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

201
20 Use of Multiple Techniques for Otoplasty (Stenstrom, Mustarde, Furnas)
Fig. 20.5 A Dingman
otoabrader is inserted
posteriorly to subcutaneously
abrade the anterior aspect of
the antihelical cartilage
(Stenstrom)

202
J.A. Friedland and R.S. Maricevich
Fig. 20.6 A 27-gauge
needle is inserted anteriorly
on each side of the antihelix
to assist in placement of 4-0
clear nylon mono fi lament
horizontal mattress sutures
tied posteriorly to create the
fold of the antihelix

203
20 Use of Multiple Techniques for Otoplasty (Stenstrom, Mustarde, Furnas)
Fig. 20.7 At least three
horizontal mattresses sutures
(Mustarde) are placed to
create the antihelical fold

204
J.A. Friedland and R.S. Maricevich
Fig. 20.8 One or two
concha-mastoid sutures are
placed (Furnas) to decrease
the concha-scaphoid angle

205
20 Use of Multiple Techniques for Otoplasty (Stenstrom, Mustarde, Furnas)
Conclusions
Controlling the degree and position of the fold
of the antihelix is a basic requisite for good
results. This is the reason why cartilage-
sparing techniques offer the surgeon the abil-
ity to achieve this goal without disrupting the
structural integrity of the ear. Cutting tech-
niques irreversibly subject the antihelix to
unpredictable distortion by wound contraction
forces, and for this reason no conchal resec-
tions are performed.
The combination of techniques allows for a
more delicate approach, and the aesthetic
improvement becomes evident even in the
immediate postoperative period. The fi nal out-
come of this combined technique is reproduc-
ible and long-lasting. It can be considered a
standard technique to be used for treating
patients of any age and with any magnitude of
defect.
Fig. 20.9 After sutures are tied, the skin incision is
closed with an intracuticular 4.0 Monocryl suture
Fig. 20.10 ( Left ) Preoperative. ( Right ) Postoperative using combined technique

206
J.A. Friedland and R.S. Maricevich
Fig. 20.10 (continued)

207
20 Use of Multiple Techniques for Otoplasty (Stenstrom, Mustarde, Furnas)
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209
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_21, © Springer-Verlag Berlin Heidelberg 2013
21
Introduction
Dieffenbach [ 1 ] is credited with the fi rst oto-
plasty report (1845) describing the correction of
a posttraumatic protruding ear by simple post-
auricular sulcus skin excision, with suture
af fi xing the auricle to the mastoid periosteum.
However, the fi rst report of a purely aesthetic
otoplasty is accredited to Ely (1881) [ 2 ] , who
performed a full-thickness vertical wedge cres-
cent excision of the antihelix for the correction
of a protruding ear.
Since these fi rst reports, throughout the 20th
century, there has been an increasing volume of
publications in the plastic surgery and otolaryn-
gology literature on different operative techniques
for the correction of ear deformities, each of them
with their own advantages and limits.
This chapter describes the combined oto-
plasty technique of the senior author (MS), dem-
onstrating the reliability and fl exibility of this
technique in treating a wide variety of deformi-
ties, from simple protruding ears to those with
accompanying moderate degrees of constriction,
lobule protrusion, and deformities of the helical
rim [ 3 ] . Besides the description of the surgical
technique, a comprehensive analysis of the rele-
vant applied external ear anatomy along with the
associated pathological conditions and a brief
summary of basic otoplasty techniques is
provided.
Relevant Applied Anatomy
of the External Ear
Embryology
Embryologically, the external ear develops from
six mesenchymal prominences that align them-
selves superiorly on the fi rst (mandibular) bra-
chial arch and inferiorly on the second (hyoid)
brachial arch. The auricular portion of the man-
dibular arch is responsible for the development
of the tragus and the helical crus. The auricular
portion of the hyoid arch, the main contributor to
ear formation. It leads to the development of the
helix, scapha, antihelix, concha, antitragus, and
lobule. The superiorly located mandibular arch
slides inferiorly and the inferiorly located hyoid
arch moves superiorly, thus de fi ning the ear
draft.
M. Salgarello , M.D. (*)
Department of Plastic and Reconstructive Surgery ,
Università Cattolica del “Sacro Cuore” ,
Largo A. Gemelli 8, 00168 Rome , Italy
Department of Plastic and Reconstructive Surgery ,
Università Cattolica del “Sacro Cuore” – University
Hospital “A. Gemelli” ,
Largo A. Gemelli 8, 00168 Rome , Italy
e-mail: m.salgarello@mclink.it
G. Visconti , M.D.
Department of Plastic and Reconstructive Surgery ,
Università Cattolica del “Sacro Cuore” – University
Hospital “A. Gemelli” ,
Largo A. Gemelli 8, 00168 Rome , Italy
e-mail: joevisconti@hotmail.com
Combined Technique
in Aesthetic Otoplasty
Marzia Salgarello and Giuseppe Visconti

210
M. Salgarello and G. Visconti
The ear normally develops between the fi fth
and the ninth weeks of gestation. At the age of
3 years, the ear is approximately 85 % of its adult
size. The ear width becomes mature at 6 years in
females and at 7 years in males; the ear length
reaches its mature size at 12 years in females and
at 13 years in males. As time goes on, the mature
ear acquires the features of the aged ear, which is
characterized by a stiffer and more calci fi ed car-
tilage along with the sequelae of skin aging and
elastosis, such as lobule ptosis.
Applied Anatomy of the External Ear
The Chondrocutaneous Portion
The external ears are paired organs mounted on
the bony base of the underlying temporal bone.
These organs are a complex chondrocutaneous
composite and are endowed with many intricate
involutions, protuberances, and folds. These
complex and unique structures serve to capture
and guide sounds through the external auditory
canal since humans have lost the ability to move
the ear appropriately to direct different sounds.
With the presence of intrinsic and extrinsic auric-
ular muscles, human ears are relatively fi xed
compared with the mobile ears of many animals.
The surface anatomy of the external ear is
de fi ned by a complex chondrocutaneous structure
in the superior and middle third and a dermoadipose
appendix in the inferior third, forming the lobule.
The chondrocutaneous structure is de fi ned by
fi ve main components: the helix, antihelix,
scapha, concha, and tragus. Other de fi ning
elements are Darwin’s tubercle, the antitragus,
and the intertragic incisure (Fig. 21.1 ). The fi ne
relationships among all these elements de fi ne the
“normal” ear.
The Auricle Muscles
Besides the chondrocutaneous structure, there
are intrinsic and extrinsic auricle muscles that
stabilize the auricle and allow limited ear move-
ment of no functional signi fi cance.
The intrinsic muscles are thus named because
their origin and insertions are within the auricle
itself. The ones located on the anterior surface of
the ear are the tragus, antitragus, and major and
Superior crus of the antihelix
Inferior crus of the antihelix
Helix
Scapha
Antihelix
Helical tail
Earlobe
Antitragus
Isthmus
Incisura
intertragica
Tragus
Cavum concha
Cymba concha
Fossa
triangularis
Fig. 21.1 The cartilaginous
ear framework is shown with
all its involutions, protuber-
ances, and folds. In yellow ,
the fi brofatty earlobe

211
21 Combined Technique in Aesthetic Otoplasty
minor helix. The intrinsic muscles on the poste-
rior surface of the ear are the intrinsic transverse
and oblique muscles.
The two extrinsic muscles have their origins
outside the auricle, and they insert on it. These
muscles are thin and normally hypo- or atrophic
and include the following:
1. The auricular anterosuperior muscle, which is
made of two portions: the anterior part, which
is triangular-shaped, originates from the galea
of the temporal region in front of the auricle
and inserts on the helix and the concha; and
the superior part, a triangular-shaped muscle
with the base facing upward, originating from
the galea of the temporal region superior to the
auricle and inserting into the cymba and supe-
rior margin of the helix.
2. The auricular posterior muscle originates from
the mastoid region and inserts into the concha.
Because of their origins from the galea
aponeurotica, both the extrinsic auricular muscles
are agonistic with the fronto-occipitalis muscle.
The minimal auricular movements, when pres-
ent, are normally associated mainly with the con-
comitant action of the fronto-occipitalis muscle
rather than with a very rare proper function.
Vessels and Nerves
The vascular supply to the auricle comes from
branches of the posterior auricular artery and
super fi cial temporal artery. The anterior and pos-
terior branches of the great auricular nerve and
the auriculotemporal nerve are responsible for
the innervation of the mandibular brachial arch
structures (tragus and helical crus) and of the
hyoid arch (the rest of the ear), respectively.
The Biomechanics of Ear Cartilage
and Its Surgical Implications
The cartilage tissue exists in various forms and
performs a range of functions in the human body.
Cartilage is composed of the extracellular matrix
enriched by two main types of macromolecules,
glycosaminoglycans and proteoglycans. These
are able to interact with elastic and collagen
fi bers. Depending on the different compositions
of these macromolecules, elastic and collagen
fi bers, cartilages are classi fi ed into three main
types as follows:
1. Articular cartilage, also called hyaline carti-
lage . The most common cartilage type in the
human body, it is mainly composed of collagen
type II fi bers. This tissue is present in freely
moveable synovial joints (dysarthroses), with
its main function being as a binder surface
between bones that permits smooth motion
between adjoining bony segments.
2. Fibrocartilage .
This
is
present
in
fi brocartilaginous joints with limited move-
ment, such as the intervertebral disc and
pubic symphysis, with a main function of
bearing between-bone surfaces. The fea-
tures of this tissue are being between the
hyaline cartilage and the dense connective
tissue, being mainly composed of collagen
type I fi bers. This cartilage is always asso-
ciated with the dense connective tissue,
from which it is sometimes histologically
indistinguishable.
3. Elastic cartilage . This is present in structures
such as the ear, Eustachian tube, epiglottis,
nasal septum and larynx. Its main function is
to maintain a de fi ned shape. Its structure is
similar to that of hyaline cartilage, but in addi-
tion to the other components, its matrix has
elastic fi bers and interconnecting sheets of
elastic material (Fig. 21.2 ).
The peculiar structure of the elastic cartilage
is responsible for maintaining the shape when a
structure undergoes a static and dynamic defor-
mation. When a force is applied on the external
ear, it keeps this position as long as the external
forces are applied. Once these forces are removed,
the elastic properties allow the structure to return
to its natural shape. Even though this behavior is
characteristic of any elastic structure that ideally
follows Hooke’s law, in the plastic surgery and
otolaryngology literature, this phenomenon is
known as the “intrinsic memory of cartilaginous
elasticity.”
According to Hooke’s law, an ideal elastic
structure follows the rule

