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

148
K. Sevin and A. Sevin
10. Furnas DW. Correction of prominent ears by con-
chamastoid sutures. Plast Reconstr Surg. 1968;
42(3):189–93.
11. Spira M, McCrea R, Gerow FJ, Hardy SB. Correction
of the principal deformities causing protruding ears.
Plast Reconstr Surg. 1969;44(2):150–4.
12. Becker OJ. Correction of protruding deformed ear.
Br J Plast Surg. 1952;5(3):187–96.
13. Converse JM, Wood-Smith D. Technical details in the
surgical correction of the lop ear deformity. Plast
Reconstr Surg. 1963;31:118–28.
14. Mustarde JC. The correction of prominent ears using
simple mattress sutures. Br J Plast Surg. 1963;16:170–8.
15. McDowell AJ. Goals in otoplasty for protruding ears.
Plast Reconstr Surg. 1968;41(1):17–27.
16. Elliott Jr RA. Complications in the treatment of
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18. Stenstrom SJ, Heftner J. The Stenstrom otoplasty.
Clin Plast Surg. 1978;5(3):465–70.
19. Fry HJ. Interlocked stresses in human nasal septal
cartilage. Br J Plast Surg. 1966;19(3):276–8.
20. Murakami WT, Wong LW, Davidson TM. Applications
of the biomechanical behaviour of cartilage to nasal sep-
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21. Mahler D. The correction of the prominent ear.
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furrow: fi ve-year results. Aesthetic Plast Surg.
1995;19(1):83–91.
23. Qureshi TR, Hurren JS, Gourlay T. The effectiveness
of scoring and bipolar diathermy on ear cartilage
behavior: ex vivo study. Ann Plast Surg. 2007;58(3):
321–7.
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149
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_16, © Springer-Verlag Berlin Heidelberg 2013
16
Introduction
Otoplasty is a century-old procedure that has
undergone many modi fi cations over the years.
Over 200 different procedures have been
described in the literature that excise, bend,
suture, scratch, or reposition the auricular carti-
lage. This plenty of surgical techniques show that
no simple “best” technique exists.
The Négrevergne otoplasty technique is a sim-
ple method of cartilage weakening mainly pre-
ferred in young children in our practice [ 1 ] . This
technique was developed by Michel Négrevergne
and adopted in the Georges Portmann Institute in
France [ 2 ] . In Négrevergne otoplasty technique, a
surgical instrument (monopolar diathermy) which
is already present in the surgical fi eld is used.
Since this technique is suture-free, low-
complication rates can be obtained. Common
complications such as suture failures and extru-
sions, suture material-induced foreign-body
granulomas, and wound breakdown are never
observed. In this chapter, preoperative issues are
discussed; perioperative routine and the surgical
technique are described in step-by-step detail.
Preoperative Issues
The most common indication for performing oto-
plasty is the prominent ear (Fig. 16.1 ). Other
indications for otoplasty include trauma, cupped
ear deformity, or to correct a previous poor result.
Anatomic norms for human ears have been estab-
lished; thus, it is possible to more objectively
quantify patients who have irregular, prominent
ears. Janis and Rohrich summarized the propor-
tions that are common in the normal, aesthetic
ear (Table 16.1 ) [ 3– 9 ] .
While the measurements and proportions of a
“normal” ear have been well documented, the
position of anatomical landmarks and relation to
one another at the end of the otoplasty procedure
are far more important. The ears must look pro-
portional to the facial features and have a natural
appearance. Prominent ear occurs as a result of
one or more anatomic variants. Most often there
is a lack of an adequate antihelix; the ear is less
furled back on itself and thus protrudes from the
skull. Another common anatomic fi nding in
patients with prominent ears is a relative excess
of conchal bowl cartilage. A third component can
be an ear lobule that is excessive in size or posi-
tioned laterally. The basic goals of otoplasty were
summarized by McDowell in 1968 and are listed
in Table 16.2 [ 3 ] .
The appropriate time for the correction of promi-
nent ears should depend on a rational approach
based on auricular growth and age of school matric-
ulation. Although the concern for ridicule and its
effect on social development has been clearly
M. Songu , M.D.
Department of Otorhinolaryngology ,
Izmir Ataturk Research and Training Hospital ,
Izmir 35360 , Turkey
Department of Otorhinolaryngology ,
Dr. Behçet Uz Children’s Hospital ,
Izmir , Turkey
e-mail: songumurat@yahoo.com
The Négrevergne Otoplasty
Technique
Murat Songu

150
M. Songu
illustrated, many children are not referred for oto-
plasty until teasing becomes an issue [ 10, 11 ] .
Otoplasty procedure in children is recommended to
be performed prior to the start of schooling [ 12 ] .
The hope is to correct the malformation before the
time of socialization in order to minimize ridicule
by peers. However, substantial psychological pres-
sure exposed to children with protruding ears among
the peers at the preschool period or in kindergarten
is usually underestimated. Changing socioeconomic
trends have increased the proportion of families in
which both parents work outside of the home. As a
result, children have been increasingly exposed to
peers through daycare centers well before age 4 or
5 years. This intense early exposure to peers and
caretakers outside of the family may signi fi cantly
affect development of self-esteem. We observed
that these children can provide information about
their psychological strain or possible problems with
other children associated with their protruding ears.
Furthermore, these children can also express con-
cern about the abnormal appearance of their ears
before age fi ve [ 13 ] .
Like many procedures involving the child’s
face, there is a concern about how the operative
site will respond to pressures of normal growth.
Until recently, very few surgeons felt comfort-
able operating on the ear of a young child due to
concerns about longevity and altered growth.
Adamson et al. studied the growth patterns of the
external ear of 2,300 ears and showed that the ear
reaches 85 % of its adult size by 3 years of age
[ 14 ] . On the other hand, Farkas differed some in
his measurements stating that the ears reach 85 %
of full size by age 6, 90 % by age 9, and 95 % by
age 14 [ 15 ] . Balogh and Millesi were the only
authors to objectively study growth alterations
following otoplasty and concluded that growth of
the ear is not arrested following otoplasty [ 16 ] .
Recently, Gosain and colleagues reported that
otoplasty can be safely performed under age 4
Fig. 16.1 Prominent ears showing increased helix-mas-
toid angle, antihelical hypoplasia, cavum hyperplasia, and
protruding lobule
Table 16.1 Proportions of the aesthetic ear
The long axis of the ear inclines posteriorly
at approximately a 20° angle from the vertical
The ear axis does not normally parallel the bridge of
the nose (the angle differential is approximately 15°)
The ear is positioned at approximately one ear length
(5.5–7 cm) posterior to the lateral orbital rim between
horizontal planes that intersect the eyebrow
and columella
The width is approximately 50–60 % of the length
(width, 3–4.5 cm; length, 5.5–7 cm)
The anterolateral aspect of the helix protrudes
at a 21–30° angle from the scalp
The anterolateral aspect of the helix measures
approximately 1.5–2 cm from the scalp (although
there is a large amount of racial and gender variation)
The lobule and antihelical fold lie in a parallel plane
at an acute angle to the mastoid process
The helix should project 2–5 mm more laterally than
the antihelix on frontal view
Table 16.2 McDowell’s basic goals of otoplasty
All upper third ear protrusion must be corrected
The helix of both ears should be seen beyond the
antihelix from the front view
The helix should have a smooth and regular line
throughout
The postauricular sulcus should not be markedly
decreased or distorted
The helix to mastoid distance should fall in the normal
range of 10–12 mm in the upper third, 16–18 mm in the
middle third, and 20–22 mm in the lower third
The position of the lateral ear border to the head should
match within 3 mm at any point between the two ears

151
16 The Négrevergne Otoplasty Technique
and as young as 9 months without signi fi cant
effect on ear growth in a cohort of 12 patients
with prominent ears [ 17, 18 ] . Due to our experi-
ence, in unilateral “Jumbo” ears, we observed
that the protruding ear is usually bigger than the
unaffected ear in all dimensions. Growth altera-
tion should be a desired consequence among
these patients, and this desire is another rationale
for the early surgical intervention. Nevertheless,
we did not observe any visible disturbance or
growth restriction in our patients, even in the uni-
lateral operated group (Fig. 16.2 ).
An important advantage of performing oto-
plasty at these younger ages is the increased mal-
leability of the auricular cartilage, decreasing the
need to use cartilage-cutting techniques. At this
age, the auricular cartilage is characteristically
pliable; however, elasticity decreases with
advancing age, often demanding more aggressive
treatment. The softer the auricular cartilage, the
easier it is to shape the cartilage or auricle into
the appropriate form and pin it back, using gentle
surgical techniques. The Négrevergne otoplasty
technique was popularized in the Georges
Portmann Institute in France. The technique
includes partial-thickness posterior scoring of the
auricular cartilage using monopolar cutting dia-
thermy. Because the ear cartilage is weak under
age fi ve, cartilage scoring can be conservative,
suf fi cient to release the cartilage spring only.
The main disadvantage of the surgery before
age fi ve is postoperative dif fi culties dealing with
the dressing. The procedure is best performed
when the auricle has reached maturation and the
child is old enough to cooperate with the postop-
erative care. It must be kept in mind that correc-
tion before age fi ve may complicate the
postoperative course when the child, even if not
intentionally, pulls apart the bandage and poten-
tially disrupts the repair. Our practice has shown
that all of the study patients were followed by
multiple extra visits for redressings and their
fi ngers were constantly inside the bandage which
resulted in more swelling and certainly greater
risk of postoperative complications. Nevertheless,
at the end of the follow-up period, no serious
complications occurred, and the patient showed
full recovery in our series (Fig. 16.3 ) [ 13 ] .
Another aspect with signi fi cant impact on pro-
cedure planning is the analysis of the cartilage
consistency and, in particular, the stiffness and
thickness of the cartilage. The consistency of the
a
b
Fig. 16.2 ( a ) Preoperative. ( b ) Postoperative after undergoing right unilateral otoplasty and adenoidectomy that dem-
onstrates the normal growth of the ear that had been operated on relative to the unaffected ear

152
M. Songu
cartilage is typically evaluated by palpitation and
cautious, controlled bending. It is important in
surgical planning to remember that the cartilage
becomes more calci fi ed and brittle with age.
Standard preoperative photographs and con-
sent form for the procedure are taken. The pur-
pose of the photographic documentation is to
document the preoperative situation. A basic
series should include full facial frontals and later-
als of both ears. Frontal close-ups, obliques, and
posterior images of each ear are also helpful
(Fig. 16.4 ).
Taking postoperative photos at intervals of 6
and 12 months helps to monitor postoperative
a
b
Fig. 16.3 ( a ) Preoperative. ( b ) Postoperative following bilateral otoplasty and adenoidectomy in combination with
tonsillectomy. The ears remain relatively symmetrical postoperatively
Fig. 16.4 Documentation showing left lateral ( a ), left oblique ( b ), frontal ( c ), right oblique ( d ), right lateral ( e ), and
posterior ( f ) images
a
b

153
16 The Négrevergne Otoplasty Technique
success and is also recommended for medical
legal reasons (Fig. 16.5 ) [ 19, 20 ] . Prophylactic
antibiotics are recommended for the majority of
aesthetic and reconstructive procedures on the
ear. The risk of chondritis is a suf fi cient indica-
tion to use an intraoperative dose of a broad-
spectrum antibiotic and to prescribe a few
postoperative days dosage of the similar agent.
Just as important as the anatomic irregulari-
ties of the auricle are the expectations of the
patient and family. It is important to discuss
the potential outcomes and complications and
to ensure the patient has realistic expectations.
The patients or the parents of the child
are informed about the potential risks and
unwanted complications, including hematoma
e
f
d
c
Fig. 16.4 (continued)

