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

411
37 Various Applications of Retroauricular Advancement Skin Flap to Treat the Surgical Defect of the Ear
Repairing Full-Thickness Helical
Rim Defect (Fig. 37.8 )
This 73-year-old male presented with helical rim
defect following excision of melanoma in situ.
Scar was excised. Retroauricular skin fl ap was
created to fi ll the helical rim defect. In order to
create a rolled appearance of the helical rim, the
skin fl ap was doubled up into a roll. This roll of
fl ap was then sutured into the surgical defect. The
ear was pinned back to the retroauricular area to
avoid inadvertent pulling of the ear that can dam-
age the fl ap. Flap has healed well after 2 weeks,
and it was divided. The retroauricular skin was
slow to granulate; hence S-plasty [ 2 ] was per-
formed for a direct closure. Cosmetic outcome
after 3 months appears satisfactory.
Discussion
Surgical defect of the ear following a skin cancer
excision, when repaired using the soft tissue
of the same ear (wedge excision and local fl ap
surgery), often produces miniaturization of that
ear, and this is particularly noticeable when the
defect is on the helical rim. Using skin or compos-
ite graft to fi ll these defects can avoid smaller ear
postoperatively, but especially when the surgical
defect involves the helical rim, the resulting cos-
metic outcome may be unsatisfactory. Distant fl ap
does emerge as an attractive option in fi lling the
surgical defects of the ear without miniaturizing
it, as it does not require the use of the soft tissue of
an already limited soft tissue reserve of the ear.
Retroauricular soft tissue is geographically
located in close proximity to the ear; thus, a skin
fl ap of this region can easily be advanced to fi ll
its soft tissue defects. Due to its close proximity
to the ear fl ap, length and mobilization can be
minimized which reduces the vascular burden of
that fl ap. Its other attractions are that there is an
abundant supply of well-vascularized soft tissue
for ear reconstruction [ 6 ] , fl ap donor site scar
can be easily concealed behind the ear, and the
miniaturization of the ear can be avoided.
There are several essential factors that need to
be taken into consideration and be customized for
a
e
f
g
h
b
c
d
Fig. 37.5 Stage 2 of retroauricular skin fl ap. ( a ) The skin
fl ap heals well, and it is ready for detachment in 2 weeks.
( b ) The fl ap is now divided from the anterior surface, at a
point where there is adequate posterior primary defect
coverage. ( c ) The divided fl ap is then suture approximated
with the posterior margin of primary defect. ( d ) Incision
in the posterior surface of the ear ( e ) is then sutured. ( e )
Healing of small secondary defect is well advanced by
secondary intention in this case, and ( f ) only a trimming
of the fl ap stump and ( g ) precise suture approximation of
its edges were required ( h ) Final result

412
P. Kim
a successful retroauricular advancement skin fl ap
surgery. And these factors are:
Flap Length
Correct approximation of the length of the skin
fl ap and by creating the fl ap that is approximately
2 mm longer than the surgical defect to be
fi lled but not to overlengthen the fl ap as to create
devascularization. When the fl ap is intended to
be rolled up to reconstruct the helical rim defect,
fl ap length should be approximately 4 mm longer
than the anticipated length.
Flap Thickness
Thick retroauricular soft tissue enables the opera-
tor to produce a variable thickness of fl ap to
a
e
f
g
h
i
b
c
d
Fig. 37.6 Repairing anterior surface defect of the lobule.
( a ) Basal cell carcinoma (BBC) surgical margin is marked.
( b ) The appropriate retroauricular advancement fl ap was
designed. ( c ) BCC is excised. ( d ) The fl ap is elevated. ( e )
The fl ap is advanced over the helical rim to fi ll the surgical
defect of the anterior surface of the lower ear lobule. ( f )
The fl ap is sutured and stabilized by pinning the ear down
to the mastoid process. ( g ) Flap after two weeks. ( h ) The
fl ap is divided and the ear released. ( i ) Three months post-
operative and both the recipient and the donor site have
healed well, and there was no miniaturization of the ear

