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

356
C. Isac and A. Isac
b
Fig. 32.23 (continued)

357
32 Cartilage Folding Technique in Otoplasty
or found together and they may be associated in
some cases with lobular protrusion. The main
challenge in otoplasty is achieving a natural
appearance of the antihelical fold, i.e., nicely
rounded with no sharp edges. Different methods
of cartilage excision, incision, scoring, and
suturing have been proposed. They can be
grouped in cartilage-cutting and cartilage-suturing
techniques. No consensus has been reached,
however, and no method has been declared supe-
rior than the other. The ideal method should be
simple, fast, and applicable to many anatomical
a
b
Fig. 32.24 ( a ) Preoperative 9-year-old boy with important conchal hypertrophy. ( b ) Fourteen months postoperative

358
C. Isac and A. Isac
variations of the auricle, with minimal complica-
tions, quick recovery, and minimal recurrence
rate.
Cartilage-cutting (incisions combined with
excisions of the cartilage) techniques have been
proposed over time by Ely [ 6 ] (1881), Morestin [ 7 ]
(1903), Luckett [ 8 ] (1910), Becker [ 9 ] (1952),
Straith [ 10 ] , Converse [ 11 ] (1963), Cloutier [ 12 ] ,
and Pitanguy [ 13 ] (1961). After Mustarde [ 14 ] and
Furnas [ 15 ] promoted their suturing techniques,
many surgeons adopted their cartilage-sparing
maneuvers which, in their opinion, avoided the
unsightly cartilage irregularities and sharpness of
the antihelical fold induced by cartilage scoring
and incision. Different techniques of cartilage
shaping without incision or excision of the carti-
lage have also been proposed. Rasping seems to be
safer than scoring in terms of producing a smoother
antihelical fold with less irregularities and sharp
edges. Stenstroem [ 16 ] (1963) abraded the ante-
rior side of the cartilage with a specially designed
rasp to form a new antihelix. Scoring may be
achieved through partial-thickness incisions with
knife, electrocautery [ 17 ] , hypodermic needle
[ 18 ] , rasp, Adson-Brown forceps [ 19 ] , or mechan-
ical abrader [ 20 ] . Cartilage scoring has been com-
bined with different suturing and incisions method
in order to obtain satisfactory results. The main
problem with all these techniques is the unnatural,
sharp-edged antihelical fold that may result if the
cartilage is excessively thinned or cut full thickness.
Scoring or abrasion of the cartilage runs the poten-
tial risk of visible cartilage irregularities and a
sharp antihelical fold.
Although cartilage-suturing techniques have
been shown to be safer and to give a more natural
shape to the antihelical fold than cartilage-cutting
techniques [ 21, 22 ] , many studies in literature
concluded that cartilage-cutting techniques have
lower recurrence rates [ 23, 24 ] . Cartilage-cutting
techniques result in good stability over time
because they break the cartilage spring, but some-
times, if used too aggressively, they may lead to
an excessively sharp, irregular, and unnatural
antihelix with an operated look. On the other
hand, cartilage-sparing techniques by means of
sutures, when used alone, carry a high risk of
undercorrection or recurrence of the deformity
[ 5 ] up to 25 % or stitch extrusion up to 15 % [ 24,
25 ] . This is especially true when the concha is
very deep or the cartilage is very stiff. That is
why lately many authors adopted a mixture of
techniques, combining some kind of cartilage
splitting or scoring [ 26 ] techniques that break the
cartilaginous spring with suture stabilization.
Thus, most of the techniques used nowadays
derive from their original descriptions of Converse
[ 3 ] and Chongchet [ 4 ] involving some type of
cartilage incision between the helix and antihelix,
folding the cartilage with or without scoring or
rasping followed or not followed by suturing.
The cartilage folding technique was fi rst
described by Davis [ 27 ] , Converse [ 3 ] , and
Chongchet [ 4 ] and modi fi ed by others [ 28– 31 ] .
Davis [ 27 ] uses an anterior approach, incises the
cartilage in the helical sulcus, so that the helical
rim and scapha are completely independent, and
obtains a folding of the antihelix by abrading the
cartilage with a sandpaper. Chongchet [ 4 ] scores
the anterior surface of the cartilage to weaken it
and obtains a natural bending, again by separat-
ing completely the helix and antihelix through an
incision. Technical re fi nements and modi fi cations
of Converse and Chongchet’s technique of carti-
lage incision have been proposed. Nordzell [ 32 ]
(1965) exposes the anterior surface of the carti-
lage through a posterior incision, abrades the
anterior surface of the scapha and antihelix until
the cartilage bends backward, and then sutures
the medial edge of the incised cartilage in front of
the lateral edge. He does not fold the cartilage.
Colpaert [ 33 ] uses the same cartilage incision,
scores the anterior surface of the cartilage with a
scalpel, and sutures the folded cartilage with 4-0
Vicryl.
All proposed methods of cartilage incision
have in common some kind of helix-antihelix
separation so that the folded cartilage which will
induce the new antihelical formed formation
should not affect the shape of the helix. Folding
the cartilage allows an important reduction in the
conchal height which contributes a lot to the
prominence of the ear. In this way, conchal exci-
sion is not needed anymore. A large concha can
be signi fi cantly reduced by a greater degree of
folding of the cartilage. In our technique we

359
32 Cartilage Folding Technique in Otoplasty
preserve the perichondrium on the posterior sur-
face of the cartilage which will determine the car-
tilage to bend toward the side with the intact
perichondrium when it is incised on one side
only, according to Gibson and Davis’ principle
[ 34 ] . The preserved perichondrium on the poste-
rior surface also helps in keeping the blood sup-
ply for the cartilage.
The excised skin should not be excessive to
prevent a telephone ear deformity and preserve a
good retroauricular sulcus. Lack of tension will
also prevent a keloid scar. Most of the authors
using cartilage folding technique design a skin
excision on the posterior surface of the auricle
with the anterior limit of skin excision corre-
sponding 1 cm medial to the helical margin [ 28 ]
or 5 mm anterior to the tattoo marks [ 29 ] . The
authors prefer designing the skin ellipse closer to
the postauricular sulcus to avoid superimposing
the incision line with the lateral edge of the folded
cartilage which may predispose to suture extru-
sion or excessive tension on the scar and keloid
formation. The skin incision is usually widened
inferiorly in a fi shtail or rhomboid shape because
after setting back the auricle, the lobule almost
always appears protruding. In these cases meth-
ods for setting back the lobule should be added. If
the antitragus is excessive, it can be partially
resected.
When the cartilage is folded, the incision
should completely separate the scapha from the
helix in order for the helix to preserve its rounded
shape. If the helix is not separated from the
scapha, then the folded antihelix will induce a
deformed, angled helix [ 27, 35 ] . The tail of the
helix should be resected in some cases. It is also
very important to extend the caudal part of the
incision through the tail of the newly formed
antihelix. This full-thickness incision allows the
cartilage to fully fold backward, creates a less
prominent antitragus, and thus, sets back the lob-
ule and also diminishes the size of the concha.
The rim of helix that is left behind should be
of suf fi cient width to avoid buckling [ 33 ] but at
the same time should not be too wide as this will
hamper the setback of the scapha.
The cartilage folding technique is very useful
in cases with very thick and sturdy cartilage, in
children or male adults especially, where the
sutures-only methods cannot be trust because
they may not have enough strength to keep the
cartilage folded. In these cases it is necessary to
break the cartilage spring in order to achieve a
long-lasting result, and this can be achieved only
by means of cartilage incisions and folding.
The method prevents superior pole recurrence
deformity compared to cartilage-suturing tech-
niques [ 36 ] . Apart from fl oding the cartilage and
forming the antihelical fold, another main advan-
tage of the technique is that it results in a smaller
size of the auricle, which in many cases is very
useful.
In order to avoid the sharp, noticeable edges
of the newly formed antihelix that may be induced
by cartilage incision and scoring, we preserve the
perichondrium on the anterior surface of the car-
tilage. Horlock [ 24 ] uses a postauricular fascial
fl ap to reduce stitch extrusion and recurrence in
association with Mustardé and Furnas sutures.
Bauer [ 37 ] states that the vast majority of
prominent ears demonstrate some degree of con-
chal hypertrophy and the concha may be the cor-
nerstone of its treatment. He excises a crescent
chondrocutaneous segment from the concha via
an anterior approach and combines the conchal
excision with suture placement via a posterior
approach in almost all cases. Elliott [ 38 ] excises
only conchal cartilage through an anterior
approach. In the cartilage folding technique, there
is no need for conchal excision, as the concha is
reduced in height as much as the surgeon feels by
simply folding the cartilage more.
Conclusions
Cartilage-cutting techniques have been much
criticized for the possible distortions created if
used by the novice. However, they can be very
reliable and can lead to stable and satisfying
results in experienced hands. The advantages
of the cartilage folding method are multiple.
Because no cartilage is excised, there are no
excess skin folds on the anterior part of the
concha. The shape of the antihelix is a very
natural one. The height of the concha can be
reduced as much as desired by folding the

360
C. Isac and A. Isac
cartilage. The method is simple and quick. It
is a very safe and reliable method, delivering
satisfactory results with minor complications.
The folded and sutured cartilage is very stable
over time so that the rate of recurrence is very
low. It is the method of choice both in children
and adults with strong, stiff, and unyielding
cartilage where sutures alone cannot fold
enough the cartilage and sustain it in time.
Also scoring techniques alone in these cases
are not enough either. Weakening the spring of
the cartilage helps in stabilizing the results
over time.
Some improvements of the method (such
as covering the folded cartilage with various
perichondrial fl aps) may allow obtaining even
better results with more natural shape of the
antihelical fold.
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363
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_33, © Springer-Verlag Berlin Heidelberg 2013
33
Introduction
Otoplasty is one of the most frequently performed
aesthetic surgical procedures in children and ado-
lescents. Many techniques have been described
that can give satisfactory results in experienced
hands [ 1– 10 ] . Some of these techniques are
dif fi cult to learn and consistent results may be
hard to achieve. The author reports on the evolu-
tion and application of a cartilage-sparing oto-
plasty technique that addresses all the components
of the typical prominent ear deformity [ 6 ] . This
technique has given good, reproducible results in
180 patients treated over a 20-year period. An
8 % revision rate and minimal complications
were encountered.
Aesthetic otoplasty is one of the most fre-
quently performed procedures in children and
teenagers. Several different otoplasty procedures
have been described over the years. The plethora
of techniques re fl ects the fact that no single tech-
nique has been deemed superior. In general the
goals of aesthetic otoplasty are decreasing the
prominence and protrusion of the ear, producing
the antihelical fold and superior crus, if absent or
effaced, and making the lobule proportionate to
the rest of the ear. More subtle technical points
include a “natural look,” avoiding a pinned-back
appearance, and achieving maximal symmetry.
Accepted techniques include variations on the
Stenstroem [ 3 ] cartilage scoring technique, the
Mustardé [ 2 ] suture technique, and the Furnas [ 4 ]
technique. Bauer et al. [ 8 ] have emphasized the
concha as the key anatomical feature in correc-
tion of the prominent ear and have reported excel-
lent overall results.
To avoid an unfavorable result in otoplasty, the
author has endeavored to develop a technique that
is not technically demanding and gives easily
reproducible and consistent results with minimal
complications. This technique has been re fi ned
over the last 20 years. Initially a conchal takeout
technique was used in over 30 patients. This tech-
nique led to several modi fi cations, which culmi-
nated in the technique presented here. This
technique borrows elements from many previous
reports, including those of Stenstroem, Mustardé,
Tanzer, Furnas, and Bauer [ 1– 9 ] . The current tech-
nique has been applied to 180 consecutive patients
with prominent ears over a 20-year period.
Follow-up has been at least 24 months in all cases.
Technique
Figures 33.1 , 33.2 , 33.3 , 33.4 , and 33.5 present
the key steps in performing this technique. The
deformity is analyzed before surgery to deter-
mine the anatomic elements that are contributing
F. D. Burstein , M.D.
Center for Craniofacial Disorders
Children’s Healthcare of Atlanta ,
975 Johnson Ferry Road, Suite 100 ,
Atlanta , GA 30342 , USA
Department of Plastic and Reconstructive Surgery ,
Emory University , Atlanta , GA , USA
e-mail: fburstein@aol.com ,
fernandoburstein@yahoo.com
Cartilage-Sparing Aesthetic
Otoplasty
Fernando D. Burstein

