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

252
A. Ragab
Sequencing of Laser-Assisted
Cartilage Reshaping Otoplasty
(Table 24.2 )
Assessment and Surgical Planning
Evaluation of normal measurements and protru-
sion of the auricle: The ear occupies a zone from
the brow superiorly to the base of the columella
inferiorly. The base of the tragus begins approxi-
mately a single ear length lateral to the lateral
orbital rim (6.5–7.5 cm in adults). The average
length of the adult ear varies from 5.5 to 6.5 cm.
The width of the ear is approximately 50–60 % of
the length. The vertical axis is inclined 15–30°
posterior [ 20 ] .
Protrusion from the skull must be analyzed
carefully. Protrusion can be described in terms
of measurements from points along the lateral-
most projection of the helical margin to points
directly perpendicular on the skull. On average,
the upper third of the helical rim measures
1–1.2 cm from the scalp, the middle third mea-
sures 1.6–1.8 cm at the midpoint of the helix,
and the lobule is located 2.0–2.2 cm from the
mastoid region. According to anthropometric
evaluation, the normal angle between the heli-
cal rim and the scalp covering the mastoid is
25–35° and that between concha and scaphoid
fossa is 80–90° [ 20 ] .
The normal concha can be described as a
hemispherical bowl with a sharply de fi ned rim.
Normal conchal depth is less than 1.5 cm [ 5 ] . The
angle between concha and scalp over the mastoid
ranges from 45 to 90°. The scapha–helix com-
plex emanates from the margin of the concha,
creating the antihelix [ 6, 7 ] . The antihelical fold
forms an acute angle between the concha and
scapha, measuring less than 90° in the normal ear
[ 5 ] . The antihelix starts at the antitragus and con-
tinues in an uninterrupted, smooth fashion supe-
riorly to eventually form superior and inferior
crura. Ideally, the helical rim and antihelical con-
tours are parallel so that the helix is visible
beyond the antihelix from the front. Approximately
50 % of persons demonstrate up to 3-mm varia-
tion in the horizontal and vertical positioning of
the ear.
Evaluation of the Type of Deformity
The outstanding ears result from two basic causes:
underdevelopment of the antihelix and/or a large
conchal bowl (Table 24.3 ). Obtuse angles repre-
sent poor development of the antihelix, promot-
ing lateralization of the helix. Prominence of the
ear is also promoted by the presence of a deep
conchal bowl (>1.5 cm) or anterior rotation of the
conchal bowl. Various degrees of both can coex-
ist. Secondary anomalies can also exist with the
above deformities, including (1) excessively
prominent helical root, (2) over-projected lobule
(lobule, cavum concha, cauda helix), (3) exces-
sive antitragal protrusion, (4) insuf fi cient curling
of the helix (shell ear), (5) cup ear deformity, (6)
Darwin tubercle, (7) telephone ear deformity, (8)
Stahl ear, and (9) macrotia. Other causes can
include cranial abnormalities (that in fl uence the
base on which the ear rests) must be evaluated
Table 24.2 Sequences of carbon dioxide laser-assisted
cartilage reshaping otoplasty
Assessment and surgical planning
a. Evaluation of normal measurements and protrusion
of the auricle
b. Evaluation of the type of deformity
c. Evaluation of the cartilage characters and thickness
Laser assisted cartilage reshaping otoplasty
a. Time of Surgery
b. Goal of Surgery
c. Anesthesia and draping
d. Marking, injection and skin incisions
e. Skin excision and elevation of the post-auricular
surface
f. Preparation of the postauricular surface and
identi fi cation of the tail of the helix
g. Laser reshaping of the scapha
h. Internal splint and securing of the new antihelix
i. Laser reshaping and repositioning of the concha
j. Management of the helical tail and control of the
lobule
k. Skin closure and postoperative dressings
Table 24.3 Characteristics of prominent ear deformity
Characteristics of protruding ears
Underdeveloped or absent antihelical fold
Increased distance between the helical rim and scalp
Increased angle between the mastoid and helical rim
Overdeveloped concha with deep conchal wall
Protruding lobule

253
24 Carbon Dioxide Laser-Assisted Cartilage Reshaping Otoplasty for Prominent Ears
[ 21 ] . Clearly, projection beyond the average val-
ues can be considered prominent to some, but
much of the fi nal opinion is derived from objec-
tive and subjective evaluation by the physician,
patient, and the family in relation to facial
morphology.
In the day of surgery, preoperative photo-
graphs are usually taken in front, posterior, and
each ear lateral and oblique views.
Evaluation of the Cartilage Characters
and Thickness
Expectation of the internal cartilage characters
according to the age of the patient is vital in
choice of otoplasty technique. Auricular elastic
fi bers in the young group were relatively homoge-
neous in diameter thickness with little branching
and fragments, whereas in the aged group, highly
branched elastic fi bers were observed frequently
and deviation in thickness, such as the occurrence
of small fragments and large masses, was con-
spicuous. In the aged group, fi ne fi brous structure
was frequently found in elastic fi bers and the ter-
ritorial matrix. The number of chondrocytes per
unit area in the aged group was signi fi cantly less
than in the young group. Moreover, collagenous
fi bers increased in number around the boundary
of the territorial matrix where multivesicular bod-
ies were also increased. All this factors must be in
mind when dealing with cartilages in different
age groups. So dif fi culties in bending and recur-
rence are anticipated with upgrading years of life.
So using laser techniques reaching to the deeper
layers of cartilages with nonabsorbable internal
splinting is preferred.
Also evaluation of the cartilage thickness at
the helix and antihelix is crucial. In very thin car-
tilages, curling of the cartilages is dif fi cult and
bending at one site may create deformity at
another area. In such circumstances, cartilage-
cutting techniques are preferred. While in normal
cartilages, laser cartilage reshaping can afford the
needed curvature with absorbable internal splints.
Application of laser in thick can be highly advan-
tageous when reaching to more depths with
increasing thickness and support with nonabsorb-
able internal splints.
The biological principles when applying carti-
lage forces, e.g., scoring on one side, lead to: (1)
auricular cartilage bends away from the scored sur-
face, (2) bending properties are intrinsic to the car-
tilage and are independent of the perichondrium,
and (3) deeper furrowing results in more profound
bending. Weinzweig et al. [ 22 ] discovered from
histologic studies in rabbits that a fi brocartilaginous
cap develops after cartilage scoring that promotes
and stabilizes cartilage bending.
Technique of Laser-Assisted Cartilage
Reshaping Otoplasty
(a) Time of Surgery
The rapid development of the ear to approxi-
mately 90 % of adult dimensions by age
3 years allows for early surgical intervention
for auricular anomalies. Also operating at
younger ages does not retard the growth of
the ear [ 23, 24 ] . So the author recommends
like many surgeons operating on prominent
ears when children are aged 3–6 years, before
the start of school. The goal is to minimize
the malformation before the period of social-
ization to avoid ridicule by other children.
The psychosocial distress created by promi-
nent ear has been previously documented in
the literature [ 24 ] . The child perception of the
anomaly is preferred as they are likely to be
more agreeable and compliant in their treat-
ment. Often surgery can be delayed safely for
a child who does not perceive the deformity
until adequate maturity is obtained.
(b) Goal of Surgery
McDowell in 1968 [ 25 ] and Wright 1970
[ 26 ] identi fi ed that regardless of the used
technique, the following requirements should
be ful fi lled:
The operative technique should be appli-
•
cable to all age groups.
The results must have postoperative sym-
•
metry of both ears.
Good auricular proportions should be
•
achieved.
The helix-to-mastoid distance should be
•
10–12 mm at the superior helix, 16–18 mm at
the midpoint, and 20–22 mm at the lobule.

254
A. Ragab
The elimination of protrusion in the upper
•
third of the ear.
The helix earlobe curve should run parallel
•
to the mastoid surface.
The posterior sulcus should be well
•
formed.
No sharp ridges should be visible.
•
The earlobe should be set back to the same
•
extent as the rest of the auricle.
(c) Anesthesia and Draping
General anesthesia is preferred for any child
aged less than 10 years. Mature children and
adults can receive sedation and regional
anesthesia (1 % lidocaine with 1:100,000
epinephrine) with little discomfort. Contrary
to intuition, the procedure is typically not
associated with a great deal of pain, and use
of Marcaine has not proven fruitful.
A cerebellar headrest is used for position-
ing and exposure; the face, ears, and hair are
scrubbed with chlorhexidine gluconate solu-
tion. Hair is positioned out of the operative
fi eld using sterile surgical gel, and the drapes
are applied. A central drape is also applied to
cover the nose, mouth, and the tube. Draping
in this manner provides simultaneous expo-
sure of the ears and midface required for
intraoperative comparison. Intra operative
assessment of the deformity is an important
step (Fig. 24.2 ) with trial of bending to evalu-
ate the forthcoming procedure (Fig. 24.3 ).
Fig. 24.2 Evaluation of intraoperative prominent ear
deformity characteristics
Fig. 24.3 Intraoperative
folding of the proposed new
antihelix

255
24 Carbon Dioxide Laser-Assisted Cartilage Reshaping Otoplasty for Prominent Ears
(d) Marking and Skin Incisions
Retroauricular
fi sh-shaped
incision
was
demarcated at the proposed incision site at the
dorsal aspect at the concha (Fig. 24.4 ). Its
transverse dimensions are decided by dorsal
measurements of the needle length between
the medial and lateral border of the proposed
antihelixes. The tail thickness was determined
according to the lobule protrusion. Four small,
sharp cutting needles tattooed with methylene
blue were pinned through the skin and the car-
tilage from the lateral surface at the posterior
border of the proposed new antihelix (scaphal
line) and passed to superior crus (fossa line)
and the anterior border of the proposed antihe-
lix (conchal line) (Fig. 24.5 ). Local anesthesia
(lignocaine with 1 in 200,000 adrenaline) was
in fi ltrated into the medial surfaces of the
auricle. Local anesthesia enhances hemostasis
and demarcates the plain of dissection.
(e) Skin Excision and Elevation of the Posta-
uricular Surface
Retroauricular fi sh-shaped excision (Figs. 24.6
and 24.7 ) was carried out. Fashioning of such
shape allowed decreasing the dead space and
subsequent hematoma formation. Also it
allows dressing the resized cartilage in ade-
quate fashion without redundancy of skin.
Repositioning a protruding lobule utilizing an
eccentric excision of posterior, lobule skin, and
fi brofatty tissue is another advantage of such
incision and excision. It gives your blessing to
extensive setback in adults when the skin lacks
elastic recoil. This is followed by standard
wide postauricular supraperichondrial under-
mining for exposing all the medial surface of
the auricular cartilage reaching to the helix
border and its perichondrium. In the present
technique, the retroauricular open approach
allocated precise laser application and control
of the auricular reshaping process and at the
same time passed up skin laser interactions.
(f) Preparation of the Postauricular Surface and
Identi fi cation of the Tail of the Helix
Hemostasis can be done after elevation of the
skin. Elevation can be accomplished when
reaching to the anterior antihelix border and
reaching to the postauricular area (Fig. 24.8 ).
Dissection and identi fi cation of the tail of the
helix can allow better use of laser and fi xation in
a proper position and positioning of the lobule.
(g) Laser Reshaping of the Scapha
The laser beam was delivered by means of a
TEKA SL 250S (Italy) CO 2 laser at a wave-
length of 15,600 nm to the medial surface of the
auricular cartilage. The laser beam was con-
Fig. 24.4 Marking of
fi sh-shaped medial surface
skin incision