413
37 Various Applications of Retroauricular Advancement Skin Flap to Treat the Surgical Defect of the Ear
a
e
f
g
h
b
c
d
Fig. 37.7 Repairing the inner ear defect, anterior conchal
surface. ( a ) This 63-year-old male presented with
squamous cell carcinoma (SCC) of the anterior conchal
surface of the right ear. ( b ) SCC was surgically excised
and the margins deemed clear from the review of its fro-
zen section. ( c ) Appropriate amount of retroauricular skin
fl ap was created. ( d ) Since the shortest distance in which
the skin fl ap needs to be advanced to fi ll the surgical defect
was through the conchal cartilage, a cartilage tunnel was
created. ( e ) The retroauricular skin fl ap was tunneled ( f )
through the cartilage to place it on the anterior surface of
concha. Flap was sutured into place. ( g ) Usual fl ap divi-
sion took place after 2 weeks, and 1 week later, those
sutures were removed. ( h ) Final result
a
e
f
g
h
b
c
d
Fig. 37.8 Repairing full-thickness helical rim defect. ( a )
This 73-year-old male presented with helical rim defect
following excision of melanoma in situ. ( b ) The scar was
excised. ( c ) Retroauricular skin fl ap was created to fi ll the
helical rim defect. ( d ) In order to create a rolled appearance
of the helical rim, the skin fl ap was doubled up into a roll.
( e ) This roll of fl ap was then sutured into the surgical
defect. ( f ) Flap has healed well after 2 weeks, and it was
divided. ( g ) The retroauricular skin was slow to granulate,
hence S-plasty. ( h ) Final result

414
P. Kim
reconstruct the surgical defect of the ear. It can be
rolled up and thickened to recreate helical rim, or
its distal end can be thinned to avoid step defor-
mity. Wide-based pedicle of this type of fl ap and
the rich random-pattern blood supply of retroau-
ricular skin do facilitate this.
Flap Tension
Reduce the tension placed along the fl ap by
immobilizing the ear to the mastoid process by
suture fi xation. By pinning the ear back onto the
retroauricular region, inadvertent pulling of the
fl ap can be prevented.
Hemostasis
Meticulous hemostasis is essential in any surgery,
but it is particularly important in the ear and the
periauricular region as the hematoma and delayed
hemorrhage can cause a signi fi cant patient distress.
Postoperative
Compression dressing is applied, and the dress-
ing is left intact for 1 week. After 1 week, the
wound can be showered and cleansed daily.
Timing: Leave the fl ap for at least 2 weeks
before dividing it and detaching it from the
retroauricular skin. This allows an adequate
collateral revascularization which is essential in
preventing fl ap loss.
Secondary Defect
The longer you leave the second procedure, there
is a more signi fi cant granulation of the secondary
defect. Smaller secondary defects (2 cm) close
completely in 2–4 weeks. The delay between the
fi rst and second procedure of greater than 2 weeks
is advantageous as the second stage procedure
can then be performed relatively quickly and eas-
ily. If the secondary defect is large and or if the
wound bed is slow to granulate, then this defect
should be closed with primary intention.
Obvious downside of this procedure is that it
is a 2-staged procedure: fi rst to create fl ap and
second to divide the fl ap at a later date. Also there
is a donor site wound that may require repairing.
However, it is a relatively simple procedure of
skin advancement fl ap with numerous advan-
tages: good match of skin color and texture, bet-
ter ear pro fi le, and no miniaturization of the ear.
Conclusions
Excisional surgery of the ear often produces a
smaller ear postoperatively. Soft tissue of ret-
roauricular region is well vascularized, and
the advancement fl ap of retroauricular skin
can be used for a successful and cosmetically
satisfying reconstruction of the ear without
miniaturizing it.
References
1. Kim P, Kim HJ. S-plasty: less is more. Aust Fam
Physician. 2011;40(4):224–5.
2. Kim P. Prophylactic Z-plasty – correcting helical rim
deformity from wedge excision. Aust Fam Physician.
2010;39(9):649–50.
3. Cordova A, D’Arpa S, Pirrello R, Giambona C,
Moschella F. Retroauricular skin: a fl aps bank for ear.
J Plast Reconstr Aesthet Surg. 2008;61 Suppl 1:S44–51.
4. Johnson TM, Fader DJ. The staged retroauricular to auric-
ular direct pedicle (interpolation) fl ap for helical ear
reconstruction. J Am Acad Dermatol. 1997;37(6):975–8.
5. Koopmann C, Couthard SW. “How I do it” – otology
and neurotology. A speci fi c issue and its solution.
A postauricular muscle-skin fl ap for conchal defects.
Laryngoscope. 1982;92(5):596–600.
6. Yang D, Morris SF. Vascular basis of the retroauricular
fl ap. Ann Plast Surg. 1998;40(1):28–33.

