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

304
T. Nagasao
Scoring of antihelix region
Fig. 28.9 ( Above ) With scoring technique, slits are made on the surface of the cartilage. ( Below ) With abrasion tech-
nique, the cartilage is thinned
Principle of structural analysis
Fig. 28.10 Basic principle of fi nite element analysis. ( Left ) Calculation results with small components are accumu-
lated to ( Right ) predict dynamic behavior of the whole entity

305
28 Prevention of Intra -Auricular Deformity in Prominent Ear Correction
Prominent ear
Normal
Fig. 28.11 ( Left ) Three-dimensional dynamic models representing a prominent ear and ( Right ) normal ear. The mod-
els consist of numerous small elements as shown in the magni fi ed box
Fig. 28.12 To evaluate differences in local thicknesses, auricles were taken from cadavers and measured. Thereby,
thickness maps were produced

306
T. Nagasao
Fig. 28.13 Simulation of auricle transformation in response to the Mustarde technique
Fig 28.12 (continued)

307
28 Prevention of Intra -Auricular Deformity in Prominent Ear Correction
Two or three pairs of points are marked on the
antihelix region of the models. Then, forces are
applied on these models so that the points of
each pair approach each other (Fig. 28.13 ). In
response to the applied forces, the auricle trans-
forms. The transformed shape is the auricular
shape after the application of the Mustarde
technique.
Using this theoretical method, the effect of the
scapha-softening technique is examined. Two
models are produced. The fi rst model represents
a prominent ear without any surgical treatments
(Fig. 28.14 ). With the second model, the thick-
ness of the scapha is reduced by half, simulating
a prominent ear with the scapha softened by scor-
ing or abrasion (Fig. 28.14 ). Application of the
Non-scoring
Scapha-scoring
Fig. 28.14 ( Left ) Responding to the Mustarde technique, the contour of the helix develops irregularity. ( Right ) Auricles
in which the scapha is softened present little irregularity of the helix

308
T. Nagasao
Mustarde technique is simulated for each of these
models to examine the transformation of the
helix. With the former model, the contour of the
helix presents obvious deformity. By compari-
son, the helix contour doesn’t present great defor-
mity with the latter model.
Theoretical Consideration
The results indicate that softening of the scapha
prevents helix irregularity in response to the
Mustarde technique. Herein, mechanisms for this
prevention effect are reviewed.
When the Mustarde technique is performed,
the part of the helix near the applied sutures is
pulled inward and bends. Namely, in Fig. 28.15 ,
as the points A and B move to points A ¢ and B ¢ ,
respectively, this dynamic event is transmitted
through the scapha (indicated with orange-col-
ored bars) to the helix, and the affected parts of
the helix move inward, accordingly (Fig. 28.15 ).
However, with auricles where the scapha was
softened by abrasion or scoring, the inward
movement is buffered by the scapha. Hence, the
helix receives less dynamic effect from the anti-
helix, presenting less irregularity than the helixes
of ears that didn’t undergo scapha softening.
Arrangement of Antihelix Shape
Besides the helix irregularity, another problem
with the Mustarde technique is the unnatural
appearance of the antihelix. Antihelixes produced
with the Mustarde technique tend to present lin-
ear shapes, which give odd impressions
(Fig. 28.6 ). To make the antihelix look natural,
alterations can be made to the antihelix so that it
presents a smooth curvature. This is achieved by
performing tissue grafting. After some fat tissues
or fascias are taken from the temporal region,
they are placed beneath the folded cartilage
(Fig. 28.16 ). This maneuver prevents the antihe-
lix from presenting linear and narrow shapes
when the Mustarde suture is applied, and helps
the antihelix to form a smooth curvature
(Fig. 28.17 ).
Conclusions
Although the main concern in the treatment of
prominent ear is the correction of the promi-
nence, care should also be taken to produce
beautiful features of the ear. In particular,
irregularity of the helix and unnaturally linear
features of the antihelix should be avoided.
The author hopes surgeons fi nd the techniques
introduced in this chapter useful in achieving
these purposes.
A
A
A’
A’
B’
B’
B
B
Fig. 28.15 Schematic explanation of the scapha-soften-
ing effect. ( Left ) As the antihelix part is folded with the
Mustarde technique, the curve of the helix is distorted.
( Right ) When the fl exibility of the scapha is increased,
dynamic effects generated in the antihelix region are
absorbed by the scapha region

309
28 Prevention of Intra -Auricular Deformity in Prominent Ear Correction
Fig. 28.16 Tissue grafting in the space beneath the antihelix
Fig. 28.17 Postoperative
appearances of the
antihelixes with ( Left ) and
without ( Right ) tissue
grafting

310
T. Nagasao
References
1. Hassanpour SE, Moosavizadeh SM. Posterior scoring
of the scapha as a re fi nement in aesthetic otoplasty.
J Plast Reconstr Aesthet Surg. 2010;63(1):78–86.
2. Brent B. Reconstruction of the auricle. In: McCarthy
JG, editor. Plastic surgery. Philadelphia: Saunders;
1990. p. 2094–152.
3. da Silva Freitas R, Sanchez ME, Manzotti MS, Baras
F, Ono MC, de Oliveira e Cruz GA. Comparing cepha-
loauricular and scaphaconchal angles in prominent
ear patients and control subjects. Aesthetic Plast Surg.
2008;32(4):620–3.
4. Mustarde JC. The correction of prominent ears using
simple mattress sutures. Br J Plast Surg. 1963;16:
170–8.
5. Erol OO. New modi fi cation in otoplasty: ante-
rior approach. Plast Reconstr Surg. 2001;107(1):
193–202.
6. Lazaridis N, Tilaveridis I, Dimitrakopoulos I,
Karakasis D. Correction of the protruding ear with a
modi fi ed anterior scoring technique. J Oral Maxillofac
Surg. 1998;56(3):307–13.
7. Dicio D, Castagnetti F, Baldassarre S. Otoplasty:
anterior abrasion of ear cartilage with dermabrader.
Aesthetic Plast Surg. 2003;27(6):466–71.
8. Oneal RM. Correction of the prominent ear with car-
tilage abrasion and concha-mastoid sutures. Aesthet
Surg J. 1997;17(5):338.
9. Bulstrode NW, Huang S, Martin DL. Otoplasty by
percutaneous anterior scoring. Another twist to the
story: a long-term study of 114 patients. Br J Plast
Surg. 2003;56(2):145–9.
10. Graham KE, Gault DT. Endoscopic assisted otoplasty: a
preliminary report. Br J Plast Surg. 1997;50(1):47–57.
11. Nagasao T, Miyamoto J, Shimizu Y, Kasai S, Kishi K,
Kaneko T. Effective scoring of scapha prevents helix
irregularity in prominent ear correction―a biome-
chanical study. J Craniomaxillofac Surg. (in press).
12. Nagasao T, Miyamoto J, Nagasao M, Ogata H, Kaneko
T, Tamaki T, et al. The effect of striking angle on the
buckling mechanism in blowout fracture. Plast
Reconstr Surg. 2006;117(7):2373–81.
13. Nagasao T, Miyamoto J, Kokaji K, Yozu R, Jiang H,
Jin H, et al. Double-bar application decreases postop-
erative pain after Nuss procedure. J Thorac Cardiovasc
Surg. 2010;140(1):39–44.
14. Nagasao T, Miyamoto J, Uchikawa Y, Tamaki T,
Yamada A, Kaneko T, et al. A biomechanical study on
the effect of premature fusion of the frontosphenoidal
suture on orbit asymmetry in unilateral coronal synos-
tosis. Cleft Palate Craniofac J. 2010;47(1):82–91.