256
A. Ragab
trolled with the micromanipulator with a focal
length of 200 mm, mounted on a surgical micro-
scope (Karl Zies, Germany). Carbon dioxide
(CO 2 ) laser evaporation (Figs. 24.9 and 24.10 )
of the posterior perichondrium, together with
partial thickness of the auricular cartilage, was
carried out on the medial surface of the proposed
new auricular antihelix and the superior crus and
guarded by the scaphal line posteriorly and con-
chal line anteriorly (Figs. 24.9 and 24.10 ) [ 27 ] .
The laser beams of evaporation were applied
parallel to Frankfort line, e.g., perpendicular to
Fig. 24.6 Fish-shaped
medial surface skin incision
Fig. 24.5 Marking of the
antihelix with needles
tattooed with methylene blue
pinned from scaphal to
conchal lines and fossa line

257
24 Carbon Dioxide Laser-Assisted Cartilage Reshaping Otoplasty for Prominent Ears
the axis of the proposed antihelix (Figs. 24.9 and
24.10 ). With such application, curling and fold-
ing of the antihelix can be observed. The depth
of penetration was determined according to age
and cartilage thickness. In normal cartilages and
age less than 6 years, the depth of laser is only
one third the thicknesses. While in thick carti-
lages and children over 6 years, the thickness
reaches from one half to two thirds thickness. A
pair of parallel laser incisions with a focused
laser beam (Figs. 24.9 and 24.10 ) was performed
(reaching to a deeper thickness of the auricular
cartilages and leaving the ventral perichondrium
intact) on either side of the antihelixes and supe-
rior crus (at scaphal line, fossa line, and conchal
line) (Figs. 24.9 and 24.10 ) [ 27 ] . To permit better
optimal angle of curling with smooth curvature
of the cartilages, laser cartilage incisions were
carried out with preservation of the lateral per-
ichondrium. Laser incisions can be healed by
formation of fi brosis-free young cartilage of per-
manent shape in comparison to classical scalpel
incisions that consisted mainly of fi brosis. The
assistant always looks to the lateral surface of the
auricle with each laser application. Pressure and
cooling with wet gauzes that were applied against
the scapha allowed curling of the superior crus
and the antihelix all through the procedure.
Fig. 24.7 Excision of skin
Fig. 24.8 Exposure of the medial surface of the auricle

258
A. Ragab
Co2 Laser parameters
Intermittent exposures
(pulse repetition rate
1 Hz), the exposure time
was 0.5 s 8 W
CO2 laser beam, the
spot diameter was
approximately
0.8 mm.
Intermittent exposures
(pulse repetition rate
1 Hz), the exposure time
was 0.5 s 5 W
CO2 laser beam
defocused beam, the
spot diameter was
2 mm.
Laser evaporation
with defocused
laser beam
Laser incisions
with a focused
laser beam
Fig. 24.9 Carbon dioxide laser parameters used in carbon dioxide laser-assisted cartilage reshaping otoplasty
Fig. 24.10 Sites of laser
vaporization of the antihelix
and laser incisions in scaphal
and conchal lines with
intraoperative shape of the
cartilage after laser-assisted
cartilage reshaping otoplasty

259
24 Carbon Dioxide Laser-Assisted Cartilage Reshaping Otoplasty for Prominent Ears
Assessment of the results is essential after laser
application (Fig. 24.11 ).
(h) Suture Internal Splints and Securing of the
New Antihelix
The cartilage is fi xed by absorbable 4-0
Prolene sutures (Fig. 24.12 ) which act as an
internal mold that allow smooth tense curve of
the antihelix without postoperative prolonged
solid mold wearing. An inter-suture distance
of 4–6 mm usually produces a soft, natural
fold. These sutures function as markers obvi-
ating needle and ink tattooing and as traction
levers for positioning. Three to four mattress
sutures were applied: one was above the junc-
tion of the crura, the second was just below the
junction of the crura to fold the superior anti-
helix, and the third and forth (when needed)
were to fi x the inferior part of the antihelix as
distant as needed.
(i) Laser Reshaping and Repositioning of the
Concha
A poorly de fi ned, “unfolded” antihelix in
conjunction with an abnormally deep concha,
possessing a prominent posterior wall, char-
acterizes the majority of ears. When this com-
bination of anomalies is encountered, surgical
correction of the concha is performed fi rst by
concha–mastoid suturing, as described by
Furnas [ 5 ] . The postauricular muscle and lig-
ament are divided. The dissection is contin-
ued downward until the cartilaginous insertion
(ponticulus) of the postauricular muscle is
identi fi ed. After exposing the ponticulus, the
skin and subcutaneous tissues are elevated off
the mastoid fascia for approximately 2 cm.
With deep concha more than 2.5 cm, excision
of postauricular muscles reaching to the
periosteum or laser ablation of the postauric-
ular tissue is advised. The concha is mobi-
lized down to its junction with the mastoid
bone. A laser incision with a focused laser
beam was performed (reaching to a deeper
thickness of the auricular cartilages and leav-
ing the ventral perichondrium intact) on the
lateral border of the concha [ 27 ] .
When the combination of “unfolded”
antihelix in conjunction with an abnormally
deep concha anomaly is encountered, surgi-
cal correction of the concha is performed
fi rst
by
concha– mastoid
suturing,
as
described by Furnas [ 5 ] . The concha is
rotated to the mastoid bone and fi xed on the
periosteum of the mastoid bone by two to
three 4-0 on a half-round, atraumatic Prolene
needle. The concha–mastoid sutures are ori-
ented in the strict anteroposterior direction.
This alignment draws the concha gently back
and reduces forward rotation and external
auditory canal narrowing produced by more
radial-oriented sutures. The sutures are syn-
ched down with half-hitch knots to gauge the
effect with the middle suture addressed last.
(j) Management of the Helical Tail and Control
of the Lobule
Excessive anterolateral projection of the ear-
lobe is a frequent contributor to prominent ear.
The magnitude of this deformity is often exac-
erbated by the production of the new antiheli-
cal fold. The lower pole of the ear possesses
moderate elastic recoil and typically maintains
the position produced by fi shtail excision of
skin and fi brofatty tissue from the lobule
(Figs. 24.13 and 24.14 ). The forgiving nature
of the lower third of the ear is the basis of sev-
eral posterior skin excision techniques. Using
Fig. 24.11 Intraoperative shape of the auricle after appli-
cation of laser

260
A. Ragab
a “training suture” can protect the lobe posi-
tion following skin excision setback. We use
single lobe–muscle suture extending from the
fi brofatty tissue of the lobe to the postauricu-
lar muscles.
(k) Skin Closure and Dressing
Postauricular skin closure is the surgeon’s
signature. This anatomic area is cosmetically
“silent” but should be closed with the same
attention to detail that is given to any other
Fig. 24.12 Internal molding
of the antihelical fold and
concha using mattress
nonabsorbable 4-0 sutures
Fig. 24.13 Intraoperative
shape of the auricle after
application of laser and
internal fi xation with sutures

261
24 Carbon Dioxide Laser-Assisted Cartilage Reshaping Otoplasty for Prominent Ears
wound. Skin closure is performed with sub-
cuticular absorbable 4-0 Vicryl sutures. That
is bathed starting on the seventh postopera-
tive day and dissolves very shortly thereaf-
ter. It obviates the discomfort of suture
removal, especially in children. Drains
should not be needed if adequate hemostasis
has been achieved. Then a fl uffed, dry, all-
cotton gauze dressing is wetted and carefully
placed into the new antihelical folds and the
concha and soaked with an antibiotic-con-
taining preparation and fi xed by a head ban-
dage. Control of the new ear contours in the
early postoperative period is very important.
The effects of shear, especially in the younger
patient, can be disastrous. The gauzes are
held in place with cling wrap. At the fi rst
postoperative visit, the entire dressing is
removed. The new dressing remains in place
for 7 days. The patient is then instructed to
wear an ear protector (either a swimming ear
protector or a tennis sweatband) each night
Fig. 24.14 Postoperative auricle after laser-assisted car-
tilage reshaping otoplasty
a
b
c
f
e
d
Fig. 24.15 ( Upper ) Preoperative prominent ear deformity children. ( Lower ) Postoperatively after laser-assisted carti-
lage reshaping otoplasty

262
A. Ragab
for a month to prevent accidental stresses on
the ear during sleep (Fig. 24.7 ). Vigorous
activities such as sports and dancing are per-
mitted 1 month from the day of surgery.
After the dressing is removed, showers and
shampooing are allowed. Gentle scrubbing
of the postauricular suture line is necessary
to encourage suture dissolution. Postoperative
photographs are taken at the 2-month visit.
Results and Complications
After early and late follow-up, no complications
or sequel, e.g., hyperpigmentation or thermal
injuries, was observed (Figs. 24.15 , 24.16 , 24.17 ,
24.18 , and 24.19 ).
According to patient satisfaction with the results
in terms of shape and symmetry 13 (81.3 %) and 14
(87.5), patients were pleased in early and late assess-
ment, respectively (Figs. 24.7 , [ 27 ] ). Using doctor
satisfaction outcome 12 (75 %) and 13 (81.3 %),
patients were good in early and late assessment,
respectively. With objective McDowell’s basic goals
in early and late assessment, the score was 4–6 and
the mean was 5 from 6 (Figs. 24.15 , 24.16 , 24.17 ,
24.18 , and 24.19 ) [ 27 ] .
The mean immediate postoperative change of
protrusion was 13.42 mm and the mean change of
protrusion found at last follow-up was 15.45 mm.
In last postoperative follow-up, the number of
ears where there was an increase of protrusion
from the early postoperative follow-up was 5
(15.6 %) [ 27 ] .
a
b
c
f
e
d
Fig. 24.16 ( Upper ) Preoperative prominent ear deformity children. ( Lower ) Postoperative after laser-assisted cartilage
reshaping otoplasty
Fig. 24.18 ( Upper ) Preoperative children with prominent ear. ( Lower ) Postoperatively after laser-assisted cartilage
reshaping otoplasty

263
24 Carbon Dioxide Laser-Assisted Cartilage Reshaping Otoplasty for Prominent Ears
a
d
e
f
b
c
Fig. 24.17 ( Upper ) Preoperative prominent ear in children. ( Lower ) Postoperatively after laser-assisted cartilage
reshaping otoplasty
a
b
d
e
f
c