154
M. Songu
and infections of skin or cartilage, and also
regarding the possibility of an unsatisfactory
cosmetic result.
Anesthetic Considerations
In an effort to reduce the potential surgical mor-
bidity related to general anesthesia, current trends
in aesthetic surgery have moved toward local
anesthesia combined with sedation, as opposed to
general anesthesia [ 21 ] . Regardless of whether
general anesthesia or monitored sedation is used,
the use of local anesthesia results in decreased
postoperative narcotic use and decreased pain
scores [ 22 ] . Local anesthesia can be delivered in
a number of ways. A peripheral nerve block can
provide broad-range analgesia with one injection,
as opposed to local in fi ltration, which must be
precisely placed to have the appropriate effects.
Local in fi ltration, however, has the added bene fi t
of hemostasis when low-dose epinephrine is
included. There are multiple choices of sub-
stances available as local anesthetics, including
prilocaine, lidocaine, mepivacaine, bupivacaine,
and ropivacaine.
Surgical Technique
In considering the proper surgical technique,
there is room for surgeon preference and vision.
The surgeon should develop a complete surgical
plan that is a conglomerate of the individual tech-
niques necessary to correct each observed ana-
tomic irregularity. Surgical techniques for the
correction of the prominent ear can be grouped
into maneuvers used to create the antihelical fold,
to correct the conchal defect, and to affect lobule
positioning.
1. Perioperative Routine: There are as many
variations in perioperative routine as there are
in surgical technique for otoplasty. The hair is
covered with a standard head bandage along
the hairline. A small sterile cotton ball is
placed in the external auditory canal to pre-
vent blood from accumulating on the tympanic
membrane (Fig. 16.6 ).
The cleansing of the external ear is performed
with povidone-iodine solution. Surgical drap-
ing with Tegaderm (3M Health Care, St. Paul,
MN) or other clear sticky drape keeps the hair
out of the surgical fi eld. Drapes are placed so
that both ears are simultaneously on view
a
b
Fig. 16.5 ( a ) Preoperative. ( b ) Postoperative after bilateral otoplasty. The ears are symmetrical postoperatively and
rising self-con fi dence is apparent even in the photograph

155
16 The Négrevergne Otoplasty Technique
providing intraoperative comparison to obtain
optimal symmetry (Fig. 16.7 ).
2. Skin Incision: As symmetry is the key, it is
recommended to begin with the more
severely
affected
side.
Before
local
in fi ltration and associated tissue distortion,
the area of redundant postauricular skin to
be excised is estimated by gentle manipula-
tion of the ear and traction in the desired
position. The postauricular skin excision is
then marked based on the estimation.
Although most investigators have advocated
an excision of skin, some have described a
simple incision [ 19, 23 ] . The desired ear
contours are simulated by exerting gentle
digital pressure on the helix, and newly
formed antihelical fold is marked on the skin
(Fig. 16.8 ). The posterior auricular skin and
mastoid soft tissues are in fi ltrated sub-
cutaneously with 1 % Lidocaine HCl and
1:100,000 epinephrine solution. Local anes-
thesia enhances hemostasis and demarcates
the plain of dissection.
The estimated skin excision on the poste-
rior surface of the ear can be done safely with
the narrowest width at the middle third to
avoid “telephone ear” deformity. This occurs
when the middle portion is reduced to a rela-
tively greater degree than the superior helix
and lobule. This overcorrection in the middle
breaks the straight line of the caudal helix and
leaves a relatively over-projected superior
helix and lobule, giving the ear a convexity
similar to the shape of a traditional telephone
(Fig. 16.9 ). The reverse phenomenon can also
occur if relatively less mid-portion correction
is performed. This is termed a reverse tele-
phone deformity.
If a lobule prominence accompanies,
the skin excision is fi nished with a
Fig. 16.6 Small sterile cotton ball placed in the external
auditory canal
Fig. 16.7 Surgical draping with clear sticky drape
Fig. 16.8 Ear contours are simulated by exerting gentle
digital pressure on the helix. Newly formed antihelical
fold and planned mattress sutures are marked on the skin

156
M. Songu
diamond-shaped inferior end to correct the
lower pole prominence. The maximal width of
the diamond-shaped excision is designed to
rest at the point of maximal lobule prominence
(Fig. 16.10 ). Others describe creating a medial-
based skin fl ap that is redraped over the poste-
rior auricle at the end of the case and excising
the distal portion of the skin fl ap as needed to
precisely fi ll the defect without tension or
excess [ 10 ] . The main advantage of this
approach is tension-free closures, which may
reduce the incidence of hypertrophic scars.
The previously marked postauricular skin is
widely undermined exposing the perichon-
drium. Hemostasis is meticulously maintained,
and dissection is developed peripherally to the
free edge of the helix and posteriorly to the level
of the mastoid bone. The bulky postauricular
soft tissue, auricularis posterior muscle fi bers,
and fi brofatty tissues cleanly excised off the per-
ichondrium and mastoid fascia with preserva-
tion of the periosteum (Figs. 16.11 and 16.12 ).
Creation of a deep, mastoid pocket accom-
modates the repositioned conchal cup, facili-
tates posterior rotation of the concha, removes
the postauricular tissues that may act as a lever
producing excessive prominence, and enhances
the setback by effectively reducing conchal
height. Utilization of the mastoid pocket also
serves to reduce distortion of the external
auditory meatus.
3. Reshaping the Antihelix and Repositioning
the Concha: The proposed position of the anti-
helical fold was previously marked on the
skin. The cartilage under the desired fold is
marked by inserting dental needles at two or
three points from anterior to posterior fashion.
The inserted needles mark the lines of carti-
lage weakening (Fig. 16.13 ).
The monopolar diathermy in cutting mode
is adjusted to a setting suf fi cient to create a
partial-thickness trough through the cartilage.
Three passes are made to form the antihelical
Fig. 16.10 The estimated
skin excision with a diamond-
shaped inferior end
Fig. 16.9 “Telephone ear” deformity evident on the sixth
month control

157
16 The Négrevergne Otoplasty Technique
Fig. 16.11 The subcutaneous
tissue over the mastoid surface
of the cartilage is dissected
Fig. 16.12 The bulky
postauricular soft tissue,
auricularis posterior muscle
fi bers, and fi brofatty tissues
excised
Fig. 16.13 Dental needles
( black arrows ) marking the
lines of cartilage weakening

158
M. Songu
fold while maintaining suf fi cient fl exibility to
prevent a sharp angle at the fold (Figs. 16.14
and 16.15 ). Next, the conchal hypertrophy
component is addressed. The conchal- mastoid
groove has been cleared of the fi brofatty tis-
sue and the postauricularis muscle previously
as described. The ear is drawn backward into
the desired position, and the site of contact
between the conchal cartilage and mastoid
fascia is checked. The marked conchal limits
are used to mark proposed conchal scoring
incisions, which are parallel the long axis of
the ear. Two or three incisions are made with
a monopolar diathermy in cutting mode
(Figs. 16.14 and 16.15 ). This maneuver breaks
the spring of the conchal bowl and lead the
fi brosis to the mastoid fascia. Any excess
conchal cartilage along the free edge of the
external auditory meatus is excised, avoiding
protrusion into the external auditory canal.
4. Lobule and Helical Rim Positioning: The lob-
ule can be an overlooked component of the
prominent ear and appears accentuated after
the auricle is repositioned. Wood-Smith
suggested a “ fi sh taillike” retrolobular skin
excision with a subsequent V-Y plasty [ 24 ] .
Fig. 16.14 Axial view
demonstrates the sequential
effects of surgical maneuvers
on ear protrusion. ( a )
Partial-thickness scoring of
scapha to create antihelical
fold. ( b ) Partial-thickness
scoring of concha to break the
spring of the cartilage
Fig. 16.15 ( a ) Partial-
thickness scoring of scapha to
create antihelical fold. ( b )
Partial-thickness scoring of
concha to break the spring of
the cartilage

159
16 The Négrevergne Otoplasty Technique
Posterior lobule skin and fi brofatty tissue can
be also excised in V-shaped, heart-shaped, and
eccentric elliptical patterns with suture approx-
imation producing the desired setback.
Additionally, a Z plasty can be fashioned at the
most inferior aspect of the postauricular inci-
sion, producing a similar effect. Gosain advo-
cated a single stitch approach in which the
lobule is secured to the mastoid region [ 25 ] .
The excess skin is then excised, and the inci-
sion is closed. Spira et al. treat the protruding
lobule by wedge excision and a periosteum
suture between the dermis and the scalp [ 26 ] .
Another method involves a curvilinear, fusi-
form excision from the anterior to posterior
lobe margin with a central V excision to effect
easy closure [ 27 ] . One further consideration in
the prominent ear, not mentioned elsewhere, is
the helical curl itself. Often this can be fl attened
and fl oppy, further contributing to the overly
abnormal appearance. Few investigators have
focused on this particular aspect. One study
does describe a simple wedge excision along
the helix alone without extending into the
scaphae [ 28 ] . This shortens the outermost edge
of the helix, enhancing its curl inward. This is
used as an adjunct when the helix itself is
noticeably fl attened. In majority of our cases,
we prefer a diamond-shaped posterior skin
excision behind the lobule and suture the
opposing points of the diamond in the closure
using a running, locked, 4–0 long-term absorb-
able suture. It obviates the discomfort of suture
removal, especially in children (Fig. 16.12 ).
5. Dressing and Postoperative Care: The appro-
priate dressing for the ear is a critical aspect
of the procedure. At the completion of the
procedure, the wounds are carefully cleansed
and dressed with greasy gauzes soaked in
Bepanthen Plus ® (50-mg Dexpanthenol , 5-mg
klorheksidin HCl). It is extremely important
that the greasy gauze be carefully molded to
fi t the new folds and contours of the ear and to
gently
pad
the
postauricular
surface
(Fig. 16.16 ).
All patients are placed on a 5-day regimen
of antibiotics and acetaminophen as needed
for pain. Aygit reported a custom-made mold
for 2 weeks postoperative [ 29 ] . Azuara used
a moldable porous polyester splint in a simi-
lar fashion for 72 h with a compression dress-
ing full time for the fi rst week postoperatively
followed by 1 month of nighttime compres-
sion (Fig. 16.17 ) [ 30 ] .
In our practice, the dressing is removed on
the fi rst postoperative day to inspect the ears.
Fig. 16.16 Molded greasy gauze placed to fi t the new
folds and contours of the reconstructed ear
Fig. 16.17 Headband to prevent inadvertent nocturnal
trauma