311
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_29, © Springer-Verlag Berlin Heidelberg 2013
29
Introduction
Several otoplastic techniques, over 200, have
been described by numerous surgeons as a rem-
edy for auricular abnormalities. This very fact
alludes to the lack of a single procedure being
seen as absolute in tackling this problem. The use
of permanent retention sutures [ 1 ] , excision and
incisions [ 2– 4 ] of auricular cartilage, and combi-
nation techniques [ 1, 5 ] have all been described.
More recently, the use of scoring of cartilage with
the use of the surgical scalpel [ 6, 7 ] .
Previous studies [ 8 ] have demonstrated the
use of diathermy – monopolar and bipolar – in
scoring the auricular cartilage, to produce com-
parable effects in de fl ecting segments of auricu-
lar cartilage, as with scalpel scoring. One recent
study goes further to carry out the comparisons in
whole porcine auricular cartilage. In addition,
whilst previous exercises only provided informa-
tion on 2-dimensional effects on cartilage scor-
ing, the authors discuss the novelty of examining
the 3-dimensional changes that occur with dia-
thermy scoring compared with scalpel scoring in
intact pig ears.
The Clinical Problem: Auricular
Anomalies
Abnormalities of the auricle, whilst less of a physi-
ological problem, often create a huge psychosocial
dilemma for its sufferers. The auricles are sym-
metrical appendages that contribute profoundly to
the aesthetic aspects of an individuals’ facial struc-
ture. Often, subtle symmetrical variations in size
or shape go unnoticed, but certain anomalies, espe-
cially when unilateral, are manifest. The social
consequences often culminate in an emotionally
distressed individual, as a result of ridicule from
members of society. Thus, in order to avoid such
psychological pressures, which can lead to the
development of personality disorder, surgical cor-
rection of prominent ears should preferably be
performed at or before the start of schooling [ 9 ] .
The only difference between the neonatal ear
and the adult ear is that, in the neonate, the carti-
lage is more malleable and soft. Otherwise, the
anatomy is the same [ 10 ] . The ear attains approx-
imately 85 % of its adult size by age 3 years [ 11 ]
with attendant calci fi cation of the cartilage with
increasing age. This in fl uences the kind of cor-
rection (operative or otherwise) that can be
offered if at all and also highlights the importance
of early intervention in the management of auric-
ular anomalies.
T. Gourlay , Ph.D., BSc (Hons), FIBiol (*)
Bioengineering Unit ,
University of Strathclyde ,
Wolfson Building , Glasgow G4 oNW ,
Scotland, UK
e-mail: terry.gourlay@strath.ac.uk
E. Irune , MBChB, MRCS, MSc
Department of Otolaryngology,
Head & Neck Surgery ,
Royal Hallamshire Hospital ,
Shef fi eld , UK
e-mail: e_irune@hotmail.com
Can Diathermy Enhance Scoring
in Otoplasty?
Terry Gourlay and Ekpemi Irune

312
T. Gourlay and E. Irune
Classi fi cation of Auricular Anomalies
Auricular abnormalities, as with most other struc-
tural anomalies of the body, can be broadly
described as congenital and acquired, with these
anomalies occurring as part of syndromes or
independently. The incidence of congenital
anomalies is unknown, although it varies between
racial groups [ 12 ] . Based on the current knowl-
edge of embryology, congenital anomalies are
further divided into malformation or deformation
types [ 13 ] .
Malformations are structural abnormalities
that result from abnormal embryologic develop-
ment [ 12 ] . They are defects that occur as a result
of a de fi ciency, absence, or excess of components
of auricular structure.
Deformation, which may occur in utero or
postnatally, is not caused by embryologic malde-
velopment but results from abnormal physical
forces applied to a normal structure. Similarly, a
deforming force may be applied to a malformed
ear [ 12 ] . In essence, deformational abnormalities
may be corrected by manipulation of the tissues
as complete and mature components of the cuta-
neous and cartilaginous tissues are present.
Examples include prominent ear (also known as
bat’s ear), cryptotia (upper auricular sulcus hid-
den in scalp), lop ear (folded superior portion of
helical rim) and Stahl’s ear (aka Stahl’s bar – a
third crux between superior and inferior crura of
the antihelix).
Deformational Abnormalities:
The Prominent Ear
The most common of the deformational abnor-
malities is the prominent ear. Prominent ears are
relatively common, with an incidence in
Caucasians of about 5 %. It is inherited as an
autosomal dominant trait and is commonly
caused by a combination of two defects: (1)
underdevelopment of antihelical folding and (2)
overdevelopment of the conchal wall [ 14 ] .
In 2007, Furnas and Lin [ 15 ] wrote “An ear
appears prominent or protruding if it projects
more than 15–20 mm or more than 21°–30° from
the temporomastoid plane of the skull. The mean
length of the ear (sa-sba, i.e., superaural to
subaural) in boys is 55 mm when aged 6 years,
60 mm when aged 12 years, and 62 mm when
aged 18 years. In girls, the values are 54, 58, and
58 mm at ages 6, 12, and 18 years, respectively.
The mean width of the ear (pra-pa, i.e., preaural
to postaural) is 34, 35 and 36 mm in boys and 33,
34 and 34 mm in girls at ages 6, 12, and 18 years,
respectively. One standard deviation in width is
2.0–2.5 mm and in length is 3.0–3.5 mm. An ear
that is two or more standard deviations from the
mean is viewed as abnormally large (macrotia).
Excessive projection is a far more frequent prob-
lem than excessive size.”
The authors [ 15 ] also mentioned other con-
tributory factors in the development of the promi-
nent ear, for example, abnormal underlying
skeletal structure in the form of a prominent mas-
toid process. In addition, the presence of promi-
nent ear as part of other anomalies, such as Stahl’s
ear or macrotia, should be borne in mind.
Management of the Prominent Ear
Prominent ears may be managed conservatively,
without any intervention to the use of splints to
correct the deformation in the very early stages of
life. In addition, surgery may also be employed.
Below, the use of surgical means is discussed in
more detail.
Cartilage Weakening: Scalpel Versus
Diathermy Cartilage Scoring
The foundations of otoplasty were essentially
laid before the nineteenth century. Thus, today,
most surgeons use a combination of techniques
borrowed from the pioneers of otoplasty.
Ballenger and Snow [ 16 ] are keen to state that
“Mastery of the precise anatomy of the auricle
(anterior and posterior), combined with a knowl-
edge of Becker’s dissection technique and
Mustarde’s mattress suture technique, modi fi ed
by Tardy and Trenta, allows the surgeon a wide
latitude in achieving natural correction of the
many varieties of outstanding ear. No single tech-
nique suf fi ces” [ 16 ] .