264
A. Ragab
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M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_25, © Springer-Verlag Berlin Heidelberg 2013
25
Introduction
The fi rst time this concept was introduced was by
Gibson and Davis in 1958 [ 1 ] based on the prin-
ciple that the injured cartilage tends to fold away
from the injured site. This was used successfully
by Stenstrom [ 2 ] and Chongchet [ 3 ] . Chongchet’s
technique used sharp scoring of the lateral scaphal
cartilage (with a scalpel) to form an antihelix.
Stenstrom, in contrast, used a rasp to score the
antihelix blindly.
In 1967, Kaye [ 4 ] combined Stenstrom’s ante-
rior scoring technique with Mustarde’s [ 5 ] poste-
rior suture placement technique. This technique,
which later became very popular, involved using
the vertical curvilinear striations of the anterior
perichondrium to weaken the cartilaginous
“spring,” followed by the creation and securing
of the new antihelical fold by placement of poste-
rior mattress sutures. Kaye also advocated the
use of nonabsorbable sutures to avoid recurrence
after failure of a knot. The knot was often promi-
nent beneath the thin antihelical skin, which was
a problem, so few other surgeons adopted ante-
rior placement.
Minimal access anterior scoring has been
described using dedicated cartilage scoring
instruments, toothed forceps, endoscopic carpal
tunnel release instruments, and a bent hypoder-
mic needle. The latter technique described by
Mahler used a needle with a bend in one axis for
scoring.
The authors use scoring as a way to shape the
antihelix. Scoring the anterior surface of the car-
tilage facilitates the formation of the antihelical
fold. A noc. 15 surgical blade is used at an angle
of 45 along a predetermined line on our future
antihelix. The depth of the incision was two-
thirds the depth of the cartilage until it twisted
through 180°.
Indication
Patient age range from 8 to 20 years, where the
predominant anatomic defect is underdevelop-
ment of antihelical fold.
Operative Technique
(Figs. 25.1 , 25.2 , and 25.3 )
Under local or general anesthesia, the patient is
prepared and draped.
Local anesthetic with adrenaline is in fi ltrated
along the line of the desired position of the refash-
ioned antihelix between the cartilage and the sub-
cutaneous tissues both anteriorly and posteriorly.
A 21G needle dipped in methylene blue solution
is used to mark the skin over the cartilage in the
line of the new antihelical fold.
A. Z. Bhatti , M.D., MBBS, BSc (*) • M. Ijaz , M.D.
Plastic, Reconstructive, Hand and Cosmetic Surgery ,
Saad Specialist Hospital , Prince Faisal
Bin Fahd Road , 30353 , 31952 Alkhobar,
Eastren Province , Kingdom of Saudi Arabia
e-mail: asif1025@yahoo.com; drbhatty@doctors.org.uk ;
muhammadijazdr@gmail.com
Sutureless Otoplasty: Anterior
Scoring of the Antihelical Fold
Asif Zubair Bhatti and Muhammad Ijaz

268
A.Z. Bhatti and M. Ijaz
A conservative dumbbell-shaped skin excision
is made posteriorly, and the tissue is dissected to
expose the points on the cartilage that mark the
new antihelical fold. The cut is made starting
about 2 mm from the marked areas. A no. 15 sur-
gical blade is held in a curved angle of 45 and is
used to cut the two-thirds depth of cartilage until
it curves completely 180°. Fine diathermy is then
used at the edges of the fold so that the antihelix
keeps its shape and contour. No suture is used at
any stage. After the cartilage has been curved to
the desired position, hemostasis is secured.
Special care must be taken not to score over the
same point twice as one may cut through the carti-
lage. If that happens, the cartilage must be repaired
to avoid an unsightly ridge under the skin. Repeated
milking of the anterior surface of the antihelical fold
removes any collection throughout the procedure.
The skin is closed using 5/0 absorbable
(Monocryl) poliglecaprone vertical mattress sutures.
Fig 25.1 Preoperative
prominent ear and absent
antihelix
Fig. 25.2 Perioperative
curved cartilage

269
25 Sutureless Otoplasty: Anterior Scoring of the Antihelical Fold
The cavum concha, cymba concha, scapha, triangu-
lar fossa, and the retroauricular sulcus are packed
with cotton wool soaked in paraf fi n. A tailored
piece of tulle gras is placed over the ears and the
skin around the auricle. Turban dressing is applied
with two rolls of crepe with a scalpel. Bandage is
applied, kept slightly loose at the lower edge so that
the ears may be examined postoperatively.
Postoperative Care
There are a number of advantages to this form of
dressing (turban dressing): it is easy to put on,
tends not to fall off, is cool in hot weather, and has
no risk of pressure ulceration. This is left in place
for a week. The use of a headband during the
night is advised for 6 weeks after the operation.
Complications
Infection 1(1.45 %)
Hemorrhage 2(2.9 %)
Hypertrophic scarring 0
Residual deformity 1(1.45 %)
Palpable sutures 0
Skin problems 1(1.45 %)
Discussion
The correction of prominent ears has been shown
by Bradbury et al. [ 6 ] to improve happiness and
con fi dence and is therefore a worthwhile opera-
tion. Many techniques have been published in an
attempt to improve the cosmetic outcome of cor-
rection and reduce the postoperative morbidity.
The one described here combines a number of
well-established methods of correction, most
importantly anterior scoring with some of our
own re fi nements.
Stenstrom [ 2 ] showed the advantage of scoring
of the anterior cartilage in both cadavers and
patients. This was taken further by Chongchet [ 3 ] .
If diathermy cuts are placed in the desired posi-
tion, they allow for precise tightening and accurate
control of the degree of folding of the antihelix.
This requires minimal dissection or degloving of
the cartilage of the ear. Mahler [ 7 ] described how
the hypodermic needle was simply hooked to the
desired curvature, but in our technique, a precise
cut can be made using the blade. This enables the
authors to produce cuts of varying depths depend-
ing on the thickness of the cartilage to break its
spring adequately but not completely transect it.
The entry point for scoring enables the milking of
any collection that may have formed anterior to
Fig. 25.3 Postoperative
after closure

270
A.Z. Bhatti and M. Ijaz
the cartilage. The postoperative morbidity com-
pares well with other published series.
The technique did not allow any potential dead
space, so there is less chance of any collection or
any swelling. As no suture is used, chances of
foreign body reaction, protrusion, and wound
breakdown become minimal.
References
1. Gibson T, Davis WB. The distortion of autogenous car-
tilage grafts: its cause and prevention. Br J Plast Surg.
1958;10:257–74.
2. Stenstrom S. A natural technique for correction of con-
genitally prominent ears. Plast Reconstr Surg.
1963;32:509–18.
3. Chongchet V. A method of antihelix reconstruction. Br
J Plast Surg. 1963;16:268–72.
4. Kaye BL. A simpli fi ed method for correcting the
prominent ear. Plast Reconstr Surg. 1973;52(21)
:184.
5. Mustarde JC. The treatment of prominent ears by bur-
ied mattress sutures: a ten-year survey. Plast Reconstr
Surg. 1967;39(4):382–6.
6. Bradbury ET, Hewison J, Timmons MJ. Psycho
logical and social outcome of prominent ear cor-
rection in children. Br J Plast Surg. 1992;45(2):
97–100.
7. Mahler D. The correction of the prominent ear.
Aesthetic Plast Surg. 1986;10(1):29–33.

271
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_26, © Springer-Verlag Berlin Heidelberg 2013
26
Anatomical Considerations
The ear is composed mainly by cartilage and
skin; its shape is oval and fl at, with the upper
extremity larger than the lower one and posi-
tioned on the lateral surface of the cranium with
an angle between 20° and 25°. The length of the
ear is between 5.5 and 6.5 cm, whereas its width
is between 3.0 and 3.5 cm. The auricular pavilion
presents an anterior and a posterior aspect. The
anterior aspect is represented by helix, fossa of
the helix, triangular notch, antihelix, concha,
antitragus, tragus, intertragic notch, and lobule.
1. Helix is the most prominent and peripheral
aspect of the ear; it originates from the concha
(crus of the helix) then courses upward to the
ascending helix until its insertion on the skull.

The point where the ascending helix separates
from the skull is called superior otobasion.
The inferior portion of the helix is melted with
the cranial aspect of the lobule.
2. Antihelix is a curve prominence that origi-
nates inferiorly from the antitragus and then
courses upward parallel to the helix until it
divides into superior and inferior crus.
3. Triangular notch is a space between the supe-
rior and the inferior crus of the antihelix.
4. Fossa of the helix is a space between the helix
posteriorly and the antihelix anteriorly.
5. Concha is the widest and deepest central
depression; anteriorly it surrounds the exter-
nal auditory meatus whereas posteriorly is
delimited by the antihelix. The concha is
divided into a narrow upper part (cymba) and
a wide lower part (cavum) that continues
directly into the external auditory meatus.
6. Tragus is a small prominence with a triangu-
lar shape sited in front of the concha and,
together with it, completes the external audi-
tory meatus.
7. Antitragus is the downward and forward
extension of the antihelix, from which it is
separated by a depression. It shows an ovoid
shape and is located behind the tragus.
8. Intertragic notch is a depression that separates
the tragus from the antitragus.
9. Lobule is the inferior one third of the auricular
pavilion, is composed by skin and fat tissue
(without cartilage), superiorly originates from
the tail of the helix, and then courses down-
ward and forward forming a free semicircular
edge. The point in which the lobule is inserted
on the skull is called inferior otobasion.
The posterior aspect is represented by two
prominences corresponding to the depressions of
the anterior aspect, called eminence of the concha
and triangular eminence.
C. Rubino , M.D. (*)
Plastic Surgery Unit, Department of Medicine and
Surgery , University of Salerno , Via S Allende 1-84081 ,
Baronissi (Salerno) , Italy
e-mail: corubino@uniss.it , crubino@unisa.it
F. Farace , M.D. • M. Faenza , M.D.
Plastic Surgery Unit, Department of Surgical,
Microsurgical and Medical Sciences ,
University of Sassari , V.le San Pietro 43B ,
Sassari 07100 , Italy
e-mail: farace@uniss.it ; mfaenza@alice.it
Anterior Scoring of the Upper
Helical Cartilage as a Re fi nement
of the Chong-Chet Technique
in Otoplasty
Corrado Rubino , Franceso Farace ,
and Mario Faenza

272
C. Rubino et al.
The auricular pavilion is composed of:
1. Cartilage.
2. Ligaments are divided into intrinsic and
extrinsic:
Intrinsic ligaments are fi brous expansions that
join various subunits together.
Extrinsic ligaments fi x the auricular pavilion
to the temporal bone.
3. The anterior ligament goes from the spine of
the helix and the tragus to the apophysis of the
zygomatic bone.
4. The posterior ligament connects the medial
aspect of the concha to the mastoid bone.
5. Muscles lie on the ligaments and, as the liga-
ments, are divided into intrinsic and extrinsic:

Intrinsic muscles are bent across the subunits
of the auricular pavilion, and their surgical
role is secondary.