212
M. Salgarello and G. Visconti


where the elastic force ( F ) elicited by an elastic
tissue with an elastic constant ( k ) depends on the
amount of tissue deformation ( D s ) impressed.
This elastic model is valid when the elastic
structure integrity is maintained. Applying any
kind of cartilage breaking force capable of dis-
rupting the elastic network integrity, a permanent
modi fi cation of the elastic properties occurs. The
manifestation of this phenomenon will depend
on the characteristics of the breaking force
applied.
However, the composition of human cartilage
makes it a viscoelastic- fi brous rather than an
ideal elastic structure. The biomechanical prop-
erties of viscoelastic tissue can be surgically ana-
lyzed by referring to four main physical
parameters: the breaking or bursting strength,
suture-type tearing forces, the tissue stress relax-
ation, and the tissue creep.
Regarding the biomechanics of human ear carti-
lage in otoplasty, the breaking or bursting strength
is of limited value as this is normally not an issue.
The suture-type tearing force is similar to the break-
ing strength but is more clinically relevant as it
evaluates the forces that are applied on a speci fi c
suture material to pull the suture out of the sample.
The tissue stress relaxation is the tension cre-
ated with a constant stretch. It is measured by
applying a constant force to the tissues for a
period of time to obtain a certain amount of tissue
distortion (deformation or elongation). During
this time, the decrease in tissue tension measured
de fi ned the stress relaxation. This method serves
to evaluate the elasticity of a tissue. If the tissue
is not elastic and completely viscous, it will relax
(distort), and the decrease in tissue tension will
be high. If the tissue is totally elastic, it will not
relax but will be distorted and lower the decrease
in tissue tension measured. This occurs until a
critical point (the breaking point) is reached
where the force becomes a breaking strength.
The tissue creep is de fi ned as the amount of
tissue deformation with a constant load over time.
The ear cartilage elasticity is age dependent
(Figs. 21.3 and 21.4 ).
In the newborn , till the third day after birth, the
cartilage shows a unique malleability that is rap-
idly lost day by day [ 4, 5 ] . Biomechanically, the
cartilage shows a virtual absence of the intrinsic
elastic memory, and it is in these days that a reli-
able nonsurgical correction of the ear deformities
can be obtained by only molding, as demonstrated
by Matsuo et al. [ 4 ] and other pediatric series.
This unique, virtually only viscous and not elastic
framework has been related to the high serum
estrogen level that rapidly drops in the next days.
In childhood before the age of 6, the cartilage
shows an elastic behavior, still being very pliable
and malleable. Biomechanically, it is a balanced
viscoelastic structure with high tissue stress
F
k s
= - D
Fig. 21.2 A schematic
section of ear cartilage.
On the periphery, the grey
tissue is the skin and
subcutis. The blue tissue is
the elastic ear cartilage

213
21 Combined Technique in Aesthetic Otoplasty
relaxation and tissue creep and consequent low
suture-type tearing forces. This means that it is
easier to modify the intrinsic cartilage elastic
memory with corresponding good long-term
results and a lower rate of deformity relapse,
according to evidence in the literature.
0
6
18
50
Years old
%
65
80
0
25
50
75
Viscous
Elastic
Fibrous
100
Fig. 21.3 The biomechani-
cal properties of the ear
cartilage in relation to age
Fig. 21.4 Schematic drawing of cartilage malleability in
relation to age. In newborns the cartilage is easily manipu-
lated, like plasticine. From childhood to elderly the
elasticity of the cartilage progressively decreases until it is
no longer elastic cartilaginous tissue

214
M. Salgarello and G. Visconti
In adolescence and adulthood , the ear cartilage
becomes progressively less pliable and stiffer [ 6–
10 ] . Its tissue stress relaxation is low, as well as
the tissue creep, with a corresponding high suture-
type tearing force. This is strictly related to the
progressively different composition of the carti-
lage extracellular matrix, as time passes. The car-
tilage aging phenomenon starts to settle down.
The framework is more elastic than viscous with
progressive fi brous degeneration. In this patient
population, the ear cartilage is progressively more
dif fi cult to manipulate, resulting in less satisfying
results and a higher relapse rate.
From adulthood to the elderly , the auricular
cartilage progressively undergoes signi fi cant struc-
tural, matrix composition, and mechanical changes
with age [ 6– 10 ] . These phenomena are strictly
related to a progressive decline of cell function and
of their ability to maintain the tissue, with a conse-
quent imbalance between chondrocyte synthetic
and degradative activity. The cartilage matrix con-
sequently undergoes loss and alterations in aggre-
gating proteoglycans, a decrease in water
concentration, increased collagen cross-linking,
and elastosis. The cartilage becomes stiffer and
almost non-pliable. The loss of elastic fi bers along
with increased fi brosis lead the elastic cartilage to
become progressively almost all fi brous-like tis-
sue. It could be not worth to perform otoplasty on
these patients, as the otoplasty technique would be
hard to apply to this modi fi ed tissue. Even if the
literature is plenty of examples of different surgical
otoplasty techniques, information is lacking on
how each technique works biomechanically.
Depending on the type of ear deformity, a car-
tilage manipulation is usually necessary when
performing otoplasty. One of the most common
ear deformities is the prominent or bat ear. Its
features are the effacement or de fi ciency of the
antihelical fold along with different degrees of
overall concha hypertrophy. One of the main
goals in the correction of prominent ear is the
creation of the missing antihelical fold. In litera-
ture, many cartilage manipulation techniques
have been reported to address this issue. The
techniques can be classi fi ed into two groups: the
cartilage-sparing and the cartilage-scoring tech-
niques [ 5– 10 ] . In cartilage-sparing techniques,
the cartilage manipulation is performed using
only sutures. All these techniques are based on
the Mustardé concept of horizontal mattress
sutures. Cartilage-scoring techniques, on the
other hand, can be divided into two major sub-
groups. The cartilage-cutting techniques are
based on the concept of cartilage “tubing”
reported by Becker in 1952 [ 11 ] . A pair of paral-
lel incisions on either side of the antihelix are
made posteriorly and the edges sutured together
to form a smooth, rounded antihelix. The carti-
lage-abrasion techniques are based on the initial
observation by Gibson and Davis [ 12 ] that the
costal cartilage tends to bend away from the
injured surface. Later, Stenstroem [ 13 ] and
Chongchet [ 14 ] applied this concept in otoplasty.
Stenstroem [ 13 ] reported his experimental obser-
vations when rasping the ear cartilage, making
the following conclusions:
1. The auricular cartilage, when scratched on
one side, bends in the opposite direction.
2. The perichondrium plays no role in this
phenomenon.
3. The deeper the scratching is, the higher the
bending effect.
4. The tendency to bend, however, becomes
smaller in the deeper layers.
The exact physiologic mechanism of the
“bending” effect after cartilage abrasion is still
not clear. The hypothesis of Gibson and Davis
[ 12 ] that the bending effect is due to matrix
expansion and outer stretched layer contraction
has been confuted by Stenstroem [ 13 ] . From his
clinical observation, he concluded that the bend-
ing phenomenon is probably related to the gradu-
ally increasing fi rmness of the rasped cartilage
and by a contraction of the opposite, non-injured
cartilage. After Weinzweig’s [ 15 ] histological
observation, we now know that a fi brocartilaginous
cap develops after cartilage abrasion that favors
and stabilizes the bending effect.
One of the major issues in surgical correction
of prominent ear is relapse. This complication
results in patients with prominent ear after oto-
plasty, meaning that the surgical technique applied
has been not effective in correcting the deformity.
The recurrence is mainly due to the intrinsic elas-
tic cartilaginous memory that brings the operated

215
21 Combined Technique in Aesthetic Otoplasty
ear back to the original shape. The cartilage manip-
ulation technique aims to hold the ear in its new
position until scar formation has stabilized the
result. In cartilage-sparing techniques, early dis-
ruption of sutures is associated to relapse because
of the intrinsic elastic cartilage memory that brings
the cartilage back to its initial shape. This is par-
ticularly true in less pliable and malleable carti-
lages. Biomechanically, their elastic constant is
higher and tissue stress relaxation is lower. When
a load is applied (i.e., sutures), the consequent
elastic rebound force generated is high. If the
sutures are not able to keep the load till scar forma-
tion, the likelihood of relapse is high. After promi-
nent ear correction in patients younger than 6 years
old, Mustardé [ 16 ] reported a 1.8 % relapse rate
with a follow-up period of 10 years. With his tech-
nique, however, he experienced a 30 % recurrence
rate in patients older than 6 years.
In 2009, Miyamoto et al. [ 17 ] investigated
the postoperative stresses and shapes of eight
prominent ears by using two modi fi ed models
(scaphal incision and abrasion) along with the
no-manipulation model to analyze the antihelical
cartilage manipulation biomechanics after the
placement of Mustardé sutures. The biomechan-
ics of conchal correction were implemented by
using two other modi fi ed models (conchal inci-
sion and conchal excision) along with the no-
manipulation model. They found that the mean
maximal stress of the scaphal and abrasion
model after Mustardé suture placement was 82
and 95 %, respectively, when compared to the
no-manipulation technique. In scaphal incision
models, they observed that the position of the
helix does not change with load, with a corre-
sponding smaller ear width on lateral view. The
cut edges along loads became irregular. So far,
while the cartilage-cutting techniques seem
more advantageous biomechanically for the
lower maximal cartilage stress, they present sev-
eral limitations in cartilage shaping. The risk of
an irregular, non-smooth antihelical fold is high,
and there is no surgical control of the helical
shape as the continuity between the helix and
antihelix is interrupted. This is why a skin exci-
sion becomes essential in cartilage-cutting tech-
niques to obtain a helix setback. These issues
are generally overcome by the cartilage-abrasion
techniques. For these reasons, today cartilage-
cutting techniques are only considered because
of their historical value and have been generally
abandoned.
The mean maximal stresses in the conchal
incision and excision model were not different
from each other, but signi fi cantly different from
the no-manipulation model, making both tech-
niques biomechanically valid.
The “Normal” and the “Deformed” Ear
The “Normal” Ear
The correct diagnosis of any type of ear defor-
mity cannot be correctly made without knowledge
about the proportions and landmarks of what is
de fi ned as the “normal” ear. This information is
essential for any surgeon performing aesthetic and
reconstructive ear surgery (Table 21.1 ; Fig. 21.5 ).
In anthropometric studies [ 18 ] , the ear is ide-
ally described as a triangular structure called the
“auricle triangle;” its base is de fi ned by the ante-
rior part that is directly attached to the most lat-
eral part of the face. This corresponds to the
earlobe attachment, such as the tragus and the
superior ear attachment. The apex of the triangle
is identi fi ed in Darwin’s tubercle. By connecting
the superior and inferior limits of the base with
the apex, a triangular structure is obtained.
In anthropometric studies, the auricular index
of Topinard is used:


It is similar to what is called the width (W)
to length (L) ratio. The AI is around 60.5 in
white males and 59 in white females. In Asians,
it is smaller, and it is higher in the black popu-
lation [ 18 ] .
The auricular index of Schwalbe


is used to compare the human ear proportions
with those of mammals and of anthropoids. When
(
)
AI of Topinard
W 100 / L
=
´
(
)
AI of Schwalbe
base 100 / height
=
´

216
M. Salgarello and G. Visconti
the height is de fi ned by connecting Darwin’s
tubercle to the anterior auricle incisura, the
Schwalbe AI is very low in mammals with long
ears. It is higher in anthropoids and even more so
in humans with the progressive reduction in ear
height (Fig. 21.6 ) [ 18 ] .
Table 21.1 Proportions and landmarks of the “normal” ear
1. Superior ear attachment on lateral view is located in the same horizontal plane as the inferior eyebrow border
2. Inferior ear attachment on lateral view corresponds to the earlobe attachment and is located on the same
horizontal plane as the columnar base
3. The tragus should be midway between the superior and inferior attachment
4. Ear position is positioned approximately one ear length posterior to the lateral orbit
5. Ear width-to-length ratio: the ear width is approximately between 3.0 and 4.5 cm and the length between 5.5 and
7.0 cm, with a corresponding ear width:length ratio of 0.5:0.6
6. The long axis of the ear is posteriorly inclined approximately 20° from the coronal plane
7. Cephalo-auricle angle designed by helix protrusion from the scalp is approximately 20–30° with a correspond-
ing distance between the lateral helix margin and the head of approximately 1.5–2.0 cm
8. Helix pro fi le on frontal view: the lateral margin of the helix should protrude more laterally than the antihelix for
approximately 2–5 mm. The lateral margin of the helix should be smooth and linear and should minimally and
gradually angle medially in the cephalocaudal direction
9. Conchal-scaphal angle: the angle de fi ned by two tangential planes passing through the concha and the scapha is
approximately 90°
10. Cephalo-conchal angle: the angle de fi ned by the head and the concha is approximately 90°
a
b
Fig. 21.5 ( a ) The aesthetic landmarks of the “normal”
ear. ( b ) Aesthetic proportions of the “normal” ear. The
green lines identify the cephalo-auricular angle, the blue
lines the conchal-scaphal angle, and the red lines the con-
chal-mastoid angle