160
M. Songu
This facilitates early identi fi cation of compli-
cations such as hematoma formation or skin
ischemia. A slightly lighter dressing is
replaced and is changed every other day for a
further 7 days. After removal of the dressings,
patients are instructed to wear a headband
nightly for 1 month to prevent inadvertent
nocturnal trauma. Patients are discouraged
from any rough play or circumstances that
might lead to accidental trauma, as a history
of external trauma has been associated with
about half of the cases of loss of correction
requiring revision surgery [ 31 ] . Patients are
then typically seen at 3–6 months postopera-
tively and 1 year postoperatively to document
results (Fig. 16.18 ).
Conclusions
Although otoplasty is a century-old procedure
that has undergone many modi fi cations over
the years, we are still unearthing the many
advantages and disadvantages of a great
variety of techniques. We herein described
our effective and rapid procedure which main-
tains the natural contours of the auricle by
addressing the poorly developed or absent
antihelical fold, an abnormally large concha,
and a prominent lobule.
Our controllable and intrinsically safe tech-
nique is relatively simple, can be applied to a
wide variety of prominent ear deformities, and
reproducible in the hands of other surgeons.
We also believe that further investigations are
required to characterize the physiological
mechanisms involved in warping behavior of
cartilage.
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a
b
Fig. 16.18 ( a ) Preoperative 14 year-old boy. ( b ) Three months postoperative

161
16 The Négrevergne Otoplasty Technique
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The impact of appearance-related teasing by family
members. J Adolesc Health. 2005;37(2):120–7.
12. Kelley P, Hollier L, Stal S. Otoplasty: evaluation,
technique, and review. J Craniofac Surg. 2003;14(5):
643–53.
13. Songu M, Adibelli H. Otoplasty in children younger
than 5 years of age. Int J Pediatr Otorhinolaryngol.
2010;74(3):292–6.
14. Adamson JE, Horton CE, Crawford HH. The growth
pattern of the external ear. Plast Reconstr Surg.
1965;36(4):466–70.
15. Farkas LG. Growth of normal and re-constructed auri-
cles. In: Tanzer RC, Edgerton MT, editors. Symposium
on reconstruction of the auricle. Mosby: St. Louis;
1974. p. 24–31.
16. Balogh B, Millesi H. Are growth alterations a conse-
quence of surgery for prominent ears? Plast Reconstr
Surg. 1992;90(2):192–9.
17. Gosain AK, Recinos RF. Otoplasty in children less
than four years of age: surgical technique. J Craniofac
Surg. 2002;13(4):505–9.
18. 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.
19. Spira M. Otoplasty: what I do now – a 30-year
perspective. Plast Reconstr Surg. 1999;104(3):
834–41.
20. Becker W, Deutsch E, Knappen FJ, Nussgens K. Panel
discussion: problems of the specialist’s duty to inform
the patient. HNO. 1976;24(6):181–96.
21. Cregg N, Conway F, Casey W. Analgesia after oto-
plasty: regional nerve blockade vs local anaesthetic
in fi ltration of the ear. Can J Anaesth. 1996;43(2):
141–7.
22. Pavlin DJ, Chen C, Penaloza DA, Polissar NL,
Buckley FP. Pain as a factor complicating recovery
and discharge after ambulatory surgery (table of con-
tents). Anesth Analg. 2002;95(3):627–34.
23. Caouette-Laberge L, Guay N, Bortoluzzi P, Belleville
C. Otoplasty: anterior scoring technique and results in
500 cases (review). Plast Reconstr Surg. 2000;105(2):
504–15.
24. Wood-Smith D. Otoplasty. In: Rees T, editor. Aesthetic
plastic surgery. Philadelphia: Saunders; 1980. p. 833.
25. Gosain AK, Recinos RF. A novel approach to correc-
tion of the prominent lobule during otoplasty. Plast
Reconstr Surg. 2003;112(2):575–83.
26. Spira M, McCrea R, Gerow FJ, Hardy SB. Correction
of the principal deformities causing protruding ears.
Plast Reconstr Surg. 1969;44(2):150–4.
27. Adamson PA, Strecker HD. Otoplasty techniques.
Facial Plast Surg. 1995;11(4):284–300.
28. Maurice PF, Eisbach KJ. Aesthetic otoplasty: wedge
excision of a fl attened helix to create a helical curl.
Arch Facial Plast Surg. 2005;7(3):195–7.
29. Aygit AC. Molding the ears after anterior scoring and
concha repositioning: a combined approach for pro-
truding ear correction. Aesthetic Plast Surg.
2003;27(1):77–81.
30. Stenstroem SJ. A “natural” technique for correction
of congenitally prominent ears. Plast Reconstr Surg.
1963;32:509.
31. Adamson PA, McGraw BL, Tropper GJ. Otoplasty:
critical review of clinical results. Laryngoscope.
1991;101(8):883–8.

163
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_17, © Springer-Verlag Berlin Heidelberg 2013
17
Introduction
Prominent ears are commonly caused by overde-
velopment of the concha, underdeveloped antihe-
lical folds, and protruding earlobes [ 1, 2 ] . These
may occur alone or in combination.
Otoplasty should be performed to correct the
deformity early, usually around the age of 7 years
when the child becomes exposed to social attention
[ 3– 6 ] . General anesthesia is usually required for
patients under the age of 10 years. After 10 years,
local anesthesia, with sedation under the supervi-
sion of an anesthesiology team, may be tolerated.
The surgeon should comprehend the fi nal
position of the ear; the angle of the ear and the
mastoid is normally around 30°, the concha and
scaphoid forming an angle of about 90° (con-
chascaphoid angle) and the angle between the
head and the concha of about 90° (cephalocon-
chal angle) so that the scaphoid fossa lies parallel
to the head. The goal of otoplasty is to reposition
the ears so that the contours appear soft and natu-
ral. The helical rim should be visible from the
frontal view protruding beyond the antihelix.
Lateral view should show contours as smooth
and round. From the posterior view, the contour
of the helical rim should be straight [ 1, 6, 7 ] .
There is no single ideal procedure to correct
prominent ears, as can be attested by the various
techniques [ 3, 6, 7 ] . Each surgeon should be
versed in the different approaches and should
adopt a procedure that aims to correct the pre-
senting signs of this deformity. Conceptually, the
“island technique” aims at creating an “island” of
cartilage, which is fashioned and projected, thus
mimicking the antihelix fold. This approach was
originally devised by Pitanguy and Flemming [ 8 ]
as an effective, simple, and reliable procedure to
correct prominent ears. Since then, other publica-
tions have con fi rmed these principles [ 9– 11 ] .
Technique
The island of cartilage is marked as the surgeon
holds the auricle with the thumb and index fi nger
(Fig. 17.1 ) [ 8– 10 ] . An ellipse of skin is excised
from the posterior surface of the ear to give opti-
mum visualization with the width of skin deter-
mined by the extent of auricle protrusion and by
bending the auricle backwards. The demarca-
tion of the island that will form the antihelical
fold (Fig. 17.2 ) is transferred to the posterior
surface of the auricle with needles stained with
methylene blue (Fig. 17.3 ). After incision of the
cartilage, edges are undermined to minimize
tension in the suture line (Fig. 17.4 ). The carti-
I. Pitanguy , M.D.
Ivo Pitanguy Clinic ,
Rua Dona Mariana, 65 ,
Rio de Janeiro 22280-020 , Brazil
e-mail: pitanguy@pitanguy.com.br
H. N. Radwanski , M.D. (*)
Department of Plastic Surgery ,
Ponti fi cal Catholic University of Rio de Janeiro and the
Carlos Chagas Post-Graduate Medical Institute ,
Rio de Janeiro, Brazil
e-mail: dr.henrique@pilos.com.br
Island Technique for Prominent Ears
Ivo Pitanguy and Henrique N. Radwanski

164
I. Pitanguy and H.N. Radwanski
Fig. 17.1 The island of cartilage is marked as the sur-
geon holds the auricle with the thumb and index fi nger
Fig. 17.2 Transferred to the posterior surface of the auri-
cle with needles stained with methylene blue
Fig. 17.3 The incised ellipse
Fig. 17.4 The cartilaginous edges are undermined to
minimize tension in the suture line
laginous edges are approximated without ten-
sion, projecting the island forwards, using 4-0
PDS, and one or two sutures passed through the
perichondrium to unite the mobilized portion of
the cartilage (Fig. 17.5 ). This projects the carti-
laginous island anteriorly to simulate the antihe-
lical fold (Fig. 17.6 ). The concha is repositioned
by rotation and fi xation to the periosteum of the

165
17 Island Technique for Prominent Ears
mastoid bone. If necessary, excess concha can
be excised, but skin folds must be avoided when
suturing the incision. The concha is undermined
from the medial edge of the postauricular skin
incision to the external auditory meatus. The
degree of rotation of the concha is limited
because excess rotation can narrow the entrance
to the external auditory meatus. The earlobe
protrusion is brought into the same plane as the
remainder of the auricle using a triangular or
bow-shaped excision of skin between the ear-
lobe and concha.
Dressing consists of packing the auricle with
moist cotton, carefully inserting the cotton in all
the crevices so as to maintain the shape of the
new auricle. A bolster of cotton is applied to
prevent pressure necrosis. External bandage
wrapping is used. Oral antibiotics are routinely
used for 5 days postoperatively.
The dressing is removed on the fi rst postop-
erative day for evaluation and then replaced. On
the 10th postoperative day, the sutures are
removed. The child should use a protective ban-
dage to cover the ears, and to ensure constant
gentle pressure, for the fi rst week. This bandage
should also be used for the next 3 weeks at
night.
Complications
Out of 111 patients there was one hematoma that
required surgical evacuation. There was no evi-
dence of chondritis, infection, necrosis, hypertro-
phic scars, granulomas, suture extrusion, or loss
of sensibility. Five patients had residual defor-
mity, 3 patients had asymmetry, 3 patients had
under-correction, and 1 patient had both asym-
metry and marked antihelical fold. There were no
recurrences of the deformity.
Discussion
The island technique is indicated for patients
who have any degree of underdevelopment of
the antihelix, even if the main etiology is an
overdeveloped concha (Figs. 17.7 , 17.8 , 17.9 ,
and 17.10 ). The procedure is relatively simple
and has few complications. There are some
complications that are inherent in any otoplasty
technique [ 12, 13 ] such as asymmetry and
under-correction that are due primarily to intra-
operative misjudgment. Some surgeons criti-
cize the cartilaginous island as appearing too
arti fi cial; this is due to poor execution, where
Fig. 17.5 The cartilage edges are approximated with 4-0
PDS, with no tension
Fig. 17.6 This projects the
cartilaginous island anteriorly
to simulate the antihelical
fold

166
I. Pitanguy and H.N. Radwanski
a
Fig. 17.8 ( a ) Preoperative 6-year-old girl with prominent ears. ( b ) Postoperative following correction by the island
technique
a
b
Fig. 17.7 ( a ) Preoperative 7-year-old girl with prominent ears. ( b ) Postoperative after correction by the island technique

167
17 Island Technique for Prominent Ears
a
b
Fig. 17.9 ( a ) Preoperative 6-year-old girl with prominent ear. ( b ) Postoperative after use of the cartilage island
b
Fig 17.8 (continued)

168
I. Pitanguy and H.N. Radwanski
a
b
Fig. 17.10 ( a ) Preoperative 12-year-old boy with prominent ears. ( b ) Postoperative following correction by the island
technique