313
29 Can Diathermy Enhance Scoring in Otoplasty?
Thus, in recent times, studies have been carried
out to examine the technique of cartilage weaken-
ing, paying particular attention to cartilage scor-
ing. It attempts to assess the 3-dimensional effect
of diathermy (monopolar) scoring on ear cartilage
obtained from the landrace pig. A comparison is
made with scalpel scoring.
Quereshi et al. [ 8 ] compared the use of bipolar
diathermy against scalpel scoring of porcine ear
cartilage (it has a similar thickness to human car-
tilage). The outcome measurements were bend
force and de fl ection angle using the two instru-
ments. They concluded that there was no statisti-
cally signi fi cant difference between the two
mediums – scalpel and diathermy (varied set-
tings) – when used independently. However,
when used together on either side of the porcine
cartilage (i.e., scalpel scoring on one side and
diathermy on the reverse side), the result was a
statistically signi fi cant increase in the outcome
measurements of bend force and angle of
de fl ection [ 8 ] . This is explained as a synergistic
effect as scalpel scoring will enable de fl ection
away from the surface scored and diathermy,
towards the surface scored.
The team postulated that though the diathermy
caused necrosis of the cartilage at the direct point
of contact, there was a secondary conduction of
heat generated that resulted in the contraction of
the intact cartilage beyond the area of the burn,
the consequence being an increased bend force
and angle of de fl ection.
Prior to this study, investigated the effects of
dehydration on strips of cartilage. They carried
out similar experiments as in Quereshi et al. [ 8 ] ,
utilizing bend angle and bend force as outcome
measures in estimating the effects of cartilage
scoring with scalpel and diathermy (monopolar
and bipolar). In addition, they investigated the
effects of skin present on the anterior cartilage
surface and cartilage orientation, on these out-
come measures. They concluded that dehydra-
tion produces a signi fi cant de fl ection of cartilage
towards the posterior surface. They found bend
angle and force were superior in strips of carti-
lage scored without skin, that with anterior skin
present. In addition, scalpel scoring produced
increasingly bigger bends for increasing amounts
of scoring on a cartilage surface in all groups.
Bipolar and monopolar diathermy did not fol-
low this pattern. Finally, they deduced that scal-
pel scoring, bipolar scoring, and monopolar
scoring are not equally effective in de fl ecting
strips of porcine ear cartilage: Variations are
dependent on orientation of the cartilage strip
and the surface scored.
More recently, Irune and Gourlay compared
the 3-dimensional effects of scalpel and monop-
olar diathermy scoring on porcine auricular car-
tilage. They utilized whole landrace pig ears
which were acquired immediately after death
(Figs. 29.1 and 29.2 ). A 3-dimensional model of
each was digitally reproduced using a 3-dimen-
sional laser scanner: the PICZA® 3D Laser
Scanner LPX-250 (Roland DGA, California,
USA). During the experiment, identical set of
maneuvres were carried out on each intact por-
cine ear, using a scalpel in one group and monop-
olar diathermy in the other. The study attempted
to mimic true otoplastic techniques, and thus
trauma to the cartilage was carried out on the
posterior surface of the auricular cartilage fol-
lowing elevation of the posterior skin fl ap only
(Fig. 29.3 ). Surrounding temperature was con-
trolled to prevent warping of the cartilage from
dehydration – a fact already established by
Millington and Gourlay. Thus, the porcine ears
were stored appropriately in moisture preserving
conditions and at temperatures of −4 °C. This
was essential during transport from the abattoir
and in-between carrying out experiments on each
ear. In addition, all measurements were taken
immediately following scoring by scalpel or
monopolar diathermy technique. The latter was
done using the same power settings as in previ-
ous studies by Qureshi et al. [ 8 ] .
These ears were then re-scanned after scoring
of the auricular cartilage with a scalpel and monop-
olar diathermy in Groups A and B, respectively.
No scoring was done in the control Group C.
Three-dimensional scanners serve to create
3-dimensional likeness or models of an actual
object or environment. Thus , a laser-generated
likeness of the porcine ear and a second image
of the same ear following either scalpel
(Figs. 29.4 , 29.5 , 29.6 , and 29.7 ) or diathermy
(Figs . 29.8 , 29.9 , 29.10 , and 29.11 ) scoring
were created. Digital images as well as outcome

314
T. Gourlay and E. Irune
Fig. 29.1 Whole landrace pig ear
– anterior
Fig. 29.2 Whole landrace pig ear
– posterior
Fig. 29.3 Posterior of whole ear
with re fl ected posterior fl ap
demonstrating underlying porcine
cartilage with completed
diathermy score pattern

315
29 Can Diathermy Enhance Scoring in Otoplasty?
Fig. 29.4 3D Topographical
changes: The Scalpel Group.
Three-dimensional image
of the pre-scalpel and
post-scalpel models
following overlapping
Fig. 29.5 Multi-view point rendered images of the two overlapped models above

316
T. Gourlay and E. Irune
measurements were carried out with the use of
the softwares PIXFORM® (Roland DGA,
California, USA) and Rhinoceros 4.0® (McNeel,
Washington, USA), respectively, outcome mea-
surements being the difference in de fl ection
angle of the cartilage (at two anatomical posi-
tions) after scoring by both media and also the
gross topographical change of the whole por-
cine ear upon scoring, as depicted by the over-
lapping of 3D models of the whole ears, pre- and
post-scoring.
Using
Rhinoceros
4.0®
(McNeel,
Washington. USA), a computer-aided design
software, a reference line is projected. It is one
which lies adjacent and parallel to the largest
anatomical area in question (either posterolat-
Fig. 29.6 Three-dimensional
image of the anterior of the
pre-scalpel ( black ) and
post-scalpel ( yellow ), images
separated
Fig. 29.7 Three-dimensional image of the anterior of the
pre-scalpel ( black ) and post-scalpel ( yellow ), images
overlapped

317
29 Can Diathermy Enhance Scoring in Otoplasty?
Fig. 29.8 Laser generated
likeness of porcine ear
Fig. 29.9 Likeness of ear after scoring

318
T. Gourlay and E. Irune
Fig. 29.10 Laser-generated
likeness of porcine ear (Left).
Likeness of porcine ear after
scoring with diathermy
(Right)
eral or superolateral surface) of the whole ear.
The angles of de fl ection was described as that
made by a straight line drawn as a tangent to
the reference line and was brought about by
the curvature of the cartilage following
physical scoring by scalpel and diathermy
(Figs. 29.12 , 29.13 , and 29.14 ). The units were
in degrees, and it was also important to note
the direction of de fl ection, in reference to the
anatomy of the whole ear, that is, anterior
versus posterior.
It was realized that scalpel scoring causes an
increase in cartilage curvature away from the
scored surface. The scalpel scoring causes a
signi fi cant difference in de fl ection angle of whole
porcine cartilage P = 0.03 (SD = 6.30). Diathermy
causes an increase in cartilage curvature towards
the scored surface. In addition, the diathermy
insult causes a difference in de fl ection angle in
whole porcine cartilage P = 0.05 (SD = 13.9).
Diathermy causes better curvature of the cartilage
(Fig. 29.15 ). However, this isn’t statistically
signi fi cant P = 0.21 (SD = 10.8).

319
29 Can Diathermy Enhance Scoring in Otoplasty?
Fig. 29.11 Porcine ear before scoring in black and after
scoring in yellow
Fig. 29.12 Yellow line is angle of de fl ection
Fig. 29.13 Yellow line is angle of de fl ection

320
T. Gourlay and E. Irune
References
1. Mustarde JC. The correction of prominent ears using
simple mattress sutures. Br J Plast Surg. 1963;16:170–8.
2. Morestin PHM. De la reposition et du plissement cos-
metiques due pavillon de l’oreille. Rev Orthop. 1903;
4:289.
3. Becker OJ. Correction of the protruding deformed ear.
Br J Plast Surg. 1952;5(3):187–96.
4. McEvitt WG. The problem of the protruding ear. Plast
Reconstr Surg. 1947;2:358–61.
5. Burningham AR, Stucker FJ. Otoplasty technique:
how I do it. Facial Plast Surg Clin North Am. 2006;
14(2):73–7.
6. Stenstrom SJ, Heftner J. The Stenstrom otoplasty.
Clin Plast Surg. 1978;5(3):465–70.
7. Bhatti AZ, Donovan DO. Sutureless otoplasty by
scoring of the cartilage: a study in 34 patients. Br J
Oral Maxillofac Surg. 2007;45(3):217–20.
8. Qureshi TR, Hurren JS, Gourlay T. The effectiveness
of scoring and bipolar diathermy on ear cartilage
behavior: ex vivo study. Ann Plast Surg. 2007;
58(3):321–7.
Fig. 29.14 Yellow line is
angle of de fl ection
Deflection angle difference (PL only) vs sample no
0
50
Sample no.
Deflection angle
difference (º)
Scalpel
Diathermy
Scalpel
25.16
17.83
12.62
Diathermy
44.63
16.94
33.58
1
2
3
Fig. 29.15 Graph to show
de fl ection angle difference as
distributed within the three
samples in the scalpel and
diathermy groups

321
29 Can Diathermy Enhance Scoring in Otoplasty?
9. Bajaj Y, Rokade A, De PR. Otoplasty: experience
with a modi fi cation using a drill, and literature review.
J Laryngol Otol. 2007;121(1):61–4.
10. Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast
Reconstr Surg. 2005;115(4):60e–72.
11. Adamson JE, Horton CE, Crawford HH. The growth
pattern of the external ear. Plast Reconstr Surg.
1965;36(4):466–70.
12. Porter CJ, Tan ST. Congenital auricular anomalies:
topographic anatomy, embryology, classi fi cation, and
treatment strategies. Plast Reconstr Surg. 2005;
115(6):1701–12.
13. Tan ST, Abramson DL, MacDonald DM, Mulliken JB.
Molding therapy for infants with deformational auricu-
lar anomalies. Ann Plast Surg. 1997;38(3):263–8.
14. Adamson PA, Strecker HD. Otoplasty techniques.
Facial Plast Surg. 1995;11(4):284–300.
15. Furnas DW, Lin SJ. Ear, prominent ear. April 9, 2007.
.
Accessed 27 Mar 2007.
16. Ballenger JJ, Snow JB. Otorhinolaryngology head
and neck surgery. 15th ed. Philadelphia: Williams &
Wilkins; 1996.