364
F.D. Burstein
to the abnormal appearance of the ear. Particular
attention is paid to the concha-scapha angle, pres-
ence or absence of the antihelical fold and supe-
rior crus, lobular size and position, asymmetries
caused by the size or position of the auricle, and
Fig. 33.1 Dingman otoabrader has been inserted through
the scapha incision. The anterior perichondrium and carti-
lage are scored along the line of the proposed antihelical
fold. Note the tattoo markings on the lateral edge of the
concha
Fig. 33.2 Measurements for placement of the antihelix
sutures are made with calipers behind the area of the
scapha. One or two parallel conchal incisions are carried
out, separated by approximately 6.0 mm. The mastoid
periosteum has been exposed
Fig. 33.3 Sutures for creation of the antihelical fold are
placed partial thickness through the cartilage and full
thickness through the perichondrium. Once tightened they
will create the antihelical fold
Fig. 33.4 After the antihelix is created, sutures are placed
from the lateral conchal incision to the mastoid perios-
teum and tightened. The sutures are placed on the lateral
conchal incision for more setback and on the medial con-
chal incision for less setback

365
33 Cartilage-Sparing Aesthetic Otoplasty
conchal depth. Standardized photographs are
obtained – most importantly, anterior/posterior
and front to back (Figs . 33.6 , 33.7 , and 33.8 ).
The procedure is performed under general
anesthesia; usually an LMA technique is suf fi cient.
A fi rst-generation cephalosporin is given at the
beginning of the case, along with a single dose of
intravenous steroids. Methylene Blue and a
22-gauge needle are used to mark the proposed
antihelical fold, superior crus, and anatomic bor-
ders of the concha.
The postauricular skin is injected with 0.25 %
bupivacaine with 100,000–400,000 epinephrine,
whereas the anterior surface is injected with bupi-
vacaine alone. An S-shaped postauricular inci-
sion is carried out from the highest point of the
proposed antihelical fold to the lobule. If a lobule
reduction is desired, a small triangle is added to
the end of the incision for debulking. Dissection
to the mastoid periosteum and helical rim is car-
ried out using a microcautery needle. The poste-
rior perichondrium is left intact for suture
retention. The scapha is pierced at the level of the
superior crus under the helix rim. The anterior
skin is undermined with small tenotomy scissors
and a tunnel created with a small septal elevator
along the proposed antihelical fold. A Dingman
otoabrader is used to create multiple micro-
abrasions along the course of the proposed anti-
helix and superior crus onto the anterior scapha
surface. Care is taken to only weaken and not
transect the scapha cartilage. In the younger
patients or those with thin pliable cartilage, the
scissor and elevator dissection may suf fi ce to
weaken the cartilage enough to create the desired
fold without scoring. Clear nylon mattress 4/0
sutures are placed along the proposed crus and
the antihelix forms an antihelical fold and supe-
rior crus. Tapered sutures are recommended. The
placement of the sutures is determined by the
markings made with the Methylene Blue tattoo.
A caliper is used to measure approximately 6.0 mm
from the center of the tattoo for placement of
each bite of the horizontal mattress suture. Fairly
small bites are taken to prevent bunching of the
cartilage. The perichondrium should be included
in each bite for strength. This suture determines
the height of the antihelical fold, approximately
6.0 mm above the plane of the scapha. This can
be modi fi ed as required so that the antihelical
fold height is slightly lower than that of the helix
on frontal view. If the fold is too low, the distance
from the central tattoo can be increased, whereas
Fig. 33.5 Sequential effects of surgical maneuvers on ear
protrusion. ( Bottom ) Partial-thickness scoring of the scapha
with suture placement to create the antihelical fold. Full-
thickness incisions in the concha to break the spring of the
cartilage are indicated. ( Middle ) Sutures placed from
the lateral conchal cut to the mastoid periosteum to bring the
concha closer to the head. ( Top ) Final result with scapha
position after creation of antihelical fold and correction of
the conchal hypertrophy. The most lateral point of the helix
should be 1.8–2.0 cm from the mastoid

366
F.D. Burstein
a
b
Fig. 33.6 ( a ) Preoperative female with prominent ears. ( b ) Following surgical correction
a
b
Fig. 33.7 ( a ) Preoperative male with prominent ears and marked superior pole protrusion. ( b ) Postoperative

367
33 Cartilage-Sparing Aesthetic Otoplasty
if it is too high the distance can be decreased
before placing an additional three sutures.
The conchal protrusion component of the
deformity is then addressed. The previously
marked conchal limits are used to mark the pro-
posed conchal scoring incisions, which parallel
the access of the ear. The fi rst mark is made at the
lateral limit of the conchal bowl in the cymba
conchae. If there is an extreme amount of protru-
sion, a parallel conchal incision is made approxi-
mately 6.0 mm medial to the fi rst. The
perichondrium is cut with the microcautery nee-
dle and the cartilage is cut with a scalpel, taking
care to preserve the anterior skin. In most cases
only the lateral incision is necessary. This maneu-
ver breaks the skin of the conchal bowl. Three to
four 4-0 clear nylon mattress sutures are then
placed 6.0 mm apart between the distal edge of
the most lateral conchal scoring incision and the
mastoid periosteum. This brings the scapha pos-
teriorly against the concha and closer to the mas-
toid, correcting the central ear prominence. It is
important that the conchal setback sutures be
placed along the entire length of the conchal
release incisions to prevent tethering of the cen-
tral ear. The wounds are then irrigated with
antibiotic solution, all bleeding points are hemo-
coagulated, and symmetry is con fi rmed. The
most lateral point of the helix should be no closer
than 18.0 mm from the mastoid to prevent a
pinned-back appearance. Redundant skin is then
trimmed in an hourglass pattern, avoiding ten-
sion. Care must be taken to avoid over-resection
of the skin in the central part of the wound to pre-
vent a telephone ear deformity. At this point if the
lobule is excessive, the previously marked wedge
of soft tissue can be completely removed perpen-
dicular to the long access incision. The wounds
are closed with a running 4-0 chromic gut suture
and coated with antibiotic ointment.
A pressure dressing consisting of Dacron
fl uffs and gauze is applied for 36 h only. Oral
acetaminophen with codeine is given, along with
oral cephalosporin for 4 days. Patients are asked
to sleep with a headband on for 4 weeks and can
shower and shampoo within 36 h.
a
b
Fig. 33.8 ( a ) Preoperative female with asymmetric ear deformity. ( b ) Postoperative

368
F.D. Burstein
Complications
A total of 180 patients (360 ears) underwent
otoplasty surgery over a 20-year period. There
were no major complications. There were no
infections. A total of 15 minor complications
were recorded. These include: three minor post-
auricular hematomas, which were evacuated
under local anesthesia; 12 patients required uni-
lateral revision for a variety of problems; six
ears had slightly recurrence of the superior pole
prominence, which was corrected by simple
postauricular skin excision under local anesthe-
sia in the of fi ce; four ears required replacement
of one or more sutures at the superior third of
the antihelical fold for recurrent deformities;
two developed small hypertrophic postauricular
scars, which were excised at the time of antihe-
lical fold correction and injected with steroid;
and one of these patients also developed a small
hypertrophic scar along the anterior aspect of
the newly created antihelical fold, which responded
to topical steroids.
Discussion
Previous authors have documented a plethora of
technical pitfalls that can occur in otoplasty sur-
gery [ 11– 14 ] . Common iatrogenic problems
include telephone ear deformity, caused by overly
enthusiastic central conchal resection or exces-
sive skin resection in the central portion of the
incision. Scoring the cartilage of the proposed
antihelical fold too deeply or completely cutting
it can create an edge effect that can be visible
from anterior view. The pinned ear can be caused
by overly tight suturing of the concha to the mas-
toid or by over-resection of the postauricular
skin. The conchal skin folding deformity may be
caused by aggressive conchal resection with
insuf fi cient skin undermining. In the previously
described technique, the concha is not removed,
which has greatly reduced any type of visible
conchal deformity after setback. Other less com-
mon problems include gross asymmetry or an
antihelical fold that is far higher than the helical
rim, giving an odd appearance. Damage to the
anterior auricular skin and hypertrophic scars or
keloid formation of the postauricular scars is rare
but reported [ 11– 14 ] .
Any surgical technique and especially any
aesthetic surgical technique must be judged by its
simplicity, reproducibility, and overall safety.
The technique described in this chapter has been
applied to 180 consecutive patients over a 20-year
period. The results have been consistently good,
with a minimum of complications and an overall
8 % revision rate. All of the minor complications
were easily corrected; most required only minor
of fi ce surgery or a brief anesthetic. All the recur-
rent deformities of this series occurred in the
superior part of the antihelical fold and were eas-
ily corrected. All were the results of suture failure
or sutures pulling through the cartilage. These
problems have become less frequent and most
occurred early in the series. These are attributed
to insuf fi cient cartilage scoring, super fi cial place-
ment of the antihelical sutures, and failure to pre-
serve the perichondrium to add strength to the
repair. All of the recognized components of
the prominent ear deformity, including lack of the
antihelical fold and superior crus, conchal hyper-
trophy, and a prominent lobule, are addressed
with this technique. A combination of mattress
sutures that describe a Mustardé technique [ 2 ]
and cartilage scoring similar to that described by
Stenstroem [ 3 ] are used for forming the antiheli-
cal fold as well as the superior crus. Unlike the
Mustardé technique, the mattress sutures are
completely tightened down rather than adjusted
individually, which can be dif fi cult to reproduce
from side to side. When the conchal-mastoid
sutures are fully tightened and are placed the
same distance on each side, reproducible results
can be easily obtained. Measuring the proposed
peak of the antihelical fold has been helpful in
achieving symmetrical results as well as in avoid-
ing the hidden helix. To avoid sharp ridges along
the antihelix, gentle partial-thickness abrasion of
the anterior surface of the scapha is used to
weaken the cartilage. Unlike the Stenstroem tech-
nique in which the entire scapha is exposed, lim-
ited skin undermining of the anterior scapha is
advocated to avoid potential subcutaneous
hematoma and resulting secondary deformity.