415
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_38, © Springer-Verlag Berlin Heidelberg 2013
38
Introduction
The earlobe size corresponds to the middle third
of the face, just like the nasal pyramid, or one-
fi fth of the facial height. Proportionate relation-
ship between ears creates a balanced and beautiful
look of the whole face and head. If the earlobes
are too large or protruding, the facial harmony is
impaired, often causing embarrassment. Even
young children with protruding ears are often
teased by their peers. This is the reason why parents
often insist on correcting this issue at a young
age. Most authors agree that otoplasty should be
done after the age of 7. Padovan considers that
otoplasty should be performed by the age of 6
and Weerda by the age of 5 years [ 1, 2 ] .
Protruding ears are diagnosed if the auriculo-
cephalic angle, determined by the line from the
root of the helix to its most lateral edge and the
mastoid plane, is over 25°. However, some
authors believe that in patients with prominent
ears, the angle of protrusion is at least 30° [ 2 ] .
The most common causes of ear protrusion are
underdeveloped or poorly developed antihelix.
According to Potter, protruding ears are transmit-
ted as a dominant characteristic, with an inci-
dence of 5 %, and most authors agree with his
opinion [ 3– 5 ] .
Dieffenbach [ 6 ] was the fi rst to describe his
technique of otoplasty in 1845, to correct a post-
traumatic prominent auricle. He excised the
retroauricular skin and used a conchomastoi-
dal suture for the fi xation of the ear. After him,
numerous authors have applied partial removal of
cartilage. This surgical concept provided unsat-
isfactory results, especially in the pro fi le view.
A new concept of protruding ear surgery was cre-
ated by Luckett [ 7 ] , who pointed to the impor-
tance of antihelical fold in shaping the earlobe.
He also analyzed the primary deformity in most
protruding ears as either the absence or underde-
velopment of the antihelical fold. Converse et al.
[ 8 ] created a new tubular procedure with a forma-
tion of antihelix in the lower part of the earlobe by
tabulation. Converse performed incomplete cartilage
V. Kljajic , M.D. (*)
Medical Faculty of Novi Sad , ENT Clinic,
Clinical Center of Vojvodina ,
Hajduk Veljkova 1 , Novi Sad , Serbia
Medical Faculty of Novi Sad , ENT Clinic,
Clinical Center of Vojvodina ,
Turgenjeva 15 , Novi Sad 21000 , Serbia
e-mail: kljaja@eunet.rs
L. Vlaski , M.D.
Medical Faculty of Novi Sad , ENT Clinic,
Clinical Center of Vojvodina ,
Branimira Ćosića 10 , Novi Sad 21000 , Serbia
e-mail: vlaskilj@eunet.rs
J. Radmanovic , M.D.
ENT Department , Hospital of Sremska Mitrovica Severni ,
Bedem 52/4 , Sremska Mitrovica 22000 , Serbia
e-mail: niki05@open.telekom.rs
S. Savovic , M.D.
Medical Faculty of Novi Sad , ENT Clinic,
Clinical Center of Vojvodina ,
Dalmatinska 24 , Veternik 21203 , Serbia
e-mail: savovics@yahoo.com
The Tubular Technique in Otoplasty
Vladimir Kljajic, Ljiljana Vlaski, Jovan Radmanovic,
and Slobodan Savovic