323
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_30, © Springer-Verlag Berlin Heidelberg 2013
30
Introduction
Prominent ears are the most common congenital
deformity in the head and neck region [ 1 ] , with
an incidence of about 5 % in Caucasians [ 1 ] .
Prominent ears are usually not associated with
other abnormalities or syndromes but may be
considered an aesthetic handicap [ 2 ] .
The basic deformities present in different
degrees and combinations are decreased de fi nition
or absence of the antihelical fold, presence of a
large, deep conchal bowl or an inadequate de fi ni-
tion of the helical rim. Due to these deformities,
the helical rim separates more than 2 cm from the
cranium. In addition, some other defects may be
present such as excessive prominence of the tail
of helix, excessive protrusion of the antitragus, or
forward bending of the earlobe. The technique is
easy to learn and master with minimal postopera-
tive morbidity.
Prominent ears may cause considerable emo-
tional disturbance as a youngster usually becomes
a subject of ridicule by schoolmates. At that age
when personality is developing, teasing may result
in a tendency towards isolation or aggressiveness
[ 3 ] . While the auricle continues to develop from
birth throughout life, the majority of growth
occurs at an early age. Eighty- fi ve percent of the
ultimate size of pinna is attained at the age of
three, and seven-eighths of the total growth takes
place before the age of seven [ 4 ] . After 9 years of
age, no substantial growth takes place. The aver-
age difference in length of a fully developed ear
and one at 9 years of age is about 5 mm [ 3 ] .
Therefore, in order to avoid emotional distur-
bances which can lead to personality disorder,
surgical correction of prominent ears should pref-
erably be done at or before the start of schooling.
The goal of otoplasty is to achieve a normal
antihelical fold with a scaphoconchal angle of
about 90 o , normally curved superior crus, and an
adequate depth of the concha. After recession of
the ear, neither the tail of the helix nor the antitra-
gus should be abnormally prominent and the lobe
should not bend forward. The vertical helical rim
should be about 1.5 cm from the scalp, and the
rim should have a curl [ 3 ] .
Although Sushruta (seventh century BC, Indian
surgeon) and Tagliacozzi (sixteenth century,
Italian surgeon) described otoplasty techniques,
the modern era of otoplasty can be traced to 1848,
when the term “otoplastik” was fi rst used by
Dieffenbach in his description of the repair of
microtia [ 1 ] . Ely performed and published oto-
plasty by an anterior approach in 1881 [ 4 ] . He
removed a full thickness strip of the auricle, but
this left a visible scar along the line of antihelix on
either side of the pinna. Keen [ 1 ] modi fi ed the
Y. Bajaj , M.D. • N. Choudhury
Department of ENT ,
Barts & Royal London Hospitals ,
London , UK
e-mail: ybajaj@hotmail.co.uk ;
natashamasood1@aol.com
© Crown Copyright 2013
Diamond Burr Drill Use
in Otoplasty
Yogesh Bajaj and Natasha Choudhury

324
Y. Bajaj and N. Choudhury
same technique by leaving the anterior skin bridge
intact to prevent a noticeable scar.
A post-auricular incision was fi rst published
by Morestin in 1903 [ 4 ] . After this, many attempts
were made to correct prominent ears by using
various antihelical and conchal cartilage exci-
sions using this posterior approach. In 1940s,
attempts were made to weaken the cartilage by
mechanically thinning or placing partial incisions
in it. In 1947 McEvitt [ 5 ] made parallel incisions
in the posterior cartilage plane, whereas Tanzer in
1962 [ 6 ] , in addition to the parallel incisions,
anchored the antihelical plica with permanent
suture. In 1960s, Mustarde used permanent reten-
tion sutures in a combined technique with a fusi-
form skin excision to recreate the antihelical fold.
In 1963, Stenstrom and Chongchet [ 7 ] scored the
anterior part of the conchal cartilage to create an
antihelix through a posterior incision. In 1968,
Furnas [ 8 ] described a procedure, which con-
sisted of securing the concha to the mastoid
periosteum posteriorly, thereby decreasing the
concha-scaphoid angle. In 1967, Kaye [ 9 ] used
mattress sutures that were placed in the auricular
cartilage through small anterior incisions, and
Johnson [ 10 ] in 1994 emphasized obliquely
placed sutures to control the fi nal curve and shape
of the antihelix, performed through a posterior
approach. An ideal technique to correct protrud-
ing ears has not yet been established. This chap-
ter describes another modi fi cation of otoplasty
using a diamond burr drill to thin the cartilage
and form the antihelix.
Surgical Technique
The operation is performed under general anaes-
thesia. The line where the antihelix has to be cre-
ated is marked with methylene blue. Three to
four markings are made by passing a straight
hypodermic needle through the skin and the car-
tilage; the tip is then dabbed with a cotton bud
soaked in the dye and withdrawn. This helps to
leave marks on the cartilage (Fig. 30.1 ). The cra-
nial surface of the pinna is in fi ltrated with 2 %
lignocaine with 1:80,000 adrenaline (Fig. 30.2 ).
Keeping the methylene blue markings as the mid-
dle reference point, a spindle-shaped incision is
marked (Fig. 30.1 ). This spindle-shaped skin is
excised from the posterior surface of the pinna
(Fig. 30.3 ). The perichondrium on the exposed
posterior surface is incised along the markings
made before with methylene blue (Fig. 30.4 ).
The perichondrium is elevated off the cartilage
for about 5 mm on either sides of the incision
(Fig. 30.5 ). The exposed cartilage is thinned
using a 2 mm diamond burr over a width of 5 mm
along the markings for the antihelix (Fig. 30.6 ).
The end point of the drilling is the pinkish hue of
the lateral surface. The aim should be to leave a
very thin layer of the cartilage over the perichon-
drium on the lateral side. Also care should be
taken not to thin the superior crus too much to
Fig. 30.1 Incision marked for skin excision
Fig. 30.2 Injecting lignocaine with adrenaline

325
30 Diamond Burr Drill Use in Otoplasty
avoid a sharp ridge. At this stage the perichon-
drial fl aps on the posterior surface are sutured
with 3.0 undyed Vicryl interrupted sutures to cre-
ate the missing antihelix (Fig. 30.7 ). The contours
are checked continuously while suturing. The
skin edges are then sutured with 3.0 undyed
Vicryl interrupted mattress sutures. Overcorrection
of the deformity is desirable at the end of the
operation (Fig. 30.8 ). Acri fl avine-soaked cotton
wool is molded into the contours on both surfaces
of the pinna. A turban dressing is done after ade-
quate padding to prevent hematoma formation.
The dressing is removed after 1 week. After this
the patients are advised to use bandage at night
for 3 weeks.
Preoperative assessment included the state of
the antihelical fold, the condition of the conchal
Fig. 30.3 Excising
spindle-shaped skin from
medial surface of pinna
Fig. 30.4 Perichondrium incised over the previously
marked antihelix
Fig. 30.5 Perichondrium elevated off the cartilage for
5 mm either side of the incision