369
33 Cartilage-Sparing Aesthetic Otoplasty
Bauer et al. [ 8 ] reported the role of conchal hyper-
trophy as a central component of the prominent
ear deformity, which must be addressed to pre-
vent undesirable results. Certainly, this is a key
component in successful repair. They perform an
anterior chondrocutaneous dissection with a pos-
tauricular approach used to create the antihelical
fold. Other authors have also advocated address-
ing the concha through excision from the ante-
rior-posterior approach. Bauer et al. point out that
failure to resect the skin with the conchal carti-
lage can result in visible skin wrinkling. The
author prefers to approach both the scapha and
the concha through a postauricular incision
because of the small but fi nite possibility of
hypertrophic scar formation, which would be vis-
ible from the anterior approach. Rather than
resect the concha with or without skin, I prefer to
weaken the spring by making parallel incisions
through the postauricular perichondrium and full
thickness through the conchal cartilage, leaving
the anterior perichondrium intact. This is similar
to the scapha incision described by Tanzer [ 9 ] ,
for creation of the antihelical fold. Currently,
most conchal hypertrophy can be addressed with
a single incision at the juncture of the concha and
scapha. If necessary a second incision can be
placed approximately 6.0 mm medially. The
amount of conchal resection can then be adjusted.
If less conchal resection is desired, the sutures
can be placed more medially along the concha,
which has the effect of allowing greater concha-
scapha angle. If more conchal setback is desired,
the sutures are placed more laterally. This method
is a powerful tool for complete correction of the
conchal hypertrophy component of the deformity
and avoids potential visible anterior scars as well
as conchal skin deformities. Anterior skin wrin-
kling has not been observed with this technique.
The fi nal skin and lobule tapering have been well
described by others [ 1– 9 ] . The surgeon must not
rely on the fi nal skin excision to correct any
signi fi cant residual cartilage deformities because
the stretching of the skin will eventually result in
recurrence. The simpli fi ed and shortened postop-
erative care regimen with minimal bandaging has
resulted in excellent patient and parental accep-
tance. Both the patient and the parents must be
committed and motivated for optimal postopera-
tive results.
This technique combines cartilage-sparing
and scoring techniques of Stenstroem and por-
tions of the Mustardé and Furnas technique,
also addressing the conchal hypertrophy as
advocated by Bauer et al. [ 2, 3, 8 ] . It allows for
symmetric aesthetic improvement of the promi-
nent ear. The author suggested guidelines for
the height of the antihelical fold, conchal set-
back, and concha-scapha distance, which can
be measured from side to side to insure a repro-
ducible result.
References
1. Luckett WH. A new operation for prominent ears
based on the anatomical deformity. Surg Gynecol
Obstet. 1910;10:635–7.
2. Mustarde JC. The correction of prominent ears using
simple mattress sutures. Br J Plast Surg. 1963;16:
170–8.
3. Stenstroem SJ. A “natural” technique for correction
of congenitally prominent ears. Plast Reconstr Surg.
1963;33:509–18.
4. Furnas DW. Correction of prominent ears by con-
chamastoid sutures. Plast Reconstr Surg. 1968;42:
189–93.
5. Kaye BL. A simpli fi ed method for correcting the
prominent ear. Plast Reconstr Surg. 1967;40(1):44–8.
6. Burstein FD. Cartilage sparing complete otoplasty
technique: a 10 year experience in 100 patients.
J Craniofac Surg. 2003;14(4):521–5.
7. McDovell AJ. Goals in otoplasty for protruding ears.
Plast Reconstr Surg. 1968;41(1):17–27.
8. Bauer BS, Song DH, Aitken ME. Combined otoplasty
technique: chondrocutaneous resection as the corner-
stone to correction of the prominent ear. Plast Reconstr
Surg. 2002;110(4):1033–40.
9. Tanzer RC. The correction of prominent ears. Plast
Reconstr Surg. 1962;30:236–46.
10. Cohen SR, Burstein FD. Protruding ear. In: Spitz L,
Coran AG, editors. Rob and Smith’s operative
surgery. London: Chapman and Hall Medical; 1995.
p. 76–85.
11. Elliott Jr RA. Complications in the treatment of prom-
inent ears. Clin Plast Surg. 1978;5(3):479–90.
12. Spira M. Otoplasty: what I do now: a 10 year perspec-
tive. Plast Reconstr Surg. 1999;104(3):834–40.
13. Spira M. Reduction otoplasty. In: Goldwyn R, editor.
The unfavorable result in plastic surgery. Boston:
Little, Brown and Company; 1972. p. 168–9.
14. Spira M, Stal S. The conchal fl ap: an adjunct in
otoplasty. Ann Plast Surg. 1983;11(4):291–8.

371
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_34, © Springer-Verlag Berlin Heidelberg 2013
34
Introduction
Prominent ear correction was fi rst described over
150 years ago [ 1 ] and since then a myriad of tech-
niques have been described. Of these the anterior
scoring methods of Stenströem [ 2 ] and Chongchet
[ 3 ] and the posterior suturing technique of
Mustardé [ 4– 10 ] have become the most popular.
There is currently no universally favored tech-
nique and long-term results of the various tech-
niques are lacking in the literature.
The posterior suturing with postauricular fas-
cial fl ap otoplasty technique was fi rst described
by Horlock et al. [ 11 ] . The innovative technique
was designed to address the high rate of postau-
ricular suture extrusion and recurrence with the
cartilage-sparing techniques of Mustardé and
Furnas. It utilizes conchoscaphoid and concho-
mastoid suturing with permanent sutures as
described by Mustardé with the addition of a pos-
tauricular super fi cial muscular aponeurotic sys-
tem (SMAS) fl ap sutured to the helical rim to
cover the permanent sutures. Inherent in the tech-
nique is the versatility and control of the posterior
suturing techniques that are not usually a feature
of the anterior scoring otoplasty techniques. At
our institution this is the favored technique
following our outcome studies that have demon-
strated superiority in long-term aesthetic outcome
and recurrence rate when compared with poste-
rior suturing alone or anterior scoring otoplasty
techniques, with improved appearance and sym-
metry with time since surgery [ 12, 13 ] .
Surgical Technique
Surgery can be performed under general or local
anesthesia, with local anesthetic with 1:200,000
adrenaline in fi ltration as a ring block and into the
anterior and posterior surfaces of the ear in all
cases. A posterior approach is utilized with exci-
sion of a narrow skin ellipse, leaving the subcuta-
neous layers intact on the posterior aspect of the
auricle (Fig. 34.1 ). The remaining anterior skin
on the back of the ear is re fl ected anteriorly in a
subdermal plane as far forward as the helical rim,
as dissecting anterior to this point can lead to dis-
tortion of the helical rim. A composite fl ap of
postauricular SMAS and perichondrium is
re fl ected from this point posteriorly, with care not
to score the cartilage. Dissection is continued
posteriorly until the mastoid periosteum is
reached using scissors to create a pocket of ade-
quate size to house the conchal bowl without
distortion. A row of four 4/0 undyed Ethibond
(Ethicon) sutures are inserted with a round-bod-
ied needle to create the new antihelical fold, start-
ing caudally. The round-bodied needle avoids the
tendency of the suture material to cut through the
M. V. Schaverien , MBChB, MRCS, MSc, MEd, M.D. (*)
K. J. Stewart , MBChB, M.D., FRCS(Ed)(Plast)
Department of Plastic Surgery , Royal Hospital
for Sick Children , 9 Sciennes Road ,
Edinburgh EH9 1LF , UK
e-mail: markschaverien@fastmail.fm ;
ken.stewart@luht.scot.nhs.uk
Posterior Suturing
with Postauricular Fascial
Flap Otoplasty
Mark V. Schaverien and Kenneth J. Stewart

372
M.V. Schaverien and K.J. Stewart
delicate cartilage. A second row of sutures is then
placed between the mastoid periosteum and the
rim of the conchal bowl (Fig. 34.1 ). The auricu-
laris posterior muscle is not divided and the fi rst
of the conchomastoid sutures is passed under the
auricularis posterior muscle to ensure good
anchorage. To facilitate access to the mastoid
pocket, all sutures are inserted and held with a
clip prior to tying, and care must be taken not to
inadvertently include the fascial fl ap when tight-
ening the sutures. In all of our cases, we do not
overcorrect at surgery, but we try to achieve the
appearance we are looking for. The posterior fas-
cial fl ap is then replaced over the cartilage and
sutured to the posterior aspect of the helical rim
with 5/0 Vicryl rapide without tension to cover
Fig. 34.1 ( a ) Postauricular incision. ( b ) Postauricular
ellipse of skin excised with preservation of the underlying
fascial layer. ( c ) Raising postauricular composite fl ap of
postauricular SMAS and perichondrium. ( d ) Conchos-
caphoid sutures. ( e ) Conchomastoid sutures