416
V. Kljajic et al.
incisions from the posterior side in combination
with fi xation sutures. Weerda [ 2 ] classi fi ed all
types of otoplasty procedures in regard to the inci-
sion site into two great groups, those with retroau-
ricular and those with auricular incision.
Preoperative Patient Preparation
Preoperative patient preparation comprises pro-
viding patient’s photographs and general preop-
erative care. Two photographs are necessary,
10 × 15 cm in size, of the front and back view.
Male patients should have short haircut in order
to evaluate the degree of ear protrusion, and
female patients should wear their hair up to reveal
their ears (Fig. 38.1 ).
Preoperative laboratory testing includes basic
analyses and hemostasis. If the patient is under-
going general anesthesia, pulmonary and cardiac
functions should be checked by a pediatrician or
an internist.
Otoplasty: Step-by-Step
Tubular techniques are recommended for manag-
ing ears without a formed antihelix. Converse is
considered the creator of these techniques. The
main difference between his techniques and the
technique we use today is that he performs carti-
lage thinning and then folds it, while our tech-
nique is characterized by full-thickness incisions
of cartilage and folding of the edges to form a
tube corresponding with the antihelix.
The surgery can be performed under general
or local anesthesia. Local anesthesia is usually
performed in adult patients. Local anesthesia is
performed using a local anesthetic solution con-
taining adrenaline 1: 200,000. Adrenaline is used
to suppress intraoperative bleeding. General
anesthesia is performed using total intravenous
anesthesia. Retroauricular in fi ltration is done
using 0.9 % NaCl and adrenaline 1: 200,000 to
prevent intraoperative bleeding.
After preoperative cleansing and isolation of
the surgical site, retroauricular in fi ltration of the
region with a diluted adrenaline solution is done,
either with a local anesthetic or with 0.9 % NaCl.
Marking an elliptical incision line 0.5 cm from the
retroauricular fold is then done. A symmetrical
semiellipse is drawn in the retroauricular region
on the mastoid plane. When the incision of the
skin and subcutaneous tissue is made, a surface of
an elongated ellipse is obtained (Fig. 38.2 ).
Hemostasis is provided by a bipolar cautery to
minimize injury. After that, soft tissues of the
posterior earlobe are lifted by fi ne scissors up to
the edge of the cartilage. It is recommended that
the posterior auricular ligament be removed as
well, if it is too prominent, in order to provide a
better layer for the earlobe cavum (Fig. 38.3 ).
When the posterior part is exposed, future
antihelix is marked. This is done using eight to
ten insulin needles on the anterior part of the ear-
lobe, marking the future antihelix (Fig. 38.4 ).
During formation of the antihelix, the surgeon
may decrease the depth of the conchal cavum in
order to create an acceptable and natural ear
shape. Half of the needles are placed along one
side of the newly formed antihelix, while the left
are placed on the other side. A retroauricular car-
tilage incision is then made between the needle
tips. When the needles are removed, the incisions
are put together to form two semiellipses, which
are nearly parallel. Fine-pointed dissecting scis-
sors are used in cutting cartilage edges. The
suture material of choice is 5-0 Prolene, which is
used to fold the newly formed antihelix. Thus, a
tubular form is made, and the antihelix is recon-
structed (Fig. 38.5 ).
4-0 Prolene is recommended for the conchal
mastoid to pull the perichondrium of the conchal
cavum cartilage to the mastoid periosteum.
Individual stitches using Vicryl 4-0 close the sub-
cutaneous and Prolene 4-0 to close the skin layer.
The newly created antihelix is then protected by
a cotton dressing soaked in Rivanol antiseptic
and Hepathrombin ointment to prevent hema-
toma. The same dressing material is used retroau-
ricularly as well.
The same procedure is repeated on the other
ear. After the surgery of both ears is fi nished, a
bulky bandage dressing is wrapped around the
patient’s head, while the elastic band should not
be too tight.