326
Y. Bajaj and N. Choudhury
bowl, the plane of the lobule and the quality and
spring of the auricular cartilage. Pre- and postop-
erative photographs should be taken for all
patients (Fig. 30.9 ). The results using this tech-
nique have been published [ 11 ] .
Discussion
Otoplasty is an artistic exercise in creating the
proper form and dimension of the ear. The goal of
otoplasty is to produce symmetrical, natural-
looking ears with no obvious signs of surgery.
The preoperative assessment should include
detailed history including bleeding tendency and
history of keloids.
A variety of techniques are available to shape
the auricular cartilage that forms the framework
Fig. 30.6 Exposed cartilage is thinned using diamond burr drill
Fig. 30.7 Perichondrium fl aps sutured to create antihelix
Fig. 30.8 End result after suturing
Fig. 30.9 Result 6 month postoperatively

327
30 Diamond Burr Drill Use in Otoplasty
of the ear. The basic requisite for good results is
controlling the position and degree of folding of
the antihelix. Otoplasty techniques can be divided,
in general, into cartilage-sparing and cartilage-
cutting techniques.
The cartilage-sparing techniques offer the sur-
geon the ability to do this without disrupting the
structural integrity of the ear. Of these, Mustarde
[ 12 ] and Furnas [ 13 ] concha-mastoid sutures are
the most commonly described. The Mustarde
technique is one of the most commonly used
methods for creation of the antihelical fold in the
prominent ear deformity. One part of this proce-
dure that can be dif fi cult to perform is precise
tightening of the cartilage-conforming sutures.
Because the surgeon’s attention is directed later-
ally to achieve the desired antihelical shape,
tightening the sutures medially generally is done
without direct exposure. This manoeuver is awk-
ward and creates a risk of undercorrection by
tying the knots too loosely because of soft tissue
entrapment and the tendency for the cartilage to
unfold [ 14 ] . There may be pain from nonabsorb-
able sutures pricking the dermis from beneath
[ 15 ] . Also, post-auricular suture extrusion may
result [ 16 ] . Messner and Crysdale [ 17 ] , observ-
ing patient’s treated using Mustarde technique
for at least 1 year after surgery, found that in up
to 40 % of ears, the fi nal position had returned to
within 3 mm of the preoperative state. Tan [ 18 ]
found that with placement of Mustarde suture
alone, 24 % of patients required reoperation for
recurrent deformities.
The other major group is cartilage-cutting
techniques of which the anterior scoring method
is most commonly used [ 19, 20 ] . Scoring facili-
tates the bending of the cartilage, but it may cause
painful and unattractive ridging if performed too
aggressively. Calder and Nassan [ 20 ] observed
that 8 % of ears treated with anterior scoring retain
some residual deformity. Cutting the auricular
cartilage subjects the antihelix to irreversible,
unpredictable distortion by wound contraction
forces [ 1 ] . There has been increasing criticism of
anterior scoring method because of unacceptably
high complication rates (24 %), especially in
training grade surgeons [ 21 ] . These complications
arise from the anterior dissection causing anterior
hematoma that may lead to anterior skin necrosis.
Chondritis may follow secondary to hematoma
and infection, and this may result in irreparable
cartilage irregularities [ 22, 23 ] .
This technique described using drill to thin
the auricular cartilage posteriorly seems to be a
more delicate approach. Thinning of the cartilage
by drilling softens the cartilage spring and allows
accurate shaping which can be held in a stable
position by mattress sutures. It is a safe and con-
trolled technique, and one can stop drilling when
the desired result has been achieved. It is a middle
path between cartilage-sparing and cartilage-cut-
ting techniques and thus avoids the complications
associated with both the techniques.
Conclusions
The technique of otoplasty described using
the drill to thin the auricular cartilage is safe
and easy to learn and perform. It has few com-
plications and has reproducible cosmetic
results. The long-term results are very good,
and it can be used as a standard technique.
References
1. Yugueros P, Friedland JA. Otoplasty: the experience
of 100 consecutive patients. Plast Reconstr Surg. 2001;
108(4):1045–51.
2. Vuyk HD. Cartilage sparing otoplasty: a review with
long term results. J Laryngol Otol. 1997;111(5):
424–30.
3. Hinderer UT, Del Rio JL, Fregnal FJ. Otoplasty for
prominent ears. Aesthetic Plast Surg. 1987;11(2):63–9.
4. Hell B, Garbea D, Heissler E, Klein M, Gath H,
Langford A. Otoplasty: a combined approach to dif-
ferent structures of the auricle. Int J Oral Maxillofac
Surg. 1997;26(6):408–13.
5. McEvitt WG. The problem of protruding ear. Plast
Reconstr Surg (1946). 1947;2(5):481–96.
6. Tanzer RC. The correction of prominent ears. Plast
Reconstr Surg. 1962;30:236–46.
7. Stenstroem SJ. A natural technique for correction of
congenitally prominent ears. Plast Reconstr Surg. 1963;
32:509–18.
8. Furnas DW. Correction of prominent ears by con-
chamastoid sutures. Plast Reconstr Surg. 1968;42(3):
189–93.
9. Kaye BL. A simpli fi ed method for correcting the
prominent ear. Plast Reconstr Surg. 1967;40(1):44–8.
10. Johnson PE. Otoplasty: shaping the antihelix.
Aesthetic Plast Surg. 1994;18(1):71–4.

328
Y. Bajaj and N. Choudhury
11. Bajaj Y, Rokade A, De PR. Otoplasty: experience
with a modi fi cation using drill and review of litera-
ture. J Laryngol Otol. 2007;21(1):61–4.
12. Mustarde JC. Correction of prominent ears using buried
mattress sutures. Clin Plast Surg. 1978;5(3):459–64.
13. Furnas DW. Correction of prominent ears with multi-
ple sutures. Clin Plast Surg. 1978;5(3):491–5.
14. Hilger P, Khosh MM, Nishioka G, Larrabee WF.
Modi fi cation of the Mustarde otoplasty technique
using temporary contouring sutures. Plast Reconstr
Surg. 1997;100(6):1585–6.
15. Rigg BM. Suture materials in otoplasty. Plast Reconstr
Surg. 1979;63(3):409–10.
16. Horlock N, Misra A, Gault DG. The postauricular fas-
cial fl ap as an adjunct to Mustarde and Furnas type
otoplasty. Plast Reconstr Surg. 2001;108(6):1487–90.
17. Messner AH, Crysdale WS. Otoplasty: clinical proto-
col and long term results. Arch Otolaryngol Head
Neck Surg. 1996;122(7):773–7.
18. Tan KH. Long term survey of prominent ear surgery:
a comparison of two methods. Br J Plast Surg. 1986;
39(2):270–3.
19. Caouette-Laberge L, Guay N, Bortoluzzi P.
Otoplasty: anterior scoring technique and results
in 500 cases. Plast Reconstr Surg. 2000;105(2):
504–15.
20. Calder JC, Nassan A. Morbidity of otoplasty:
a review of 562 cases. Br J Plast Surg. 1994;47(3):
170–4.
21. Jeffery SL. Complication following correction of
prominent ears: an audit review of 122 cases. Br
J Plast Surg. 1999;52(7):588–90.
22. Reynaud JP, Gary-Bobo A, Mateu J, Santoni A.
Chondrites postopertoires de l’oreille externe: 2 cases
from a series of 200 cases (387 otoplasties). Ann Chir
Plast Esthet. 1986;31(2):170–3.
23. Adamson PA. Complications of otoplasty. Ear Nose
Throat J. 1985;64(12):568–74.