169
17 Island Technique for Prominent Ears
sharp limits of the island produce a very promi-
nent shape of the new antihelix, and can be
avoided by carefully softening the edges.
Conclusions
The island technique, as originally described
by the senior author, is an effective, simple,
and reliable method of otoplasty to correct
prominent ears. The procedure is reproducible
and has had low recurrence and complication
rates.
References
1. Macgregor FC. Ear deformities: social and psycho-
logical implications. Clin Plast Surg. 1978;5(3):
347–50.
2. 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.
3. Mustarde JC. The correction of prominent ears using
simple mattress sutures. Br J Plast Surg. 1963;
16:170–8.
4. Mustarde JC. The treatment of prominent ears by bur-
ied mattress sutures: a ten-year survey. Plast Reconstr
Surg. 1967;39(4):382–6.
5. Stenstroem SJ. A “natural” technique for correction
of congenitally prominent ears. Plast Reconstr Surg.
1963;32:509–18.
6. Stenstrom SJ, Heftner J. The stenstrom otoplasty. Clin
Plast Surg. 1978;5(3):465–70.
7. Furnas DW. Correction of prominent ears with multi-
ple sutures. Clin Plast Surg. 1978;5(3):491–5.
8. Pitanguy I, Flemming I. Plastiche Eingriffe an der
Ohrmuschel. Stuttgart: Georg Thieme Verlag; 1976.
p. 69.
9. Pitanguy I. Aesthetic plastic surgery of head and body.
Berlin: Springer; 1981. p. 306–14.
10. Pitanguy I, Muller P, Piccolo N, Ramalho E, Solinas
R. The treatment of prominent ears: a 25-year survey
of the island technique. Aesthetic Plast Surg.
1987;11(2):87–93.
11. Bartkowski SB, Szuta M, Zapata J. Pitanguy’s method of
protruding ear correction from our own experience: review
of 80 cases. Aesthetic Plast Surg. 2001;25(2):103–10.
12. Calder JC, Naasan A. Morbidity of otoplasty: a review
of 562 consecutive cases. Br J Plast Surg. 1994;47(3):
170–4.
13. Jeffery SL. Complications following correction of
prominent ears: an audit review of 122 cases. Br
J Plast Surg. 1999;52(7):588–90.

171
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_18, © Springer-Verlag Berlin Heidelberg 2013
18
Introduction
Otoplasty is the reshaping of the ears, typically
the correction of protruding ears or lop-ear defor-
mities. Reshaping of the ears also occurs in the
form of microtia repair on a more grand scale and
earlobe reduction or repair of iatrogenic deformi-
ties to a more minor degree, but this is not typi-
cally considered otoplasty.
Otoplasty most commonly refers to the reduc-
tion of protruding ears. This usually involves rec-
reating normal cartilaginous contours on the
anterior surface of the ear and reducing the depth
of the conchal bowl. Contour recreation and
depth reduction of the bowl may be done inde-
pendently; however, they are most often done
together, to varying degrees. This affects the pro-
trusion of the ear away from the side of the head
and creation of the ideal postauricular angle or
cephaloauricular angle of less than 45° [ 1 ] .
The goal of this chapter is to summarize the
abnormalities that produce the protruding ear, to
describe how to correct them, and to offer rela-
tively simple solutions for the aging lobule and
postsurgical lobular deformities.
History
Otoplasty has an extensive history. Auricular
reconstruction was described as early as the
seventh century by Sushruta in ancient India [ 2 ] .
In Die Operative Chirurgie (Operational Surgery,
1845), Dieffenbach (1794–1847) reported the
fi rst surgical approach for the correction of prom-
inent ears. In his treatise, he described a pinna
setback technique of excising postauricular skin
and then suturing the auricular cartilage to the
mastoid periosteum [ 3 ] . Almost 40 years later, in
the Archives of Otology, Ely [ 4 ] advocated excis-
ing both skin and cartilage on the anterior as well
as posterior surface. He reported a case of a
12-year-old boy who presented with a complaint
of being ridiculed due to the prominence of his
ears. A few years later, Keen [ 5 ] described an
improved approach to the deformity, advocating
the excision of only posterior skin and cartilage.
In 1910, Luckett [ 6 ] acknowledged the impor-
tance of the antihelical fold and noted the
de fi ciency of this structure in children with pro-
truding ears. He described a procedure to create
the antihelix by excising a crescent-shaped piece
of cartilage and closing the defect with buried
mattress sutures. In his original description, he
also envisioned the possibility of reconstructing
the antihelix without excising cartilage, but rather
D. J. Archibald , M.D.
Department of Plastic & Reconstructive Surgery ,
Rockwood Clinic , 801 West 5th Avenue, Suite 504 ,
Spokane , WA 99204 , USA
e-mail: david@drarchibald.com
E. H. Farrior , M.D. (*)
Farrior Facial Plastic Reconstructive
and Cosmetic Surgery Center ,
2908 West Azeele Street , Tampa , FL 33609 , USA
e-mail: ed@drfarrior.com ; farrior@tampabay.rr.com ;
efarrior@tampabay.rr.com
Otoplasty and Earlobe Repair
David J. Archibald and Edward H. Farrior

172
D.J. Archibald and E.H. Farrior
folding the cartilage in patients with thin, fl exible
cartilage. Many other surgeons subsequently
reported on various methods of making relaxing
cartilage incisions, excisions, and shavings, facil-
itating posterior plication to decrease projection
of the concha and create the antihelix [ 7– 13 ] .
Modern otoplasty techniques have evolved to
less invasive therapies, as surgeons have recog-
nized the underlying anatomic defects. Though
described previously, Mustarde [ 14 ] re fi ned and
popularized the technique of reestablishing the
antihelical fold by using suture plication at three
points without incision of the cartilage. Shortly
thereafter, Furnas [ 15 ] published his method of
addressing conchal excess by suturing the concha
to the mastoid.
Embryology, Anatomy,
and Malformations
During the sixth week of fetal life, the ear arises
from the fi rst and second branchial arch in the
form of six auricular hillocks of condensed
ectoderm and mesoderm that form within the
fi rst and second branchial arches. The fi rst three
hillocks (1 through 3) are attributed to the fi rst
branchial arch, and the second three hillocks (4
through 6) are attributed to the second branchial
arch. It is the general consensus that the bulk of
the ear is formed from the third through fi fth
hillocks and that the sixth hillock contributes to
the lobule and antitragus with the tragus and
helical crus originating from the fi rst and sec-
ond hillocks [ 16 ] . Development of the pinna
primarily occurs during the fi rst trimester of
pregnancy; therefore, the majority of auricular
deformities develop during this phase of embry-
ological maturation.
Malformations of the external ear occur on a
wide spectrum and may result in microtia, the
absence of most external anatomy including the
external auditory canal, and are frequently asso-
ciated with underdevelopment of the middle and
inner ear. This is considered a third-degree dys-
plasia (Weerda’s classi fi cation) of the ear [ 17 ] .
The cupped ear deformity, second degree, is most
often represented by an undersized ear with
reduced components, most frequently affecting
the superior helical margin, superior crus of the
antihelix, and scaphoid fossa. First-degree defor-
mities of the ear are deformities of excess rather
than absence and are manifested by the protrud-
ing or overly large ear. Lop-ear deformity, or pro-
truding ears, is inherited as an autosomal
dominant trait with variable penetrance, 59 % of
patients having a positive family history [ 18 ] .
Protruding ears affect 5 % of the Caucasian race,
most commonly secondary to lack of develop-
ment of the antihelical fold [ 19 ] .
Abnormalities of the ear can also be caused by
iatrogenic and traumatic sources. One of the most
frequently occurring iatrogenic abnormalities is
the pixie deformity that can be the sequelae of a
facelift (Fig. 18.1 ). The pixie deformity describes
an elongated, downward displaced earlobe that
may be caused by improper incision placement
around the lobule, aggressive skin removal, or
excessive tension at the time of closure. There is
a similar congenital variation in the degree of
attachment of the lobule to the neck that can be
released, if so desired, in the same fashion as the
repair of the postsurgical pixie-ear deformity.
Fig. 18.1 The pixie deformity describes an elongated,
downward displaced earlobe that may be caused by
improper incision placement around the lobule, aggres-
sive skin removal, or excessive tension at the time of
closure

173
18 Otoplasty and Earlobe Repair
Abnormalities that are the consequence of
aging may also affect the lobule, resulting in
elongation and thinning. If these are not addressed
at the time of a facelift, there will be a severe lack
of harmony after completion of the facial rejuve-
nation, and this may distract from an otherwise
satisfactory result.
In performing otoplasty, it is imperative to
realize that for each eminence, there is a fossa
and that by recreating the normal convexities and
concavities of the auricular cartilage, it is possi-
ble to create an ear that looks normal, with long-
lasting results.
Patient Selection
The ear continues to grow after birth and reaches
approximately 85 % of its adult size by age three.
Slower growth of the ear proceeds until 6 years of
age, at which time the ear has reached adult size,
approximately 6 by 3 cm. Ears that protruded
often become the source of ridicule and can be
corrected as early as 5 or 6 years of age. There is
evidence to suggest that teasing and harassment
will begin when the patient enters elementary
school [ 20 ] . This of course may depend upon the
degree of protrusion, the gender of the patient,
and the hairstyle. The parents of male children
are more likely to seek correction at a younger
age than those of females. There is an upper limit
on the age at which an otoplasty can be per-
formed. In elderly patients, the cartilage becomes
more rigid and may require more aggressive sur-
gical techniques.
Surgical Management
Lop-Ear Deformity
Correction of the lop-ear deformity takes many
forms and has been covered extensively in the past
[ 10, 14, 15, 21 ] . Regardless of technique, surgery
must be customized to address the deformities
that exist to prevent over- or undertreatment.
In the senior author’s (EHF) practice, there is
a 93 % occurrence of absent or underdeveloped
superior crus of the antihelix in patients with pro-
truding ears. This may present in isolation, result-
ing in the protrusion of the superior pinna or in
conjunction with the absence or underdevelop-
ment of the antihelix along its entire length,
which occurs in 75 % of the patients and results
in the protrusion of the entire helical margin.
Protrusion of the entire helical margin in the
absence or underdevelopment of the antihelix is
almost universally associated with a prominent
cauda helicis, contributing to protrusion of the
lobule. A deep conchal bowl, which further exac-
erbates the protrusion, occurs in approximately
45 % of patients.
Absence of the superior crus is the most
straightforward and most consistently encoun-
tered deformity. It is addressed through the exci-
sion of an ellipse of skin on the posterior surface
of the ear over the desired fossa of the superior
crus of the antihelix. This is determined by fold-
ing the ear to recreate the superior crus and iden-
tifying the corresponding position on the posterior
surface. This can be accomplished by the place-
ment of Keith needles through the ear from the
anterior surface. Needles are placed at the junc-
tion of the superior and inferior crus of the anti-
helix in the fossa triangularis, the lateral conchal
bowl at the junction of the superior and inferior
crus, and the anterior margin of the scaphoid
fossa (Fig. 18.2 ). These are used guide posts for
the scoring of the posterior surface of the ear in
the antihelical fossa while avoiding incisions that
would cross the inferior crus, a devastating error.
After scoring, horizontal mattress sutures are
placed from the scaphoid eminence to the emi-
nence triangularis and the lateral conchal bowl
sequentially. These sutures are performed with a
4-0 Mersilene and then tightened to the desired
projection, positioning the helical margin
1.5–2 cm off the mastoid at the junction of the
superior and inferior crus [ 22, 23 ] .
When the antihelix is entirely absent, the pos-
terior skin excision is extended as an elliptical
dumbbell inferiorly until the beginning of the
lobule (Fig. 18.3 ). After the skin incision is com-
plete, the skin is dissected off the posterior surface
of the cauda helices, and the lateral margin of the
distal 5–7 mm is resected obliquely (Fig. 18.4 ).