373
34 Posterior Suturing with Postauricular Fascial Flap Otoplasty
all Ethibond sutures. Skin is closed using 4/0
Prolene subcuticular sutures that are removed at
1 week postoperatively. A standard head bandage
is applied for 1 week that is replaced with a head-
band worn at night for 6 weeks following removal
of sutures.
Preoperatively, on the table following surgical
correction, and at all follow-up points, the authors
measure and record the perpendicular distance
from the mastoid to the helical rim at the middle
third of the pinna at level of Frankfort line, a stan-
dardized cephalometric line connecting the
infraorbital rim and the superior aspect of the
external auditory meatus. With the same person
taking this measurement, there may be a differ-
ence of 1–2 mm if the measurement is repeated
twice on the same ear, and therefore, this can be
considered a standardized measurement of cor-
rection [ 9 ] .
Surgical and Aesthetic Outcomes
The surgical and aesthetic outcomes of the poste-
rior suturing with postauricular fascial fl ap oto-
plasty technique were studied and comparison of
cartilage scoring and cartilage-sparing otoplasty
was done in 203 cases [ 12 ] . The authors per-
formed bilateral otoplasty by either posterior
suturing with postauricular fascial fl ap otoplasty
( n = 41 patients), posterior suturing alone ( n = 94
patients), and anterior scoring otoplasty ( n = 68
patients) techniques. The median patient age was
9 years (range 5–16 years) and the median fol-
low-up was 11 months (range 9–36 months). The
study found that the overall complication rate,
recurrence rate, and rate of reoperation for recur-
rence was lowest in the posterior suturing with
postauricular
fascial
fl ap
otoplasty
group
(Table 34.1 ). The overall appearance and symme-
try scores on a visual analogue scale (VAS) as
assessed by a blinded physician and blinded lay
observer demonstrate consistently better scores
for the posterior suturing with postauricular fas-
cial fl ap technique (Figs. 34.2 and 34.3 ).
A study was done [ 13 ] , which evaluated long-term
outcomes of the posterior suturing with postauricular
fascial fl ap otoplasty technique. Sixty patients (112
ears) who had their surgery performed by a single
surgeon (KJS) were included in the study. Patients
were invited on a single episode to a follow-up clinic
where detailed evaluation was performed and fur-
ther measurements taken by two separate observers.
Photographs taken preoperatively, at 6 weeks postop-
Table 34.1 Complications of posterior suturing with postauricular fascial fl ap otoplasty ( n = 82 ears), posterior suturing
otoplasty alone ( n = 188 ears), and anterior scoring otoplasty ( n = 136 ears) techniques
Posterior suturing with
postauricular fascial fl ap
Posterior suturing
Anterior scoring
Early complications Delayed healing
0
2.1
1.5
Infection
0
0.5
0.7
Bleeding/
haematoma
1.2
2.7
0.7
Late complications
Anterior skin
necrosis
0
0
0.7
Residual pain
0
0
1.4
Cartilage spur
0
0
0.7
Scarred notch
0
0
0.7
Stitch granuloma
0
1.1
0
Extrusion
1.2
2.1
0
Prominent scars/
keloids
0
2.1
1.4
Recurrence
4.8
8
11
Reoperation for
recurrence
3.6
6
8.8
Figures given as percentages of number of ears (Adapted from Mandal et al. [ 12 ] )

374
M.V. Schaverien and K.J. Stewart
eratively, and at the follow-up clinic were evaluated
by an independent blinded consultant plastic sur-
geon observer for overall appearance and symmetry
using a VAS. The mean age at surgery was 8.5 years
(range 4–14) and the mean postoperative follow-up
period was 3.9 years (range 1.5–7.8). Overall fi ve
patients ( fi ve ears) had clinical recurrence (4.5 %),
three of which had undergone revisional surgery.
Clinical recurrence occurred at a mean of 2.5 years
following surgery (range 1–5.8 years). The immedi-
ate postoperative measurements were 20 mm or less
for all ears except two.
Thirty patients attended follow-up clinic fol-
lowing a single invitation (57 ears). The mean
immediate postoperative correction was 11.3 mm
and the mean correction found at follow-up was
10.6 mm, with a mean loss of correction of
0.7 mm (6.2 %) at the Frankfort line. The number
of ears where there was a loss of correction of
1 mm or more was 26 (46 %). In 15 ears (26 %),
there was improvement in correction from that
found immediately postoperatively of 1 mm or
more. There was no relationship between the
mastoid-to-helical rim measurement and duration
since surgery, and there was also no relationship
between the amount of initial correction and the
loss of correction at long-term follow-up.
Patients were generally satis fi ed with the
results in terms of size, shape, and symmetry
(Figs. 34.4 , 34.5 , and 34.6 ). All patients that were
dissatis fi ed with their outcome had an obvious
clinical recurrence except for one. The mean VAS
scores given by the blinded observer at late post-
operative review were higher than those given for
photographs taken at 6 weeks postoperatively
(Table 34.2 ). The blinded observer gave better
Good (8–10)
Satisfactory (4–7) Unsatisfactory (0–3)
Posterior suturing
with fascial flap
Posterior suturing
alone
Anterior scoring
Figs. 34.2 and 34.3 Overall
appearance and symmetry
score based on pre- and
postoperative photographs
(Adapted from Mandal et al. [ 12 ] )
Good (8–10)
Satisfactory (4–7) Unsatisfactory (0–3)
Posterior suturing
with fascial flap
Posterior suturing
alone
Anterior scoring

375
34 Posterior Suturing with Postauricular Fascial Flap Otoplasty
Very satisfied
0
10
20
30
40
50
Satisfied
Patient satisfaction with long term outcome
No. of ears
Dissatisfied
Fig. 34.4 Patient satisfaction
with outcome at late
postoperative follow-up
(Adapted from Schaverien
et al. [ 13 ] )
a
b
Fig. 34.5 ( a ) Preoperative. ( b ) Six weeks postoperative. ( c ) Four years postoperative

376
M.V. Schaverien and K.J. Stewart
c
Fig. 34.5 (continued)
Fig. 34.6 ( a ) Preoperative. ( b ) Six weeks postoperative. ( c ) Five and three fourths years postoperative
a
b

377
34 Posterior Suturing with Postauricular Fascial Flap Otoplasty
scores at late compared with 6-week postopera-
tive follow-up for 11 patients. There was a statis-
tically signi fi cant improvement in appearance
between the 6-week postoperative photographs
and those taken at late follow-up ( P = 0.01). There
was no relationship between VAS scores and
duration since surgery.
Minor complications occurred in six ears
(5.4 %). Suture extrusion occurred in one ear, and
three ears developed painful and palpable perma-
nent sutures, two of which required local anes-
thetic procedures for removal of sutures.
Discussion
Otoplasty is an effective procedure in alleviating
psychosocial distress in the vast majority of chil-
dren that undergo the operation [ 14 ] . The ultimate
goal for the procedure is the production of ears
with a natural and symmetrical appearance with
minimal complications or recurrence. Unfortunately
all pinnaplasty techniques have a clinical recur-
rence rate and little is known about the long-term
stability of the technique [ 4, 8, 9, 15 ] .
At our institution posterior suturing combined
with a postauricular fascial fl ap as described
by Horlock et al. [ 11 ] is our favored technique.
The literature is supportive of the excellent out-
comes that are achievable with this technique
(Table 34.3 ). In their original study Horlock et al.
evaluated their results in 51 patients (96 ears). The
patients ranged in age from 4 to 72 years, with a
median of 10 years of age, and median follow-up
was 11 months. There were no hematomas and no
patients developed suture extrusion or granuloma.
Recurrence of deformity occurred with eight ears
in six patients (8.3 % of ears, 11.8 % of patients),
two of whom requested further surgery (4 %)
Appearance
Mean
Range
P -value
Preoperative overall appearance
32.3
16–60
Immediate postoperative overall appearance
62.7
32–91
Late postoperative overall appearance
70
48–91
P = 0.01
Symmetry
Preoperative symmetry
44.1
15–80
Immediate postoperative symmetry
58.9
33–93
Late postoperative symmetry
64.1
40–92
Adapted from Schaverien et al. [ 13 ]
Table 34.2 Blinded
observer visual analogue
scale scores
Fig. 34.6 (continued)
c

378
M.V. Schaverien and K.J. Stewart
[ 11 ] . Sinha and Richard reported their outcomes
using the technique in 435 ears in 227 consecu-
tive patients, with age range from 6 to 16 years.
Ten patients (14 ears) had complications (4.4 %
patients, 3.2 % ears), 6 of which had suture extru-
sions, and 1 patient had a head bandage-related
bilateral anterior skin necrosis that fully healed
with conservative treatment. There were 6 uni-
lateral and 5 bilateral recurrences representing
4.8 % patients and 3.7 % ears, and all but one of
these required redo of the original technique with
a satisfactory outcome. Ninety-seven percent of
patients had a good or excellent outcome noted at
the time of fi nal review by the clinician [ 16 ] .
The authors feel that conchoscaphoid suturing
leads to greater control and predictability in con-
touring of the antihelix than with cartilage scoring
or cutting techniques, creating a natural-looking
antihelical fold and helical rim (Figs. 34.5 and
34.6 ). The avoidance of anterior skin dissec-
tion leads to an inherently safer procedure than
cartilage-cutting otoplasty, where anterior skin or
cartilage necrosis has been reported.
The addition of the postauricular fascial fl ap
to cover the internal permanent sutures, which is
fast and easy to raise, appears to provide a supple-
mentary vascularized layer to reduce the risk of
suture extrusion [ 4, 5, 7 ] . The fl ap is repositioned
without tension and therefore is unlikely to
contribute postauricular support to prevent
recurrence. The reasons for improved aesthetic
appearance with time since surgery as assessed
by a blinded observer, however, are unclear [ 13 ] .
The authors’ long-term results suggest that it is
unnecessary to overcorrect during surgery, as the
correction is stable or improves with time. Any
recurrence that does occur can be addressed rela-
tively simply by revisional surgery. The authors
prefer to use undyed Ethibond sutures (Ethicon)
as the extrusion rate is lower when compared
with Prolene (Ethicon) sutures.
Although during these studies a posterior skin
ellipse was excised, it is currently our practice
not to excise any skin as it does not play any part
in maintenance of correction. Reconstruction for
complications is also much more dif fi cult when
there is a skin shortage posteriorly.
The authors’ studies have demonstrated a low
suture extrusion and other complication rate and
a low rate of recurrence, with an excellent long-
term aesthetic outcome that may improve further
with time since surgery. These results are limited
to children since adults tend to have stiffer carti-
lage and therefore perhaps a higher predisposi-
tion to recurrence due to higher constant strain on
the permanent fi xation sutures. For this reason
although our usual method for revision is further
simple suturing in children, we have a low thresh-
old for simultaneous conchal reduction in adults
where the cartilage is stiff.
Conclusions
The addition of the postauricular fascial fl ap to
Mustardé and Furnas otoplasty as described by
Horlock et al. [ 11 ] is a valuable re fi nement that
reduces suture extrusion and recurrence rates.
The re fi nement maintains a relatively simple,
controllable, and intrinsically safe otoplasty
that avoids irreparable complications and has
become our technique of choice.
Acknowledgements The authors are indebted to the
Department of Medical Photography at the Royal Hospital
for Sick Children for production of the photographs; Mr.
Patrick Addison, consultant plastic surgeon, for his help
with this study; Miss Elizabeth Whallett, consultant plas-
tic surgeon, for illustrative fi gures; and above all the
patients involved in the study and their parents.
Table 34.3 Outcomes from studies of the posterior suturing with postauricular fascial fl ap otoplasty technique
No. of patients
No. of ears
Suture extrusion
Recurrence (%)
Horlock et al. [ 11 ]
51
96
0
8.3
Mandal et al. [ 12 ]
41
82
1.2 %
4.8
Schaverien et al. [ 13 ]
60
112
0.9 %
4.5
Sinha and Richards [ 16 ]
227
435
2.6 %
3.7