329
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_31, © Springer-Verlag Berlin Heidelberg 2013
31
Introduction
Providing a natural-appearing ear contour has
always been a key component of a successful
prominent ear surgery. To achieve a natural-
appearing ear, the surgical manipulations should be
kept as simple as possible with little dissection and
with minimum destruction. Another surgical phi-
losophy we share is that no tissue should be
removed from the body unless it is absolutely nec-
essary. From this standpoint the authors feel that
conchal cartilage hypertrophy can be and should be
managed without removing the excess cartilage. To
achieve a natural shape, a technique is presented
that was reported by the senior author (NK) which
is based on the conchal setback without resection
combined with antihelical fold formation [ 1 ] .
Markings and Surgical Technique
The deformity is analyzed before surgery to
determine the anatomical elements that are con-
tributing to the abnormal appearance. Standardized
photographs are obtained. Before the local anes-
thesia injection, a gentle setback of the antihelix
with fi nger pressure will accurately estimate the
severity of conchal hypertrophy and the amount
of setback needed to restore balanced and aes-
thetically pleasing ears. Incision line is deter-
mined and marked with marker pen (Fig. 31.1 ).
N. Karacaoglan , M.D. (*)
Istanbul Medipol Universitesi Tip Fakultesi ,
Ataturk Bulvari no 27 Unkapani , Fatih,
Istanbul 34083 , Turkey
Department of Plastic and Reconstructive Surgery ,
Medipol University , Kadikoy,
Istanbul 34718 , Turkey
e-mail: naci.karacaoglan@medipol.com.tr
M. Keskin , M.D. • B. Cigsar , M.D.
Istanbul Medipol Universitesi Tip Fakultesi ,
Ataturk Bulvari no 27 Unkapani , Fatih,
Istanbul 34083 , Turkey
Department of Plastic and Reconstructive Surgery ,
Medipol University Medical School Istanbul ,
Istanbul , Turkey
e-mail: mustafa.keskin@medipol.com.tr ;
bulent.cigsar@medipol.com.tr
Conchal Setback Without Resection
in Prominent Ear Deformity
Naci Karacaoglan, Mustafa Keskin, and Bulent Cigsar
Fig. 31.1 Incision line is preoperatively marked between
conchal-mastoid sulcus and conchal-scaphoid fold

330
N. Karacaoglan et al.
After appropriate surgical cleaning and drap-
ing, the local anesthesia injection with a lidocaine
and 1/100,000 adrenalin solution to block the ear
sensation and minimize bleeding is performed.
The skin incision reaches down to the cartilage. The
posterior skin of the ear is undermined up to
the conchal-mastoid sulcus medially and to the
helical rim laterally. After exposing all the poste-
rior side of the ear cartilage, the border of conchal
cartilage is marked with pen according to guid-
ance of the needles approaching from the anterior
side (Fig. 31.2 ). Through the cartilage incision the
anterior skin and conchal cavum are separated
with dissection (Fig. 31.3 ). It is preferred to do the
cartilage incision obliquely rather than perpen-
dicularly. With gentle pressure on the helix, the
amount of overriding required to produce the
desired ear position can be determined. With a
slight digital pressure over the conchal rim, the
lateral conchal segment is positioned anteriorly
and the medial segment posteriorly. If the upper
and lower parts of the cartilage incision are imped-
ing the medial movement of the cartilage, the
incision can be lengthened upwards and down-
wards until impediment is overcome. Stabilization
of the two overlapped edges of the cartilages is
achieved by interrupted, inverted nonabsorbable,
multi fi lament, white polyester 4/0 suture (with
16 mm ½ tapered needle) (Politer ® Doğsan,
Trabzon, Turkey) (Figs. 31.4 and 31.5 ). After the
conchal setback is performed the Mustardé’s
approach is utilized to create a soft, gentle antihelical
Fig. 31.2 Posterior ear skin is elevated up to helical rim
and the conchal border is determined by the guidance of
the needles inserted from anterior surface
Fig. 31.3 Cartilage incision is done obliquely while the
anterior skin is dissected to let the cartilage to override
Fig. 31.4 The cartilages are held in their new position
with nonabsorbable sutures
Fig. 31.5 Lateral cartilage segment overrides the lateral
segment anteriorly to allow setback

331
31 Conchal Setback Without Resection in Prominent Ear Deformity
fold. The desired antihelical fold contour pro-
duced by exerting gentle digital pressure on the
helix is marked on the skin. Three mattress sutures
(Politer ® Doğsan, Trabzon, Turkey) are used for
creating the antihelical fold (Fig. 31.6 ). After
meticulous hemostasis, the postauricular skin
incision is closed subcuticularly using an absorb-
able suture material. Drains should not be
needed and are not routinely used (Figs. 31.7 ,
31.8 and 31.9 ).
Postoperative Care
The dressing is carried out as follows: an antibi-
otic ointment impregnated nonsticky gauze is
placed over the postauricular suture line. Then a
fl uffed, cotton gauze dressing is wetted and care-
fully placed into the new antihelical folds and the
concha. This gauze is continued to the posterior
surface. Dry, fl uffed, all-cotton gauze is then
placed over the wet gauze. The gauzes are held in
place with an Ace bandage. The dressings are
removed on the third postoperative day and the
patient is given a headband that is to be worn con-
tinuously for 3 weeks and at night for a minimum
of 1 month to prevent accidental stresses on the
ear during sleep. After the dressing is removed,
showers and shampooing are allowed.
Complications
Regardless of the procedure used, the prominent
ear surgery yields a high patient satisfaction rate
with minimal complications. Complications such
as hematoma, infection, and skin and cartilage
necrosis are usually preventable with skillful sur-
gery and not strictly related to the technique
implemented. Depending on the technique used,
recurrence can be a common complication and
may be decreased by combining appropriate
techniques. The technique described here has the
potential to cause sharp edge deformity at the
anterior conchal bowl. The sliding anterior seg-
ment edge can be visible if the cartilage has been
cut perpendicular. To prevent this deformity the
sliding anterior edge should be cut obliquely and
should be smooth.
Discussion
Many methods have been described to correct
prominent ears, but no single operation is
currently capable of resolving all cases. A critical
evaluation and planning is critical to accommo-
date the different etiologies. It is better to de fi ne
the components of the problem for each case
and plan the surgical correction rather than
Fig. 31.6 Schematic design of the conchal setback without excision and formation of antihelical fold with Mustarde’s
technique

332
N. Karacaoglan et al.
performing a standard approach for each case.
A prominent ear is characterized by either under-
development of the antihelical fold or an over-
sized concha alone or in combination of these
two in varying degrees [ 2 ] . Most of the surgeries
done for prominent ears are primarily focused on
antihelical fold alone and conchal hypertrophy is
ignored. The majority of patients seen for sec-
ondary otoplasty have been those whose conchal
hypertrophy has been ignored, inadequately cor-
rected, or missed [ 3 ] .
Conchal deformity can be successfully addressed
by several methods, including suturing techniques,
excisional techniques, and posterior auricular mus-
cle manipulations [ 4 ] . Conchal-mastoid sutures
can be used to correct conchal excess of the ear.
This is performed before correction of any antihe-
lix defect. The main problem with conchal-mastoid
suture is that medial repositioning of the cartilage
causes narrowing of the acoustic meatus. If exces-
sive medial rotation is required to achieve adequate
setback, the tragus will be forced to rotate in a
a
b
Fig. 31.7 ( a ) Preoperative. ( b ) Postoperative a year after the operation of a patient treated with described technique

333
31 Conchal Setback Without Resection in Prominent Ear Deformity
a
b
Fig. 31.8 ( a ) Preoperative. ( b ) Postoperative a month after the operation of a patient treated with described technique.
Rhinoplasty was also performed

334
N. Karacaoglan et al.
lateral direction, which produces an unsightly
prominence and deformity of the tragus [ 3 ] . If
excessive dissection over the mastoid area is done,
there is the risk of damaging posterior auricular
muscle which pulls the auricle back toward the
head and affecting its dynamics [ 5, 6 ] .
The hypertrophied concha may be recalcitrant
to conchal-mastoid suture repositioning tech-
niques and may require cartilage excision.
Cartilage can be excised alone or with anterior
skin. The cartilage-only procedures are usually
performed through a posterior approach, whereas
a
b
Fig. 31.9 ( a ) Preoperative. ( b ) Postoperative a month after the operation of a patient treated with described technique