174
D.J. Archibald and E.H. Farrior
The scoring is then performed, extending down
the entire length of the antihelix (Fig. 18.5 ).
Horizontal mattress suture of 4-0 Mersilene is
placed from the scaphoid eminence to the lateral
conchal bowl (Fig. 18.6 ). The sutures all radiate
from the external auditory canal. When placing
the sutures, care is taken to avoid the skin on the
anterior surface.
In the presence of a deep conchal bowl, con-
chal reduction or conchal setback needs to be
performed. Conchal reduction is more reliable
and results in much less postoperative pain and
discomfort. With conchal setback alone, there is
no recreation of the antihelix in its absence. To
perform conchal reduction, the posterior surface
of the cartilage is marked with trans-auricular
Keith needles, corresponding to the previously
described locations, in addition to the place-
ment of a needle at the lateral conchal bowl
even with the antitragus (Fig. 18.2a, b ). The
index or middle fi nger is placed in the conchal
bowl to palpate the deep surface of the conchal
incision, and an ellipse of lateral bowl cartilage
is resected with the width dependent on need
(Fig. 18.7 ). This defect is then incorporated into
the posterior suturing. The additional sutures are
placed from the scaphoid eminence in a horizon-
tal fashion to the lateral and subsequently medial
a
b
Fig. 18.2 ( a ) Recreation of
the superior crus and
identifying the corresponding
position on the posterior
surface can be accomplished
by the placement of Keith
needles through the ear from
the anterior surface. ( b )
Needles are placed at the
junction of the superior and
inferior crus of the antihelix
in the fossa triangularis, the
lateral conchal bowl at the
junction of the superior and
inferior crus, and the anterior
margin of the scaphoid fossa

175
18 Otoplasty and Earlobe Repair
margin of the conchal bowl, as a vertical suture
(Fig. 18.6 ).
The postauricular incision is closed with a
running, locked, 5-0 plane gut suture. Antibiotic
ointment is applied to the incision, and mineral-
oil-impregnated cotton is placed in the postau-
ricular sulcus, fossa triangularis, scaphoid fossa,
concha cavum, and concha cymba (Fig. 18.8 ).
Fluffed cotton 4 × 4 gauze is secured over the ears
with a circumferential dressing encompassing
both ears.
When the elliptical dumbbell excision of
posterior auricular skin, trimming of the cauda
helicis, and a combination of conchal reduction,
posterior scoring, and mattress suture are applied
appropriately, anatomically correct-appearing
ears can be created with little to no evidence of
surgical correction (Figs. 18.9 and 18.10 ).
Earlobe Abnormalities
Earlobe abnormalities may take many forms.
They may be postsurgical in nature, the result of a
congenital variation, or part of the aging process.
The most common variation is the congenital
Fig. 18.3 When the
antihelix is entirely absent,
the posterior skin excision is
extended as an elliptical
dumbbell inferiorly until the
beginning of the lobule
a
b
Fig. 18.4 ( a ) Green is the ellipse of lateral bowl of concha to be excised, purple is leteral margin of the distal 5–7 mm to be
resected obliquely. ( b ) After the skin incision is complete, the skin is dissected off the posterior surface of the cauda helicis.

176
D.J. Archibald and E.H. Farrior
attached lobule. The management of the congeni-
tal attached lobule is similar to the technique for
correcting the postsurgical pixie deformity. The
technique for correction of the senile and large
lobule will depend upon the vertical and hori-
zontal dimensions of the earlobe and the nature
of the attachment of the lobule to the posterior
face, as well as the patient’s desire or lack thereof
to change that attachment. With the large lob-
ule, simple marginal excision, as described by
Adamson, can be performed [ 22 ] .
With the normal-sized attached lobule, whether
congenital or iatrogenic, the goal is achieving a
more acute angle of attachment without a scar
extending vertically into the neck. This is best
achieved with a simple transposition fl ap created
from the skin of the inferior margin of the lobule
(Fig. 18.11 ). This fl ap is repositioned into a post-
auricular recipient incision, maintaining all visible
incisions in the postauricular sulcus and mastoid.
When the attached lobule is enlarged, and
overall size reduction as well as release is desired,
a
b
Fig. 18.5 ( a , b ) Cartilage scoring ( yellow lines ) is performed extending down the entire length of the antihelix
a
b
Fig. 18.6 ( a , b ) Horizontal mattress sutures of 4-0
Mersilene ( red lines ) are placed from the scaphoid emi-
nence to the lateral conchal bowl. The sutures all radiate
from the external auditory canal. When placing the
sutures, care is taken to avoid the skin on the anterior
surface

177
18 Otoplasty and Earlobe Repair
creativity is the key to a successful release and
camou fl aged scar. If this is being performed in
conjunction with a facelift, it is easy to avoid a
vertical cervical incision when lobular reduction
is performed fi rst and the facelift fl ap trimming is
executed. This accommodates the repositioning
of the earlobe, i.e., eliminating infra-lobular ten-
sion with minimal fl ap resection.
Attached lobule size reduction is achieved
through a hemi-crescentic resection of the lobule,
with the wider portion anterior at the lobular
facial junction (Fig. 18.12 ). The incision can be
blended into the soft tissue furrow of the inferior
extent of the scaphoid fossa. If the desired result
is to reduce the overall size and release the lobule
from its attachments to the posterior face and
neck, it is then necessary to butter fl y the inferior
segment, creating a transposition fl ap as in the
release of the attached lobule prior to creating the
hemi-crescentic excision.
For the lobule that is detached and of increased
horizontal and vertical dimension, stellate exci-
sion is performed. This is planned to include any
preexisting rhytids and will more than likely
necessitate the repiercing of the ear after comple-
tion. With both the stellate and pie-shaped exci-
sion, the pattern is offset at the inferior margin of
the lobule to prevent a circumferential scar and
contracture between the anterior and posterior
surface (Fig. 18.13 ).
Postoperative Care
The otoplasty dressing remains in place for
5 days, but is removed for any complaints of dis-
comfort, pain, or bleeding. After the dressing is
removed, the patient is instructed to secure the
ears while asleep for 6 weeks postoperatively.
Fig. 18.7 An ellipse of
lateral bowl cartilage is
resected with the width
dependent on need. This
defect is then incorporated
into the posterior suturing
Fig. 18.8 Antibiotic ointment is applied to the incision,
and mineral-oil-impregnated cotton is placed in the post-
auricular sulcus, fossa triangularis, scaphoid fossa, con-
cha cavum, and concha cymba

178
D.J. Archibald and E.H. Farrior
Fig. 18.9 ( Left ) Preoperative. ( Right ) Postoperative following otoplasty

179
18 Otoplasty and Earlobe Repair
Fig. 18.10 ( Left ) Preoperative. ( Right ) Postoperative following otoplasty with earlobe reduction

180
D.J. Archibald and E.H. Farrior
This can be accomplished with an athletic head-
band. The postauricular incision is cleaned with
hydroperoxide and dressed with antibiotic oint-
ment until the fast-absorbing sutures have
resorbed. Swimming is allowed immediately
after the head dressing is removed, but diving is
prohibited for 6 weeks postoperative. Patients are
also forbidden from wearing athletic or recre-
ational headgear for 6 weeks.
With earlobe reduction, it is virtually impossible
to dress the lobule. Patients are instructed to clean
the surgical incisions with peroxide and apply
antibiotic ointment twice a day. If the ear is
pierced at the time of the procedure, the 14-karat-
gold post remains in place for 6 weeks to allow
epithelialization and is then changed under the
supervision of a nurse in the of fi ce.
Complications
As is the case with most elective cosmetic surgi-
cal procedures, the rate of complications or
adverse incidents is minimal. The most common
a
b
d
c
Fig. 18.11 ( a – d ) Correction of the normal-sized attached
lobule is best achieved with a simple transposition fl ap
created from the skin of the inferior margin of the lobule.
This fl ap is repositioned into a postauricular recipient
incision, maintaining all visible incisions in the postau-
ricular sulcus and mastoid
Fig. 18.12 Attached lobule size reduction is achieved
thought a hemi-crescent resection of the lobule (C to A to B)
with the wider portion anterior at the lobular facial junction

181
18 Otoplasty and Earlobe Repair
complication of otoplasty may in fact be the pre-
viously unidenti fi ed preoperative asymmetry. It
is therefore imperative to point out any preopera-
tive differences prior to surgery. These preopera-
tive asymmetries may or may not have been
identi fi ed by the parents or patient before sur-
gery, but will assuredly be noticed postopera-
tively. If a postoperative asymmetry exists, this
can be addressed with local anesthesia as an out-
patient. Most patients are initially counseled to
avoid intervention for at least 12 months after
surgery. Cartilaginous irregularities may occur
on the anterior surface of the ear where carti-
laginous incisions were made. When performing
a conchal setback, careful posterior suture
placement must be performed to avoid anterior
displacement of the posterior border of the exter-
nal auditory canal.
The second most common complication is the
extrusion of one of the contouring sutures. This
may happen years after the original procedure. In
most cases, the cartilage will have recontoured
and the protruding suture can be removed with-
out consequence. Hypertrophic and keloid scar
formation in the postauricular incision can occur
and will more than likely require excision and
scar repair, but should initially be treated with
intralesional steroid injections.
Postoperative hematoma can develop and nec-
essitate evacuation. If left untreated, the likelihood
a
b
Fig. 18.13 ( a , b ) Correction of the enlarged attached
lobule is by either stellate or pie-shaped excision and is
offset at the inferior margin of the lobule to prevent a
circumferential scar and contracture between the anterior
and posterior surface ( red line anterior incision, blue line
posterior incision)