217
21 Combined Technique in Aesthetic Otoplasty
The “Deformed” Ear
Aesthetic otoplasty is mainly restricted to the cor-
rection of the external ear deformities. Plastic sur-
geons treating patients complaining of external ear
deformity must keep in mind that the ear is a com-
plex sensory organ made of the external, middle,
and inner ear. Thus, a deformed external ear can be
associated with middle or inner ear problems that
need to be ruled out before performing an aesthetic
otoplasty of the external ear. This is particularly
true when facing craniofacial syndrome patients.
Ear deformities can be classi fi ed into two main
categories: congenital and the acquired ear defor-
mities [ 18, 19 ] .
1. Congenital ear deformities: Congenital ear defor-
mities are conditions existing before and at birth
or developing during the fi rst month of life:

(a) Malformation ear deformities: These
anomalies develop by the tenth week of
gestation and are caused by embryologic
maldevelopment. They are also called
“true” malformations and consist of
de fi cient supernumerary auricular com-
ponents, ranging from anotia and micro-
tia to auricular sinuses and tags.

(b) Deformation ear deformities: These
anomalies occur on embryologically
mature ears and can develop starting from
the tenth week of gestation. Their etiology
is usually related to abnormal physical
forces (from imbalance of auricular mus-
cle action to abnormal positioning) that
act on the embryologically mature, mal-
leable framework, altering its shape. They
represent the majority of ear deformities,
including the prominent or bat ear, which
occurs most frequently, the Stahl defor-
mity, cup and lop ear, and others.
The Prominent or Bat Ear
Prominent ear deformity is probably the most
frequently encountered congenital malforma-
tion (Fig. 21.7 ). It occurs relatively frequent
among Caucasians, with an incidence of approx-
imately 5 %; men and women are equally
affected [ 19, 20 ] . This condition is genetic,
transmitted in an autosomal dominant pattern
with varying degrees of penetration [ 20 ] . It is
universally recognized at a glance and often
responsible for psychological problems during
childhood. This deformity is usually present at
birth. However, Matsuo et al. [ 4 ] emphasized
that prominent ear can also be an acquired defor-
mity. They observed an increase in the promi-
nent ear deformity rate from 0.4 % at birth to
5.5 % at 1 year of age. They hypothesized that
abnormal forces acting on the malleable ear
framework, mainly when the baby is in the cra-
dle, can favor its development. In these cases,
D3
D2
D1
A
B
C
Fig. 21.6 Human external
ear ( pink ) compared to the
baboon ear (A-D 2 -C) and
the calf ear (A-D 3 -C). D 1 , D 2 ,
and D 3 are Darwin’s tubercle
of each ear. When each of
these points is connected to B
(anterior auricle incisura), the
auricle height is de fi ned,
according to Schwalbe AI.
A-B-C is the auricle base

218
M. Salgarello and G. Visconti
the prominent ear should be classi fi ed as an
acquired deformity.
When performing aesthetic otoplasty to treat this
condition, the most important step is the correct
analysis of each ear and of each different defor-
mity. This condition, in fact, can be monolateral
or bilateral. When bilateral, it is not uncommon to
be presented with different issues on each side.
One or more of the following features charac-
terize the anatomy of the prominent ear:
1. The anatomical relationship among the supe-
rior antihelical crus, scapha, and fossa trian-
gularis is preserved (this differentiates the bat
ear from “constricted ears”).
2. Effacement or de fi cient formation of the anti-
helical fold (the root, superior crus, inferior
crus, or complete). Different degrees of inad-
equate antihelix formation exist, from subtle
to complete without de fi nition of the antiheli-
cal fold. A con fl uent concavity from the anti-
helix to the scapha can be appreciated as well
as a lateral and forward displacement of the
helix.
3. Various degrees of conchal hypertrophy or
shape abnormalities (upper pole, lower pole,
or complete). The evaluation of the conchal
contribution in the de fi nition of prominent ear
is paramount as it represents the base on
which the de fi cient antihelix and the displaced
helix are mounted. The correction of the anti-
helical fold without addressing conchal hyper-
trophy could lead to unsatisfying and
incomplete results. The concha can become
completely
enlarged.
However,
conchal
hypertrophy can be localized mostly on the
upper pole where the conchal cartilage creates
a “bar” that pushes away the auricle or on the
lower pole at the level of the antitragus where
it can ultimately be responsible for earlobe
protrusion.
4. Consequent conchal-scaphal angle greater
than 90°.
5. Deformity of the skeletal auricular base. The
deformities of the underlying skeleton can be
responsible for the prominent appearance of
the ear even if the two main features of
a
b
Fig. 21.7 An example of bat ear. The antihelical fold is not present; the helical tail is laterally displaced. The concha
is hypertrophied, and the lobules show some grade of protrusion. ( a ) Frontal view; ( b ) inferior view

219
21 Combined Technique in Aesthetic Otoplasty
prominent ear, the inadequate antihelix and
conchal hypertrophy, are not present or evi-
dent. The skull anomalies can be subtle or
minimal in non-syndrome patients or can be
the predominant feature in prominent ear like
in craniofacial syndromes such as nonsynos-
totic plagiocephaly and the hemifacial
microsomia without microtia.
6. Lobular protrusion. This condition can be iso-
lated even if it is normally related to the lower
pole or complete conchal hypertrophy.
7. Lateral displacement of the helical tail.
8. Macrotia. “True” macrotia is a very rare condi-
tion characterized by a too large auricle with
normal proportions that can be due to an
isolated congenital ear overgrowth or to a hemi-
facial hypertrophy. However, it can be associ-
ated with diseases such as neuro fi bromatosis or
vascular anomalies. “Apparent” macrotia is a
more common condition in which part of the
ear is disproportionately enlarged, with earlobe
hypertrophy being the most common.
The Stahl Ear Deformity
In the nineteenth century, Stahl fi rst described a
peculiar ear malformation characterized by the
presence of an abnormal third antihelical crus
extending from the superior helical crus to the
edge of the helix, deforming the regular curvature
of the upper third of the ear in a triangular struc-
ture. This condition, nowadays known as Stahl
syndrome or Satiro’s ear, is thought to be geneti-
cally transmitted as it reaches its highest expres-
sion in identical twins. A further etiopathogenesis
has been proposed, which hypothesizes that the
altered growth or function of the transverse mus-
cle
is
responsible
for
the
cartilaginous
malformation.
It is interesting to analyze Stahl’s ear defor-
mity in relation to the evolution of the human
species. Satiro’s ear can be seen as an anthropo-
genic ear underdevelopment, as the AI of
Schwalbe in Stahl’s ear deformity is closer to that
of anthropoids than of humans. The ear shape is
similar to that of baboons (Fig. 21.6 ).
Lop and Cup Ear Deformities
Lop and cup ear deformities represent a curious
group of auricle anomalies characterized by a
“constricted” appearance of the ear. They differ
from the prominent ear in that the scapha, fossa
triangularis, and superior crus of the antihelix do
not have a normal anatomical relationship.
The different terms given to these anomalies
have increased the confusion and dif fi culty in
categorizing these malformations. In his 1975
paper, Tanzer [ 21 ] coined the generic term “con-
stricted ear” for all ear anomalies that share a
degree of overhanging upper third (lop) with a
degree of protrusion and the ear tubing in on itself
(cup). Then, he classi fi ed the constricted ear
according to the speci fi c type of deformation and
severity:
1. Grade I: the minor form of constricted ear is
characterized by an altered helical shape. The
helix is fl atted or rolled along its superior rim
with a corresponding reduction in ear height
(lop appearance). It usually lacks cartilage
support as the helical cartilage is normally
found to be acutely angulated on itself, almost
adherent to the scapha.
2. Grade II: the helix and scapha are involved at
various degrees. They are divided into two
subgroups:

(a) Grade II A: minor form characterized by
a rolled and constricted helix along with
conchal enlargement or hypertrophy.
Grade II A anomalies are similar to prom-
inent ear deformities as there is also an
effacement of the antihelix (Fig. 21.8 ).
They differ from the more severe grade II
B deformities as no supplemental skin is
needed to cover the expanded cartilage
during reconstruction.

(b) Grade II B: a more severe form of grade II
constricted ear with a more pronounced
helix rolling along with a sharply reduced
ear height. The antihelix and its crura are
not folded with a corresponding protrud-
ing or constricted ear appearance. It nor-
mally needs additional skin to cover the
reconstructed cartilaginous framework.

220
M. Salgarello and G. Visconti
3. Grade III: the most severe form of constricted
ear characterized by an extreme cupping
appearance. The auricle is rolled like a tube in
a pouch-like fashion. The anterior margin of
the helix is almost in contact with the earlobe.
It is often associated with a mislocated auricle
(almost always low set), forward tilt, stenosis
of the external auditory canal, and deafness. It
is not easy to deal with grade III anomalies.
This condition is better handled by plastic sur-
geons well trained in ear reconstruction in col-
laboration with an expert otorhinolaryngologist
for the exploration and, eventually, reconstruc-
tion of the middle third, which can result in
distortions. Both external and middle ear
alterations contribute to the hearing impair-
ment in these patients.
Patient Evaluation and Surgical
Indications
Many of the patients coming to the outpatient
clinic for the fi rst time are children accompanied
by their parents, who are often highly motivated
to have their child operated on to reduce the
potential social embarrassment. This is particu-
larly true when the child is around 3–6 years old
and is going to start school. However, there are
other types of patients, adolescents and adults,
who have overcome the psychological impact of
the deformity and are seeking surgery for other
reasons.
While adolescents and adults are offered oto-
plasty under local anesthesia plus intravenous
sedation, for children operating under general
anesthesia is preferred because of minimal patient
cooperation.
There are few contraindications to otoplasty.
Children usually tolerate the operation well.
However, some children are particularly worried
about the operation, seeing the doctor, and entering
a clinic. In this case, the operation is better delayed
until the child’s awareness of the deformity arises
and the child openly requests the procedure. The
adult population requesting otoplasty, however, has
greater need of a thorough psychological analysis
than the pediatric population. As the social embar-
rassment is normally of minor concern to these
patients, it is important to understand their
a
b
Fig. 21.8 Patient with moderate II A constricted left ear. The minimal helical altered shape and the moderate cupping
appearance are accompanied by the anatomical features of the prominent ear. ( a ) Frontal view; ( b ) lateral view