335
31 Conchal Setback Without Resection in Prominent Ear Deformity
the skin and cartilage techniques are usually per-
formed through an anterior approach. Cartilage
removal is an aggressive and complicated proce-
dure and may cause cartilage destruction and
irregularities. Scarring is also a problem if ante-
rior approach to the concha is used. Furthermore,
cartilage excision is irreversible so it should be
done cautiously [ 7 ] .
Cartilage-sparing techniques are gaining pop-
ularity in cosmetic surgeries [ 8 ] . They are pre-
ferred because of their safety and readjustability.
To reposition the concha, we use the technique
where the conchal hypertrophy is corrected with-
out excising the conchal cartilage but by sliding
the lateral conchal cartilage segment over the
medial segment after a cartilage incision. As a
consequence of this maneuver, the conchal-
mastoid angle is restored again and the antiheli-
cal fold is formed up to some degree so lesser
Mustarde’s sutures are needed. For this reason
the conchal hypertrophy must be corrected before
creating the antihelical fold. The sliding of carti-
lage segments over each other reduces the risk of
anterior skin redundancy, preserves cartilaginous
support, and helps creating a softer conchal bowl
contour when compared to conventional conchal
excision. There is no need for wide posterior dis-
sections over the mastoid bone so the posterior
auricular muscle is not affected. The movement
of the lateral conchal cartilage segment over the
medial segment does not disturb the external
auditory canal. On the other hand conchal sutures
can be undone and symmetry can be provided
again by reestablishing the setback. The revers-
ible nature of suture placement allows adjust-
ment. We believe it is this controllability and
precision that allows us to achieve better form
and symmetry. Finally as conchal cartilage is not
excised, it is saved as a possible cartilage graft
donor in further reconstructive operations espe-
cially considering rhinoplasty.
References
1. Karacaoglan N, Ciloglu SN. Conchal setback without
resection in prominent ear deformity. Otolaryngol
Head Neck Surg. 2011;145(6):930–1.
2. Salgarelli AC, Bellini P, Multinu A, Landini B,
Broccaioli E, Consolo U. Combined technique for the
correction of prominent ears: results in 140 patients.
Br J Oral Maxillofac Surg. 2009;47(7):545–9.
3. Bauer BS, Song DH, Aitken ME. Combined otoplasty
technique: chondrocutaneous conchal resection as the
cornerstone to correction of the prominent ear. Plast
Reconstr Surg. 2002;110(4):1033–40.
4. Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast
Reconstr Surg. 2005;115(4):60e–72.
5. Guyuron B, DeLuca L. Ear projection and the posterior
auricular muscle insertion. Plast Reconstr Surg.
1997;100:457–60.
6. Yazici I, Findikçioğlu F, Ozmen S, Noyan N, Yavuzer
R. Posterior auricular muscle fl ap as an adjunct to
otoplasty. Aesthetic Plast Surg. 2009;33(4):527–32.
7. Bauer BS, Margulis A, Song DH. The importance of
conchal resection in correcting the prominent ear.
Aesthet Surg J. 2005;25(1):72–9.
8. Keskin M, Tosun Z, Savaci N. The importance of
maintaining the structural integrity of the lateral crus
in tip rhinoplasty. Aesthetic Plast Surg. 2009;33(6):
803–8.

337
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_32, © Springer-Verlag Berlin Heidelberg 2013
32
Introduction
Few if any other features as prominent ears can
elicit such negative reactions and lead to serious
psychosocial disturbances beginning with child-
hood. They may be a major cause of distress and
frustration for the patient. Prominent ears have a
frequency of 5 % in Caucasians and their heredi-
tary component is well known. The surgery is
recommended beginning with the age of 5 before
the child is school-aged, considering that at age 3
the ear has achieved 85 % of its total growth [ 1 ]
and at 5–6 years of age, the growth is almost
completed [ 2 ] .
Prominent ears have a normal chondrocutane-
ous structure which is abnormally shaped. Thus,
they differ from other congenital malformations,
such as cup ear, lop ear, Stahl’s ear, cryptotia, or
microtia. Their main feature is an increased
cephaloauricular angle (greater than 35°), con-
choscaphal angle greater than the normal 90°,
and an increased distance of the auricle from the
temporal scalp greater than the normal range of
17–21 mm. The goal of any otoplasty procedure
is achieving a natural, symmetric result with min-
imal complications and short recovery.
Perhaps more than 200 procedures have been
described over the years for correction of pro-
truding ears. There is no single technique appli-
cable in every case, rather the surgeon should
posses an armamentarium of techniques and
apply different procedures according to each
deformity. These techniques are roughly catego-
rized as either those using sutures or those using
cartilage incision or excision. Nowadays, most of
the techniques are a combination of cartilage
incision and suturing and the innumerable varia-
tions of the techniques attest to the fact that in
pursuit of the “holy grail” in otoplasty there is
still a long way.
This chapter will deal mainly with protruding
ears, although they are many times associated
with other malformations, such as constricted ear
or macrotia which are treated separately in other
chapters. The authors will describe in detail their
preferred technique consisting of cartilage inci-
sion and folding described in 1955 by Converse
[ 3 ] and modi fi ed in 1963 by Chongchet [ 4 ] . The
authors also tried to brie fl y summarize in com-
parison the other techniques used; also this is
rather dif fi cult considering their impressive
number.
C. Isac , M.D., Ph.D. (*)
Department of Plastic Surgery ,
University of Medicine and Pharmacy “Carol Davila” ,
Bucharest , Romania
Department of Plastic Surgery ,
University Hospital for Plastic Surgery and Burns ,
Calea Grivitei 218, Sector 1 , Bucharest , Romania
e-mail: ina@drisac.ro , inaisaac@yahoo.com
A. Isac , M.D., Ph.D.
Department of Plastic Surgery ,
University Hospital for Plastic Surgery and Burns ,
Calea Grivitei 218 , Bucharest , Romania
e-mail: ireli fl orin@yahoo.com
Cartilage Folding Technique
in Otoplasty
Cristina Isac and Aurelia Isac

338
C. Isac and A. Isac
Preoperative Assessment
Preoperatively the ear is assessed in terms of:
1. Antihelical fold development (superior and
inferior crus) (Fig. 32.1 )
2. Conchal depth (Fig. 32.2 )
3. Earlobe protrusion (Fig. 32.3 )
4. Cartilage stiffness
5. Degree of auricular protrusion assessed by the
cephaloauricular angle, conchoscaphal angle,
and the distance from the auricle to the temporal
scalp
6. Symmetry [ 5 ]
Full-face anterior and posterior photographs
are taken as well as close-up views of both
ears.
Fig. 32.1 Antihelical fold underdeveloped
a
b
Fig. 32.2 ( a , b ) Excessive conchal depth
Fig. 32.3 Lack of antihelical fold, deep conchal bowl,
and protrusion of the earlobe

339
32 Cartilage Folding Technique in Otoplasty
Technique of Cartilage Folding
The auricular and periauricular region are cleaned
and the area is draped. The location of the new
antihelical fold is established by gently pressing
on the helical rim toward the mastoid region
(Fig. 32.4 ). The ear will be bent backward and an
antihelix with a natural appearance will be formed.
The degree of conchal hypertrophy can also be
estimated using this maneuver. The location of the
antihelix is marked. The marking begins at the
upper part of the triangular fossa and crosses over
the future superior crus, parallel to the helical rim,
in the deepest part of the scapha. Then it follows
the lateral part of the future antihelix and reaches
the helical tail (Fig. 32.5 ).
If the patient is a child, the surgery is per-
formed under general anesthesia; if the patient
is adult, it may be performed under local anes-
thesia potentially combined with sedation. The
local anesthesia is composed of 1 % lidocaine,
1:100,000 epinephrine, and bicarbonate. Ten
minutes should be awaited before beginning the
surgery.
An elliptical shape of skin is excised from
the posterior part of the auricle (Fig. 32.6 ). The
skin incision extends from the upper corner of
the fossa triangularis to the antitragus and is
placed close to the postauricular sulcus. The
width of the ellipse is about 1–2 cm. In the cau-
dal part, the ellipse is widened in a rhomboid
shape to correct the protruding lobule. The
Fig. 32.4 The new antihelical fold is established by gen-
tly pressing the helical rim toward the mastoid region
Fig. 32.5 The new antihelical fold marked
Fig. 32.6 The skin excision marked