Extrinsic muscles are very thin and connect
the auricular pavilion to the skull and to the
scalp orienting the ear (anterior auricular m.,
posterior auricular m., superior auricular m.).
6. Adipose tissue is poorly represented on the
anterior aspect and well represented on the
posterior aspect.
7. Skin.
Vascular Supply
Arterial Blood Supply
1. Super fi cial temporal artery (STA) is the termi-
nal branch of the external carotid artery; it
courses upward in front of the pavilion and
gives three branches for the lobule, the ascend-
ing helix, and the tragus, respectively. These
collateral branches move to the external
aspects of the mentioned structures and then
give anastomosis with perforator branches of
the posterior auricular artery.
2. Posterior auricular artery (PAA) is a collateral
of the external carotid artery that courses
upward between the parotid gland and the sty-
lomastoid process and then continues between
the auricular cartilage and the mastoid process
giving an inferior branch for the posterior
aspect of the lobule. At this point the PAA
courses upward under the posterior aspect of
the concha, and the posterior auricular muscle,
at this level, gives two branches (intermediate
and superior) for the posterior aspect of the
auricular pinna and the peripheral margin of
the helix and then gives anastomosis with ter-
minal branches of STA.
Venous Blood Supply
1. Anteriorly the super fi cial veins drain into the
venous plexus of the cheek, whereas the deep
veins drain into the temporal vein superiorly
and into the deep veins of the parotid gland
inferiorly.
2. Posteriorly super fi cial veins drain into super fi cial
occipital veins, the posterosuperior veins drain
into the deep temporal vein, and the middle and
the inferior veins join together in a posterior
arch that drains into the deep parotid veins.
Nerve Supply
The motor innervation of the auricular pavilion
is provided by the facial nerve; its temporal
branch innervates anterior auricular muscle,
superior auricular muscle, and intrinsic muscles
of the anterior aspect. The posterior auricular
branch innervates the posterior auricular muscle
and the intrinsic muscles of the posterior aspect.
Sensitivity innervation is provided by:
1. Great auricular nerve originates from cervical
plexus (C2–C3) and gives two branches for
the inferior half of the auricular pavilion.
2. Minor occipital nerve originates from cervical
plexus and innervates the superior one third of
the pavilion.
3. Arnold’s nerve originates from vagus nerve
and innervates the concha and the external
auditory meatus (Ramsay-Hunt area).
4. Auriculotemporal nerve originates from the
mandibular nerve (branch of the trigeminal
nerve) and innervates the ascending portion of
the antihelix and tragus.
Anatomical Considerations
in Auricular Deformities
Angles between the auricular pavilion and the
skull are expressed by codi fi ed values, whose

273
26 Anterior Scoring of the Upper Helical Cartilage
knowledge may suggest which surgical treatment
is most indicated.
There are three angles that we consider during
the clinical evaluation of an auricular pavilion:
1. Cephaloconchal angle is delimited between
two lines, one which passes through the
mastoid bone and the other one runs tangen-
tial to the concha. Normal values are
included between 80° and 90°. Malformations
occur when this value is increased for more
than 10°.
2. Scaphoconchal angle is delimited by the inter-
section of the conchal and the scaphal planes,
which rules the angulation of the helix on the
antihelix. Normal values are included between
85° and 90°. In “loop deformities” this angle
may be more than 150°.
3. Cephaloauricular angle is described as the
space between the mastoid bone and the pos-
terior aspect of the auricular pavilion. Normal
values are included between 20° and 30°. An
increase in this angle of more than 10° causes
an aesthetic deformity.
Anesthesia
A peripheral nerve block of the auricular pavilion
is performed together with a direct intraconchal
in fi ltration (Ramsay-Hunt area) with 0.5 % bupi-
vacaine with 1:200,000 epinephrine. No sedation
is required for the adult patients, whereas it is
necessary for pediatric patients. The patient
should be positioned in a comfortable supine
position in order to facilitate the procedure.
The procedure consists of three different steps:
1. After an accurate disinfection of the area, the
needle is inserted at the level of the superior
otobasion and then is pushed toward the tragus.
After a progressive in fi ltration of the local anes-
thetic, the needle is retracted, but not disinserted
from the skin, and is pushed backward along
the superior portion of the cephaloauricular sul-
cus, and another in fi ltration is performed.
2. Once the superior aspect of the pavilion is
blocked, the needle is inserted at the level of
the inferior otobasion and then is pushed
upward along the caudal aspect of the cepha-
loauricular sulcus. After a progressive
in fi ltration of the local anesthetic, the needle
is retracted, but not disinserted from the skin,
and is pushed forward to the tragus, and
another in fi ltration is performed.
3. The needle is inserted directly in the Ramsay-
Hunt area, and the local anesthetic is in fi ltrated.
The peripheral block of the auricular pavilion
is easy to perform. The only trap could be repre-
sented by the accidental cannulation of the
super fi cial temporal artery. If this happens, a fast
disinsertion of the needle and a mechanical com-
pression for at least 30 min should be performed.
The in fi ltration must not be performed without
previous aspiration, in order to check directly if
the needle is positioned inside a vessel.
Surgical Technique [ 1 ]
The concept of otoplasty concerns hundreds of
different techniques. This means that there is not
a single standard surgical procedure. Anyway,
inside this wide technical reservoir, three differ-
ent groups could be de fi ned: the “cartilage-
incision” procedures, the “suture-placement”
procedures, and the “combined” procedures.
Scoring of the anterior surface of the auricular
cartilage represents one of the most common tech-
niques in otoplasty. The authors have reported a
further re fi nement to the Chong-Chet anterior scor-
ing technique [ 2 ] , which involves anterior scoring
of the upper helical cartilage to correct helical
radix upper prominence and prevent postoperative
residual deformity. The principle is the same: the
restoration of the antihelix fold by incising the car-
tilage trough by anterior scoring technique.
The patient is positioned in a supine fashion
with the head lying on a silicone ring in order to
prevent the deformation of the auricular pavilion
by the weight of the skull. With pressure applied
medially to the prominent helix by fi ngers, the
ideal missing antihelical fold is created on the
anterior aspect of the auricular pavilion, and then
three dots are drawn on a line on the posterior
auricular cartilage and skin by passing three 21 G
needles dipped in methylene blue through the car-
tilage on an imaginary line between the helix and
the future antihelix (Fig. 26.1 ). This line indicates
the point in which the cartilage will be incised.

274
C. Rubino et al.
A 3 cm clepsydra-shaped strip of skin is
excised from the posterior aspect of the auricu-
lar pavilion between the free edge of the pinna
and the cephaloauricular angle (Fig. 26.2 ). Soft
tissues are removed also, and the underlying
cartilage is exposed. Posterior undermining
of the remaining soft tissues is performed in
order to expose the blue dots on the cartilage
(Fig. 26.3 ). Cartilage then is incised from
the superior antihelical crus to the tail of the
future antihelix. Skin and soft tissues from
the anterior aspect of the pavilion are now
detached from the cartilage which is rotated
back after the creation of a cartilaginous fl ap by
prolonging the incision in a conchal direction
(Fig. 26.4 ).
The back-rotated anterior surface of the carti-
lage is weakened by scoring it with parallel and
cross-hatched cuts; in this way the cartilage folds
spontaneously (Fig. 26.5 ). The newly restored
antihelix is then fi xed by two 4/0 white Vicryl
rolling sutures in its upper and lower parts (an
extra suture could be placed in the middle part if
necessary).
A small portion of soft tissues on the upper
anterolateral aspect of the radix of the helix
prominent area is undermined without cartilage
exposure on a line which is a direct continuation
of the neo-antihelix on the upper helix cartilage
to weaken also a part of the helix curve. This area
is weakened by anterior scoring in the antihelical
area (Fig. 26.6 ). The skin closure is performed by
four nonabsorbable 4/0 horizontal mattress
stitches, whereas the inferior part of the skin is
left not sutured for 0.5 cm of length (Fig. 26.7 ).
Fig. 26.2 A 3 cm clepsydra-shaped strip of skin is
excised from the posterior aspect of the auricular pavilion
between the free edge of the pinna and the cephaloauricu-
lar angle
Fig. 26.1 With pressure applied medially to the promi-
nent helix by fi ngers, the ideal missing antihelical fold is
created on the anterior aspect of the auricular pavilion,
and then three dots are drawn on a line on the posterior
auricular cartilage and skin by passing three 21 G nee-
dles dipped in methylene blue through the cartilage on an
imaginary line between the helix and the future
antihelix

275
26 Anterior Scoring of the Upper Helical Cartilage
The procedure could be bilateral or monolat-
eral depending on the clinical case.
The ears are dressed by stuf fi ng of the triangu-
lar fossa, concha, and scapha with nonadherent
gauze, which is placed also on the suture line on
the posterior aspect of the pavilion. A cotton
wool piece covers both the ears, and dry gauze
covers the cotton. An elastic bandage holds the
dressing in place for 7 days. Early postoperative
check should be performed after 3 days.
Discussion
The authors have treated 36 patients affected by
prominent ears with bilateral otoplasty using
anterior scoring of the upper helical cartilage.
These patients were followed with regard to the
fi nal outcome (residual upper third prominence
or recurrence) and occurrence of complications.
An antimicrobial prophylaxis with amoxicillin
and clavulanic acid was administered orally to all
the patients. Follow-up was at 3, 7, and 15 days
and then 3, 6, and 12 months after surgery. No
postoperative complications occurred, except for
physiological mild ecchymosis due to the proce-
dure. None of the patients developed postopera-
tive hematoma, infection, or hypertrophic scars.
No residual or recurrent prominence of the ear/of
the upper third or cartilage irregularities at the
last follow-up control.
Elasticity and memory are most representative
features of the auricular cartilage. The anterior
scoring technique described by Chong-Chet in
1963 [ 2 ] alters these two characteristics and
controls the degree and the fi nal position of the
antihelical fold. An 8 % of residual cartilage defor-
mity treated with this procedure has been described
in literature [ 3 ] . Intraoperative undercorrection is
responsible for this kind of complication [ 4 ] .
The cartilage of the upper third of pinna is
likely to have more memory than the middle
Fig. 26.3 With the soft tissues removed and the underly-
ing cartilage exposed, posterior undermining of the
remaining soft tissues is performed in order to expose the
blue dots on the cartilage
Fig. 26.4 Skin and soft tissues from the anterior aspect
of the pavilion are detached from the cartilage that is
rotated back after the creation of a cartilaginous fl ap by
prolonging the incision in a conchal direction

276
C. Rubino et al.
third; in fact, residual deformities are more
common in the pinna than in other components
of the pavilion. To prevent this late complica-
tion, the authors use the Chong-Chet modi fi ed
technique [ 5 ] associated with anterior scoring of
the upper helical cartilage. This means that it is
necessary to cut the cartilage up to a few
millimeters from the helical rim (without
interrupting it) in order to harvest a cartilage
fl ap that simulates the antihelix. This fl ap also
reduces the height of the concha. The correction
of the upper helical prominence with one or two
sutures between the helix and the antihelix, as
described by Mustarde [ 6 ] , does not really
weaken the cartilage, but it just bends the apical
part of the pinna leading to a higher risk of
undercorrection or recurrence of the deformity.
Our re fi nement is based on the principles
described by Gibson and Davis [ 7 ] .
The authors perform anterior scoring of the
radix of the helix, weakening a part of the cartilage
usually left untouched by other techniques.
Fig. 26.5 The back-rotated anterior surface of the carti-
lage is weakened by scoring it with parallel and cross-
hatched cuts; in this way the cartilage folds spontaneously
Fig. 26.6 A small portion of soft tissues on the upper ante-
rolateral aspect of the radix of the helix prominent area is
undermined without cartilage exposure on a line which is a
direct continuation of the neo-antihelix on the upper helix
cartilage to weaken also a part of the helix curve. This area
is weakened by anterior scoring in the antihelical area
Fig. 26.7 The skin closure is performed by four nonab-
sorbable 4/0 horizontal mattress stitches, whereas the
inferior part of the skin is left not sutured for 0.5 cm of
length