182
D.J. Archibald and E.H. Farrior
of developing a wound infection is increased and
this may lead to perichondritis and the possible
loss of the affected ear.
Conclusions
The graduated technique for otoplasty incor-
porates the reduction of conchal depth and
recreating the antihelix. The most consistent
combination of surgical techniques is reduc-
ing conchal depth through conchal reduction
and recreating the antihelix with scoring in the
antihelical fossa on the posterior surface of the
ear, followed by the placement of vertical mat-
tress sutures from the scaphoid fossa to
approximate the lateral conchal bowl and
medial antihelix.
Modi fi cations of lobular size, position, and
attachment may be performed as stand-alone
procedures or as adjunct to facial rejuvenation
or otoplasty for the protruding ear. Their use
in facial rejuvenation patients can sometimes
be essential to overall facial harmony. Ignoring
an enlarged earlobe at the time of a facelift
will create an inconsistent appearance postop-
eratively. These procedures are a safe and
simple approach to enhancing outcomes from
otoplasty and rhytidectomy, as well as simply
reducing an enlarged lobule.
References
1. Richards SD, Jebreel A, Capper R. Otoplasty: a review
of
the
surgical
techniques.
Clin
Otolaryngol.
2005;30(1):2–8.
2. Hauben DJ. Sushruta Samhita (Sushruta’a collection)
(800–600 B.C.?). Pioneers of plastic surgery. Acta Chir
Plast. 1984;26(2):65–8.
3. Tanzer RC, Converse JM, Brent B. Deformities of
the auricle. In: Converse JM, editor. Reconstructive
plastic surgery. Philadelphia: WB Saunders Co.;
1977.
4. Ely E. An operation for the prominence of the auricles.
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5. Keen WW. New method of operating for relief of
deformity from prominent ears. Ann Surg. 1890;11(1):
49–51.
6. Luckett WH. A new operation for prominent ears
based on the anatomy of the deformity. Surg Gynecol
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7. Becker OJ. Surgical correction of the abnormally pro-
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8. Converse J, Nigro A, Wilson FA. A technique for sur-
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1955;15:411.
9. Davis JS, Kitlowski EA. Abnormal prominence of the
ears: a method of readjustment surgery. Surgery.
1937;2:835–47.
10. Farrior RT. A method of otoplasty; normal contour of
the antihelix and scaphoid fossa. AMA Arch
Otolaryngol. 1959;69(4):400–8.
11. Gibson T, Davis WB. The distortion of autogenous
cartilage grafts, its cause and prevention. Br J Plast
Surg. 1958;10:257–74.
12. Stenstrom SJ. A natural technique for correction of
congenital ear deformities. Br J Plast Surg.
1963;99:562.
13. Kaye BL. A simpli fi ed method for correcting the
prominent ear. Plast Reconstr Surg. 1967;40(1):44–8.
14. Mustarde JC. The correction of prominent ears 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. Rogers BO. Microtic, lop, cup and protruding ears:
four directly inheritable deformities? Plast Reconstr
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17. Weerda H. Classi fi cation of congenital deformities of
the auricle. Facial Plast Surg. 1988;5(5):385–8.
18. Potter EL. A hereditary ear malformation transmitted
through fi ve generations. J Hered. 1937;28:255–8.
19. Bardach J. Congenital ear deformities. Surgery for
congenital and acquired malformations of the auricle.
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CJ, Schuler DE, editors. Otolaryngology-head and
neck surgery. St. Louis: Mosby; 1986.
20. Nachlas NE, Duncan D, Trail M. Otoplasty. Arch
Otolaryngol. 1970;91(1):44–9.
21. Farrior RT. Modi fi ed cartilage incisions in otoplasty.
Facial Plast Surg. 1985;2(2):109–18.
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Plast Surg Clin North Am. 2006;14(2):79–87.
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183
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_19, © Springer-Verlag Berlin Heidelberg 2013
19
Introduction
The ear pinna in humans adds very little to audi-
tory function; besides helping to collect sound,
some have stated that its main purpose is to
“appear normal” [ 1 ] . Naturally, the term “normal”
is subjective and based on what any speci fi c society
in general deems as “acceptable.” Prominent ears
are sometimes referred to as “cup ears” or “lop
ears .” These prominent ears are often portrayed in
cartoon characters depicting an oddball or a less
intelligent individual [ 1 ] . The prominent ear is a
congenital anatomic fi nding found in approxi-
mately 5 % of the population and is characterized
by deformities of various auricular structures such
as concha valga, hypertrophy of the concha,
change in the auricular-cranium angle, and
absence of antihelix modeling [ 2, 3 ] . An ear is
termed prominent if the ear projects more than
15–20 mm or more than 21–30° from the tem-
poromastoid plane of the skull. In boys, the mean
length of the ear is 55 mm at 6 years, 60 mm at
12 years, and 62 mm at 18 years; in girls, the mean
length of the ear is 54 mm, 58 mm, and 58 mm at
6, 12, and 18 years, respectively. The mean width
of the ear in boys is 34, 35, and 36 mm at 6, 12,
and 18 years while in girls, the mean width of the
era is 33, 34, and 34 mm, respectively [ 1 ] . If an
ear is 2 or more standard deviations from the mean
(2.0–2.5 for width, 3.0–3.5 for length), it is con-
sidered abnormally large (macrotia).
Children with prominent ears are often the tar-
get of abuse resulting in long-term psychological
complications [ 4– 6 ] . Studies have shown that
following corrective surgery, there is a marked
improvement in the quality of life experienced by
these individuals [ 6– 9 ] . Even with known
standards for ideal anthropomorphic measure-
ments and facial proportions, societal standards
A. M. S. Ibrahim , M.D. • S. J. Lin , M.D.
Divisions of Plastic Surgery
and Otolaryngology-Head and Neck Surgery ,
Beth Israel Deaconess Medical Center,
Harvard Medical School ,
110 Francis Street, Suite 5A , Boston , MA 02215 , USA
Division of Plastic Surgery ,
Beth Israel Deaconess Medical Center,
Harvard Medical School ,
Boston , MA , USA
e-mail: aibrahim@bidmc.harvard.edu ;
sjlin@bidmc.harvard.edu
B. S. Bauer , M.D. (*)
Pediatric Plastic Surgery , NorthShore University
HealthSystem , Northbrook , IL, USA
Department of Surgery , University of Chicago, Pritzker
School of Medicine , Chicago , IL, USA
Section of Pediatric Plastic Surgery,
Division of Plastic and Reconstructive Surgery ,
NorthShore University Health System,
University of Chicago Medical School ,
501 Skokie Blvd , Northbrook , IL 60062 USA
email: bbauer@northshore.org
The Bauer Otoplasty Technique
Ahmed M. S. Ibrahim , Samuel J. Lin ,
and Bruce S. Bauer

184
A.M.S. Ibrahim et al.
continue to change. Naturally, humans under-
stand how a “normal” face should appear, and
any deviation from that (such as prominent ears)
may elicit a negative response [ 1 ] .
Many authors have contributed to the evolu-
tion of otoplasty [ 3, 10– 53 ] . In essence, a major-
ity of otoplasty procedures are effective in
reducing the prominence of the ear; however, one
approach may be better suited for a particular
problem than another, and each is characterized
by variations based on the nature or the shape of
the auricle.
History of the Procedure
Sushruta is credited with the development of the
fi rst otoplasty in ancient India in the fi fth century
BC. His otoplastic principles, slightly modi fi ed,
are still being applied nearly two millenniums
later. Johann Friedrich Dieffenbach (1794–1847)
reported the fi rst surgical approach for correction
of prominent ears which combined excision of
excess cartilage from the posterior sulcus of the
ear with suturing of the corrected pinna to the
mastoid periosteum. In 1881, Ely [ 54 ] is reported
as having performed the fi rst otoplasty in medical
literature. Ely’s technique was then expanded
upon by Hippolyte Morestin in 1903 where he
described the use of concha-mastoid (C-M)
sutures, antihelix (Mustarde) sutures, an antihelix
incision, and thinning of the posterior surface of
the cartilage. In addressing the fl at antihelix, in
1910, Luckett reported incising the cartilage and
creating a crest by joining the cut edges with mat-
tress sutures. In 1920, Harold D. Gillies was able
to reproduce the pinna by burying an external-ear
support framework constructed with autologous
rib cartilage under the skin of the mastoid region
followed by separation of the reconstructed pinna
from the skin of the mastoid area using a cervical
fl ap. GW Pierce in 1930 was able to weaken the
line of the crest of the antihelix and hence facili-
tate formation of the fold by scoring the posterior
surface of the cartilage. In 1958, Gibson showed
that disrupting a balanced cross section of costal
cartilage could cause warping distal to the site of
disruption. While working with Pierce, Stenstrom
and Heftner [ 55 ] noted that cartilage would curl
away from a scored surface, and therefore, ante-
rior scoring replaced posterior scoring of the
antihelix. A tubelike crest was formed by making
parallel cartilage incisions, and mattress sutures
were later employed to create the fold of the anti-
helix [ 56– 58 ] . To reduce the deep concha, Furnas
[ 59 ] expanded on Morestin’s original C-M
sutures; this technique was later modi fi ed by
Gault et al. [ 60 ] and Elliott [ 33 ] .
Kaye [ 15 ] and Davis [ 61 ] later described
anterior approaches for altering the antihelix
which were recently modi fi ed by Nordzell [ 62 ]
and Erol [ 10 ] . More recently, the importance of
conchal enlargement on overall ear structure and
prominence has been emphasized. The senior
author (BSB) presents an approach in which
chondrocutaneous resection rather than being an
adjunctive procedure became the cornerstone of
otoplasty recognizing that release of the conchal
support to the antihelical body allowed gentle
reshaping of the antihelix avoiding many of the
drawbacks of prior approaches. Additionally,
with more experience, the anterior approach to
the concha allows for precise correction of more
subtle aspects of the challenging prominent ear
patient as well as a means of preventing and cor-
recting secondary deformities; this technique
may decrease the revision rate following correc-
tion of the prominent ear.
Indications
In assessing a patient for otoplasty, one needs to
consider the anatomic causes for protrusion of
the ear. Prominence is typically a result of three
variants: (1) underdevelopment of the antihelical
fold, (2) overdevelopment of the conchal bowl
and wall, and (3) a scaphoconchal angle greater
than 90°. Additionally, contributing factors may
include (1) protrusion of the lower auricular pole,
(2) prominence of the mastoid process, and (3) a
prominent-tipped upper auricular pole. Protrusion
of the auricle may also be one component of a
more complex deformity such as constricted ear,
Stahl ear (third crus), macrotia, or syndromic
facial deformity [ 63 ] .

185
19 The Bauer Otoplasty Technique
A majority of the patients who present for oto-
plasty have visibly prominent ears; however, not
all patients have a desire to change their appear-
ance. Generally, the parents of children with
prominent ears will bring them in for correction
in an effort to spare their child embarrassment
and teasing [ 64 ] . Children under the age of
5 years are rarely perceptive enough about their
appearance to feel that surgery is necessary; this
dynamic may occasionally result in dif fi culty
cooperating with postoperative care. Regardless,
ear surgery is best addressed at a younger age as
the ear becomes fi rmer, less malleable, and
calci fi ed with age. At infancy, the prominent ear
can even be addressed with nonsurgical molding.
More subtle cases of ear prominence, distortion
of ear shape, or ear asymmetry may not necessi-
tate the need for correction until a child is older
and oriented with his or her appearance.
Ultimately, a decision regarding surgery needs to
be made on a case-by-case basis.
Adults seeking otoplasty must be able to ade-
quately provide substantial reasoning for seeking a
change, demonstrate an understanding of the real-
istic expectations of a postoperative result, and
understand postoperative management. It is vital
that cases be meticulously selected especially when
the deformity is a minimal or a subtle fi nding.
Contraindications
Contraindications may exist with each patient. In
children, potential contraindications include (1) a
strong resistance by the child to undergo surgery
which may be hidden in the form of misbehavior
or becoming extremely nervous about going to the
doctor or to the hospital and (2) a history of chronic
ear infections and ear drainage that have not been
thoroughly treated. Conditions such as scalp infec-
tions or acne must also be treated well in advance
of surgery. A simple surgical wound infection can
lead to an ear-threatening chondritis.
There are various ethnic and cultural consider-
ations that the operating surgeon should take into
consideration in preoperative planning. In
Japanese culture, prominent ears denote intelli-
gence while in Celtic communities they are very
common. Most children quickly conform to the
cultural values of their adopted country.
Preoperative Preparation
A thorough history and physical examination
should be obtained. Suf fi cient time for adequate
preoperative planning is paramount. Proper
assessment of the auricular deformity is key. The
speci fi cs of the deformity are discussed, and the
procedure is described in detail; preoperative dis-
cussion includes anesthesia type and postopera-
tive routine. Possible risks such as hematoma,
chondritis, and infection are reviewed. It is impor-
tant to carefully listen to what the patient (and
parent) is expressing and attempt to adequately
answer their questions. The patient (and parent)
should express an understanding of the expecta-
tions and possible complications of the proce-
dure. Dealing with any concerns that the patient
might have in the preoperative period increases
the likelihood that a technically excellent oto-
plasty will be viewed with satisfaction and grati-
tude. It is not necessary to worry the patient, but
full disclosure dictates that patients understand
the risks and bene fi ts of otoplasty. All patients
should be told that there is a risk that a revision
may be necessary.
Anesthesia
Local Anesthesia
A potential ideal candidate for local anesthesia
without premedication is a suitably mature child
aged at least 10 years with uncomplicated promi-
nent ears. A eutectic mixture of local anesthetics
(EMLA) cream is applied to the postauricular
area 2–3 h before surgery. An oral antibiotic is
administered an hour prior to surgery. A 27- or
30-gauge needle is used to in fi ltrate the retroau-
ricular and posterior surfaces of the ear with buff-
ered 1 % lidocaine (Xylocaine) with epinephrine
1:100,000. Bupivacaine (0.25 %) with epineph-
rine 1:100,000 is then administered, and lido-
caine or bupivacaine (Marcaine) is reinforced