221
21 Combined Technique in Aesthetic Otoplasty
motivation as well as to make sure that their request
for surgery is based on realistic expectations.
Medical contraindications are skin diseases,
chondritis, acute otitis media, and chronic ear
infections [ 6– 10, 19, 22 ] . The presence of ear
piercing can also be a problem that needs to be
addressed. The pierced area represents a full-
thickness skin and cartilage defect. If it is located
exactly on the area of interest for surgery, this
will limit cartilage manipulation in that area, thus
in fl uencing the result. Moreover, this area could
be a source of bacterial contamination and sub-
clinical infection, increasing the risk of skin
infection and chondritis. All of these issues should
be taken into account before operating on a patient
with ear piercing, and a detailed and thorough
informed consent on the limits of surgery and on
the increased risk of infection is essential.
Nonsurgical Correction and Timing
of Surgery
During the fi rst days of life, the ear cartilage pres-
ents unique biomechanical features. It is particu-
larly malleable and more viscous than elastic
structures. It seems not to have developed the
“intrinsic elastic cartilaginous memory” yet. This
concept is the basis of nonsurgical correction of
prominent ear. Literature reports from Japan and
the UK have demonstrated that it is possible to
achieve satisfying long-term correction of promi-
nent ear by simple auricular molding if this is
started within the fi rst 3 days of birth and contin-
ued till the fi rst 6 months [ 4, 5 ] . The high serum
maternal estrogen level has been postulated to be
responsible for the unique biomechanical ear fea-
tures in this speci fi c period of life. As the estro-
gen serum level starts to decrease (from 3 days
after birth until reaching normal levels by
6 weeks), the result of nonsurgical correction is
poor, as demonstrated by Matsuo [ 4 ] . So far, the
nonsurgical prominent correction is of limited
value if applied later than the fi rst 3 days of life.
The rationale for the correct timing of surgery
requires a balance between the ear growth state
and patient age. It is preferable to operate before
the child reaches school age in order to reduce
the psychological embarrassment and teasing by
peers. In the literature, no general agreement
exists on the exact timing of surgery. Even though
there is a general opinion among surgeons world-
wide that the best age is around 5–6 years for the
reasons explained above, some authors advocate
that the operation can be safely performed even at
4 years old without altering the physiological ear
growth. Gosain et al. [ 5 ] demonstrated that chil-
dren can safely undergo otoplasty before the age
of 4 years and as early as 9 months. Furthermore,
they stressed the biomechanical concept that at
this age the highly malleable ear is more compli-
ant to correction with a consequently higher rate
of successful long-lasting results.
The authors encourage surgery before the
child reaches school age, and we reassure the
parents, when needed, that there are no risks of
interference with the physiological ear growth.
Goals of Correction
The general goal of otoplasty is to restore the
anatomy and the shape of the ear to look like a
“normal” ear in an aesthetically acceptable and
permanent way. McDowell [ 23 ] de fi ned the basic
goals of otoplasty in his paper (Table 21.2 ).
Besides the McDowell goals of otoplasty, some
anatomical goals should be kept in mind when
treating protruding ears:
1. The antihelical fold should be shaped in a
round and smooth way along with the superior
crus.
2. Conchal-scaphal angle of 90°.
Table 21.2 McDowell goals of otoplasty
1. All trace of protrusion in the upper one-third of the
ear must be corrected. Some remaining protrusion in
the middle or lower third may be acceptable
provided that the superior aspect is thoroughly
corrected; however, the reverse may not be true
2. From the front view, the helix of both ears should be
seen beyond the antihelix (at least down to the
mid-ear and preferably all the way)
3. The helix should have a smooth and regular line
throughout
4. The postauricular sulcus should not be markedly
decreased or distorted
5. Protrusion should measure between 15 and 20 mm
from the helix to the head
6. Position of the two ears: the distance from the lateral
border to the head should be within 3 mm at any
given point

222
M. Salgarello and G. Visconti
3. Reduction of conchal excess and reduction of
the angle between the concha and mastoid.
4. Reduction of the cephalo-auricular distances.
5. Correction of an abnormal position of the lob-
ule (if the lobule projection is beyond the heli-
cal rim).
Acquired Ear Deformities
Acquired ear deformities occur during a patient’s
lifetime, with trauma being the main etiology.
The most common source of trauma is earring
avulsion, burns, human bites, infection, acci-
dents, shotgun wounds, and cutting weapons.
The upper third of the ear is the most frequent site
of ear trauma in male patients, whereas the ear-
lobe is the most frequent site of trauma in women
(earring avulsion). With the exception of some
conditions (i.e., earring avulsion) that are easily
addressed, acquired ear deformities usually
require complex reconstructive operations.
Combined Technique in Aesthetic
Otoplasty
Preoperative evaluation of the ear deformity to be
corrected is essential to achieve a tailored result
able to address the speci fi c type of deformity. The
speci fi c type of deformity along with the carti-
lage shape and consistency of both ears is evalu-
ated in detail as are comprehensive 3D ear
proportions and symmetry.
The external ear is a bilateral structure that usu-
ally is not symmetrical. When treating a case of
severe deformity on one side with a minimal
anomaly on the other side, we prefer to operate
on both sides to achieve a more symmetrical
result. When a unilateral deformity is present
with a “normal” contralateral ear, we still prefer
to operate on both ears to achieve symmetry. Rare
cases presenting a contralateral “normal” ear
with maximum setback are operated only on the
affected side.
The operation is usually performed under
local anesthesia plus intravenous sedation except
in young children, in whom general anesthesia is
required because of minimal patient compliance.
The local anesthesia solution (xylocaine 2 % and
epinephrine 1:100,000) is used on both the poste-
rior surface of the ear and the anterior surface
over the antihelix and concha with the aim to
achieve both a bloodless surgical fi eld and hydro-
dissection. Before anesthesia induction, systemic
broad-spectrum prophylactic antibiotics are
administered.
The helical rim is folded back against the head
to visualize the position of the antihelix to recon-
struct. This is marked with methylene blue
(Fig. 21.9 ). The posterior projection of the new
antihelix is marked on the posterior surface of the
ear. This de fi nes the linear surgical incision that
is normally located 1–1.5 cm above the retroau-
ricular fold. The length of the skin incision
extends from a few millimeters above the tail of
the antihelix inferiorly to a few millimeters above
the bifurcation of the lateral and medial antiheli-
cal crus superiorly. No skin is excised. By using
our technique, this maneuver is not needed to
address the ear deformity (Fig. 21.10 ).
A straight, full-thickness, skin-subcutis linear
incision is performed following the marked line
on the posterior ear surface. Then the posterior
ear skin is undermined up to the tail of the antihe-
lix inferiorly, laterally toward the helix margin,
and toward the postauricular sulcus medially.
Thus, the posterior cartilage surface is widely
exposed (Fig. 21.11 ). This allows an easier posi-
tioning of the Mustardé sutures in order to bend
Fig. 21.9 Manual maneuver of folding back the helical
rim toward the head to visualize the position of the antihe-
lical fold that is then marked with methylene blue

223
21 Combined Technique in Aesthetic Otoplasty
the cartilage of the antihelix. Accurate hemosta-
sis is achieved.
At this point, the anterior cartilage is
approached by creating a blunt tunnel with a
mosquito through the antitragus-helical fi ssure.
A Stenstroem otoabrader is inserted in this tunnel
and is directed toward the anterior surface of ear
following the marked new antihelix position
(Fig. 21.12 ). The otoabrader needs to be gently
advanced in order to fi rst bluntly divide the skin
from the cartilage.
Then, the perichondrium and the antihelical
and scapha cartilage are carefully abraded in
order to weaken the anterior surface elastic fi ber
cartilage network and obtain the “bending-
away” effect. Precise cartilage scoring is also
performed at the tail of the antihelix and medi-
ally toward the concha. At this level, the carti-
lage is thicker than in the upper third of the ear.
The resulting “bending-away” effect at this level
allows a posterior rotation of the tail of the anti-
helix with a resulting desirable retroposition of
the earlobe.
The helix is manually pressed toward the mas-
toid to create the correct fold of the antihelix.
Straight needles dipped in methylene blue are
passed through repeatedly to mark the cartilage
posteriorly with three pairs of points:
1. The fi rst straight needle is passed inferiorly
through the tail of the antihelix on the scaphal
and the conchal side.
2. The second straight needle is passed midway
at the antihelix bifurcation on the scaphal and
the conchal side.
3. The third straight needle is passed superiorly
between the triangularis fossa and the scapha
to delineate the superior crus of the antihelix
(Fig. 21.13 ).
Fig. 21.10 The skin incision being marked
Helix
Tail of the
helix
Concha
Scapha
Fig. 21.11 The posterior ear cartilage exposed after
blunt soft tissue undermining . The ear structures come
into view
a
b
Fig. 21.12 ( a ) The mosquito used to approach the ante-
rior cartilage surface through the antitragus-helical fi ssure.
( b ) The Stenstroem otoabrader is inserted

224
M. Salgarello and G. Visconti
On the posterior cartilage surface, the three pairs
of points identify the exact position of the three
horizontal mattress Mustardé sutures to de fi ne
the new antihelical fold.
Three 3-0 Vicryl sutures are now passed
through the posterior cartilage surface with a
partial-thickness bite placed exactly on the blue
points. Starting inferiorly and progressing superi-
orly, each suture is tied, determining the bending
of the antihelix (Fig. 21.14 ).
The correct position of these mattress sutures
is a key point of the operation. With the inferior
suture, we both rotate the helical tail medially
toward the concha, decreasing the conchal-
scaphal and the cephalo-auricular angle, and, at
the same time, an earlobe setback is achieved. In
fact, the earlobe fi brofatty tissue is a natural
downward continuation of the helical tail, and,
being a completely viscous structure, it follows
the movement of the helical tail. The midway
and the superior sutures serve to shape the anti-
helical fold in two critical points: before the
bifurcation in the superior and inferior crus and
to correctly shape the superior crus at the trian-
gular fossa.
When facing with a very deep and hypertro-
phied concha, the authors prefer to add a small
crescent full-thickness cartilage excision (width
ranging from 2 to 6 mm) at the junction of the
fl oor and posterior wall of the concha. The edge
of this crescent is widely undermined from the
skin to favor the natural alignment without plac-
ing sutures.
The posterior linear skin incision is now
closed with a few interrupted 4-0 Vicryl rapid
sutures to allow eventual blood drainage in case
of minimal bleeding (Fig. 21.15 ). Three 5-0
trans fi xing Prolene sutures over tulle gras are
placed on the anterior surface of the ear to stabi-
lize the result and to further reduce tension on
the Mustardé sutures (Fig. 21.16 ). These sutures
are removed after 10 days (Figs. 21.17
and 21.18 ).
The patient is instructed to wear a light ban-
dage for 10 days for stabilization and to protect
a
b
Fig. 21.13 ( a , b ) Three straight needles have been used
to position the antihelix
a
b
Fig. 21.14 ( a , b ) Three 3-0 Vicryl sutures have been
placed with partial-thickness bites