277
26 Anterior Scoring of the Upper Helical Cartilage
This procedure leads to a complete correction
of prominent ears, avoiding the suturing of the
cartilage. This re fi nement could be used in the
management of the recurrent deformities after
primary correction or even in the management of
deformities due to an incomplete development of
the antihelix (Fig. 26.8 ).
Conclusions
The authors’ re fi nement in combination with
classic otoplasty techniques may prevent
upper third prominence and may be useful in
secondary procedures. The technique is safe,
fast, and easy to perform, adding more or less
5 min to the standard procedure. It gives good
and reproducible aesthetic results with no
complications.
References
1. Rubino C, Farace F, Figus A, Masia DR. Anterior scor-
ing of the upper helical cartilage as a re fi nement in aes-
thetic otoplasty. Aesthetic Plast Surg. 2005;29(2):
88–93.
2. Chongchet V. A method of antihelix reconstruction. Br
J Plast Surg. 1963;16:268–72.
3. Calder JC, Naasan A. Morbidity of otoplasty: a review
of 562 cases. Br J Plast Surg. 1994;47(3):170–4.
4. Jeffrey SL. Complications following correction of
prominent ears: an audit review of 122 cases. Br J Plast
Surg. 1999;52(7):588–90.
5. Pancrazi E, Campus GV, Rubino C. Correzione delle
orecchie ad ansa con la tecnica di Chongchet modi fi cata.
Riv Ital Chir Plast. 1999;31:35–9.
6. Mustarde JC. The correction of prominent ears using
simple mattress sutures. Br J Plast Surg. 1963;16:170–8.
7. Gibson T, Davis WB. The distortion of autogenous car-
tilage graft: its cause and prevention. Br J Plast Surg.
1958;10:257–74.
a
b
Fig. 26.8 ( a ) Preoperative. ( b ) Postoperative

279
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_27, © Springer-Verlag Berlin Heidelberg 2013
27
Introduction
Corrective otoplasty is a commonly performed
procedure aiming at changing the shape of the
auricular cartilage to decrease the lateral projec-
tion of the auricle (Fig. 27.1 ). Many techniques
use anterior scoring of the cartilage to take advan-
tage of the natural tendency of the cartilage to curl
in a direction opposite to the side weakened [ 1– 4 ] .
The depth of the scoring varies with the thickness
of the cartilage, and it has proven particularly
helpful in cases where the cartilage is thick and
dif fi cult to handle with suture techniques. There
are many published methods to access and score
the anterior surface of the ear cartilage through an
anterior or a posterior approach, ranging from a
limited exposure combined with suture techniques
(cartilage sparing) to a wide exposure of the ante-
rior surface of the cartilage and scari fi cation under
direct vision. Scoring of the cartilage can be
achieved with partial-thickness incisions done
with a blade, a needle, toothed forceps, or even
abrasion with a rasp or a burr/obrader .
Review of Surgical Techniques
1. Combined Techniques with “Minimal Access”
Anterior Cartilage Scoring. Anterior scoring or
weakening of the auricular cartilage can be
achieved with a limited anterior skin incision
(Fig. 27.2 ): small incisions either in the scapha
or along the edge of the helix are done where the
superior crus of the antihelix is anticipated
[ 5– 8 ] . With these techniques, a periosteal elevator
or curved scissors are inserted to create a small
tunnel to allow the insertion of a rasp, an abrader,
a toothed forceps, or a needle that will be used
to make the scari fi cations to weaken the carti-
lage of the antihelix without direct vision. The
thickness of the scari fi cations may be dif fi cult to
assess. Other authors [ 2, 5, 9– 13 ] use a posterior
skin incision and access the anterior aspect of
the cartilage via an incision at the lower aspect
of the ear in the antitragohelicine fi ssure. An
elevator or scissors are then used to create the
tunnel on the anterior surface of the cartilage for
the scari fi cations (Fig. 27.3 ). The majority of
these authors use permanent sutures with the
scoring/weakening of the cartilage to maintain
the desired fold of the antihelix.
2. Anterior Scoring with Wide Exposure of the
Anterior Surface of the Cartilage. Erol [ 14 ] uses
an anterior skin incision in the concha (Fig. 27.2 ).
This incision serves two purposes: it allows a
resection of cartilage with or without anterior
skin to lower the concha, and it provides access
to elevate the anterior skin/perichondrium fl ap
on the antihelix area to facilitate the scari fi cations/
L. Caouette-Laberge , M.D. (*) • P. Bortoluzzi , M.D.
Division of Plastic Surgery , CHU Sainte-Justine ,
3175, Cote Sainte-Catherine, Room 7907 ,
Montréal (Québec) H3T 1C5 , Canada
University of Montreal ,
Montréal (Québec) , Canada
e-mail: caouette-laberge@umontreal.ca,
louise_laberge@ssss.gouv.qc.ca ;
patricia_bortoluzzi@ssss.gouv.qc.ca
Anterior Scoring Technique
in Otoplasty
Louise Caouette-Laberge and Patricia Bortoluzzi

280
L. Caouette-Laberge and P. Bortoluzzi
abrasions under direct vision. More authors
make a posterior skin incision combined with a
transcartilaginous incision (Fig. 27.4 ) to gain
access to the anterior surface of the ear cartilage
[ 15– 22 ] . The lower limit of this incision is often
the antitragohelicine fi ssure, and it continues
superiorly in the scapha, to different extents
depending on the technique. Some continue this
transcartilaginous incision to the superior crus
of the antihelix [ 16, 17, 21 ] or to the fossa trian-
gularis [ 19, 20 ] . Others continue to section the
helix either at the level of the superior crus of
the antihelix 18 or beyond at the origin of the
helix [ 15, 22 ] . With these techniques, the skin
with or without the perichondrium is lifted from
the cartilage widely to expose the antihelix and
the superior portion of the concha. The cartilage
incision does not lie on the antihelical fold but
rather at the periphery of the antihelix in the
scapha. Partial-thickness cartilage incisions
(scari fi cations, scoring) or abrasions (obrader,
rasp) are done in a vertical or curved direction to
obtain folding of the superior crus of the antihe-
lix either unidirectionally (vertical scoring) or
bidirectionally (curved scoring). Some authors
add sutures to maintain the antihelix in this cor-
rected position [ 20 ] .
Author’s Preferred Method
Preoperative Evaluation
Preoperatively the ear is examined from the
frontal view. It is important to recognize that
the distance between the auricle rim and the
Superior crus antihelix
Triangular fossa
Lower crus antihelix
Root of helix
Tragus
Antitragus
Helix
Scapha
Antihelix
Concha
Antitragohelicine fissure
Cauda helicis
Fig. 27.1 Nomenclature of
the ear components
Elliott
Spira
Kelley
Burstein
Onur erol
Fig. 27.2 Anterior skin incisions to access the anterior
surface of the cartilage

281
27 Anterior Scoring Technique in Otoplasty
cranium and mastoid area varies with the age of
the patients. It is not uncommon to see an adult
with normal projection of the auricle from the
frontal view and very little retroauricular space
due to a large mastoid. Another important fact is
that the proportion of the ear to the face is dif-
ferent in 7-year-old children since the ear
reaches near-normal adult size in children well
before the age of 7, while the lower face matures
at the end of puberty. Therefore, the ear is more
noticeable in a young child, particularly if the
ears are large and the face is narrow. If the shape
of the ear and the frontal projection are normal,
the parents should be reassured that the ear will
progressively “ fi t” the child’s face, and aggres-
sive reduction of the lateral projection of the ear
will make the child look strange as he grows
older. An excellent description of the “normal
ear” projection and measurements was pub-
lished by Kelly et al. [ 7 ] .
During the preoperative evaluation, the child
is asked to stand in front of a mirror while the
parents stand behind to observe the change in the
shape of the ear that is proposed with the surgery.
It is important that everyone understands
the necessity to preserve lateral projection of the
auricle, with the newly formed antihelix, the
helix, and lobule on a straight line, and the mid-
dle third of the auricle as the most projecting part
of the ear. Families are asked to notice the ret-
roauricular space that is necessary to obtain nor-
mal frontal projection in a young child.
Antitragohelicine fissure
Anterior
aspect
Posterior aspect
Hoehn
Stenstrom
Dingman
Elliott
Schlegel-Wagner
Yugueros
Fig. 27.3 Posterior access
through the antitragohelicine
fi ssure to the anterior surface
of the cartilage
Chongchet
Tolhurst
Crikelair
Chait
Tamerin
Caouette-Laberge
Nordzell
Fig. 27.4 Location of transcartilaginous incisions to
expose anterior surface of the cartilage

282
L. Caouette-Laberge and P. Bortoluzzi
It is also a good time to point out any asymme-
try in size or shape of the ears and explain what
features of the ear will be corrected with the proce-
dure and what will not (e .g., asymmetry in size). It
is however more dif fi cult to detect asymmetry after
the surgery because of a lesser degree of lateral
projection; both ears are not so easily visible and
comparable from the frontal view. Irregularities of
the helix and the presence of a Darwin’s tubercle
are also discussed so that the parents have realistic
expectations and understand better the limitations
of the procedure. Minor helical irregularities are
often best left alone since they become less notice-
able postoperatively when the helix is not facing
anteriorly. If Darwin’s tubercle is to be removed, a
separate skin and cartilage resection on the helical
rim is necessary. The scar is usually very discrete.
The presence of an accessory fold of the antihe-
lix (Stahl’s ear) (Fig. 27.5 ) produces an irregular-
ity of the helix (unfolding) that should also be
discussed as it often persists even after correction
of the antihelix. It may be improved with a wedge
resection of the helix at the cost of an additional
scar. Constricted ears (cup ear deformities) may
have a de fi cient or absent lower crus of the antihe-
lix and absent fossa triangularis. Again, pointing
this to the parents before the surgery will help
them understand the shape of the newly formed
antihelix with the de fi cient fossa triangularis post-
operatively. It is important to recognize the pres-
ence of a preauricular sinus because the surgical
technique used requires a sharp section of the root
of the helix. Given the dissection in this area, the
presence of a preauricular sinus and underlying
cyst increases the risk of infection, and the sinus
should be removed completely before undertaking
the otoplasty. The authors often combine the two
surgeries in the same setting but suggest that anti-
biotics be used in these selected cases.
The concha may also be prominent and pro-
duce a marked elevation of the middle third of the
auricle. It is often due to the fact that the concha
is missing the normal fold that is present where
the concha meets the scapha in the middle third
of the ear [ 6 ] . Finally the shape and position of
the lobule is assessed. When a large bulky lobule
is present, one should be particularly hesitant to
lower the middle one-third of the ear because it
does easily produce a more conspicuous lobule.
It is also particularly important in these cases to
keep the lobule at the same level than the rest of
the ear, so it is not visible from the frontal view.
This privileged time in front of the mirror with
the child and family gives the surgeon a good
idea of the child’s motivation and cooperation for
the surgery. The procedure can be performed
under local anesthesia without any sedation in a
5- or 6-year-old child who is motivated since the
total duration of the procedure including anesthe-
sia is generally under 1 h.
Surgical Technique
The parents are requested to wash the patient’s
hair and auricle with particular care the day
Fig. 27.5 Accessory fold of the antihelix (Stahl’s ear)
produces an irregularity of the helix (unfolding)