417
38 The Tubular Technique in Otoplasty
Postoperative Care
In the early postoperative period, the patient
receives analgesics. In our opinion, re-bandaging
is not necessary until the seventh postoperative
day, when the stitches are usually removed. On
the seventh postoperative day, bandages are care-
fully removed from both ears. The treated area is
disinfected, usually by Octenisept, and then
retroauricular stitches are removed. After that,
a
b
Fig. 38.1 ( a ) Preoperative patient. ( b ) Postoperative

418
V. Kljajic et al.
a smaller quantity of folded gauze is placed over
both ears, and the elastic band remains for another
5 days. On the 12th postoperative day, the
bandages are removed, and the patient is recom-
mended to wear the elastic band during the night.
Three months after the surgery, the patient brings
two pictures (10 × 15 cm in size), his front and
back view.
Complications
Complications can be divided into intraoperative
and postoperative, whereas postoperative may be
early and late.
Intraoperative complications include allergic
reactions to the local anesthetic, or in case of gen-
eral anesthesia, allergic reaction to anesthetic
agents used for general anesthesia. During sur-
gery and cartilage incision, the skin may also be
involved. If the skin lesion is small, it can be
stitched using Prolene 5-0 after fi nal cartilage
incision, which is usually treated with an antibi-
otic ointment. These skin lesions, if primarily
carefully stitched, result with minimal scarring.
Intraoperative bleeding is usually minimal, and it
is managed with cauterization.
Fig. 38.2 Skin excision
Fig. 38.3 Resection of the posterior auricular ligament
Fig. 38.4 Marking the future antihelix

419
38 The Tubular Technique in Otoplasty
Early postoperative complications include
bleeding, when revision surgery is required.
Postoperative bleeding is never life threatening,
but if it is not managed, it may cause hematoma
in the earlobe area, leading to sterile cartilage
necrosis, or if in fl ammation takes place, to per-
ichondritis (abscess). Proper ear cavity tampon-
ade and placement of an elastic band on ears is a
very important factor in preventing postoperative
hematoma and abscess.
Late postoperative complications include
development of keloid scars (Fig. 38.6 ); earlobe
deformities, especially “telephone ear”; and sharp
cartilage edge on the anterior part of the auricle.
The authors have not had any postoperative com-
plications in the last 10 years, except in one case of a
retroauricular wound dehiscence after stitch removal.
The problem was managed by secondary sutures.
After removal of stitches, the earlobe was of pleas-
ing appearance, without prominent scarring.
Conclusions
1. In the management of protruding ears,
tubular techniques are suitable for cases
without formed antihelix.
2. A modi fi ed Converse technique is success-
fully used in patients with poorly formed
antihelix, but with a deep conchal cavity.
3. When using this surgical procedure, com-
plications are extremely rare.
4. The basic advantage of this procedure is that the
anterior auricular surface is spared of damage.
References
1. Padovan I. Otorinolaringologija. Kirurgija uha. Zagreb:
Školska klnjiga; 1982. p. 255–70.
2. Weerda H. Surgery of the auriculae: tumors. Trauma. Defects.
Abnormalities. New York: Georg Thieme Verlag; 2007.
3. Potter EI. A hereditary ear malformation transmitted
through fi ve generations. J Hered. 1937;28:255–8.
Fig. 38.5 Formation of the tubular structure
Fig. 38.6 Retroauricular keloid

420
V. Kljajic et al.
4. Janis JE, Rohrich RJ, Gutowsky KA. Otoplasty. Plast
Reconstr Surg. 2005;115(4):60e–72.
5. Kompatscher P, Schuler CH, Clemens S, Seifert B,
Beer GM. The cartilage-sparing versus the cartilage-
cutting technique: a retrospective quality control com-
parison of the Francesconi and Converse otoplasties.
Aesthetic Plast Surg. 2003;27(6):446–53.
6. Dieffenbach JF. Die Operative Chirurgie. Leipzig: FA
Bruckhaus; 1845.
7. Luckett WH. A new operation for prominent ears based
on the anatomy of the deformity. Surg Gynecol Obstet.
1910;10:635–7.
8. Converse JM, Nigro A, Wilson FA, Johnson N. A tech-
nique for surgical correction of lop ears. Trans Am
Acad Ophthalmol Otolaryngol. 1956;60(4):551–6.