186
A.M.S. Ibrahim et al.
during the procedure. All throughout the proce-
dure, a parent may read a favorite story or play a
favorite audio tape for the child.
General Anesthesia
General anesthesia is recommended in younger
patients. Following induction, an endotracheal
tube is placed in the midline and secured with a
circum-mandibular or transalveolar suture of 0
or #1 Prolene. The table is then turned 180° with
the anesthesiologist at the foot of the table.
A broad-spectrum antibiotic is then adminis-
tered intravenously. After all markings have
been placed, the anterior and posterior surfaces
of both ears are injected with 0.5 % lidocaine
with 1:200,000 epinephrine solution. The patient
is also injected with 0.25 % bupivacaine to pro-
vide bilateral great auricular nerve blocks for
postoperative analgesia.
Position/Markings
The patient is placed in the supine position,
prepped and draped in the usual sterile fashion
with both ears and the retroauricular skin exposed.
Skin prepping solution is used to sterilize the face
and both ears. These areas are then draped with a
standard head drape with both ears exposed.
A Tegaderm or other clear sterile drape is used to
secure any stray hairs. Surgical soap is then used
to shampoo the hair, and Betadine is applied to
prep the face, neck, ears, and adjacent ventilating
tube. Mastisol adhesive solution is applied to the
face, and a series of 1-in. Steri-Strips are placed
to hold the head towels securely to the face and
neck. Steri-Strips are also placed over the eyes.
A body sheet is used that is made of clear plastic
and thereby provides visibility of the entire venti-
lating system. The patient’s head may be placed
on a doughnut.
The incision is marked along the retroauricu-
lar sulcus and less frequently on the posterior sur-
face of the concha if a conchal excision is planned.
If a lobular setback is planned, a triangular area
of the skin is marked for incision at the most
medial area of retrolobular skin. The intended
region of antihelical fold creation is marked.
Technique
The procedure begins with incisional injection of
local vasoconstrictive/anesthetic agents. This
local solution not only helps with hemostasis but
also aids in soft tissue dissection from cartilage.
In addition, bipolar cautery is used throughout
the procedure. The incision is made with a #15
blade on the anterior surface of the concha; it is
placed at the junction of the fl oor of the concha
and the posterior conchal wall. It starts in the
cymba concha and continues along the cavum
concha to a point below the antitragus but does
not extend as far as the external auditory meatus.
It is important to avoid placing the incision too
high in the concha which will reduce control of
the antihelical fold leading to dis fi gurement of
the antihelix. The incision continues through both
the anterior skin and conchal cartilage and is
stopped just before the posterior conchal skin.
Using sharp dissection in the loose areolar plane
behind the concha, the incision is then deepened
through the subcutaneous tissues to expose soft
tissue and skin from the posterior surface of the
conchal bowl. A crescent-shaped chondrocutane-
ous segment is then excised. To ensure a tension-
free closure, it is fundamental that more cartilage
than skin be resected especially along the inferior
concha deep to the antitragus. The amount of car-
tilage and skin resection needed to create an aes-
thetically pleasing position for the ear and to
address conchal hypertrophy can be accurately
assessed with by applying fi nger pressure to pro-
duce a gentle setback of the antihelix. Three or
four interrupted 5-0 clear nylons are used to
suture the edges of the conchal cartilage. The
most inferior suture should be placed at the
junction of cavum concha and antitragus to aid
the cartilage in supporting the lobule. A slight
overlapping of cartilage (antitragal segment over
conchal segment) will cause the lobule to tip
posteriorly.
Next, using a combination of 5-0 chromic gut
with horizontal mattress sutures and a running

187
19 The Bauer Otoplasty Technique
6-0 mild chromic gut, the anterior skin is closed.
Initially, the ear and helical rim may appear
prominent; this is easily corrected by gently
applying pressure to the antihelix which will
cause relaxation of the tension required in order
to bend the antihelix. To correct prominence of
the lobule and the effaced antihelix, a dumbbell-
shaped ellipse of skin with the inferior end wid-
ened to a diamond shape (positioned with its
maximal width at the point of maximal lobule
prominence) is excised down to the perichon-
drium. This maneuver will help to correct lower
pole prominence by providing access to the pos-
terior surface of the scapha and helical sulcus for
the placement of sutures. When exposing the
posterior surface of the conchal bowl and scapha,
it is important to preserve the perichondrium to
reduce the chances of subsequent sutures pulling
through the cartilage. Care is also taken to prop-
erly identify and free the helical tail. Cartilage of
the tail from the skin overlying its anterior sur-
face must not be freed as this may diminish the
effectiveness of correcting prominence of the
lobule. Finally, dissection proceeds onto the mas-
toid surface, where soft tissues are freed ensuring
that sutures placed later can be securely fastened
into the mastoid fascia.
Before proceeding with the placement of
sutures to further correct the ear prominence, it
is important to assess the spring or resistance of
the cartilage to further shaping by putting pres-
sure on the helical rim and antihelix. Even a lim-
ited amount of conchal resection results in
lessening of this spring and increased ease of
shaping the antihelix. At this stage, any addi-
tional sutures needed to complete an accurate
closure of the conchal defect are placed. To cor-
rect prominence of the upper and middle thirds
of the ear, two or three 4-0 clear nylon sutures
are placed from the scaphal cartilage and helical
sulcus cartilage to the mastoid fascia. The most
superior suture is placed from the region of the
triangular fossa to the temporal fascia. To ensure
proper placement of these sutures, a straight
Keith needle is used to apply pressure to the pre-
ferred points on the anterior surface of the ear.
The point of the needle is then passed through
the selected spot and visualized on the posterior
surface of the cartilage. A nylon suture is then
placed at each speci fi c point, and the needle is
withdrawn; sutures are passed through either the
temporal or mastoid fascia. When all the sutures
are placed, they are carefully tied beginning with
the scaphal suture (one should be meticulous of
the relationship of the helical rim and the
reshaped antihelix so that the helical rim remains
visible from the frontal view). It is imperative
that the sutures be tied at the proper tension to
create a smooth antihelical fold. If there is a need
to approximate the helical root and head, an
additional suture is placed from the triangular
fossa to the temporal fascia. In adult patients, the
cartilage of the antihelix may be less fl exible,
and therefore, extra sutures may be needed to
shape and round the antihelix (placed prior to the
ones described previously to preshape the anti-
helix before further correcting the prominence).
These sutures are placed from the helical sulcus
to the cut edge of concha at right angles to the
antihelix and from the scapha to the cut edge of
the concha and deep to the inferior crus.
Following correction of the upper and mid
auricular prominence, position of the lobule is
addressed. Lobule position is determined by the
closure of the squid-shaped ellipse using 5-0
chromic gut. The optimum shape, contour, and
projection of the lobule is obtained by altering
the initial position of the suture; the remaining
closure is continued with a running 5-0 chromic
suture. Correcting the more prominent side fi rst
provides a symmetrical setback; guiding the
placement of sutures de fi nes the antihelix and
lobule prominence.
Correction of irregularities of the helical rim
in the area of Darwin’s tubercle and reduction of
prominence of the antitragus are the most com-
mon adjunctive procedures. A small incision is
created parallel to the border of the prominence;
excess cartilage is exposed and resected. This is
then closed with an interrupted and running 6–0
mild chromic suture. Enlargement of the lobule
can be addressed by a large resection at the junc-
tion of the lobule and middle third where the
splice can be stair stepped at the splice point or
small wedge resection within the lobule itself for
smaller degrees of lobule enlargement.

188
A.M.S. Ibrahim et al.
Postoperative Period
The ends of the subcuticular sutures are taped
with Steri-Strips. Petroleum jelly gauze is molded
into the lateral contours of the ear and in the pos-
tauricular sulcus. The ears are covered with soft
gauze pads. Kerlix strips are placed over each
eye, and the head is wrapped with a roll of Kerlix
gauze. Each of the vertical gauze strips is tied,
compressing the head wrap to clear the visual
fi elds. To minimize shifting, the wrap is taped to
the skin at several points.
Follow-Up
Dressings are removed on postoperative day one
to check for shifts in position, pressure points,
and hematomas. Skin sutures are removed on
postoperative day 5–7 (the subcuticular suture in
the postauricular sulcus is removed on postopera-
tive day 10 or later). Patients are asked to look in
the mirror daily to familiarize themselves with
the features of their newly positioned ears and to
report any changes that are noticed.
Discussion
A thorough understanding of the anatomy of the
prominent ear and meticulous analysis of the
complex deformity that comprises the prominent
ear are required to perform the best possible oto-
plasty procedure [ 65, 66 ] . The ultimate goal is to
achieve an aesthetically pleasing result that con-
forms to the patient’s appearance in accordance
with the patient’s body image [ 1 ] .
The prominent ear has numerous etiologies,
but the common denominator has always been
hypertrophy of the concha [ 67 ] . Understanding
this fact is imperative; even with minor resection
and resuturing of the cut concha, posterior place-
ment of sutures will cause the antihelix to yield
with a soft, smooth, rounded shape unmarred by
any sharp irregular surfaces [ 67 ] .
Attainment of perfect symmetry is highly
unlikely in every single patient undergoing
this procedure; however, the application of
adjunctive procedures (see technique) at the ini-
tial procedure has helped to evade this concern.
To date, all revision procedures, even in younger
children, have been accomplished with a single
procedure under local anesthesia in the of fi ce
setting [ 1 ] .
In the senior author’s (BSB) experience with
this technique, there have been no major or minor
complications. In a series of 292 patients, Baker
and Converse [ 32 ] reported a 3 % incidence of
telephone deformity, 1.2 % localized cellulitis,
0.7 % chondritis, and 0.8 % hematoma. Keloids
developed in 11 % of black patients (one bilat-
eral) and 2.1 % of white patients. Despite other
authors criticizing this approach as a potential
source of keloid formation [ 39, 68, 69 ] , Bauer
has not reported keloids in any cases including a
larger series of conchal donor sites for composite
grafts used for ear reconstruction [ 70 ] . Limandjaja
et al. [ 71 ] found that the incidence of early com-
plications (hematoma, bleeding, infection, skin
necrosis, and wound dehiscence) associated with
otoplasty was low (0–8.4 %) while late complica-
tions (suture extrusion, scarring, hypersensitivity,
asymmetry) occurred more frequently (up to
47.3 % of the time). Occasionally, patients
develop tenderness in the postauricular area
which decreases over time.
Recurrence of prominence of the ear is quite
rare. Should that scenario present itself, a repeat
procedure is selected, taking into account the
causes of the relapse. The patient is asked to
wear an elastic headband in the postoperative
period for anywhere from 6 to 12 months. Bauer
has reported a higher incidence of recurrence in
younger children with a constriction component
to the prominence. To avoid this occurrence, an
additional scaphal suture to the cut edge of the
concha is placed to resist the forward spring of
the upper pole of the ear. Following this
approach, no recurrence has been noted [ 65 ] . It
is also important to note that it is not uncom-
mon for an otoplasty that appears pleasing at
the end of a surgery to curl, buckle, or shift as a
result of external pressures such as gravitational
pressure when sleeping. These phenomena can
easily be dealt with in the early postoperative
period using molding material. They key to a