283
27 Anterior Scoring Technique in Otoplasty
before surgery. No antiseptic soap is used. The
surgery is done in day surgery under local or gen-
eral anesthesia as requested by the parents and
depending on the cooperation of the child.
Antibiotics are not given routinely. In the operat-
ing room, the face is prepped with chlorhexidine-
aqueous solution, and the auricular area and scalp
are prepped with Betadine except for the children
done under local anesthesia where chlorhexidine-
aqueous solution alone is used for all areas
prepped. A head drape is placed, leaving both
ears and face exposed. It is particularly important
not to cover the patient’s face when working
under local anesthesia to keep a good contact
with the patient and alleviate any potential anxi-
ety with having the face covered. The ears are
then in fi ltrated with Xylocaine 1 % with epineph-
rine 1/100,000. A total of less than 10 cc is
used for both ears. The same in fi ltration is done
whether the surgery is under local or general
anesthesia. This hydrodissection (Fig. 27.6 ) facil-
itates the procedure and lessens the bleeding.
A 30-gauge needle and a very slow in fi ltration of
anesthetic are particularly helpful in children
who often do not feel the needle prick but
rather the tissue distension from the in fi ltration.
A 3.5 cm posterior auricular incision is located
1 cm from the helical rim (Fig. 27.6 ) so that it lies
in the concavity created by the antihelical fold
and therefore is hidden.
No skin excision is done. It is not necessary to
excise skin to control the cartilaginous correction
of the auricle. Very little skin undermining is
done on the posterior aspect of the ear since the
skin incision lies close to the proposed transcarti-
laginous incision (Fig. 27.7 ). This lessens the risk
of postoperative hematoma. The cauda helicis
and the antitragohelicine fi ssure are located, and
a transcartilaginous incision is made in the
scapha, parallel to the border of the helical rim
superiorly into the upper one-third of the auricle
(Fig. 27.6 ). It can be useful to mark the location
of the scapha from the anterior surface of the ear
with tattoo marks that will allow easy location of
the transcartilaginous incision on the posterior
surface of the cartilage. Access to the anterior
surface of the concha and antihelix is then pro-
vided (Fig. 27.6 ) by elevation of the anterior skin
and perichondrium using a periosteal elevator
and continued with scissors in the upper portion
of the antihelix (Fig. 27.6 ). It is important to
make this dissection deep to the perichondrium
where there is a relatively avascular plane, ensur-
ing minimal bleeding and preserving the blood
supply to the skin. The use of the cautery is sel-
dom needed. Very little dissection is required in
the concha since only modest reduction of the
conchal height is necessary (often no reduction is
done). The incision between the helical rim carti-
lage and the antihelix cartilage is continued sub-
cutaneously with scissors up to the origin of the
helix maintaining a constant helical width
(Fig. 27.6 ). The section of the origin of the helix
is mandatory (Fig. 27.7 ) if the helical rim is to
follow the posterior rotation of the antihelical
fold which will be created. The helical cartilage
becomes like a “handle” that can freely follow
the new position of the antihelix and, because it is
completely sectioned, it does not tend to “spring
back” anteriorly and cause protrusion of the
upper one third of the auricle.
After the section of the origin of the helical car-
tilage, the skin and perichondral elevation on the
anterior surface of the antihelix and triangular fossa
is completed the antihelical cartilage is completely
exposed up to its origin (Fig. 27.6 ) and scari fi cations
consisting of partial-thickness cartilage incisions
(scoring) are then done with a number 15 blades
(Figs. 27.7 and 27.8 ). The directions of these inci-
sions are important in order to have a normal
appearing “fan-shaped” antihelix that will curve
both superiorly and posteriorly (Fig. 27.6 ). These
partial-thickness incisions are bidirectional, the
fi rst following the curvature of the newly formed
antihelical fold allows for the posterior curvature
of the cartilage where the concha reaches the
scapha and the second fan-shaped perpendicular
ones that meet at the middle third of the ear, allow-
ing for anteroposterior roundness, particularly
superiorly. At the very caudal part of the newly
formed antihelix, the incision is full thickness so
that the cartilage can be folded sharply upon itself
at the appropriately chosen conchal height
(Figs. 27.6 and 27.8 ). This can effectively correct
any conchal excess. Care should be taken to avoid
lowering excessively the height of the concha at

284
L. Caouette-Laberge and P. Bortoluzzi
Fig. 27.6 Operative procedure: ( a , b ) Hydrodissection. ( c )
3.5 cm posterior auricular incision. ( d , e ) The cauda helicis and
the antitragohelicine fi ssure are located, and a transcartilagi-
nous incision is made in the scapha, parallel to the border of the
helical rim superiorly into the upper one-third of the auricle. ( f )
Access to the anterior surface of the concha and antihelix is
then provided. ( g , h , i ) Access to the anterior surface of the
concha and antihelix is then provided. ( j , k , l ) The incision
between the helical rim cartilage and the antihelix cartilage is
continued subcutaneously with scissors up to the origin of the
helix maintaining a constant helical width. ( m ) The antihelical
cartilage is completely exposed up to its origin. ( n ) The direc-
tions of the incisions are important in order to have a normal
appearing “fan-shaped” antihelix that will curve both superi-
orly and posteriorly. ( o ) At the very caudal part of the newly
formed antihelix, the incision is full thickness so that the carti-
lage can be folded sharply upon itself at the appropriately
chosen conchal height. ( p , q ) Two sutures of 5-0 plain catgut
are used to keep the sharp fold of the caudal end of the new
antihelix and to insure a smooth cartilage shape in this area
where the overlying skin is particularly thin and any cartilage
irregularity will be noticeable. ( r ) The lobule’s position is con-
trolled by fi xing the cartilage of the cauda helicis posteriorly
behind the conchal cartilage. ( s ) The skin is then closed with a
running horizontal mattress 5-0 plain catgut. ( t ) The skin is
carefully molded on the cartilage framework, and a 5-0 plain
gut suture is inserted percutaneously from the fossa triangu-
laris to the scapha to prevent any anterior displacement of the
helical rim. ( u ) Dressing is then applied, starting with one thin
gauze covered with Xeroform dressing in the posterior auricu-
lar sulcus. ( v ) A moistened elongated gauze is placed to con-
form the concha, fossa triangularis, and scapha. ( w ) Fluffed
and Kling gauze complete the dressing. ( x ) Fluffed and Kling
gauze is usually left in place for 7–10 days
a
b
d
f
e
c

285
27 Anterior Scoring Technique in Otoplasty
g
h
j
l
k
i
Fig. 27.6 (continued)

286
L. Caouette-Laberge and P. Bortoluzzi
q
r
p
n
m
o
Fig. 27.6 (continued)

287
27 Anterior Scoring Technique in Otoplasty
w
u
s
t
v
x
Fig. 27.6 (continued)

288
L. Caouette-Laberge and P. Bortoluzzi
A
S
H
CH
a
b
Fig. 27.7 ( a ) Location of
transcartilaginous incision
( red dotted line ) H helix,
S scapha, A antihelix, CH
cauda helicis (encircled
section of the root of helix).
( b ) Orientation of the
partial-thickness scoring
incisions on the anterior
aspect of the auricular
cartilage
A
S H
CH
a
A
S H
CH
H
S
A
H
S
A
H
S
C
H
S
C
b
Fig. 27.8 ( a ) Upper third: partial-thickness cartilage
scoring creating a regular antihelical fold. ( b ) Sharp fold
of cartilage ( green arrow ) at the junction of antihelix and
scapha. A antihelix, CH cauda helicis, H helix, S scapha
with cartilage section

289
27 Anterior Scoring Technique in Otoplasty
this point. Once these cartilaginous incisions are
done, the cartilage should stay in the desired posi-
tion without the help of any suture material since
its natural elasticity and intrinsic memory have
been overcome. Two sutures of 5-0 plain catgut
(Fig. 27.6 ) are used to keep the sharp fold of the
caudal end of the new antihelix and to insure a
smooth cartilage shape in this area where the over-
lying skin is particularly thin and any cartilage
irregularity will be noticeable. When necessary,
the antitragus can easily be exposed and lowered.
The helical rim and anterior skin fl ap are then
returned to their original position, and the projec-
tion of the lobule is examined. The lobule is promi-
nent in most cases. Its position is controlled by
fi xing the cartilage of the cauda helicis (Fig. 27.6 )
posteriorly behind the conchal cartilage. A limited
undermining of the skin is done on the anterior
aspect of the cauda helicis to preserve the contact
between the cauda helicis and the anterior lobule
skin. The posterior aspect of the concha is exposed,
and a 5-0 plain catgut suture is used to secure the
cauda helicis to the conchal cartilage producing a
posterior and superior transposition of the cauda
helicis. It is not necessary to place a nonresorbable
suture. Occasionally, in constricted ears with a
small helical circumference, it is necessary to use a
suture that will be retained longer, such as a 5-0
Maxon (Davis & Geck). One notices at this point
that the more prominent lobule being set back tends
to produce an elevation of the upper one-third of
the helical cartilage (i.e., with one structure in con-
tinuity, lowering one end will elevate the other)
(Fig. 27.9 ). When this is the case, it is necessary to
interrupt the continuity of the helical cartilage.
This is done by removing a 2–3 mm closing wedge
a
b
d
c
Fig. 27.9 ( a ) C-shaped helix with upper and lower third
prominence. ( b ) Lowered cauda helicis behind the concha
(upper third prominence). ( c ) A 3 mm closing wedge of
cartilage is resected immediately above cauda helicis. ( d )
Resulting straight helix