421
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_39, © Springer-Verlag Berlin Heidelberg 2013
39
Introduction
Otoplasty surgical techniques continue to evolve
since the original description in 1845. As newer
techniques are introduced, it is important to realize
that the basis of management arises from careful
evaluation of the ear. There are four general catego-
ries of abnormalities that contribute to prominent
ear deformity: absent or poorly formed antihelix,
deep conchal bowl, inadequate helical rim, and an
abnormal lobule, with the fi rst two being most
common [ 1 ] . It is important for the surgeon per-
forming otoplasty to critically assess the prominent
ear and to understand different approaches to opti-
mize its appearance. We will focus on a novel
approach to address the deep conchal bowl.
The conchal bowl is embryologically derived
from the fi rst Branchial groove. The conchal bowl
is a concavity separated by the helical crus into
the concha cymba superiorly and concha cavum
inferiorly. It is also important to assess the rela-
tionship of the conchal bowl with the scapha and
the mastoid cortex. A deep conchal bowl, gener-
ally de fi ned as deeper than 1.5 cm, can be present
in isolation or in combination with other anoma-
lies, most notably involving the antihelical fold.
There have been many techniques described
to address the deep conchal bowl. In 1845
Dieffenbach described conchomastoid fi xation
through a postauricular incision with the goal of
minimizing the appearance of the deep concha
bowl; this was also the focus of techniques popu-
larized by Furnas [ 2 ] and Morestin [ 3 ] , with the
latter excessive conchal cartilage.
Some of the commonly used procedures can
be categorized based on technique: suturing, con-
chal cartilage fl ap, and cartilage scoring [ 4– 6 ] .
Placement of conchomastoid sutures requires
a great deal of precision, as placement more
anterior on the mastoid or more posterior on the
concha will result in anterior rotation of the con-
chal bowl. This has been associated with narrow-
ing of the external auditory meatus resulting in
cerumen retention and dif fi culty with otoscopic
examination. Spira and Stal [ 7 ] modi fi ed this by
anchoring a lateral cartilage fl ap to the mastoid
periosteum helping to decrease the potential for
external auditory meatus narrowing and creating a
strong anchor for suturing. Excisional techniques
in which a strip of cartilage with or without skin
is excised to help minimize conchal prominence
have been proposed [ 4 ] . The third popular tech-
nique is cartilage scoring, with attempts to create
S. Patel , M.D.
Department of Dermatology , Dermatologists &
Dermatologic Surgeons ,
Morristown , NJ
e-mail: sapnap@uw.edu
K. C. Y. Sie , M.D. (*)
Department of Otolaryngology, Childhood
Communication Center, Seattle Children’s Hospital ,
4800 Sand Point Way , Seattle ,
WA 98105 , USA
Department of Otolaryngology
Head and Neck Surgery , University of Washington ,
Seattle , WA , USA
e-mail: kathysie@uw.edu;
kathleen.sie@seattlechildrens.org
The Deep Conchal Bowl:
Accentuation of the Helical Crus
Sapna Patel and Kathleen C. Y. Sie

422
S. Patel and K.C.Y. Sie
striations in the cartilage to weaken its natural
spring.
With the understanding that patients with
prominent ear deformity typically have poorly
de fi ned convexities of the ear, as opposed to
excessive cartilage, the senior author recognized
that the deep conchal bowl deformity is com-
monly associated with an absent or poorly formed
helical crus (Fig. 39.1 ). This observation is anal-
ogous to the role of the poorly de fi ned antihelical
fold in the appearance of prominent ears. The
techniques used to emphasize the antihelical fold
[ 8, 9 ] have been applied to the helical crus [ 10 ] .
After de fi nition of the antihelical fold with
cartilage scoring and mattress sutures, the helical
crus is created using similar techniques. A postau-
ricular incision is created to expose the perichon-
drium of the posterior conchal bowl. This is left
intact and the antihelical fold is addressed. Then
the helical crus width is estimated using forceps
(Fig. 39.2 ). Black nylon sutures are placed to
de fi ne the position of the clear nylon sutures that
are placed on the deep aspect of the conchal carti-
lage (Fig. 39.3 ). The deep aspect of the conchal
cartilage between the sutures is scored using a
5910 Beaver blade. Care is taken to preserve the
integrity of the cartilage that will accommodate
the sutures. Once the clear nylon sutures have
been placed, the black nylon sutures are removed.
Accentuation of the helical crus is used in con-
junction with other otoplasty techniques depend-
ing upon the issues that need to be addressed for
any particular ear (Figs. 39.4 and 39.5 ).
In addition to managing the helical crus, shav-
ing any eminentia on the deep surface of the con-
chal bowl can be helpful in cosmetic otoplasty.
Postoperative management follows with an
antibiotic-ointment-coated cotton ball in the
Fig. 39.1 Poorly formed helical crus contributes to the
appearance of the deep conchal bowl
Fig. 39.2 Use of forceps to de fi ne the helical root after
the antihelical fold has been accentuated. The laterally
placed black sutures will be removed
Fig. 39.3 Placement of the black nylon sutures that are
used to de fi ne the position and tension of the permanent
4-0 clear nylon mattress sutures