225
21 Combined Technique in Aesthetic Otoplasty
the ear from unintentional movements and posi-
tion (such as during sleeping) that could jeopar-
dize the surgical result . After 10 days, the patient
is instructed to wear an elastic band for 15 days.
Arnica-based medications along with instruc-
tions to sleep between two pillows are prescribed
to reduce postoperative edema. Broad-spectrum
oral antibiotics and painkillers are prescribed as
well.
Complications
In otoplasty we should distinguish early compli-
cations that can occur within the fi rst 14 days
postoperatively and late sequelae that can occur
from the 15th day postoperatively onward.
Overall, the complication rates in otoplasty are
low, and when complications occur, they are
often minor complications [ 6– 10, 20 ] .
Early Complications
1. Hematoma: Limandjaja et al. [ 20 ] found this
complication to range from 0 to 7.5 % in the
literature. Insuf fi cient hemostasis is the main
cause of hematoma development. Rarely, it
can be due to a rebound vasodilatation effect
from local anesthesia, hypertension, postop-
erative trauma, and coagulopathy. It can be
recognized as the patient usually reports
excessive, disproportionate, persistent unilat-
eral pain a few hours postoperatively.
Continuous bleeding from the surgical wound
can be associated as well. Hematoma is
fraught with the risk of cartilage and skin
necrosis due to excessive pressure. It requires
prompt and immediate intervention. If
encountered, the fi rst thing to do is remove
the sutures and drain the hematoma. In case of
ongoing bleeding, the patient has to be taken
back to the operating room or the hemostasis
controlled.
2. Infection: This complication is rarely reported
in otoplasty as the extensive auricular
blood supply represents a suf fi cient protective
system. However, insuf fi cient sterility as well
as hematoma and wound dehiscence can favor
infection. It can be clinically recognized by a
deep, continuous pain along with skin ery-
thema, swelling, and pus formation. This con-
dition needs to be readily recognized to
establish an appropriate systemic antibiotic
therapy to control it in order to avoid its even-
tual progression to perichondritis and chondri-
tis, which can lead to cartilage necrosis and
acquired malformation.
3. Bleeding. Bleeding from the surgical wound
can be a minor complication managed by
bandage changes. However, it has to be viewed
as a warning signal for a possible hematoma
requiring immediate surgical intervention.
4. Skin necrosis. This rare complication can
occur when there is a subdermal plexus venous
discharge impairment normally related to
undue pressure applied on the auricle (i.e.,
thigh dressings, hematoma). It can also be
experienced as the fi nal stage of an infection.
5. Wound dehiscence.
Fig. 21.15 A few interrupted 4-0 Vicryl rapid sutures
close the skin in a tension-free fashion. No excess skin is
present
Fig. 21.16 Ear appearance at the end of surgery before
wound dressing

226
M. Salgarello and G. Visconti
a
b
Fig. 21.17 ( a ) A 17-year-old boy with mild prominent ears. ( b ) One year postoperatively

227
21 Combined Technique in Aesthetic Otoplasty
Late Complications
1. Unsatisfactory cosmetic outcomes. Under this
category, many different conditions can be
experienced:

(a) Relapse: The recurrence of ear deformity
after surgery is normally directly related
to the age of the patient and the technique
used. It is more frequent after non-com-
bined techniques as the cartilage recoil
will defeat the forces applied by the sur-
gery and return to the original condition.
In combined techniques, insuf fi cient car-
tilage weakening and suture failure are
the main causes of relapse. The relapse
rate increases with the age (less frequent
in children under 6 years old and more
frequent in adolescents and adults) and is
far higher for techniques relying solely on
skin
excision
than
on
cartilage
manipulation.

(b) Undercorrection: Undercorrection is
recognized as a failure in some steps of
the surgical technique with a corre-
sponding insuf fi cient correction of the
deformity. The ear will appear less
prominent, for example, but it is still
possible to recognize the features of
bat ear.

(c) Overcorrection: Contrarily, overcorrec-
tion is also a failure of some steps of the
surgical technique with corresponding
Fig. 21.18 ( Above ) A 9-year-old girl with right prominent ear and left cup ear of mild degree, preoperatively. ( Below )
Result 6 months postoperatively. The constricted left ear has been corrected

228
M. Salgarello and G. Visconti
results going beyond the goals of the oto-
plasty. The classic example of overcor-
rection is a “pinned-back” appearance
with the auricle fl attened against the
head, with a corresponding cephalo-
auricular angle of less than 20° and the
helix no longer visible in the frontal
view.

(d) Cartilage irregularities (Fig. 21.19 ): Acute
crests and irregular contours along the
fold of the antihelix with a tendency to
overcorrection are typical deformities
seen with the cartilage-cutting techniques,
which require a full- thickness cartilage
incision. These residual deformities
require secondary correction surgery.
Frequently seen in the past, these compli-
cations are rarely found now as cartilage-
cutting techniques have generally been
abandoned.

(e) Telephone ear (Fig. 21.20 ): This peculiar
deformity is the result of both undercor-
rection of the upper and lower third of the
ear and overcorrection of the mid-ear.
This complication is usually experienced
with the skin excision technique when a
classic lozenge excision pattern is used.

(f) Reverse telephone ear: This complica-
tion, on the other hand, is the result of
both overcorrection of the upper and
lower ear third and undercorrection of the
mid-ear. This is frequently the result of an
undercorrection of a very deep and hyper-
trophied concha. Like the telephone ear
deformity, it is more frequently experi-
enced with the skin excision technique
with a modi fi ed pattern, such as the dumb-
bell pattern. A millimeter underestima-
tion in skin excision will lead to this
deformity.

(g) Asymmetry: This condition is physiologi-
cally present in people with both normal
and deformed ears. The goal of otoplasty is
the achievement of a pleasant and symme-
trical result. Asymmetry can be considered
acceptable when minimal (hardly appre-
ciable by the patient) and when already evi-
dent preoperatively.
2. Suture extrusion. This complication can be
experienced when sutures are placed in too
close proximity to the skin, when using per-
manent sutures, when there is too much ten-
sion on the sutures, and in case of infection.
According to Limandjaja et al. [ 20 ] , the
suture extrusion rate is from 0 (absorbable
sutures) to 22.2 %. Interestingly, according
to their review, suture extrusion has been
experienced mainly by surgeons using per-
manent nylon sutures. Since the fi rst descrip-
tion by Horlock et al. in 2001 [ 24 ] , the use of
the postauricular fascial fl ap has been popu-
lar in otoplasty. This fl ap serves as an inter-
vening tissue layer between the cartilage and
the skin with the aim to reduce the suture
extrusion complication rate. However, some
series have demonstrated that this complica-
tion is still possible when using this tech-
nique. The real issues in suture extrusion
seems to be the type of material used (perma-
nent vs. absorbable sutures) and the tension
applied.
3. Scarring. Dystrophic scars, such as hypertro-
phic scar and keloids (Fig. 21.21 ), can occur in
otoplasty, especially when using a posterior
approach, as this part of the body is normally
prone to abnormal scarring. In black people,
the rate of this complication is higher. Abnormal
scarring can be prevented by using a tension-
free closure. This is also the reason why we
prefer the postauricular skin incision over other
skin excision patterns.
4. Hypersensitivity. Some patients describe a
sense of postauricular tenderness. This condi-
tion is related to axon regeneration and tends
to disappear within months.
The Evolution of the Combined
Technique
Postauricular Skin Incision or Excision?
The postauricular approach is largely favored
when performing an aesthetic otoplasty because
it allows good exposure of the auricular cartilage,
direct and indirect access to anterior and posterior

229
21 Combined Technique in Aesthetic Otoplasty
a
b
Fig. 21.19 ( a , b ) Two examples of sharp cartilage edges with acute crests and irregular contour, signs of the cartilage
full-thickness cutting technique
Fig. 21.20 An example of telephone ear. Note the upper
and severe lower ear third protrusion and the mid-ear
retroposition
Fig. 21.21 A keloid at the retroauricular scar

230
M. Salgarello and G. Visconti
cartilage surfaces, and the fi nal scar is not visible
as it is hidden postauricularly.
Both postauricular skin incision and skin
excision allow the same advantages. Much has
been written regarding variously shaped post-
auricular skin excision patterns to facilitate
wound closure and to improve the surgical cor-
rection of a prominent ear [ 6– 10 ] . By using a
skin excision pattern, it is believed that the fi nal
skin closure will also contribute to the auricle
and earlobe setback. However, the retroauricu-
lar skin excision is frequently responsible for
poor cosmetic outcomes, leading to dystrophic
scars and iatrogenic complications, such as the
telephone ear.
In our opinion, the postauricular skin excision
should generally be avoided as it does not add
any bene fi t to prominent ear correction.
Considering the anatomy of bat ear, skin excess
is not an issue. We fi rmly believe that the skin
should be preserved in order to compensate for
excessive skin retraction, which can lead to pos-
terior sulcus obliteration and to unexpected and
uncontrollable mid-ear setback with a consequent
telephone ear deformity. However, when the skin
excision pattern is reduced in the mid-third to
avoid telephone ear, the excessive undercorrec-
tion can lead to a reverse telephone ear deformity.
Moreover, the likelihood of dystrophic scars and
keloid formation is higher as the skin is not closed
in a tension-free fashion.
By using a linear postauricular skin incision,
normally located 1–1.5 cm over the retroauricu-
lar fold, we have been able to offer satisfactory
otoplasty to all our patients without experiencing
the common drawbacks of a skin excision.
Moreover, by preserving all the postauricular soft
tissues, good soft tissue coverage is provided
over the Mustardé sutures, thus minimizing bow
stringing and suture extrusion.
A skin excision pattern should be performed
only in very rare cases, in which skin excess is a
real issue, such as in adulthood and in the elderly .
In this limited subset of patients, the skin has lost
its elasticity and can be redundant. However, it is
always better to start with a skin incision and to
customize the skin excision when performing the
fi nal skin closure.
Surgery of the Antihelix
When treating prominent ears, some subtypes of
constricted ear and Stahl ear deformities, the efface-
ment or misdevelopment of the antihelical fold is
normally an issue. A practical and effective way to
evaluate the amount of antihelical shaping is to
manually bend the auricle against the head and then
mark how the new antihelix should look like.
Surgery of the antihelix can be divided into
two major schools of thought: the cartilage-spar-
ing and the cartilage-scoring techniques.
The cartilage-sparing techniques rely on the
Mustardé concept of posteriorly located full-
thickness horizontal mattress sutures to create the
antihelical fold [ 26 ] . These sutures are tightened
accordingly to the extent required to obtain a
pleasant antihelical fold shape. The main issues
with the Mustardé technique are the relatively
high rate of relapse, especially in patients over
6 years old, and the possible stitch extrusion.
Relative to the relapse rate, Mustardé [ 16 ] ret-
rospectively reviewed his otoplasty patients,
reporting a relapse rate of 1.8 % in patients younger
than 6 years old and a very high recurrence rate of
30 % in patients older than 6 years old. His fi ndings
are in line with the biomechanical properties of the
auricle. The hypothesized mechanisms are that,
the insuf fi cient suture load for holding the carti-
lage in its new position together with the conse-
quent cartilagineous recoil, increase the suture
load and breaks the sutures. A further explanation
could be the suture tearing forces, also known as
the “cheese wire” effect. It is possible that an
incorrectly placed suture (not full-thickness) and/
or a high suture tearing force in a cartilage with
low stress relaxation causes the suture to have a
cutting effect on the cartilage with the consequent
loss of suture load on the cartilage itself.
Relative to the suture extrusion rate, two main
factors can contribute to this complication: the
type of suture material used and the tension on
the Mustardé sutures. Concerning the type of
suture material, the extrusion rate is de fi nitely
higher for permanent sutures . In our otoplasty
series, we never experienced suture extrusion,
con fi rming that our choice of using absorbable
sutures is advantageous.