379
34 Posterior Suturing with Postauricular Fascial Flap Otoplasty
References
1. Dieffenbach JF. Die operative Chirurgie. Leipzig: FA
Brockhause; 1845.
2. Stenstroem SJ. A “natural” technique for correction
of congenitally 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. Mustardé JC. The correction of prominent ears using
simple mattress sutures. Br J Plast Surg. 1963;16:170–8.
5. Mustarde JC. Results of otoplasty by the author’s
method. In: Goldwyn RM, editor. Long-term results
in plastic and reconstructive surgery. Boston: Little
Brown & Co; 1980. p. 138–44.
6. Furnas DW. Correction of prominent ears by conchal mas-
toid sutures. Plast Reconstr Surg. 1968;42(3):189–93.
7. Minderjahn A, Hüttl WR, Hildmann H. Mustardé’s oto-
plasty–evaluation of correlation between clinical and sta-
tistical fi ndings. J Maxillofac Surg. 1980;8(3):241–50.
8. Adamson PA, McGraw BL, Tropper GJ. Otoplasty:
critical review of clinical results. Laryngoscope.
1991;101(8):883–8.
9. Messner AH, Crysdale WS. Otoplasty. Clinical proto-
col and long-term results. Arch Otolaryngol Head
Neck Surg. 1996;122(7):773–7.
10. Ellis D, Keohane J. A simpli fi ed approach to oto-
plasty. J Otolaryngol. 1992;21(1):66–9.
11. Horlock N, Misra A, Gault DT. The postauricular fas-
cial fl ap as an adjunct to Mustardé and Furnas type
otoplasty.
Plast
Reconstr
Surg.
2001;108(6):
1487–90.
12. Mandal A, Bahia H, Ahmad T, Stewart KJ. Comparison
of cartilage scoring and cartilage sparing otoplasty –
a study of 203 cases. J Plast Reconstr Aesthet Surg.
2006;59(11):1170–6.
13. Schaverien MV, Al-Busaidi S, Stewart KJ. Long-term
results of posterior suturing with postauricular fascial
fl ap otoplasty. J Plast Reconstr Aesthet Surg. 2010;
63(9):1447–51.
14. Cooper-Hobson G, Jaffe W. The bene fi ts of otoplasty
for children: further evidence to satisfy the modern
NHS. J Plast Reconstr Aesthet Surg. 2009;62(2):
190–4.
15. Webster RC, Smith RC. Otoplasty for prominent ears.
In: Goldwyn RM, editor. Long-term results in plastic
and reconstructive surgery. Boston: Little Brown &
Co.; 1980. p. 146–86.
16. Sinha M, Richard B. Postauricular fascial fl ap and
suture otoplasty: a prospective outcome study of 227
patients. J Plast Reconstr Aesthet Surg. 2012;65(3):
367–71.

381
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_35, © Springer-Verlag Berlin Heidelberg 2013
35
Introduction
The ultimate goal for otoplasty is to provide
a simple operative procedure that produces a nat-
ural correction of deformity, with the least degree
of tissue trauma and the lowest rates of recur-
rence and complications. While numerous tech-
niques exist, a number of outcome measures are
not routinely examined by surgeons. Therefore,
of the numerous techniques which may yield
equivalent technical results in the correct hands,
they may do so in a way that does not take into
account factors such as patient comfort, postop-
erative inconvenience, necessity for postopera-
tive head bandages, and requirement for patients
to attend appointments to deal with dressings.
There has been a resurgence of interest in
suture-based techniques. There is a perception by
some that while cartilage scoring techniques [ 1, 2 ]
can achieve consistent and favorable results in the
majority of patients, when complications do occur
they can be signi fi cant and dif fi cult to correct
without residual deformity. It has been suggested
but not proven without doubt that scoring tech-
niques have a higher hematoma rate. Moreover,
patients undergoing anterior scoring otoplasty
usually need dressings and head bandages and at
least one appointment in a dressing clinic. The
head bandages themselves can be a cause of a
number of problems including a need to re-attend
the ward or clinic if they have slipped off, over-
tight dressings leading to necrosis of part of the
skin, the negative effect on hearing while they
are worn, the cosmetic issues of wearing a head
bandage, and the inability to shower or wash the
hair because of the head bandage. Therefore,
while anterior scoring can give good results,
the occasional severe complications, and all the
listed problems with discomfort and dressings,
lead the author to favor an alternative approach
which means that the aesthetic outcome is better
and complications are minimal and if they occur
they are easy to correct. Patients do not need head
bandages and can shower the day after surgery
while not requiring attendance for dressings, and
especially in females with long hair, there are no
stigmata of surgery at all.
Nevertheless, suture techniques such as origi-
nally described by Mustardé [ 3 ] have their own
complications, the main ones being recurrence or
suture extrusion. If undertaken incorrectly, they
can also cause an overly angulated appearance at
the antihelical fold and an unnatural form with a
greater chance of “overcorrection.”
K. Shokrollahi , MD, BSc, MB ChB, MSc, LLM,
MRCS(Eng), FRCS(Plast)
Mersey Regional Burns and Plastic Surgery
Unit, Ward 4D , Whiston Hospital ,
Warrington Rd , Liverpool L35 5DR , UK
e-mail: kshokrollahi@hotmail.com
Electronic supplementary material The online version
of this chapter (doi: 10.1007/978-3-642-35431-1_35 )
contains supplementary material, which is available to
authorized users.
The Role of the Postauricular Fascia
in Otoplasty: A Complete System
for Otoplasty
Kayvan Shokrollahi

382
K. Shokrollahi
Horlock et al. [ 4 ] raised a fl ap of fascia on
the posterior surface of the pinna, under which
the sutures/suture knots could be placed for the
purpose of reducing extrusion. This posteriorly
(proximally) based fascial fl ap is raised and then
sutured back into place over the Mustardé repair.
The subsequent advance in using the postauricu-
lar fascia was the concept that the fascia itself
can play an integral role in the structural and
aesthetic otoplasty technique with the following
advantages [ 5 ] :
1. Minimal recurrence rates due to removal of all
tension on the Mustardé sutures.
2. A natural aesthetic without angularity.
3. Removing the need for head bandages.
4. Maintaining cover of sutures and knots.
5. A “nothing to lose” approach – raising the fl ap
does not interfere with a surgeon’s usual technique,
as a starting point for learning/experimenting
with the fl ap.
These superior endpoints using the fascial fl ap
are achieved by raising an anteriorly/distally
based fl ap, based on the helical rim, instead of a
posteriorly based fl ap. The advantages of this
strategy are summarized in Fig. 35.1 .
Flap Anatomy and Vascular Supply
The fascia on the posterior aspect of the pinna –
which the author calls the intrinsic postauricular fas-
cia (IPF) – receives its blood supply from branches
of the posterior auricular and super fi cial temporal
branches of the external carotid artery (Fig. 35.1 ).
The auricular branch of the posterior auricular artery
and the posterior branch of the super fi cial temporal
artery provide a dense and prosperous anastomotic
arcade [ 5, 6 ] , which subsequently allows a fascial
fl ap to be raised with a distal base. The fascia itself is
less fi brous and tough than the fascia overlying the
Fig. 35.1 Advantages of using an anteriorly based (helix-
based) postauricular fascial fl ap in otoplasty: a natural
symmetrical result, minimal bruising and discomfort post-
operatively, hiding of the stigmata of surgery beneath long
hair by avoiding head bandages, and using skin glue as
both a dressing and splint which also allows showering
the day after surgery

383
35 The Role of the Postauricular Fascia in Otoplasty: A Complete System for Otoplasty
region of the head posterior to the auriculocephalic
sulcus which we refer to as the extrinsic postauricu-
lar fascia (EPF); however, its elastic properties and
presence of perichondrium enable it to act as an
excellent strong supportive framework.
Surgical Technique
Raising the Anteriorly/Distally
Based Fascial Flap
After in fi ltration of local anesthetic with epineph-
rine, excision of a postauricular skin ellipse is
undertaken (Fig. 35.2 ), which instead of being
positioned over the auriculocephalic sulcus, is
undertaken closer to the helical rim – about half-
way between the sulcus and the rim. As well as
providing mechanical advantage for a fascial fl ap,
this positions the eventual scar to be less visible
from the back as we have demonstrated in a pro-
visional study. The excision should be skin only,
such as when harvesting a full-thickness skin
graft to maintain a thick and robust layer of fas-
cia. The underlying fascia is then incised at its
inferior border down to the chondral surface
(Fig. 35.3 ) and elevated distally (Fig. 35.4 ). The
most appropriate instrument to utilize is a pair of
sharp tenotomy scissors, as the curve aids with
dissection. The fl ap should be raised until the
Fig. 35.2 Excise a thin
postauricular skin ellipse
Fig. 35.3 Incise the
inferior border of the fascia

384
K. Shokrollahi
sulcus of the helical rim is reached. The fascia is
adherent to the cartilage along the entire length of
the helical rim. This results in a good level of
exposure for positioning of Mustardé sutures
near the rim. It also provides good exposure
around the mastoid area for suture positioning for
the fascia-to-mastoid suture which is a key part
of the procedure.
Suturing the fl ap to the mastoid once the fas-
cial fl ap is raised, it can be held in a forceps
(Fig. 35.5 ) and moved around such that the entire
ear will move and can be positioned in such a way
as to correct the prominence of the ear. A natural
antihelical fold can be created by grasping the fas-
cia and approximating it to the appropriate loca-
tion in the mastoid area, which has the same effect
as numerous sutures and without the possibility of
an arti fi cially angular appearance. A location on
the mastoid should be found such that the correc-
tion of the ear prominence and correction of the
antihelical fold are ideal (Fig. 35.6 ). It is impor-
tant to keep this location medial to reduce any
potential to obliterate the postauricular sulcus.
The simplest method is to approximate the fascia
to the appropriate area on the mastoid using the
forceps (Figs. 35.6 , 35.7 , 35.8 , and 35.9 ).
Fig. 35.4 Raise the fascial
fl ap to the sulcus of the
helical rim
Fig. 35.5 Grasp the fascia

385
35 The Role of the Postauricular Fascia in Otoplasty: A Complete System for Otoplasty
Fig. 35.6 Manipulate the ear
Fig. 35.7 Best location for
fascial manipulation

386
K. Shokrollahi
Mark the area on the skin, dissect down to the
mastoid (Figs. 35.10 , 35.11 , and 35.12 ), and
place a 4/0 braided suture such as Ethibond or
Ticron at the periosteal level (Fig. 35.13 ). Next
take a bite of the fascia (Fig. 35.14 ) where it was
previously gripped in the forceps (Fig. 35.10 ),
and tie the fascia-to-mastoid suture with a single
non-locking throw as a trial (Figs. 35.15 , 35.16 ,
and 35.17 ), thereby correcting the prominence of
the ear. Experiment with the ideal position for the
fascial bite suture position – after a shallow learn-
ing curve, the ideal position will come naturally
at the fi rst attempt and be con fi rmed by tying the
suture. When the ideal location is chosen, release
the suture from the fascia (Fig. 35.18 ) and posi-
tion Mustardé sutures between the concha and
the scapha to create a gentle antihelical curve
(Figs. 35.19 and 35.20 ). Mustardé sutures should
Fig. 35.8 The antihelix is
created when the fascia is
approximated to the mastoid
Fig. 35.9 The prominence
of the ear is corrected with
this maneuver

