor blades. Later, devices
reported for cartilage scoring include rasps, hypo-
dermic needles [ 21 ] , and dermabrasion tool [ 22 ] .
Qureshi et al. [ 23 ] studied the use of bipolar
Fig. 15.1 ( a ) Preoperative
view of 23-year-old female.
( b ) Six months postoperative
view after otoplasty with
Mustarde suture cartilage
scratching and rasping
a

146
K. Sevin and A. Sevin
cautery to achieve a similar effect in an ex vivo
pig ear model. No statistical difference was found
in the degree of warping caused by either scalpel
scoring or bipolar cautery. We should note that the
desired amount of cartilage warping can be
adjusted by the extent of the scratching and rasp-
ing. In our clinical practice, a scalpel blade is the
usual and preferred method to scratch and rasp the
cartilage. Contrary to a general belief that the car-
tilage tends to warp away from an injured surface,
we were able to achieve an adequate antihelical
fold by warping and rasping the posterior surface
of the ear cartilage to produce a thin cartilage.
Thus, no anterior approach for the cartilage was
necessary, also eliminating the risk of anterior
hematoma or bruising.
Excision techniques used to reduce conchal
hypertrophy can be grouped into those that excise
cartilage alone and those that excise both skin
and cartilage [ 24 ] . Luckett’s [ 2 ] procedure to cre-
ate a new antihelical fold involved excising a
crescent segment of cartilage from the posterior
and reapproximating the remaining edges to
each other. However, this creates a sharp fold
with an unnatural appearance. The cartilage-only
b
Fig 15.1 (continued)
Table 15.1 Complications of otoplasty with Mustarde
suture in a study of 132 cases
Complication
Number of cases
Percentage
Bleeding
2
1.5
Infection
1
0.7
Suture extrusion
5
3.8
Recurrence
9
6.8
Keloid
2
1.5