231
21 Combined Technique in Aesthetic Otoplasty
Concerning the tension applied and the soft tis-
sue covers, some authors sustain that the skin
excision technique favors suture extrusion because
of a tenting effect and the minimal soft tissue cov-
erage over the Mustardé sutures. To overcome the
issue of insuf fi cient tissue coverage, the postau-
ricular fascia fl ap has been advocated by many
authors since its fi rst description by Horlock et al.
in 2001 [ 24 , 25 ] . In our opinion, these drawbacks
can be avoided by combining a skin incision pat-
tern with the use of absorbable sutures.
The cartilage-scoring techniques can be further
divided into two main subgroups: the cartilage-
cutting and the cartilage-abrasion techniques.
1. The cartilage-cutting techniques are based on
the initial report by Luckett [ 6 ] that creates the
new antihelical fold by excising a crescent seg-
ment of cartilage posteriorly and approximat-
ing the remaining edges to each other.
Following this report, the concept of cutting
the cartilage in a full-thickness fashion to cre-
ate the antihelical fold was popularized in the
1960s, after Becker introduced the tube-like
shaping of the antihelix. He incised the carti-
lage by using two parallel incisions on either
side of the antihelix and sutured these edges in
order to make a tube of the intervening carti-
lage to form the antihelical fold. Other popular
techniques are those of Converse et al., Farrior,
and Pitanguy. Nowadays, the cartilage-cutting
techniques have been abandoned because they
produce sharp, visible, not natural-looking
ridges on the antihelical fold that are very
dif fi cult to correct. Furthermore, by cutting the
cartilage, there is no surgical control of the
helical protrusion as the cartilage continuity
has been interrupted. All these drawbacks favor
the use of the cartilage-abrasion techniques.
The cartilage-abrasion techniques rely on the fi rst
observation of the bending effect experienced in
injured costal cartilage by Gibson and Davis [ 12 ] .
Later on, Stenstroem [ 13 ] and Chongchet [ 14 ]
applied this concept to aesthetic otoplasty. Many
instruments have been used to abrade the carti-
lage, such as rasps, abraders, Adson-Brown for-
ceps, and hypodermic needles. As with Mustardé
sutures, the cartilage-abrasion techniques are
effective by themselves when treating prominent
ears of children younger than 6 years old. When
treating older patients with thicker and more elas-
tic cartilage, the cartilage-abrasion techniques
have been reported to have a virtual relapse rate
of 100 % [ 6– 10 ] .
Cartilage-abrasion technique are largely pre-
ferred to the cartilage-cutting techniques as they
avoid the deleterious creation of sharp edges and
allow obtaining smooth and round contours
[ 6– 10 ] .
Considering the advantages and limitations of
both the cartilage-sparing and cartilage-cutting
techniques, nowadays many surgeons have re fi ned
their otoplasty techniques, which are normally a
combination of both cartilage-sparing and cutting
methods.
Our technique is a combination of the
Stenstroem cartilage-abrasion and Mustardé car-
tilage-sparing technique. The cartilage is scored
with Stenstroem otoabraders in order to de fi ne
the new shape by the bending effect and to weaken
it in order to reduce the tension on the sutures.
During the maneuver of cartilage abrasion, the
surgeon must assess the cartilage thickness at
each level in order to perform an appropriate and
non-aggressive abrasion. Furthermore, the abra-
sion should be performed along the antihelical
fold in a rectangular-shaped area and along the
superior crus in a fan-shaped area in order to
weaken the cartilaginous area to be shaped.
The 3-0 Vicryl Mustardè sutures give the fi nal
and permanent shape to the antihelix once it has
been correctly weakened. By combining the two
techniques with the use of absorbable sutures, we
experienced satisfying long-term results with a
0 % rate of suture extrusion. Our fi ndings are in
line with the actual biomechanical principles of
the ear cartilage.
Surgery of the Concha (Mid-Third
of the Ear)
Besides effacement of the antihelical fold, con-
chal hypertrophy represents another major issue
in prominent ears. However, it is rare to fi nd a
patient with an isolated conchal hypertrophy
and normal antihelix development. A review of

232
M. Salgarello and G. Visconti
current otoplasty techniques by Nuara and
Mobley [ 9 ] found that the residual conchal
prominence is generally addressed after correc-
tion of the antihelical fold. Conchal hypertrophy
can be managed by using several techniques:
1. Conchal suture setback: Conchal-mastoid
sutures were originally described by Owens
and Delgado to correct conchal hypertrophy
or prominence. However, the modi fi ed Furnas
technique [ 27 ] is the most reported. Furnas
used nonabsorbable, full-thickness (till the
anterior perichondrium) mattress sutures
placed between the conchal cartilage and the
mastoid fascia. Three to four sutures are
placed in a strict anteroposterior direction in
order to gently set back the concha, avoiding
its forward rotation and external auditory
canal narrowing. As reported by Elliot [ 28 ] ,
the concha setback can be more effective if
the postauricular muscle and fi brofatty tissue
over the mastoid are excised in order to cre-
ate a hosting pocket. As reported by Furnas,
the concha suture setback is effective for mild
to moderate cases with a conchal height less
than 2.5 cm. In our hands, mild to moderate
cases of conchal enlargement are managed by
the placement of inferior Mustardè sutures.
2. Excision techniques: The use of these tech-
niques has been advocated when treating con-
cha hypertrophy of higher grades. The cartilage
can be incised using either an anterior or pos-
terior approach based on the surgeon’s prefer-
ence. Once the base of the concha cartilage
has been dissected from the anterior and pos-
terior skin, the ear is manually retroposed,
producing conchal cartilage overlapping. The
excess cartilage is marked and excised with-
out skin. The free edges can or cannot be repo-
sitioned by sutures [ 6– 10 ] .
3. Scoring techniques: Using the same concept
of scoring techniques in de fi ning the antihelix,
the conchal anterior abrasion can be used
alone or in combination with sutures to allow
a conchal setback with lower tension. In fact,
the same issues experienced with Mustardé
sutures for the antihelical fold, such as relapse
and suture extrusion, can be equally experi-
enced with Furnas sutures. Thus, the same
concepts applied for Mustardé sutures are
valid for the Furnas sutures as well [ 6– 10 ] .
The authors correct mild to moderate concha
hypertrophy with inferior mattress sutures. When
a very enlarged concha is present after the antihe-
lical shaping has been fi nished, adding a small
crescent, full-thickness cartilage excision (width
ranging from 2 to 6 mm) at the junction of the
fl oor and posterior wall of the concha is preferred.
The edge of this crescent is widely undermined
from the skin to favor the natural alignment,
without placing sutures.
The Concept of Helical Tail Setback
and Management of Earlobe
Protrusion (Lower Third of the Ear)
Earlobe protrusion can be an important issue in
prominent ear. The lobule is the natural down-
ward continuation of the upper cartilaginous ear
framework. It represents the lower third of the ear
and differs from the upper two-thirds because it
is a noncartilaginous structure, being made of
fi brofatty tissue with different biomechanics,
which makes it similar to normal skin (more vis-
cous than elastic structures). Earlobe protrusion
is usually a feature of the prominent ear.
The helical tail setback represents an impor-
tant step in otoplasty to restore a gentle, balanced
sweep to the helical rim as well as to correct the
earlobe protrusion [ 8 ] .
Many different techniques are reported for the
helical tail setback, most of them relying on pexy
sutures between the helical tail and the concha,
besides Mustardé sutures.
In our technique, the helical tail setback is an
important maneuver. It is achieved by correctly
moving the skin toward the helix margin and the
helical tail, by abrading the helical tail itself and
by precisely placing the lowest Mustardè suture
without adding other sutures. The authors do not
normally perform any direct earlobe procedure to
correct a prominent earlobe as a precisely
performed helical tail setback is effective in
correcting the earlobe protrusion.

233
21 Combined Technique in Aesthetic Otoplasty
Other authors prefer to approach the earlobe
protrusion directly by using different patterns of
postauricular skin excision to posteriorly displace
the earlobe. This maneuver is effective because
of the viscoelastic properties of the earlobe, with
a low-elastic spring, allowing obtaining long-
lasting results as the new position is typically
maintained.
Conclusions
Over 200 otoplasty techniques have been
described, each of them with its own advan-
tages, disadvantages, and limits. The authors
present a technique that combines the princi-
ple of the cartilage-sparing techniques with
those of the cartilage-abrasion techniques.
This technique adapts well to different types
of prominent ears as well as to some subtypes
of constricted ear (type I and some IIA) and
lobule protrusion, allowing pleasant and satis-
fying results for both the patients and surgeon
with low complication rates.
Acknowledgment
Thanks to Emiliano Visconti, MD,
( ) resient in training, Department
of Bioimages and Radiological Sciences, Catholic
University of “Sacro Cuore,” University Hospital “A.
Gemelli,” for his contribution to the digital artwork.
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235
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_22, © Springer-Verlag Berlin Heidelberg 2013
22
Introduction
Prominent ear may cause major psychological
problems for school-age children. A study per-
formed by Bradbury et al. [ 1 ] in 1992 showed
that 10 % of patients requiring prominent ear sur-
gery needed psychiatric therapy.
Prominent ear deformation is a condition with
an autosomal dominant trait and a prevalence of
5 % in the white race. It emerges for two ana-
tomical reasons: underdevelopment of the antihe-
lical fold and lateral overdevelopment of the
conchal bowl (Fig. 22.1 ) [ 2 ] .
Multiple anatomical problems may coexist
together in prominent ear deformation. Various
surgical methods have been developed to address
these problems. Since otoplasty was fi rst de fi ned
by Ely in 1881 [ 3 ] , more than 200 surgical tech-
niques have been de fi ned. These techniques can be
classi fi ed as those forming an antihelix and those
addressing the conchal bowl and lobule [ 4, 5 ] .
A traditional open otoplasty can give rise to
surgical dif fi culties and complications in the post-
operative period, especially in the area of inci-
sion, with the potential for hematomas, abscess
formation, and perichondritis.
The incisionless otoplasty technique presents
an easy and direct approach to bending the
nondeveloped antihelix. It is convenient to use
in fl exible, thin, malleable ears, but can also be
applied in to ears with strong cartilage with scor-
ing. If lateral overdevelopment of the conchal
bowl exists, excess cartilage removal should be
addressed fi rst. Management of a hypertrophic
conchal bowl was presented in another study
including cartilage excision of a semilunar shape
together with similar suture fi xation as described
in this technique [ 6 ] . According to our technique,
a new antihelical fold is acquired with hidden sub-
dermal pulling sutures, providing backward bend-
ing of the helix and forming a new antihelical fold,
in full view, with a direct anterior approach used
for non- or underdeveloped antihelical fold prob-
lems (Fig. 22.2 ).
There are several advantages of the incision-
less hidden suture technique. These are:
1. Easy and rapid correction of an underdevel-
oped antihelical fold with an incisionless tech-
nique using hidden sutures
2. Easy adjustment of posterior bending of the anti-
helical fold by tightening of the hidden sutures
3. Local or general anesthesia can be used
4. Direct control of ear contours
5. Providing suturing compatible with the anti-
helical fold
Surgical Technique
Before surgery, photographs are obtained.
The surgical technique can be applied under
general or local anesthesia. Permanent folding
Y. Çokkeser , M.D.
ENT Department , Mustafa Kemal University,
Tayfur Sökmen Ata Medical School ,
Tayfur Sökmen Ata Campus ,
Serinyol Antakya, Hatay , Turkey , 31000
e-mail: ycokkeser@yahoo.com
Incisionless Otoplasty
Yaşar Çokkeser