340
C. Isac and A. Isac
incision stops 1 cm short of the superior and
inferior poles of the auricle (Fig. 32.7 ). The pre-
viously marked line is transposed on the poste-
rior side of the ear using transcutaneous needles
(Fig. 32.8 ).
After the skin is excised (Fig. 32.9 ), the under-
mining is performed in the loose areolar plane
toward the helical margin and the cartilage is
incised parallel to the helical rim. The cartilage
incision is guided by the corresponding needles
Fig. 32.7 Skin incision
Fig. 32.8 The anterior
markings are transposed on
the posterior surface using
transcutaneous needles

341
32 Cartilage Folding Technique in Otoplasty
and should leave a strip of helix of at least 0.4 cm
(Fig. 32.10 ). The dissection is supraperichondrial
so that the perichondrium on the posterior surface
is carefully preserved. The upper cartilage inci-
sion follows the markings and it starts as far up as
possible, anteriorly beyond the superior crus,
separating the scapha from the helical rim. At the
caudal end of the helix, the incision is full
thickness, separating completely the helical tail
from the new antihelical fold (Fig. 32.11 ). This
will break the cartilaginous spring and will allow
the cartilage to be folded back 180°. The
undermining is continued on the anterior surface
of the cartilage in the subperichondrial plane. It is
Fig. 32.9 Skin excised and
the supraperichondrial plane
exposed
Fig. 32.10 Skin undermin-
ing in the supraperichondrial
plane and cartilage incision
parallel to the helical margin,
leaving a strip of 0.4 cm of
helix

342
C. Isac and A. Isac
important to manipulate the cartilage very gently
(the ear cartilage is very fragile and brittles eas-
ily) in order not to injure it which may cause
abnormal visible irregularities. The skin on the
anterior side is freed from the cartilage surface all
over the antihelical area and continued down on
the surface of the conchal bowl as much as the
surgeon feels that, by folding the cartilage on
itself, he/she can achieve the appropriate shape
and dimension of the auricle as well as the appro-
priate distance from the helical rim to the mas-
toid. It is important that the anterior perichondrium
be left intact to camou fl age any irregularities.
When the concha is very deep, the undermining
continues on the anterior side of the concha so
that when the cartilage is folded, much of the
concha is diminished in size.
The anterior part of the cartilage which has
been rolled can be gently scored (only partial-
thickness incisions and only at the periphery at
the newly formed antihelix, not on the top of it)
with the knife but with great care so that no
fracture of the cartilage should occur which can
lead to visible and palpable irregularities.
At the superior end of the rolled cartilage, a
triangular wedge can be excised to facilitate the
folding. At the helical tail-antitragus junction
there usually is a double layer of resistant cartilage
that is completely removed in order for the anti-
helix to roll backward.
The rolled cartilage is sutured on itself with
4-0 PDS or clear nylon horizontal mattress
sutures (Fig. 32.12 ). If the free edge of the
folded cartilage seems excessive, it can be
trimmed in order to avoid a protruding edge
which
would
allow
wound
dehiscence
(Fig. 32.13 ). The prominent lobule is set back
with different methods. The authors prefer to
use a single suture from the helical tail to the
most inferior part of the concha to set back the
lobule (Figs. 32.14 and 32.15 ). If the helical
root is also prominent, then it is fi xed to the tem-
poroparietal fascia with a fossa-fascia suture in
order to avoid a telephone ear deformity.
Fig. 32.11 The cartilage is
incised from the scapha to the
helical tail and the anterior
undermining is performed in
the subperichondrial plane.
Note the full-thickness
incision which completely
separates the helical tail from
the newly formed antihelix.
This allows the cartilage to be
folded back, by weakening its
spring, and diminishes the
size of the scapha and the
protrusion of the earlobe

343
32 Cartilage Folding Technique in Otoplasty
Fig. 32.12 The cartilage is
folded back and sutured with
4-0 clear PDS horizontal
mattress sutures
Fig. 32.13 The excessive
free edge of the folded
cartilage is trimmed

344
C. Isac and A. Isac
Fig. 32.14 A single suture is
used from the helical tail to
the concha in order to set
back the lobule which forms a
unit with the helix being
attached to it
Fig. 32.15 The folded
cartilage and the helical
tail-concha suture in place
Hemostasis is achieved throughout the proce-
dure using fi ne-tipped electrocautery.
Most patients develop signi fi cant swelling
and marked ecchymosis after the procedure
(Figs. 32.16 and 32.17 ). The dressing consists of
rolls of Betadine-impregnated cotton which fi ll
the various depressions of the ear, and an elastic
bandage is applied externally (Fig. 32.18 ). One

345
32 Cartilage Folding Technique in Otoplasty
Fig. 32.16 Appearance of
the auricle immediate after
skin suture
Fig. 32.17 Appearance of
the auricle 24 h after surgery

346
C. Isac and A. Isac
dose of intravenous antibiotic is administered
before the procedure and then is continued orally
for 5 days. The patient wears the elastic headband
for 1 month.
Some results using the technique described
above are illustrated in Figs. 32.19 , 32.20 , 32.21 ,
32.22 , 32.23 , and 32.24 .
Complications
Hematoma is usually due to insuf fi cient hemosta-
sis and warrants reintervention and evacuation.
Infection is rare in ear surgery because of the
luxuriant blood supply of the pinna; when it
appears, however, it necessitates aggressive intra-
venous antibiotic therapy to prevent permanent
cartilage damage.
Skin necrosis is rare because of the rich bold
supply of the ear which allows wide undermin-
ing; it is usually due to tight dressings which
obstruct the venous return.
Recurrence of the deformity is rare with the
cartilage folding technique compared with
sutures-only techniques due to suture fatigue or
knot looseness.
Irregular helix with sharp edges produced
mainly by aggressive scoring of the anterior part of
the antihelix or full-thickness cartilage incisions.
Overcorrection (pinned-back look)/under
correction.
Telephone ear deformity – the upper and lower
third of the ear remain protruded and the middle
third is closer to the mastoid area.
Other complications are keloid formation,
suture extrusion, asymmetry, abnormal helical
shape, and helix behind the antihelix.
Discussion
The two main causes of prominent ears are an
unfolded antihelix with a fl at scapha and a deep
conchal bowl. These two features may be isolated
Fig. 32.18 The dressing
consists of rolls of Betadine-
impregnated cotton which fi ll
the various depressions of the
ear

347
32 Cartilage Folding Technique in Otoplasty
Fig. 32.19 ( a ) Preoperative 25-year-old girl with protruding ears, abnormal shape of the helix, and very stiff cartilage.
( b ) Four months postoperative after using the cartilage folding technique
a

348
C. Isac and A. Isac
b
Fig. 32.19 (continued)

349
32 Cartilage Folding Technique in Otoplasty
Fig. 32.20 ( a ) Preoperative 6-year-old boy with left prominent ear. ( b ) Two weeks postoperative after using the carti-
lage folding technique
a

350
C. Isac and A. Isac
b
Fig. 32.20 (continued)

351
32 Cartilage Folding Technique in Otoplasty
a
Fig. 32.21 ( a ) Preoperative 13-year-old boy with protruding ears, lack of antihelical fold, deep concha, and stiff carti-
lage. ( b ) Six months postoperative following use of the cartilage folding technique

352
C. Isac and A. Isac
b
Fig. 32.21 (continued)

353
32 Cartilage Folding Technique in Otoplasty
Fig. 32.22 ( a ) Preoperative 21-year-old girl with left
prominent ear. ( b ) Four months postoperative after treated
with the cartilage folding technique. The technique allows
decreasing the size of the auricle at the same time with the
creation of the antihelical fold
a

354
C. Isac and A. Isac
b
Fig. 32.22 (continued)