423
39 The Deep Conchal Bowl: Accentuation of the Helical Crus
concavities of ear with an eye pad or folded
gauze pad overlying it. Patients are instructed to
wear a neoprene headband dressing day and
night for 1 week and then nighttime only for an
additional week.
This technique addresses the deep conchal
bowl when the helical crus is underdeveloped.
The creation or accentuation of the crus is fl exible
and can be performed, using one many of the pre-
viously described techniques from excision of
cartilage to scoring. Moreover, this technique
avoids any potential narrowing of the cartilagi-
nous external auditory meatus. Conversely, this
approach pulls the anterior edge of the conchal
cartilage posterior superiorly, thereby opening
the external auditory meatus. Also by avoiding
placement of conchomastoid sutures, the postau-
ricular sulcus remains well preserved.
There are a variety of potential causes of
prominent ear deformity. A majority of the time,
there are several etiologies. One must recognize
the abnormalities of the ear and use appropriate
surgical techniques to address each abnormality.
The absent or poorly de fi ned helical crus is a
cause of the “deep” conchal bowl. Presence of
small cartilaginous prominences, or eminentia,
on the deep surface of the conchal cartilage can
also affect the position of the conchal cartilage.
These should be shaved at the time of otoplasty.
Creation of the helical crus and shaving of emi-
nentia should be considered for surgical manage-
ment of the deep conchal bowl.
References
1. Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast
Reconstr Surg. 2005;115(4):60e–72.
2. Furnas DW. Correction of prominent ears by concha-
mastoid sutures. Plast Reconstr Surg. 1968;42(3):
189–93.
3. Morestin H. De la reposition et du plissement cosmé-
tiques du pavillon de l’oreille. Rev Orthop. 1903;|4:394.
4. Beasley NJ, Jones NS. Otoplasty: the problem of the
deep conchal bowl. J Laryngol Otol. 1996;110(9):
864–8.
5. Bhatti A, Donovan D. Sutureless otoplasty by scoring
of the cartilage: a study in 34 patients. Br J Oral
Maxillofac Surg. 2007;45(3):217–20.
6. Bulstrode N. Otoplasty by percutaneous anterior scor-
ing. Another twist to the story: a long-term study of
114 patients. Br J Plast Surg. 2003;56(2):145–9.
7. Spira M, Stal S. The conchal fl ap: an adjunct in oto-
plasty. Ann Plast Surg. 1983;11(4):291–8.
8. Luckett WH. A new operation for prominent ears base
on the anatomy of the deformity. Surg Gynecol Obstet.
1910;10:365–7.
9. Mustarde JC. The correction of different types of
prominent ears. Aesthetic Plast Surg. 1983;7(3):
163–8.
10. Sie KC, Ou H. Otoplasty: an alternative approach to
management of the deep conchal bowl. Laryngoscope.
2006;116(11):2092–4.
Fig. 39.4 Suture placed to create the helical crus
Fig. 39.5 Appearance of the reconstructed ear after
removal of the black nylon positioning sutures. Note the
accentuated helical crus