387
35 The Role of the Postauricular Fascia in Otoplasty: A Complete System for Otoplasty
Fig. 35.10 Mark the skin
over the mastoid at the
location where correction is
optimum
Fig. 35.11 Dissect down to
the mastoid beneath the mark
Fig. 35.12 Identify the
suture position

388
K. Shokrollahi
always be tied, inferior suture fi rst and superior
suture last. This is so that the critical superior
suture is tied with the greatest degree of accuracy
leaving the superior pole at exactly the correct
distance from the head and avoiding angularity.
Once the Mustardé sutures are tied, the mastoid-
fascia suture is fi nally tied over the top as judged
in the initial “trial and error” (Figs. 35.15 , 35.16 ,
and 35.17 ). This results in the following
advantages:
1. The tension on the mastoid sutures is com-
pletely released, reducing the likelihood of
knots slipping, tearing out, and recurrence.
2. The sutures and knots are covered with vascu-
lar tissue, reducing the possibility of suture
extrusion.
Fig. 35.13 Place a 4/0
Ethibond or Ticron at the
periosteal level
Fig. 35.14 Take a bite of
the fascia in the appropriate
location as a “test”

389
35 The Role of the Postauricular Fascia in Otoplasty: A Complete System for Otoplasty
Fig. 35.15 Tie the test
suture with only one
non-locking throw on the
suture, for easy release
Fig. 35.16 The ear begins
to correct
3. An “internal corset” for support of the ear is
created which reduces the need for head
bandages.
4. A fi ne-tuning and “naturalization” of the con-
tour of the ear is created.
5. A rotational effect is created, similar to a con-
chamastoid suture (Furnas suture [ 6 ] ).
If the lower pole of the ear, or the earlobe itself,
requires a greater degree of correction, a second
suture can be sited. The fascia can also be par-
tially divided centrally to create separate superior
and inferior fascial fl aps, with different vectors
acting upon them dependent upon suture position-
ing. Learning this technique is simple as the sur-
geon does not have to commit to using the fascial
suture after raising the fascia unless, and until
such time as, he or she is convinced that it will
provide a suitable result. The procedure can con-
tinue as a simple suture-based technique once the
fascial fl ap has been raised, with the fascia simply
taking on the role as a cover and reinforcement for
the sutures once they have been placed.

390
K. Shokrollahi
Fig. 35.17 The prominence
of the ear is corrected, and
a natural antihelix is formed
Fig. 35.18 Loosen the
suture and remove the bite
from the fascia, keeping the
deep mastoid suture in
place. Place a clip on this
suture so it can be tied
towards the end of the
procedure

391
35 The Role of the Postauricular Fascia in Otoplasty: A Complete System for Otoplasty
Fig. 35.19 Place Mustardé
sutures between the scapha
and the concha
Fig. 35.20 Use three
Mustardé sutures and tie
them in the order inferior to
superior

392
K. Shokrollahi
Completing the Surgery and Avoiding
Head Bandages
To complete the procedure, the skin is closed
with 4/0 Vicryl or Monocryl as per surgeon pref-
erence. The wound is sealed with skin glue, and
fi nally the ear is glued to the side of the head with
more skin glue (Fig. 35.21 ). This was fi rst
described by Shokrollahi et al. in the context of
the fascial fl ap otoplasty technique in 2008 [ 5 ]
and by Shokrollahi and Tanner [ 7 ] as a separate
short paper in the same year and subsequently
recommended by other authors in 2010 [ 8, 9 ] .
These and other papers regarding the role of glue
in otoplasty were reviewed by Patel and Price in
2011 [ 10 ] . The fascial fl ap is already supporting
the ear internally, reducing the requirement for
external support. Skin glue, depending on brand,
will last for up to 2 weeks, but averages about a
week. Those with long hair will therefore exhibit
no stigmata of surgery, and all patients can shower
the next day (Fig. 35.22 ). One less appointment is
needed in clinic for removal of head bandages
and dressings as there are no dressings at all.
Patients need to be informed preoperatively that
they will have an overcorrected look due to the
glue (Fig. 35.23 ) and that often one ear is some-
times released from the adhesive effects of the
glue earlier than the other. Some brands of glue
create more crusting than others, and patients
should be reassured regarding the robustness of
their ear correction such that they feel comfort-
able washing gently in the shower to clean the
ears and residual glue if necessary. All patients
should be photographed preoperatively and post-
operatively. Patients should be given access to a
dressing clinic appointment in case of any prob-
lems but not as routine, and a routine appoint-
ment in outpatients at 6–10 weeks is appropriate.
Postoperative results of patients who have had
fascial fl ap combined with Mustardé sutures
show good symmetry with very natural shape to
the ears without an “operated” look (Figs. 35.24 ,
35.25 , 35.26 , and 35.27 ).
Potential Pitfalls of the Fascial Flap
Otoplasty Technique
The fi rst few attempts at raising the fl ap may
result in the surgeon believing that the fascia is
not strong or robust enough to undertake the pro-
cedure. It is essential to ensure that the skin exci-
sion is extremely thin and relatively wide, in
order to preserve as much of the fascia as possi-
ble. Perseverance will lead to the raising of a
substantial fl ap on a consistent basis. It is not
uncommon at fi rst to raise fl aps with holes in,
especially on the inferior aspect. This rarely has
Fig. 35.21 Close the skin, glue the suture line, and glue
the ear to the side of the head for splintage

393
35 The Role of the Postauricular Fascia in Otoplasty: A Complete System for Otoplasty
a
b
c
Fig. 35.22 ( a – c ) Two hours postoperative with glue as splint. No stigmata of surgery and she is able to hear without
dif fi culty. Furthermore, she will have a shower tomorrow the following day

394
K. Shokrollahi
any signi fi cant effect on its suitability for use or
on the force of the correction vectors, and the
issue will be eliminated with practice. It is also
important to ensure the lower pole of the ear is
assessed accurately to determine if a second
suture may be necessary. It is worth realizing
that historically when skin was excised, both the
fascia and skin were often excised and
discarded.
Postoperative Results
In the fi rst series of otoplasties utilizing the fas-
cial fl ap adjunctively, performed on 15 patients
(age range 8–16 years) by a single surgeon
(KS), there were no signi fi cant complications
over an 11-month period [ 5 ] . To date, over 40
such surgeries have been performed without
signi fi cant complications with reliable results
and symmetry. “Soft” outcome measures such
as patient comfort, ability to shower, and oth-
ers are dif fi cult to quantify but become obvious
after a few surgeries.
Conclusions
The raising of a distally based fascial fl ap can
act as an adjunct to suture-based otoplasty
techniques and offers numerous advantages
for both patients and surgeons aiming for the
ultimate goals in otoplasty: satis fi ed patients
and simple and stress-free surgery with con-
sistent results.
Fig. 35.23 Two hours postoperative with glue as splint.
Those with short hair must be warned about the overcor-
rected look for some days after surgery. Nursing staff and
other staff need to be educated about the technique which
they may not have encountered before

395
35 The Role of the Postauricular Fascia in Otoplasty: A Complete System for Otoplasty
a
b
Fig. 35.24 ( a ) Preoperative teenage female. ( b ) Postoperative with a natural “unoperated” and symmetrical look with-
out overcorrection. Well-hidden scar

396
K. Shokrollahi
a
b
Fig. 35.25 ( a ) Preoperative teenage male. ( b ) Four-
month postoperative with a natural “unoperated” and
symmetrical appearance without overcorrection
a
b
Fig. 35.26 ( a ) Preoperative young female (the fi rst
patient to have had this procedure). ( b ) Postoperative with
some mild asymmetry but a good result in light of the
severity of presenting deformity. Demonstrates the natural
shape of the antihelical fold

397
35 The Role of the Postauricular Fascia in Otoplasty: A Complete System for Otoplasty
References
1. Chongchet V. A method of antihelix reconstruction.
Br J Plast Surg. 1963;16:268–72.
2. Thomas SS, Fatah F. Closed anterior scoring for
prominent-ear correction revisited. Br J Plast Surg.
2001;54:581–7.
3. Mustardé JC. The correction of prominent ears using
simple mattress sutures. Br J Plast Surg. 1963;16:
170–8.
4. Horlock N, Misra A, Gault DT. The postauricular fas-
cial fl ap as an adjunct to Mustardé and Furnas type
otoplasty. Plast Reconstr Surg. 2001;108:1487–90.
5. Shokrollahi K, Cooper MA, Hiew LY. A new strategy
for otoplasty. J Plast Reconstr Aesthet Surg. 2009;
62(6):774–81.
6. Furnas DW. Correction of prominent ears by con-
chamastoid sutures. Plast Reconstr Surg. 1968;42:
189–93.
7. Shokrollahi K, Tanner B. “Glue Ear”: beginning of
the end for head bandages after prominent ear correc-
tion? J Plast Reconstr Aesthet Surg. 2008;61:1077.
8. Vetter M, Foehn M, Wedler V. A new postoperative
otoplasty dressing technique using cyanoacrylate tis-
sue adhesives. Aesthetic Plast Surg. 2010;34(2):
212–3.
9. Bovill ES, Boulton R, Wharton S. Use of dermabond
as a dressing for prominent ear correction: a sound
alternative to head dressings. J Plast Reconstr Aesthet
Surg. 2010;63(6):1065–6.
10. Patel AJ, Price RD. The use of tissue glue in prominent
ear correction surgery. Aesthetic Plast Surg. 2011;
35(2):245–7.
Fig. 35.27 ( Left ) preoperative young girl. ( Right ) postoperative