236
Y. Çokkeser
can be achieved with 3/0–4/0 Prolene 26-mm cut-
ting sutures (Ethicon, Turkey) for antihelix for-
mation using hidden sutures for young patients
with soft, foldable cartilage having no lateral
hypertrophy of the conchal bowl cartilage and
needing no cartilage excision. This technique
involves Mustardé asymmetric quadrangular
suturing (Fig. 22.3 ), which is wider at the periph-
ery and narrower on the medial side in proportion
to the antihelical fold to the medial conchal level .
By manually bending the pinna, the surgeon
de fi nes where the planned antihelix will be. If the
cartilage spring resists bending, then scoring
should be done (Fig. 22.4 ). A 20-gauge phlebot-
omy needle, bent at the tip and serving as a
microknife, is used to produce scoring along the
anterior surface of the cartilage. The needle enters
through the skin in only two places horizontally;
then, it is turned perpendicularly to scratch the
cartilage (Fig. 22.5 ). Cartilage scoring with the
bent-tip needle passes between the cartilage and
the skin anteriorly over the planned antihelical
fold. Weakening of the newly formed antihelix
(Fig. 22.5 ) allows a good rim of antihelix
(Fig. 22.5 ) if the cartilage is strong enough to
resist suture bending.
The suturing procedure (Fig. 22.6 ) starts by
passing the needle through the conchal bowl
anteriorly through the skin, perichondrium, and
cartilage to the posterior face of the auricular
cartilage under the posterior perichondrium, then
passing it through between the cartilage and the
perichondrium in the posterior face, and then
turning it back again through the cartilage, per-
ichondrium, and skin, exiting between the helix
and the newly formed antihelix anteriorly. In the
next phase, the needle is inserted in the same hole
as it exited perpendicular to the previous needle
axis, moving superiorly and passing in the same
manner as previously done, then passing between
Helix
Scapha
Antihelical
fold
Antihelix
Antitragus
Lobule
Tragus
External
auditory
meatus
Concha
Fossa
Fig. 22.1 Auricular anatomy

237
22 Incisionless Otoplasty
Fig. 22.2 Presurgical diagnosis and assessment of the
pathological anatomic structure is vital. ( a ) Overdeveloped
conchal bowl. ( b ) Overdeveloped conchal bowl together
with dimensional problem. ( c ) Lack of antihelical fold in
the right ear

238
Y. Çokkeser
the cartilage of the posterior face and the poste-
rior side of the perichondrium. This needle exits
1 cm superiorly between the antihelix and helix.
The needle again is inserted in the same hole as
it exited, this time moving medially. The process
is repeated without exiting from the skin in the
posterior face from superior to inferior. The same
point is reached and exited where it started. Then,
the knot is tied as tightly as necessary. In the third
phase, the ear cartilage is bent, and a nicely formed
antihelical fold is seen (Fig. 22.7 ). The fi nal
ear position should be slightly overcorrected to
Fig. 22.3 Asymmetrical, quadrangular suture needle
entry points. 1 the fi rst needle entry point, consequtively
other needle entry points
a
b
Fig. 22.4 ( a ) Strong ear cartilage. ( b ) Resistance to
bending by this strong ear cartilage
a
b
c
Fig. 22.5 ( a ) Scoring on the anticipated antihelical ridge
for easy bending by the suture. ( b ) Scoring by 20-gauge
needle bent at the tip. ( c ) Pliable ear cartilage after scoring
bends easily

239
22 Incisionless Otoplasty
“aesthetic normal” to ensure patient satisfaction
(Fig. 22.8 ). The suturing can be repeated if nec-
essary. Generally, only one suture is suf fi cient; if
necessary, two or more quadrangular sutures can
be applied.
The operation is completed using bending
sutures with 3/0–4/0 polypropylene and no ban-
dages or dressing is necessary.
All cases achieved satisfactory results, without
no incisions or cartilage removal. Two cases
Fig. 22.6 Surgical technique: ( a ) The needle passes
through the conchal bowl anteriorly through the skin, per-
ichondrium, and cartilage to the posterior face of the
auricular cartilage under the posterior perichondrium then
is passed through between the cartilage and the perichon-
drium in the posterior face; it then is turned back again
through the cartilage, perichondrium, and skin, exiting
between the helix and the newly formed antihelix anteri-
orly. ( b – d ) The needle is inserted in the same hole as it
exited perpendicular to the previous needle axis, moving
superiorly and passing in the same manner as previously,
then passing between the cartilage of the posterior face
and the posterior side of the perichondrium. This needle
exits 1 cm superiorly between the antihelix and helix. ( e , f )
The needle again is inserted in the same hole as it exited,
moving medially this time. ( g ) The process is repeated
without exiting from the skin in the posterior face from
superior to inferior. The same point is where the sutures
were started is reached and exited. ( h ) Then, the knot is
tied as tightly as required
a
b
d
c

240
Y. Çokkeser
required resuturing because of suture disruption,
1 h and 1 week later . Intraoperative suture disrup-
tion is immediately resolved with resuturing. None
of the needle entry or exit points are visible, and
they healed well, without noticeable scarring.
Discussion
Prominent ear deformation is a signi fi cant cos-
metic problem. For this important reason, many
surgical techniques have been developed. One of
the widely used techniques is the conchal mastoid
suture technique, which is known as the “classic
conchal setback technique” de fi ned by Furnas in
1968 [ 7 ] . In this technique, permanent sutures are
applied between the periosteum and conchal car-
tilage by applying a wide retroauricular incision.
In this technique, a wide incision is needed for the
posterior part, and the nonnatural auricle fi xation
is carried out with permanent sutures .
For the correction of the lack of antihelical fold-
ing, Stenströem [ 8 ] de fi ned the antihelix formation
technique with a loop through the non-scored face
e
f
h
g
Fig. 22.6 (continued)

241
22 Incisionless Otoplasty
using the anterior scoring method. This technique
fails, giving no reliable results, and also cartilage
necrosis can be encountered in patients with thin
cartilage. Two procedures come from Mustardé
for correction of the missing antihelical fold.
In the method de fi ned by Gibson and Davis
[ 9 ] , folding is provided by scoring of the counter
side of the cartilage. In our technique, permanent
mono fi lament polypropylene sutures are used for
antihelix bending and fi xation. If strong cartilage
resists bending, scoring of the anterior face of the
cartilage is applied, and the cartilage is folded to
the side where the perichondrium is intact.
In incisionless suture placement, it is very
important for the needle to reenter the skin
through exactly the same puncture site from
which it exited in order to ensure that no squamous
epithelium is buried subcutaneously and to pre-
vent dimpling of the skin.
In the author’s technique, a natural helix and
antihelical fold are obtained without an incision
or dissection.
Limitations of this technique are that strong,
thick ear cartilage in adult patients can resist
bending with asymmetric quadrangular mat-
tress sutures; this problem is solved by scoring.
Also, without correction of the lateral hypertro-
phy of the conchal cartilage, this technique may
result in an unnaturally evident antihelix. So if
there is lateral hypertrophy of the conchal
Fig. 22.7 ( Left ) Preoperative. ( Right ) Postoperative. Note the nicely formed antihelical fold
Fig. 22.8 The fi nal ear
position should be slightly
overcorrected from
“aesthetic normal” to ensure
patient satisfaction

242
Y. Çokkeser
cartilage, it is recommended to perform conchal
surgery fi rst and afterwards to correct the anti-
helical pathology [ 10 ] . Semilunar cartilage
incision and excision in the lateral conchal bowl
are required to provide good antihelical folding
by reducing resistance and obtaining a more
malleable, pliable, nonresistant formation with
sutures and a natural-looking new lateral con-
chal level [ 6 ] . In the anterior approach tech-
nique, both pathologies can be solved in the
same operation [ 6 ] .
Widely observed early complications after
otoplasty are hematoma and infection. Late com-
plications are suture rupture and patient dissatis-
faction. Since there is no wide dissection to
adjacent regions by operating from the subper-
ichondrial area, there is almost no risk of hema-
toma compared to other surgical techniques.
Again, for the same reasons, the frequency of
infection will be less. Therefore, no signi fi cant
complications,
including
hematoma,
were
observed in any of our cases. Only in two cases
did the sutures open; resuturing was carried out
without a problem.
The incisionless otoplasty technique results in
excellent cosmetic effects with a minimal manip-
ulation and few complications. It does not require
postoperative bandaging, and no maintenance
efforts are required of the patient or suture care of
the physician.
The de fi ned technique for prominent ear sur-
gery is shown to be satisfying for both the sur-
geon and patient (Figs. 22.9 , 22.10 , 22.11 , 22.12
and 22.13 ).
Conclusions
The incisionless otoplasty operation corrects
underdeveloped antihelical fold deformities.
In addition, conchal bowl problems can be
addressed in conjunction with the same suture
placement. Incisionless otoplasty is an outpa-
tient procedure of minimum morbidity, need-
ing minimal postoperative care, and it is well
tolerated by patients. Over 15 years of experi-
ence with this operation has proven its long-
term reliability, low complication rate,
cost-effectiveness, and great appreciation by
patients.
Fig. 22.9 ( Top ) Preoperative. ( Bottom ) Postoperative

243
22 Incisionless Otoplasty
Fig. 22.10 ( Top ) Preoperative. ( Bottom ) Postoperative
Fig. 22.11 ( Top ) Preoperative. ( Bottom ) Postoperative

244
Y. Çokkeser
References
1. Bradbury ET, Hewison J, Timmons MJ. Psychological
and social outcome of prominent ear correction in
children. Br J Plast Surg. 1992;45:97–100.
2. Adamson PA, Strecker HD. Otoplasty techniques.
Facial Plast Surg. 1995;11:284–300.
3. Ely ET. An operation for prominence of the auricles.
Arch Otolaryngol. 1881;10:97–9.
4. Campbell
AC.
Otoplasty.
Facial
Plast
Surg.
2005;21(4):310–6.
5. Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast
Reconstr Surg. 2005;115(4):60–72.
6. Cokkeser Y, Karaoglu E. Anterior approach technique
in otoplasty (how I do it). Kulak Burun Bogaz Ihtis
Derg. 2011;21:349–55.
7. Furnas DW. Correction of prominent ears by concha-
mastoid sutures. Plast Reconstr Surg. 1968;42:
189–93.
8. Stenstroem SJ. A “natural” technique for correction
of congenitally prominent ears. Plast Reconstr Surg.
1963;32:509–18.
9. Gibson T, Davis WB. The distortion of autogenous
cartilage grafts: its cause and prevention. Br J Plast
Surg. 1958;10:257–74.
10. Burres S. The anterior-posterior otoplasty. Arch
Otolaryngol Head Neck Surg. 1998;124:181–5.
Fig. 22.12 ( Top ) Preoperative. ( Bottom ) Postoperative
Fig. 22.13 ( Top ) Preoperative. ( Bottom ) Postoperative