189
19 The Bauer Otoplasty Technique
favorable response is early recognition and
rapid treatment.
To achieve the best outcomes, it is important
to remember that correct analysis of each ear
deformity is the most important step. A failure
to appreciate all the elements causing distortion
of ear position will result in a poor aesthetic out-
come. One must remember to avoid placing the
incision for conchal resection too high in the
concha, assure a tension-free closure of the con-
cha, stay away from excessive resection of skin
or cartilage, and attempt to preserve the per-
ichondrium on both surfaces of the cartilage.
Additionally, when designing the dumbbell-
shaped excision, it is imperative that the skin
excision be tapered at its midportion to prevent
the development of postoperative telephone ear
deformity. This approach has been consistent
and durable and can serve as viable option when
considering otoplasty for the correction of
prominent ears.
Conclusions
Various otoplasty techniques exist that have
been modi fi ed over time. Many of these proce-
dures are useful in addressing prominence of
the ear. Depending on the shape and nature of
the auricle in addition to patient expectations,
one approach may be better suited than another.
A myriad of techniques exist for otoplasty sug-
gesting that there is not one de fi nitive approach,
and each surgery must be tailored to the indi-
vidual patient. The Bauer Otoplasty Technique
offers an alternative option and can be applied
to a multitude of ear deformities requiring
reconstruction. To yield the best possible aes-
thetic outcomes not only is a proper under-
standing of the normal anatomy essential, it is
paramount that the operating surgeon compre-
hend the principles of this procedure and have
an appreciation of the minor details that this
approach entails (Figs. 19.1 , 19.2 , 19.3 , 19.4 ,
19.5 , 19.6 , 19.7 , and 19.8 ).
Fig. 19.1 Preoperative image of patient with prominent ears (left). Postoperative image following correction (right)

190
A.M.S. Ibrahim et al.
Fig. 19.2 Intraoperative
view of the patient’s left ear
Fig. 19.3 Beginning of
cartilage dissection using an
anterior approach

191
19 The Bauer Otoplasty Technique
Fig. 19.4 Dissection of
concha by an anterior
approach
Fig. 19.5 Planned resection
of a chondrocutaneous
section of the concha from an
anterior approach

192
A.M.S. Ibrahim et al.
Fig. 19.6 Dissection of the
chondrocutaneous portion of
the concha
Fig. 19.7 Resection of the
chondrocutaneous portion of
the concha

193
19 The Bauer Otoplasty Technique
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19 The Bauer Otoplasty Technique
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197
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_20, © Springer-Verlag Berlin Heidelberg 2013
20
Introduction
Prominent ears are the most common congenital
deformity in the head and neck region, with an
incidence described for Caucasians of about 5 %
[ 4 ] . Prominent ears are usually not associated with
other abnormalities or syndromes, but may be con-
sidered an aesthetic handicap [ 45 ] . The forces
governing the development of this deformity are
unknown, and only 8 % of patients with this condi-
tion have some family history [ 3 ] . In approxi-
mately 61 % of children with this condition, the
deformity can be diagnosed at birth [ 42 ] , and there
is no apparent sex predilection. Since Luckett’s
original description [ 22 ] , a number of anatomical
features associated with prominent ears have been
described. These have been summarized as (1)
absence of an adequate antihelical fold; (2) pres-
ence of a large, deep conchal bowl; (3) inadequate
de fi nition of the helical rim; and (4) abnormalities
of the lobule [ 20 ] . Patients usually present with a
combination of all these features.
Although Sushruta and Tagliacozzi described
otoplasty techniques, the modern era of otoplasty
can be traced to 1848, when the term “otoplastick”
was fi rst used by Dieffenbach in his description
of the repair of microtia [ 12 ] . In 1881, Ely
removed a complete-thickness strip of the auricle
from the cephaloauricular angle, but this left a
visible scar in front of and behind the ear [ 14 ] .
Keen modi fi ed the same technique by leaving
the anterior skin bridge intact to prevent a notice-
able scar [ 19 ] . After the turn of the century, many
attempts were made to correct the protruding
ear by using various antihelical and conchal carti-
lage excisions through a postauricular approach
[ 5, 6, 11, 20, 26, 28, 34, 46 ] . Later, in the late 1940s,
attempts were made to weaken the cartilage by
mechanically thinning or placing partial-thickness
incisions in it. Initially, parallel incisions were made
on the posterior surface of the auricle with or with-
out cartilage excision, allowing the antihelical fold
to form [ 24, 32 ] . Abrasive brushes were then used
to weaken the antihelix [ 39 ] . In the 1960s, Mustarde
used permanent retention mattress sutures in a com-
bined technique with a fusiform skin excision to
recreate the antihelical fold [ 29 ] . The simplicity and
good results obtained have gained this procedure
widespread application, especially with regard to
the delicate form of the antihelix. In 1963, Stenstrom
[ 40 ] and Chongchet [ 10 ] scored the anterior part of
the antihelix through a posterior incision, allowing
the elastic forces to bend the cartilage along the
antihelical fold, a maneuver that offers a more nor-
mal, rounded shape. In 1968, Furnas [ 17 ] described
a procedure based on Miller’s technique (further
J. A. Friedland , M.D., FACS (*)
Clinical Professor of Surgery (Plastic) ,
University of Arizona Medical School ,
Phoenix, Arizona, AZ , USA
Associate Professor of Plastic Surgery ,
Mayo Medical School ,
Rochester , Minnesota , USA
e-mail: jaf@jackafriedlandmd.com
R. S. Maricevich , M.D.
Division of Plastic Surgery, Department of Surgery ,
Mayo Clinic , 200 First Street SW ,
Rochester , MN 55901 , USA
e-mail: maricevich.renata@mayo.edu
Use of Multiple Techniques
for Otoplasty (Stenstrom,
Mustarde, Furnas)
Jack A. Friedland and Renata Souza Maricevich

198
J.A. Friedland and R.S. Maricevich
developed by Owens and Delgado [ 30 ] ), which
consisted of securing the concha to the mastoid
periosteum posteriorly, thereby decreasing the con-
cha-scaphoid angle.
In 1981, Pitanguy described the island tech-
nique, which consisted of dissecting a cartilagi-
nous island to reconstruct the antihelix and form
the triangular fossa, in addition to correcting the
conchascaphal angle. This technique is not indi-
cated for patients with a normal antihelix [ 23 ] .
Anterior and posterior approaches have been
described. Incisionless techniques were initially
reported in 1995 by Fritsch, and multiple ver-
sions have been created since then [ 15, 16 ] .
Ragad and Leclere published the use of laser-
assisted cartilage reshaping with and without
additional surgical intervention [ 21, 33 ] . There is
lack of long-term results for these techniques.
Early splinting of the newborn ear may correct a
degree of prominence and may obviate the need for
surgery in later life [ 41 ] , but most patients will
require an operation. And when it becomes neces-
sary, the surgeon should be able to select the best
features of the most useful techniques to create the
ideal procedure for correction of the deformity.
Overall, more than 200 techniques have been
described for the correction of prominent ears [ 1, 2,
7– 9, 13, 18, 25, 27, 31, 35– 38, 43, 44 ] , and the pro-
cedures have become increasingly complex because
of the aesthetic requirements of patients and the
efforts by surgeons to achieve the fi ne and harmo-
nious shape typical of the normal human auricle.
The goal of surgery for prominent ears is to
produce symmetrical, natural-looking ears, with
no obvious signs of surgery having been per-
formed. Therefore, a combination technique of
the most bene fi cial features of three previously
described techniques, without cartilage resection,
which has been tested over time and which pro-
vides excellent cosmetic results, a high level of
patient satisfaction, and minimal complications,
is presented in this chapter [ 47 ] .
Preoperative Evaluation
First and foremost, patients should be asked to
describe the bothersome aspects of their deformi-
ties, their motivation to have the deformities
corrected, and their expectations for the procedure.
The abnormalities and asymmetries have to be dis-
cussed with the patient and his or her family.
A complete preoperative work-up should
include assessment of medical, personal, and
family histories, including a tendency for bleed-
ing and any previous occurrences of hypertrophic
scars or keloids.
Preoperative photographic documentation con-
sists of frontal, posterior, right and left lateral, and
oblique views. No speci fi c measurements are taken.
Technique
Local anesthesia with 1 % lidocaine and 1:100,000
epinephrine and intravenous sedation is used in
most cases, but pediatric procedures are always
performed under general anesthesia.
The surgical technique (Figs. 20.1 , 20.2 , 20.3 ,
20.4 , 20.5 , 20.6 , 20.7 , 20.8 , and 20.9 ) includes
excision of a small ellipse of posterior auricular
skin, scoring of the antihelical cartilage on its
anterior surface in a subcutaneous position (as
described by Stenstrom), suturing to recreate the
fold of the antihelix (in the fashion of Mustarde),
and concha-mastoid suturing applied to the back
of the ear to decrease the concha-scaphoid angle
(in the manner of Furnas).
Postoperative dressings consist of antibiotic
ointment and Xeroform gauze (Sherwood
Medical, St. Louis, MO) placed over the postau-
ricular incisions, saline-soaked cotton placed in
all anterior crevices of the ears, gauze fl uffs cov-
ered
by
circumferential
Kerlix
(Kendall
Healthcare Products, Mans fi eld, MA), and an
elastic bandage held in place by a woven net
dressing. Drains are not used.
Results and Complications
The combined technique presented is safe, easy
to perform, and has few complications. Excellent
symmetry, as perceived both by the surgeon and
the patient, is achieved resulting in high patient
satisfaction (Fig. 20.10 ).
Undercorrection that requires intervention is
rare with this combination of techniques, noted in

199
20 Use of Multiple Techniques for Otoplasty (Stenstrom, Mustarde, Furnas)
less than 5 % of patients [ 47 ] . A few patients may
experience a Mustarde suture extrusion, which
can be easily dealt with under local anesthetic in
an outpatient setting in the of fi ce.
The authors have not experienced any cases of
hemorrhage, hematoma formation, skin break-
down, hypoesthesia, or perichondritis using this
technique. In case of loss of initial correction,
which has not been observed with this previously
published technique, revision operation is relatively
easy to perform on intact cartilage (Fig. 20.11 ).
There are usually no cases of postoperative
lobule prominence since any lobule deformity is
addressed during the initial operation, with a
wedge excision being performed on the posterior
surface, if necessary.
Fig. 20.1 Preoperatively,
there is unfurling of the
antihelix and increase of
concha-scaphoid angle
Fig. 20.2 A small ellipse of skin is usually excised from the back of the ear to assist with exposure and closure