399
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_36, © Springer-Verlag Berlin Heidelberg 2013
36
Introduction
Commonly accepted anatomical components of
prominent ear deformity are (1) antihelical fold
de fi cit or poor de fi nition, (2) conchal hypertrophy,
(3) a “wider-than-normal” angle between helical
root and scalp, and (4) prominent lobule [ 1 ] . These
deformities may have variable expression or com-
binations among patients. Although less stressed
and mentioned in the de fi nition of prominent ear
deformity, some other concerns shall also be taken
care of during surgical correction such as (1) the
nature (stiffness-elasticity) of the ear cartilage, (2)
patient cooperation and expectation, and (3) com-
bination of variable deformities with variable
phenotypic expression such as macrotia, cup ear,
constricted ear, and Stahl’s ear. These combina-
tions make prominent ear surgery demanding and
comprehensive. Underestimation of these compo-
nents may lead to failure.
Although components of prominent ear defor-
mities were de fi ned clearly in many textbooks,
prominent ear correction techniques reveal a het-
erogeneous strategical spectrum. Precise choice
of surgical technique, when combined with com-
prehensive clinical experience, reveals the fact
that each prominent ear patient needs serious
preoperative evaluation prior to tailoring of indi-
vidualized surgical procedure combinations. In
other words, “one-size- fi ts-all” approach com-
monly leads to disappointment.
In order to de fi ne a position for posterior auric-
ular muscle fl ap otoplasty techniques, there is a
necessity to classify surgical techniques of promi-
nent ear correction. A systematic classi fi cation for
this purpose can be found in Table 36.1 including:
(1) excisional techniques, (2) suture techniques
with or without cartilage scoring, (3) using ana-
tomical structures in order to obtain anatomical
correction, and (4) molding techniques.
Posterior Auricular Muscle
From everyday perspective, we see domestic dogs
retract their ears as a gesture of gratitude and joy.
An entertaining artifact from evolution, some peo-
ple can also selectively move their ears posteriorly.
The muscle which its function is mentioned above
(pulling ear posteriorly) is known as “posterior
auricular muscle,” a member of extrinsic auricular
muscles. Extrinsic ear muscles consist of supe-
rior auricular, anterior auricular, and posterior
auricular muscles (Fig. 36.1 ). Most functional of
all, posterior auricular muscle origins from mastoid
process and inserts to ponticulus innervated by
facial nerve and receiving perfusion from posterior
auricular artery. Because of its more superior inser-
tion and position, the amount of posterior excur-
sion during ear retraction is more on upper pole
than lower parts of the ear (Fig. 36.2 ).
I. Yazici , M.D.
Department of Plastic Reconstructive
and Aesthetic Surgery ,
Kirikkale University Medical Faculty ,
Sağlık Sok. Fabrikalar Mah , Kirikkale 71100 , Turkey
e-mail: ilkeryazici@gmail.com
Posterior Auricular Muscle Flap
with Otoplasty
Ilker Yazici

400
I. Yazici
The posterior auricular muscle plays an impor-
tant role on prominency of the ear and prominent
ear deformity pathogenesis. Smith and Takashima
[ 3 ] worked on the ears of anencephalic births and
found that absence or hypoplasia of this muscle is
associated with prominency of the ear. They also
present ear prominency as a neuromuscular sign.
As a part of facial nerve innervated mimic mus-
cles inserting on ear cartilage, dysfunction or
hypoplasia of posterior auricular muscle eventually
leads to ear prominency. Another study regarding
the role of posterior auricular muscle on promi-
nent ear pathogenesis was performed by Guyuron
and DeLuca [ 4 ] in 1997. They observed a linear
relationship between posterior auricular muscle
insertion site and projection of ear, based on their
measurements during surgeries of 30 prominent
ear cases. They also worked on the usage of this
muscle for correction of prominent ear defor-
mity. It is obvious that there is a rising attention
Table 36.1 Classi fi cation of otoplasty techniques including some instances and the qualitative position of poste-
rior auricular muscle fl ap techniques among them
Target tissue
Excisional
techniques
Suture techniques with or
without cartilage scoring
Using anatomical structures
in order to obtain correction
Molding techniques
Cartilage –
antihelix
Luckett
Mustarde
Karacaoglan et al.
Matsuo et al.
Converse
Stenström
Scuderi et al.
Lindford et al.
Pitanguy
Fritsch (minimal invasive)
Cartilage –
concha
Conchal
excision
Furnas (concha-mastoid
suture)
Karacaoglan et al.
Matsuo et al.
Scuderi et al.
Lindford et al.
Posterior
auricular muscle
and/or fascia
Elliot
Furnas (concha-mastoid
suture)
Posterior auricular muscle
fl aps
NA
Posterior auricular muscle
fl aps
Horlock et al. (fascial fl ap)
Horlock et al. (fascial fl ap)
Note that some instances may not be included. Majority of these techniques were referenced by Patterson and
Friedman [ 2 ]
Fig. 36.1 Anatomy of the
extrinsic ear muscles which
are temporal area extensions
of galea aponeurosis,
resembling frontalis and
occipitalis muscles
anatomically, sharing the
same anatomical plane

401
36 Posterior Auricular Muscle Flap with Otoplasty
to prominent ear deformity pathogenesis and the
role of posterior auricular muscle [ 3, 4 ] . The pri-
mary effect of posterior auricular muscle anatom-
ical variation or failure is the valgus deformity of
the ear. Cranio-auricular angles of 25 for men
and 21 for women are regarded normal [ 5 ] .
Generally, valgus deformity denotes the increased
angle between helix and scalp. Cranio-auricular
angle greater than 40° is named as auricular val-
gus deformity [ 4, 5 ] . Although this deformity
may be originated from conchal hypertrophy,
conchal anterior displacement, and less de fi ned
antihelical fold; the principle deformity dedicated
to the failure of the posterior auricular muscle is
the abductory slide of the ear.
Posterior Auricular Muscle Flap
Utilized in Otoplasty
Nicoletis and Guerin-Surville [ 6 ] published the
fi rst report on the utilization of posterior auricu-
lar muscle for otoplasty in 1978. They transposed
the posterior auricular muscle to scapha com-
bined with cartilage incision. They have obtained
correction of valgus deformity and enhancement
of antihelical fold with no recurrence. In contrast
to Mustarde sutures and Stenstrom technique, in
which the primary target is to create an antiheli-
cal fold transferring the tension of cartilage fold
on the cartilage and sutures, using posterior
auricular muscle enables a well-vascularized and
a more durable repair in order to fold the carti-
lage. Additionally enabling posterior relocation
of the whole ear, addressing valgus deformity.
Although perichondrioplasty (perichondrial fl ap
tacked posteriorly which has the effect of creat-
ing antihelical fold and posterior setback) proce-
dure can also provide these, muscular repair
seems to be more durable and relapse-free. Azad
et al. [ 7 ] have also transferred posterior auricular
muscle to scapha in 2003. Scuderi et al. [ 8 ] pub-
lished the largest series consisting of 103 patients.
They have re fi ned the technique and transferred
the muscle fl ap to scapha by including conchal
cartilage insertion on the tip of the fl ap. This
approach addresses conchal hypertrophy and
antihelix by including a reliable muscle fl ap.
Additionally repair site was reinforced by the
cartilage graft/ fl ap. Patients with stiff auricular
P
Ah
P
P’
Ah’
Ah’
P’
Ah
Fig. 36.2 The function of the posterior auricular muscle
on human. The bars adjacent to the ears show the projec-
tion of upper pole ( P ) and antihelix to helical border dis-
tance ( Ah ). Please note the excursion amounts before P,Ah
and after P ¢ ,Ah ¢ posterior auricular muscle contraction.
The upper pole excursion is more than antihelix to helix
distance as well as lobule. ( Left ) before contraction.
( Right ) after contraction

402
I. Yazici
cartilage and excessive valgus deformity may
bene fi t from this technique provided to the arma-
mentarium of prominent ear surgery.
Conchal reduction surgery is another fi eld for
the usage of posterior auricular muscle. Bauer
et al. [ 9 ] stress the importance of conchal hypertro-
phy in prominent ear deformity. Blindly focusing
to correct scapha-conchal angle “antihelix” is a
common mistake. Well-established cornerstone
procedures for conchal correction were presented
and appreciated as follows: Concha-mastoid
suture, described by Furnas [ 10 ] , and excision of
conchal cartilage are among the mostly performed
ones. As routinely performed by Elliot [ 11 ] , exci-
sion of postauricular muscle and posterior fi brofatty
tissue is another adjunctive method for correction
of valgus deformity. Deep concha (>2.5 cm) com-
bined with stiff auricular cartilage grants conchal
reduction. Concha-mastoid sutures and conchal
excision are respectively prone to recurrence and
meatal narrowing. Spira’s posterior conchal fl ap
was designed to decrease meatal complications of
conchal reduction. Redundant anterior skin after
conchal reduction is another complication to pre-
vent. Anterior approach for conchal reduction may
be used, a gamble for the price of keloid forma-
tion. Conchal angulation and irregularities may
also be a problem to be encountered associated to
conchal excision. In order to accomplish a smooth
conchal
curve
during
conchal
reduction,
Karacaoglan and Ciloglu [ 12 ] have used excised
conchal cartilage as an onlay graft.
In order to overcome some of the drawbacks of
conchal reduction and to present another reliable
prominent ear correction technique, Yazici et al.
[ 13 ] have used posterior auricular muscle as a
fl ap. The purpose was to overcome the risks of
conchal reduction surgery by using posterior
auricular muscle fl ap combined with perichon-
drioplasty (perichondrial fl ap tacked posteriorly)
for better results with repositioning (Figs. 36.3
and 36.4 ). This approach enables (1) better poste-
rior replacement by positioning conchal fl oor pos-
teriorly by the help of muscle tonus and placing
helical rim posteriorly by the virtue of additional
perichondrioplasty (this maneuver also increases
antihelix de fi nition) (Fig. 36.5 ), (2) to hide knots
and provide a better healing environment, and (3)
creating a softer conchal bowl, preventing ante-
rior skin redundancy (Fig. 36.6 ). This approach
can relieve the necessity of anterior approach for
conchal excision and utilizes posterior auricular
muscle rather than excising, enabling two lines of
repair site serving to correct valgus deformity.
a
d
e
b
c
Fig. 36.3 ( a ) Posterior auricular muscle outlined before
surgery using a simple manipulation, anterior traction of
ear. It is easy to see the size of the muscle after traction.
( b ) Posterior auricular muscle inserted to ponticulus. ( c )
Muscle fl ap is dissected and ready to transfer. ( d ) Muscle
fl ap is detached from ponticulus and conchal excision per-
formed. ( e ) Transfer of the muscle fl ap to conchal base as
published by Yazici et al. [ 13 ]