245
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_23, © Springer-Verlag Berlin Heidelberg 2013
23
Introduction
The aim of incisionless otoplasty technique is to
create a cosmetically pleasing pinna. There are
two steps necessary to create a pleasing pinna.
First, percutaneous needle modeling of the carti-
lage breaks the cartilage memory spring and
establishes a speci fi cally weakened tract in the
cartilage which will bend in a certain way so as to
create a new pinna form. Secondly, permanent
sutures are percutaneously placed in order to hold
the cartilage during the scar healing process.
Separate incisionless techniques deal with the
antihelical fold, lobule, and conchal bowl. Each
of these techniques can be used alone or in com-
bination for any speci fi c patient’s ear deformity.
Individualization of treatment, effectiveness and
reproducibility, and atraumatic techniques lead-
ing to a low complication rate make incisionless
otoplasty an excellent choice for correction of the
lop ear deformity. Using these tried methods, a
reliable otoplasty procedure with pleasing results
can be accomplished.
Technique (Figs. 23.1 , 23.2 , 23.3 , 23.4 ,
23.5 , 23.6 , 23.7 , 23.8 , 23.9 , and 23.10 )
There is a sequence of surgical events that is best
suited for successful incisionless otoplasty.
Initially, all of the percutaneous needle cartilage
modeling work for all of the to-be-corrected areas
is performed. The cartilage weakening and break-
ing is completed before any sutures are placed.
The entire cartilage modeling work is completed
fi rst in order not to cut any already placed reten-
tion sutures. Thereafter, the retention sutures for
the conchal bowl, lobule, and then the antihelical
fold are placed. The order of conchal bowl, lob-
ule, and antihelical fold suture placement pro-
gresses from the conchal foundation to the
lowered antihelical shape.
Conchal Bowl Correction
In almost all cases of otoplasty, there is a
signi fi cant abnormality of the conchal bowl. The
conchal bowl is the foundation for the otoplasty
repair. If the antihelix is corrected without atten-
tion to the conchal bowl, then there is often an
unnatural appearance to the correction. The main
reason for this is that the antihelix will need to be
overcorrected to compensate for the conchal bowl
problem. The unnatural appearance is best char-
acterized as an “angularity” to the fi nished oto-
plasty. Therefore, an overall reduction in conchal
bowl prominence translates to a more natural-
appearing antihelical correction.
M. H. Fritsch , M.D., FACS
St Vincent Medical Center ,
9002 N. Meridian st., suite 204 ,
Indianapolis , IN 46260 , USA
e-mail: mfritschmd@gmail.com
Incisionless Otoplasty
Michael H. Fritsch

246
M.H. Fritsch
Fig. 23.1 To begin an incisionless technique, conchal
recession procedure of the left ear, suture anchor points of
maximal effectiveness are chosen by using a cotton swab
to simulate the correction
Fig. 23.2 Once the points have been found, an ink dot
is placed to accurately guide the surgeon’s needle
placement
Fig. 23.3 A 3-mm stab opening is created. It almost
always is in the area of the postauricular muscle
Fig. 23.4 Tissue between the conchal cartilage and mas-
toid is removed through the 3-mm opening using needle-
tip monopolar cautery and iris scissors. This broadly
undermined area will create a scar tissue anchor plane
Fig. 23.5 Undermining of the skin above the perichondrium
creates a scar tissue tunnel that, in addition to the sutures, will
help fi rmly and permanently secure the correction
Fig. 23.6 The fi rst limb of the four-sided incisionless
retention suture loop begins. The needle exits through the
posterior skin surface

247
23 Incisionless Otoplasty
The conchal bowl correction proceeds through
several steps: Initially, the suture anchor points
for maximal correction are found; then, excess
soft tissue is removed from between the conchal
bowl and mastoid bone; next, a plane for scar tis-
sue development is created; and lastly, the reten-
tion suture is placed and very fi rmly anchored to
the mastoid.
Antihelical Correction
After the conchal bowl and lobule have received
retention sutures, the antihelical sutures are
placed. All of the percutaneous retention sutures
are placed before any sutures are tightened.
As with all incisionless corrections, of prime
technical importance are that the retention sutures
enter and exit from the same needle holes at a 90°
angle to the skin surface and also that they follow
the same needle tract on entering and exiting.
These two aspects are important in order to pre-
vent skin inclusion cysts and skin dimpling by
allowing all sutures to slip below the skin surface
and down to the perichondrium.
There are several other technical issues to
remember. On the posterior pinna surface, the
best entry point to start the four-cornered reten-
tion suture loop is the medial superior corner;
this allows the suture knot to be buried deeply
under thicker skin. The needle is guided as
deeply under the skin throughout the entire
Fig. 23.7 Since the needle exits and enters the same
needle tract at a 90° angle to the skin surface, there is no
dimpling or skin inclusion cyst formation. On exiting the
skin, as the skin surface is approached by the curved nee-
dle, the 90° exit from the skin is achieved by “back-
scratching” the undersurface of the skin
Fig. 23.8 Reentry through the same needle hole and tract
is performed before the needle is guided through the tun-
nel and out of the stab opening
Fig. 23.9 A very fi rm anchor into the mastoid perios-
teum of 5–6 mm width and depth is made in order to retain
the conchal cartilage as the scar tissue planes mature
Fig. 23.10 After placement of the conchal bowl, lobule,
and antihelical sutures, the conchal bowl suture is tight-
ened. Points A and B are near each other as predicted by
the initial cotton swab simulation

248
M.H. Fritsch
course of the suture loop as possible; the
perichondrium is even picked up along the nee-
dle course in order to better anchor the suture to
the cartilage – this prevents suture bridging under
the skin. Since the suture is permanent, only the
unraveling of the knot could endanger the integ-
rity of the suture loop; the knot should be redun-
dantly knotted. As each patient’s ears are slightly
symmetrical between themselves, the fi nal tight-
ening of the suture retention loop should be done
by a combination of a measuring ruler and sur-
geon’s perspective as this gives rise to the great-
est accuracy and symmetry in aesthetic form.
Lastly, the antihelical work is always overcor-
rected as there is a tissue relaxation that takes
place and will loosen the correction over the
6-month postoperative time. By overcorrecting,
the end result will meet the patient’s expecta-
tions and please the patient.
Conclusions
Through a systematic use of incisionless oto-
plasty techniques, the protuberant lop ear can
be brought into an aesthetic position and shape
for a natural, pleasing appearance. The inci-
sionless process is relatively atraumatic and
avoids the many possible complications of
open otoplasty. Thus, the patient and physi-
cian are both well served by use of the inci-
sionless otoplasty.
General References
1. Fritsch MH. Incisionless otoplasty: early techniques
without address of the cartilage spring. Laryngoscope.
1995;105(5 Pt 3 Suppl 70):1–11.
2. Fritsch MH. Incisionless otoplasty. Otolaryngol Clin
North Am. 2009;42(6):1199–208.

249
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_24, © Springer-Verlag Berlin Heidelberg 2013
24
Laser and the Auricular Cartilage
Throughout thinking in correction of outstanding
ears, working as sculpture artists can push us for-
ward towards the aim of putty auricle and face.
The auricle has a perfect suite which is the skin
and skeleton, i.e., the cartilage. What is under-
neath the skin surface constitutes the puzzling of
otoplasty sculpture. Cartilage is an avascular tis-
sue that consists of chondrocytes and an extensive
extracellular matrix produced and maintained by
chondrocytes. Extracellular matrix accounts for
90 % of the composition. Cartilage matrix is
composed predominantly of aggrecan and type
II collagen. It is believed that type II collagen is
primarily responsible for tensile strength, while
aggrecan molecules, entrapped within the type
II collagen lattice, provide compressive strength.
The highly sulfated glycosaminoglycan side
chains of chondroitin sulfate and keratan sulfate
enable the matrix to structure large amounts of
water and thereby create a large osmotic pres-
sure [ 1 ] . Long chains of hyaluronan are present
throughout the matrix and serve to speci fi cally
bind aggrecan and to link protein to retain the
aggrecan molecules within the cartilage extracel-
lular matrix [ 1 ] .
Reshaping the skeleton (the cartilage) in per-
manent forms with the least trauma and com-
plications remains the gold standard of care
in reshaping otoplasty [ 2 ] . Multiple surgical
operations were used in correction of deformed
outstanding auricles (Table 24.1 ). Otoplasty tech-
niques are either cartilage-sculpting (cutting) [ 3 ] ,
cartilage-sparing (suturing) [ 4, 5 ] , or composite
techniques (combining sutures and sculpting) [ 6, 7 ] .
Different complications can take place according
to the used technique (Fig. 24.1 ). Recurring prob-
lems, suture extrusion, and some loss of correc-
tion over time were associated with techniques
relying only on cartilage suturing procedures [ 8, 9 ] .
Thick cartilage and its tricky reshaping is another
dif fi cult task in suture techniques. Alternatively,
cutting techniques can permanently distort the
shape of the ear [ 10 ] with the possibility of sharp
edgings [ 11, 12 ] , cartilage irregularities [ 12, 13 ] ,
and dif fi culty in revision surgery [ 2 ] .
Using other methods in cartilage reshaping,
e.g., electrothermal or laser, became an area of
research during the last years aiming to achieve
otoplastic surgeons’ aims adequately. Application
of laser to cartilage results in changes of its ultra-
structure (chondrocytes, febrile components of
type 2 collagen, and intercellular matrix material
of proteoglycans and hyaluronic acid) and subse-
quently in change of its biophysical belongings
[ 14, 15 ] .
Laser-mediated cartilage reshaping (thermo-
chondroplasty) is a non-ablative low-intensity
A. Ragab , M.D., Ph.D. (Brussels)
Department of ORL Head and Neck Surgery ,
Menou fi a University Hospital ,
Shibin El Kom , Egypt
e-mail: ahmedragab2000@hotmail.com
Carbon Dioxide Laser-Assisted
Cartilage Reshaping Otoplasty
for Prominent Ears
Ahmed Ragab

250
A. Ragab
interaction in which heat accelerates stress relax-
ation in mechanically deformed cartilage speci-
mens, resulting in shape change. Cartilage can be
reshaped when heated to approximately 60–75 °C
[ 3 ] . Sobol et al. [ 14 ] pioneered the develop-
ment of this procedure and suggested that stress
relaxation is owing to a phase transformation of
water molecules from a bound state (binding to
proteoglycans or collagen) to a free or mobile
state. Microscopic fi ndings showed distortion of
the proteoglycans and alterations in the collagen
skeleton. It was then suggested that laser energy
would destroy the water-binding ability of pro-
teoglycans and lead to uneven reduction in the
tensile stresses within the cartilage. The collagen
network resists tensile and shear stresses and
strains, while the fl uid component resists the high
hydrostatic compressive stresses that are gener-
ated. The cartilage cells are directly attached to
the extracellular matrix and are part of the fl uid
continuum of the tissue. The cells do not provide
any special structural resistance, but their cellu-
lar shapes, pressures, and chemical environments
Table 24.1 Surgical procedures used in correction of
prominent ear deformity
Recreation of underdeveloped antihelix
Suture techniques: conchascaphal sutures
Cartilage sculpting techniques: incising, wedge
excisions, scoring, abrading, fi ling
Composite technique: combining sutures and
sculpting
Correcting conchal protrusion
Suture techniques: Furnas’ conchamastoid sutures
Cartilage sculpting techniques: excision
Composite technique (combining sutures and
sculpting)
Complications of
otoplasty
Early
(within 2 weeks)
Late
(after 2 weeks)
Hematoma
Bleeding
Skin infection
Wound
dehiscence
Hypersensitivity
Asymmetry
Scarring
Unsatisfactory
aesthetic results
Suture extrusion
Telephone ear
Reverse
telephone ear
Cartilage
irregularities
Under correction
Overcorrection
Recurrence
Fig. 24.1 Complications of
different types of otoplasty
operations