290
L. Caouette-Laberge and P. Bortoluzzi
of cartilage immediately above the cauda helicis
(Fig. 27.9 ) where the anterior skin is thickened
with subcutaneous tissue. This discontinuity in the
inferior helix allows posterior and superior posi-
tioning of the lobule without elevation of the rest of
the helix giving a harmonious redraping of the
helix around the antihelix (Fig. 27.9 ). The skin is
then closed with a running horizontal mattress 5-0
plain catgut (Fig. 27.6 ). No skin is excised.
Although there may be an apparent skin excess
particularly in the lower third, it will rapidly fl atten
and leave an inconspicuous scar. One should never
rely on skin to correct the ear shape. Skin excision
in an attempt to correct inadequate cartilaginous
remodeling will only lead to recurrent deformity.
At the completion of the procedure, the skin is
carefully molded on the cartilage framework, and a
5-0 plain gut suture is inserted percutaneously from
the fossa triangularis to the scapha to prevent any
anterior
displacement
of
the
helical
rim
(Fig. 27.6 ).
The dressing is then applied, starting with one
thin gauze covered with Xeroform dressing in the
posterior auricular sulcus (Fig. 27.6 ) and one
moistened elongated gauze to conform the con-
cha, fossa triangularis, and scapha (Fig. 27.6 ).
Care is taken to ensure that this conforming gauze
does not cross any auricular prominences but
remains in the depths of the new concha and
scapha so as not to cause any pressure wounds on
the vulnerable undermined skin. Fluffed and
Kling gauze complete the dressing (Fig. 27.6 ),
which is usually left in place for 7–10 days
(Fig. 27.6 ). Routine analgesics (acetaminophen
and codeine) are used only during the fi rst 12–24
h. The parents are advised to return for evaluation
should the pain require any medication after this
time. Complications such as hematoma, infec-
tion, or necrosis can be diagnosed early when
unusual pain is present, and the dressing is then
removed for early ear inspection. The parents are
also advised to return should the dressing be
displaced.
The dressing is removed 7–10 days after the
surgery, and parents are requested to wash the
hair and auricle. Antibiotic ointment is placed on
the remaining resorbable 5-0 plain gut sutures
daily for 1 week, and the parents are instructed to
rub off the sutures to help dissolution. No dress-
ing or headband is used after dressing removal,
but the use of a nightcap, often the Lycra swim-
ming caps, is recommended for a week. Some
ecchymosis and edema may be present for the
following week, and de fi nitive result is usually
obtained after 3 months (Fig. 27.10 ). Sports
including swimming are permitted after dressing
removal with the exception of contact sports.
Helmet protection is then suggested.
Complications
Five hundred cases were operated on with this
technique [ 22 ] and evaluated to assess the com-
plication rates. When compared with other series,
the complication rates were similar or lower in
our study. The early complications were bleed-
ing (2.6 %) and hematoma (0.4 %). There were
no infections or ear necrosis. A 2–3 mm cutane-
ous wound was present on the anterior skin in
three patients (0.6 %), and there was one wound
dehiscence (0.2 %). Late complications were
keloids in two cases and inclusion cysts in three
cases. Residual deformity was noted in 22 cases
(4 %) and asymmetry in 28 cases (5.6 %).
Secondary surgery was performed in six cases.
A long-term follow-up was obtained through a
questionnaire answered by 77.4 % of the patients
2–5 years after the surgery. The satisfaction rate
was 94.8 % even if 18.4 % of the patients were
able to see some degree of residual asymmetry.
Some patients (7.5 %) found the ear more sensi-
tive to touch or cold, while 3.9 % found their ear
less sensitive to touch. No permanent sutures are
used with this technique since the natural elastic-
ity of the cartilage has been overcome. This
inherently eliminates any risks of chronic sinuses
or loss of correction as previously reported with
permanent suture techniques [ 23– 30 ] . There is
no need for overcorrection since there is no
relapse as may happen after a suture correction
technique [ 24 ] . This technique also has the
advantage of giving access to all areas of the ear
and therefore can be used for many different
forms of ear anomalies.

291
27 Anterior Scoring Technique in Otoplasty
a
c
b
Fig. 27.10 ( a ) Preoperative. ( b , c ) Postoperative

292
L. Caouette-Laberge and P. Bortoluzzi
Avoidable Technical Pitfalls
in Otoplasty
Prominent Upper Third (Helix)
This deformity can occur if the section of the root
of the helix (Fig. 27.7 ) is not complete so that
helix can freely follow the antihelical fold.
Rubino [ 31 ] does not section the root of the helix
as we propose but rather makes scari fi cations on
the helical cartilage at this level. Calder [ 17 ] cau-
tions against a section of the helix because of the
risk of producing a pointed squared ear; this can
be seen if the helix is sectioned at the level of the
superior crus of the antihelix, but not when the
section is done at the level of the root of the helix
as in our technique. Some authors correct the
prominent upper third by adding a suture from
the root of the helix to the temporalis fascia
(Hatch suture) [ 7, 32 ] through the posterior inci-
sion or another incision at the root of helix.
Another reason to have a prominent upper
third is a misplaced transcartilaginous incision
that leaves a wide rim of cartilage on the helix
and too little cartilage to create the normal anti-
helix [ 17 ] . In so doing, the superior crus of the
newly created antihelix is too small to make a
complete fold, and the wide cartilage of the anti-
helix cannot hold posteriorly since the antihelical
fold is de fi cient (Fig. 27.11 ). To correct this
deformity, a strip of cartilage has to be removed
from the helix and sutured to the antihelix to
restore the normal anatomy.
It is also possible to see a protruding upper third
due to an anterior dislocation of the helical carti-
lage (Fig. 27.11 ). To prevent this deformity we now
A
S
A
A
S
H
CH
a
H
H
S
b
H
S
A
H
S
A
Fig. 27.11 Prominent upper third. ( a ) Transcartilaginous
incision located too low ( blue dotted line ) below the scapha,
remaining antihelix too narrow for complete curve and helix
too wide and prominent. ( b ) Helix anterior dislocation:
faulty repositioning of helix (orange dotted lines) at the
completion of the procedure. A antihelix, H helix, S scapha

293
27 Anterior Scoring Technique in Otoplasty
routinely use a percutaneous 5-0 plain gut suture
from the triangular fossa to the scapha (Fig. 27.6 ).
If present, the deformity can be corrected by repo-
sitioning the helix and fi xing it behind the antihelix
as suggested by Nordzell [ 21 ] .
Narrow Ear
Reduction of the width of the auricle can be seen
when the scari fi cations or abrasions of the newly
constructed antihelix are too deep and create a
sharp fold rather than the normal fan-shaped
appearance of the antihelix (Fig. 27.12 ). It can
also be seen if the curl of the antihelical cartilage
is exaggerated (Fig. 27.12 ). The same problem
may occur if too much skin has been excised
from the posterior incision or when the sutures
used to obtain the antihelical fold are too tight.
This deformity is not easily corrected since
expanding a constricted fold is dif fi cult. Some
authors suggest the addition of a mastoid fascia
fl ap or cartilage graft [ 33 ] interposed on the pos-
terior surface of the antihelix to widen the con-
stricted antihelical fold. If there is also a shortage
of retroauricular skin, a full thickness skin graft
or mastoid skin advancement fl ap can be done.
Vertical Antihelical Fold
The superior crus of the antihelix should curve
anteriorly to obtain a normal folding of the auri-
cle in two planes bringing the superior third
closer to the temporal area and the middle third
closer to the mastoid area. When only the vertical
portion of the antihelical fold is done, with sutures
or with scoring, it creates an unnatural appearance
H
S
A
H
S
A
a
b
Fig. 27.12 Narrow ear. ( a ) Sharp fold of antihelix. ( b ) Excessive folding of antihelix reducing the transverse diameter
of the ear

294
L. Caouette-Laberge and P. Bortoluzzi
of the ear from the frontal view with protruding
upper third away from the temporal area expos-
ing this anomalous “vertical post” shape and evi-
dent triangular fossa.
Disappearing Helix
Although some authors state that the helical rim
should always be visible from the frontal view, it
is normal to fi nd that the helix slowly disappears
from the frontal view in the middle third of the
ear. However, the position of the helix should not
be too far behind the antihelix creating a deep
scapha in the middle third. To avoid this defor-
mity, the cartilage folded on itself to set the height
of the concha can be trimmed to reduce the height
of the scapha and the location of the helical rim
(Fig. 27.13 ). Aggressive retroauricular skin exci-
sion can also produce a posterior displacement of
the helix. The authors prefer not to remove any
skin during the otoplasty; it is not necessary when
the shape of the cartilage has been corrected.
Irregular Helix
The “buckled” helix is a well-documented com-
plication of suture technique corrections [ 5 ] . It
can also happen in techniques where the helix is
completely freed from the antihelix since there is
a risk of weakening of the helical cartilage and
creation of irregularities (or waves, sharp angles)
of the helical cartilage. It is particularly true in
young children with thin pliable cartilage, and
caution should be taken to preserve enough width
of helical cartilage, particularly in the presence of
a narrow area seen preoperatively. One should
also resist the temptation to reduce the size of a
large ear by excising a strip of cartilage at the
periphery of the antihelix. When the antihelix is
signi fi cantly reduced in diameter, the helical rim
becomes too wide to fi t the reduced antihelix. It
loses its normal support and can easily become
irregular. To correct this problem, an excision of
a wedge of the helical rim (skin and cartilage)
can be done.
Prominent Lobule/C-Shaped Helix
The authors agree with many authors [ 5, 24, 34– 36 ]
that the key to the position of the lobule is the
cartilage of the cauda helicis as long as the attach-
ment to the anterior skin fl ap is maintained. The
tail of the cauda helicis is transposed posteriorly
and superiorly and fi xed behind the concha carti-
lage. This creates a posterior rotation of the lob-
ule to place it in a straight line with the rest of the
auricle. It is important to observe the shape of
the helix preoperatively to predict the location of the
lobule after correction of the antihelix. When the
H
C
A
S H
CH
H
H
a
b
c
S
S
C
C
Fig. 27.13 Disappearing helix. ( a ) Location of the sharp
fold of cartilage to lower concha ( blue dotted arrow ). ( b )
Wide strip of cartilage folded behind the concha causing
a low position of the helix (disappearing helix). Cartilage
to be resected (green arrow and striations). ( c ) Position of
helical rim after cartilage resection