403
36 Posterior Auricular Muscle Flap with Otoplasty
All surgical procedures which use posterior
auricular muscle fl ap transposition for the service
of prominent ear correction share the same techni-
cal point: “the preparation of posterior auricular
muscle fl ap.” In order to prepare the fl ap, sequen-
tial to postauricular incision, 1–2 cm of posterior
undermining is enough after visualizing ponticu-
lus and the base of concha (Fig. 36.3 ). Blunt dis-
section is enough to dissect the muscle. Next the
surgeon can detach the muscle from ear cartilage or
can include the conchal resection portion cartilage
on the fl ap. After dissection of the fl ap, it is possi-
ble to use it for prominent ear correction as stated
above with combination of conventional tech-
niques (Fig. 36.4 ). Regarding the existence and
size of the muscle, variations may exist. Posterior
auricular muscle may be too weak for use in some
cases, and this risk should be kept in mind while
planning the procedure. Preoperative examination
of the ear by anterior traction can be helpful to
check the muscle “whether usable or not.” The
author has encountered only two cases of very thin
and unusable posterior auricular muscles in around
50 otoplasty cases (sequential cases having promi-
nent ear in which mustarde, perichondrioplasty
and posterior auricular muscle fl ap techniques
were used for correction). These techniques using
posterior auricular muscle are needed to be evalu-
Fig. 36.4 Different surgical
procedures utilizing posterior
auricular muscle fl ap used up
to date. ( a ) Transposition of
the fl ap to scapha as fi rst
performed by Nicoletis and
Guerin-Surville [ 6 ] . Dotted
area represents antihelical
fold area. ( b ) Conchal
cartilage on the tip of the
graft prior to transposition to
scapha as performed by
Scuderi et al. [ 8 ] . ( c )
Posterior auricular muscle
fl ap transfer to conchal base
with conchal excision and
perichondrioplasty as
published by Yazici et al.
[ 13 ]

404
I. Yazici
ated with further clinical studies, involving a much
bigger patient population.
Posterior auricular muscle is a good adjunct in
antihelix creation, conchal hypertrophy, and
associated valgus deformity correction. The
author has not used this fl ap for isolated antihelix
creation. According to our experience, posterior
auricular muscle fl ap-indicated cases were
approximately 15 % of all prominent ear cases.
According to reports of techniques and our
experience, utilization of posterior auricular
muscle in conchal reduction and auricular val-
gus deformity enables good results. Using pos-
terior auricular muscle as mentioned above or
Fig. 36.5 ( Left ) Preoperative. ( Right ) Postoperative patient after conchal reduction and perichondrioplasty combined
with postauricular muscle fl ap as published by Yazici et al. [ 13 ]
Fig. 36.6 ( Left )
Preoperative. ( Right ) Note
the natural conchal bowl
contour 6 months postopera-
tively after transfer of
posterior auricular muscle
fl ap combined with conchal
excision

405
36 Posterior Auricular Muscle Flap with Otoplasty
any other way will provide at least a vascular
healing environment and eventually increase the
durability of the correction. Alternative transpo-
sition procedures of this muscle may also be
possible in the future. Using anatomical struc-
tures rather than excising is an important recon-
structive virtue. Posterior auricular muscle is a
good instance for this.
References
1. Spira M. Otoplasty: what do I do now- a 30-year per-
spective. Plast Reconstr Surg. 1999;104(3):834–40.
2. Petersson RS, Friedman O. Current trends in oto-
plasty. Curr Opin Otolaryngol Head Neck Surg. 2008;
16(4):352–8.
3. Smith DW, Takashima H. Ear muscles and ear form.
Birth Defects Orig Artic Ser. 1980;16(4):299–302.
4. Guyuron B, DeLuca L. Ear projection and posterior
auricular muscle insertion. Plast Reconstr Surg.
1997;100(2):457–60.
5. Kelley P, Hollier L, Stal S. Otoplasty: evaluation,
technique, and review. J Craniofac Surg. 2003;14(5):
643–53.
6. Nicoletis C, Guerin-Surville H. Prominent ears. Trans-
position of the posterior auricular muscle on the scapha:
a new technique. Aesthetic Plast Surg. 1978;2:295.
7. Azad S, Edwin A, Kumar PV. Posterior auricular
muscle – a useful adjunct in otoplasty. Br J Plast Surg.
2003;56(7):722–3.
8. Scuderi N, Tenna S, Bitonti A, Vonella M.
Repositioning of posterior auricular muscle combined
with conventional otoplasty: a personal technique.
J Plast Reconstr Aesthet Surg. 2007;60(2):201–4.
9. Bauer BS, Song DS, Aitken ME. Combined otoplasty
technique: condrocutaneous conchal resection as the
cornerstone to correction of the prominent ear. Plast
Reconstr Surg. 2002;110(4):1033–41.
10. Furnas DW. Correction of prominent ears by concha-
mastoid sutures. Plast Reconstr Surg. 1968;42(3):
189–93.
11. Elliot Jr RA. Complications in the treatment of promi-
nent ears. Clin Plast Surg. 1978;5(3):479–90.
12. Karacaoglan N, Ciloglu SN. Conchal setback without
resection in prominent ear deformity. Otolaryngol
Head Neck Surg. 2011;145(6):930–1.
13. Yazici I, Findikçioğlu F, Ozmen S, Noyan N, Yavuzer
R. Posterior auricular muscle fl ap as an adjunct to oto-
plasty. Aesthetic Plast Surg. 2009;33(4):527–32.

407
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_37, © Springer-Verlag Berlin Heidelberg 2013
37
Introduction
Surgical defect of the ear, whether due to removal
of a skin cancer or due to other trauma, is rela-
tively common, and it is frequently managed in
the of fi ce-based setting [ 1 ] . Limited availability
of skin is one of the main challenges in the cos-
metically satisfying reconstruction of the anterior
surface and helix of the ear following a skin can-
cer excision. Various surgical options are avail-
able to repair the surgical defects of the ear [ 2 ] :
wedge excision, local fl ap surgery (using skin
from same anatomical unit), and skin grafting.
They do produce a successful outcome, but they
invariably cause ears that are smaller postopera-
tively (Fig. 37.1 ). In majority of cases, the size
discrepancy between the two ears is well accepted,
but the avoidance of this complication is cosmeti-
cally desirable especially if a procedure is not
associated with a signi fi cant morbidity. Distant
fl ap, by fi lling the surgical defect using the soft
tissue outside the ear (e.g., retroauricular area
[ 3– 5 ] ), does provide a solution to this postsurgi-
cal miniaturization of the ears.
This chapter presents various applications of
retroauricular cutaneous advancement fl ap, a ver-
satile fl ap, to successfully repair the surgical
defects of the ear in its different locations,
following a skin cancer excision.
Technique
Advancement fl ap is a well recognized and a
popular skin fl ap technique in skin cancer sur-
gery. It is a sliding type of fl ap where the surgical
defect is fi lled by the fl ap of skin that is slid/
advanced towards it (Fig. 37.2 ). In retroauricular
area, a fl ap of retroauricular soft tissue can be
advanced towards and fi ll the surgical defects of
the anterior surface and the helical rim of the ear.
This fl ap can be placed over the helical rim,
through the cartilage to fi ll the defect of the
deeper anterior conchal surface, or be rolled up to
recreate the helical rim defect (Fig. 37.3 ).
Although the mechanism of this fl ap is that of
advancement, as the fl ap is skipping over a bridge
of normal skin to fi ll the surgical defect of the ear,
it is by de fi nition termed interpolation fl ap. This
fl ap needs to be divided at a later date to free the
ear from the retroauricular area, hence making
this a two-staged procedure.
Design and Creating the Flap (Fig. 37.4 )
Markings
Basal cell carcinoma (BCC) and its appropriate
margins are preoperatively marked (Fig. 37.4a ).
Tunnel through which the fl ap will be pulled
through (from posterior auricular surface anteriorly)
P. Kim , M.D., MBBS, FACCS, FIBCS
Simply Beautiful Cosmetic Surgery
& Laser Clinic , 4 Farnell Street, West Ryde ,
Sidney , NSW 2114 , Australia
e-mail: drpeterkim@yahoo.com ,
dr.peterkim@yahoo.com.au
Various Applications
of Retroauricular Advancement
Skin Flap to Treat the Surgical
Defect of the Ear
Peter Kim

408
P. Kim
is marked (corresponding to the posterior border
of the surgical margin) and the length of the
retroauricular skin fl ap marked (Fig. 37.4 ).
Retroauricular skin is marked posterior to the ret-
roauricular skin crease and a few mm longer than
the length of the surgical defect. Ensure that the
fl ap length is not more than 1:2.5 ratio to maxi-
mize the fl ap survival.
Procedure
The skin cancer is excised (Fig. 37.4c primary
defect). Cartilage slit is made to allow the skin
fl ap to be pulled through on the anterior auricular
surface (Fig. 37.4d ). Retroauricular skin fl ap is
incised (Fig. 37.4e ), and it is then undermined to
its base (Fig. 37.4f , secondary defect). Undermine
to enhance the fl ap mobility but only as required
to minimize the damage to the fl ap vascularity.
Elevated skin fl ap is then grasped (Fig 37.4g ) and
pulled through the cartilage tunnel and placed on
the anterior surface of the ear (Fig. 37.4h ). At this
point, the fl ap should be comfortably fi lling the
surgical defect and under minimal tension. Base
of the fl ap is sutured to the postauricular sulcus
a
b
c
Fig. 37.1 Ears from the same patient. ( a ) Right ear
following skin cancer excision using local fl ap surgery,
( b ) anterior view, ( c ) left ear following skin cancer
excision using distant fl ap. The right ear is noticeably
smaller and distorted compared to the left ear
Fig. 37.2 ( a ) Advancement skin fl ap with arrow showing the direction of advancement. ( b ) Flap advanced to fi ll the
surgical defect

409
37 Various Applications of Retroauricular Advancement Skin Flap to Treat the Surgical Defect of the Ear
(Fig 37.4i ). Skin fl ap is then sutured into place
(Fig 37.4j ). The ear is immobilized by suturing it
down to the mastoid process by using deep
periosteal sutures (Fig 37.4k, l ). This suture
reduces the resting tension and prevents the fl ap
from inadvertent and accidental tension.
Dividing the Flap (Fig. 37.5 )
The skin fl ap heals well, and it is ready for detach-
ment in 2 weeks (Fig. 37.5a ). The fl ap is now
divided from the anterior surface (Fig. 37.5b ), at a
point where there is adequate posterior primary
defect coverage. The divided fl ap is then suture
approximated with the posterior margin of pri-
mary defect (Fig. 37.5c ). Incision in the posterior
surface of the ear (Fig. 37.5d ) is then sutured
(Fig. 37.5e ). For a small cartilage defect such as
this, repair is not required. Healing of small sec-
ondary defect is well advanced by secondary
intention in this case (Fig. 37.5e ), and only a trim-
ming of the fl ap stump (Fig. 37.5f ) and a precise
suture approximation of its edges (Fig. 37.5g )
were required. Sutures were removed after 1 week.
Final result is usually satisfactory after 3 months,
and there were no miniaturizations of the ear.
Applications
Repairing Anterior Surface Defect
of the Lobule (Fig. 37.6 )
This 63-year-old woman presented with a biopsy-
proven BCC of the anterior surface of the right
lower ear lobule. BCC and the surgical margin
were marked, and the appropriate retroauricular
advancement fl ap was designed. BCC was excised
and the fl ap elevated. In this case, the fl ap was
advanced over the helical rim to fi ll the surgical
defect of the anterior surface of the lower ear
Fig. 37.3 Various applications
of retroauricular advancement
fl ap to fi ll the surgical defects
of the anterior surface and helix
of the ear