295
27 Anterior Scoring Technique in Otoplasty
helix has a C-shape facing anteriorly, it is natural
that after the antihelical fold is created and the
ear faces laterally, the C-shaped helix will face
laterally with protrusion of the upper third and
the lobule. As the correction of the protrusion of
the upper third is obtained (see above), the pro-
trusion of the lower third (the lobule) will only be
more prominent since it is one structure in conti-
nuity. To be able to correct this C-shaped helix,
we recommend excising a small wedge of helix,
immediately above the cauda helicis fi xed behind
the concha. This closing wedge will allow main-
tenance of the lowering of both the upper
and lower portions of the ear simultaneously
(Fig. 27.9 ).
Conclusions
Anterior scoring of the auricular cartilage in
otoplasty has been used for many decades to
create the antihelical fold. The technique the
authors use provides a wide exposure of the
anterior surface of the auricular cartilage to
weaken and remodel the cartilage so as to pro-
duce a smooth regular antihelical fold without
the addition of any permanent sutures. It also
provides a simultaneous correction of the
height of the concha. The position of the helix
is corrected by a subcutaneous section of the
root of the helix to control the prominence of
the upper third, and the cauda helicis is fi xed
behind the concha to correct the position of
the lobule. It is a versatile technique that can
be used to correct many ear deformities since
every part of the auricle is accessible. Long-
term follow-up shows that the correction
obtained is stable. The duration of the proce-
dure is generally less than 1 h, and it can be
performed under local anesthesia in children
as young as 5 years of age.
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M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_28, © Springer-Verlag Berlin Heidelberg 2013
28
Introduction
In surgical correction of prominent ears, the
Mustarde technique – a technique to fold the
antihelix – is frequently performed. The Mustarde
technique effectively reduces the prominence of the
ear and produces an antihelix. On the other hand,
the Mustarde technique has two disadvantages.
First, the contour of the helix develops irregularity
after its application. Second, antihelixes produced
with the Mustarde technique tend to present exces-
sively linear shapes compared with ordinary antihe-
lixes. The fi rst problem can be solved by softening
the scapha by scoring or thinning it. To enhance the
usefulness of the Mustarde technique, this chapter
introduces some troubleshooting methods address-
ing these disadvantages. In particular, theoretical
rationales of the troubleshooting technique for the
fi rst problem – reduction of the contour irregularity
of the helix – are minutely explained.
Morphological Pathology
of Prominent Ear
Prominent ear is the condition where the auricle
forms an excessive angle with the temporal
region. Among congenital auricular deformities,
prominent ear has the greatest incidence, with
5 % occurrence per population [ 1 ] . Prominent
ears usually occur on both sides. High incidence
in certain lineages implies genetic in fl uences in
the occurrence of the condition [ 2 ] .
Cultural differences exist in esthetic views of
prominent ears. In Asian countries, big ears are
associated with wealth, and consequently, exces-
sive prominence of the ear isn’t viewed as unfa-
vorable, as in Western countries. Hence, persons
with prominent ears do not necessarily seek treat-
ment. On the other hand, prominent ears are dis-
liked in Western countries, since the features may
be associated with demons. Consequently, the
frequency of patients seeking treatment is greater
for Western countries than in Oriental countries.
The prominence of the ear can be quantita-
tively evaluated by referring to two morphologi-
cal parameters. The fi rst parameter is the
cephalo-auricular angle – the angle between the
auricle and temporal region; the second parame-
ter is the scapho-conchal angle – the angle
between the concha and scapha. In auricles of
prominent ear patients, both of these parameters
are greater than normal [ 2 ] . Freitas [ 3 ] , in his
measurement study of these parameters in ado-
lescents and adults, reports that the cephalo-
auricular angles and scapho-conchal angles for
normal persons are 31° ± 6° and 106° ± 19°,
respectively; with prominent ear patients, these
values are 47° ± 10° and 132° ± 18°, respectively.
The difference between normal auricles and
auricles of prominent ear patients is demonstrated
in Fig. 28.1 . Because of these morphological
T. Nagasao , M.D.
Department of Plastic and Reconstructive Surgery ,
School of Medicine, Keio University Hospital ,
Shinjuku-Ward Shinanomachi 35 , Tokyo , Japan
e-mail: nagasao@sc.itc.keio.ac.jp
Prevention of Intra -Auricular
Deformity in Prominent Ear
Correction
Tomohisa Nagasao

298
T. Nagasao
abnormalities, the auricles of prominent ear
patients protrude outward, presenting an odd
impression. Furthermore, although inner struc-
tures of the auricle, such as the antihelix and con-
cha, are invisible to the frontal view with normal
persons, they are visible with prominent ear
patients, which adds to a curious impression.
Besides the positional abnormality, auricles of
prominent ear patients present two abnormal fea-
tures in terms of intra-auricular geometry
(Fig. 28.2 ). First, the antihelix is hypoplastic and
inconspicuous. Because of the hypoplasia, the
upper part of the auricle presents fl at features.
Second, the horizontal length of the auricle is
longer than normal. In performing correction for
prominent ears, not only the prominence of the
ear but also these intra-auricular abnormal fea-
tures need to be appropriately corrected.
Mustarde Technique
In surgical correction for prominent ears, two
purposes need to be achieved. First, the auricle
should be moved closer to the temporal region, so
that these two structures form a smaller angle.
Second, the antihelix needs to be reshaped to
present a more natural form.
The fi rst purpose of reduction of the auricular
prominence can be achieved to some extent by
working on the concha. The distance between the
lateral part of the auricle and the temporal region
is reduced by removing part of the concha and
suturing the defect (Fig. 28.3 ). For cases with
severe protrusion, a sizable piece of cartilage
needs to be removed from the concha. In suturing
the margins of thus-made defects, the edges of
the defect often develop unsightly contours at
their junction. Furthermore, natural-looking anti-
helixes cannot be produced by merely depending
on this maneuver.
To solve the problems with the above-stated
maneuver on the concha, Mustarde [ 4 ] invented a
technique for surgical correction of prominent
ears. The Mustarde technique, also called the “in-
suture technique,” was reported in 1962 (Fig. 28.4 ).
Although a long time has passed since the tech-
nique was initially reported, it still remains impor-
tant for the correction of prominent ears. Actual
application of Mustarde technique consists of two
or three pairs of points that are marked on the
parts of the concha where the internal edge of the
Normal ear
Prominent ear
a
b
Fig. 28.1 Prominence of the ear is de fi ned by two factors: the cephalo-auricular angle ( a ) and the scapho-conchal
angle ( b ). These angles are greater than normal in prominent ear patients

299
28 Prevention of Intra -Auricular Deformity in Prominent Ear Correction
inferior crus and exterior edge of the superior crus
are to be produced (Fig. 28.5 ). After the skin is
dissected from the auricular cartilage, threads are
introduced into the space connecting the paired
points. Threads made of nonabsorbable materials
– such as nylon – should be used for this maneu-
ver, to avoid postoperative recurrence of ear
prominence. As these stitches are tied, the paired
points approach one another, forming the antihe-
lix. After the antihelix is produced, rolled ban-
dages are applied to secure its shape. These are
removed about a week postoperatively.
Problems with Mustarde Technique
Although the Mustarde technique is an effective
and frequently used surgical method for the cor-
rection of prominent ears, it also has its share of
disadvantages. There are two main disadvantages
with the Mustarde technique. First, the contour of
the helix often develops irregularity after the
Mustarde technique is applied. A typical example
Manuever for concha
Fig. 28.2 Characteristic features of the prominent ear
Morphological etiology
Hypoplastic anti-helix
Excessive length
Fig. 28.3 Ear prominence is reduced to some extent by
removing part of the concha

300
T. Nagasao
of the irregularity is demonstrated in the left
picture of Fig. 28.6 . Because the helix is pulled
inward by the threads of the Mustarde suture, the
part of the helix indicated with the arrow presents
a concavity. As the second disadvantage, natu-
rally looking antihelixes are dif fi cult to achieve
Fig. 28.4 The Mustarde
technique. ( Left ) Sutures are
applied to the antihelix
region. ( Right ) As the threads
are tied, the auricle is folded,
enhancing the antihelix
a
b
c
d
Fig. 28.5 Actual application of the Mustarde technique. ( a ) Paired points are marked. ( b ) Threads are introduced to
connect the paired points. ( c ) The threads are tied. ( d ) Rolled gauzes are applied to maintain the shape of the antihelix

301
28 Prevention of Intra -Auricular Deformity in Prominent Ear Correction
with the Mustarde technique. Although the anti-
helix presents a smooth curvature in ordinary
ears, antihelixes produced with the Mustarde
technique often have unnaturally straight features
(Fig. 28.6 ).
Irregularity of the Helix
Biomechanical Etiology
How can the fi rst problem of irregularity of the
helix be avoided? Herein, causative mecha-
nisms for the irregularity are fi rst clari fi ed to
provide solutions to this problem. The cross-
section of the transformation pattern the auricle
presents on application of the Mustarde tech-
nique is demonstrated in the Fig. 28.7 . As the
sutures connecting the paired points are tied, a
fold appears on the auricle. Subsequently, the
sutured part of the helix is pulled inward by
the distance a in the picture. As a result of this, the
edge of the helix near the sutures collapses.
Since the antihelix, scapha, and helix form a
united entity, they are modeled as three con-
nected plates. A, S, and H in the diagrams
indicate the antihelix, scapha, and helix,
respectively. As the antihelix is folded by the
application of the Mustarde technique, the
length of the antihelix is reduced. According to
this change, the helix is pulled inward and
develops the irregularity (Fig. 28.6 ).
Prevention of Irregularity
Transmission of the dynamic effect generated in
the antihelix is the causative factor for the irregu-
larity of the helix. Hence, the irregularity is
avoided by blocking transmission of the dynamic
force from the antihelix to the helix. This can be
achieved by working on the scapha, because it
functions as the dynamic interface between the
antihelix and helix. The basic principle for this
idea is explained by referring to Fig. 28.8 . When
the Mustarde technique is applied in an ordinary
fashion, the edge of the helix is pulled inward
(Fig. 28.8 ).
However, when the scapha is softened, its
fl exibility increases. Accordingly, even when the
antihelix is folded by the application of the
Mustarde technique, the transformation is
absorbed in the scapha and is smoothly transmit-
ted to the helix (Fig. 28.8 ). The difference in the
movement presented by the helix in response to
the Mustarde technique is demonstrated in the
Fig. 28.6 Problems with the
Mustarde technique are
indicated with arrows . ( Left )
Irregularity of the helix
contour. ( Right ) Unnaturally
linear antihelix

302
T. Nagasao
lower row pictures of Fig. 28.8 , where a ¢ is
smaller than a .
Softening of the scapha is achieved by scoring
it or by abrading it. Scoring is the maneuver of
making slits on the surface of the cartilage, which
can be performed with a scalpel [ 5, 6 ] ; abrasion is
the maneuver of thinning the cartilage using
operative devices such as diamond bars [ 2, 7, 8 ] .
These techniques, originally developed for the
purpose of preventing postoperative recurrence
of ear prominence (Fig. 28.9 ), are usually per-
formed after the surface of the auricular cartilage
is exposed by separating it from the overlying
skin. However, if needles are used instead of scal-
pels, scoring can be achieved without exposing
the cartilage [ 9 ] . Similarly, abrasion can be per-
formed under endoscopic observation without
exposing the auricle [ 10 ] .
Experimental Evaluation
of the Method’s Effectiveness
The effectiveness of scapha softening in reduc-
ing the helix irregularity in response to the
Mustarde technique is theoretically proven by
means of computer simulation in the author’s
previous study [ 11 ] . Herein, the essence of the
study is introduced.
First, the basic principles for the study’s
method are explained, referring to an example
problem of dynamic transformation of boards in
response to application of forces (Fig. 28.10 ).
When material properties such as thickness and
hardness of this board are available, the trans-
formation pattern this board presents in response
to a certain force can be predicted by perform-
ing a relatively simple dynamic calculation.
a
A
S
H
a
A
S
H
Interaction of helix and antihelix
Fig. 28.7 Diagram of the transformation in response to the Mustarde technique. As the antihelix region is folded, the
helix is pulled inward by the distance a