425
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_40, © Springer-Verlag Berlin Heidelberg 2013
40
Introduction
Otoplasty is a common procedure for the treat-
ment of protuberant ears [ 1 ] . The term promi-
nent ears can be de fi ned as ears that “stick out”
regardless of size [ 2 ] . Prominent ear deformities
occur in approximately 5 % of the population
and can cause signi fi cant psychological stress
on patients [ 3 ] . The goal of otoplasty is to make
the protuberant ears less apparent by restoring
them to a normal form and position while main-
taining symmetry.
Historical Background
In 1845, Dieffenbach [ 4 ] reported the fi rst surgi-
cal approach to correction of protuberant ears.
His method involved simple excision from the
posterior sulcus with sutures fi xing the cartilage
to the mastoid periosteum. This is known today
as the posterior approach. In 1881, Ely [ 5 ] was
credited for the fi rst description of surgical altera-
tion of the cartilage to treat prominent ears. Since
that time, over 170 techniques and modi fi cations
have been reported in the literature for treatment
of this condition.
The techniques can be categorized into three
groups: (1) leaving the auricular cartilage intact
and using only sutures to treat the prominent ears,
a technique created by Mustarde [ 6, 7 ] ; (2) incis-
ing the cartilage without resection in an effort to
make it more pliable [ 8– 10 ] ; and (3) excising of
cartilage to reduce protrusion [ 11 ] . The applica-
tion of tape to the ears for several months while
in infancy has even been described to success-
fully treat prominent ears, although many may
fi nd this to be a controversial method [ 12– 14 ] .
Anatomy and Development of the Ear
The ear of a newborn measures approximately
66 % of the length and 76 % of the width of an
adult ear. By the age of 3, the ear has achieved
approximately 85 % of its fi nal size, and by the
age of 7, the ear has nearly completely achieved
its fi nal, adult size. Interestingly, between the
P. Patel , D.O. (*)
Department of Dermatology ,
Af fi liated Dermatologists and Dermatologic Surgeons ,
182 South Street , Morristown 07960 , NJ , USA
e-mail: ppatel702@gmail.com
E. Bisaccia , M.D.
Department of Dermatology ,
Af fi liated Dermatologists and Dermatologic Surgeons ,
182 South Street , Morristown 07960 , NJ , USA
Department of Dermatology ,
Columbia University of Physicians and Surgeons ,
New York , NY , USA
e-mail: ebisaccia@gmail.com
D. A. Scarborough , M.D.
Department of Dermatology ,
Af fi liated Dermatologists and Dermatologic Surgeons ,
650 Shawan Falls Drive , Dublin 43017 , OH , USA
Department of Dermatology ,
Ohio State University Hospital , Columbus , OH , USA
e-mail: das989sa@gmail.com
Otoplasty for the Treatment
of Protuberant Ears
Payal Patel, Emil Bisaccia,
and Dwight A. Scarborough

426
P. Patel et al.
ages of 30 and 80 years, the length of the auricle
may actually increase up to 1 cm due to lengthen-
ing of the cartilage and the cutaneous lobe.
A thorough knowledge of the intricate anatomy
of the ear is essential to perform a safe and suc-
cessful otoplasty [ 15, 16 ] .
The external ear consists of the auricle and the
external auditory canal. The helix arises anteri-
orly and inferiorly from a crus extending hori-
zontally above the external auditory meatus, thus
creating the outer frame of the auricle. The helix
merges inferiorly into the cauda helicis and con-
nects to the lobule. The antihelical fold lies
between the antihelical crus and is also known as
the scapha. The antihelix extends upward from
the cauda helicis medially to the helix until it
bifurcates into the anterior superior and anterior
inferior crura. The antihelix borders medically to
the rim of the concha and the concha proper. The
concha is composed of the conchal cymba supe-
riorly and the conchal cavum inferiorly. These
are separated by the helical crus and meet the
antihelix at the antihelical rim. The conchal
cavum anteriorly extends to the tragus and the
external auditory meatus; inferiorly and posteri-
orly, it borders to the antitragus, which connects
laterally with the antihelix. The tragus and anti-
tragus are separated by the intertragal notch. The
lobule does not contain cartilage and displays a
variety of shapes and attachments to the adjacent
cheek and scalp.
The ear consists of six clinically insigni fi cant
intrinsic muscles, which include the major and
minor helices, tragus, antitragus, transverse,
and oblique muscles. There are three extrinsic
muscles of the ear, which include the anterior
auricularis, posterior auricularis, and superior
auricularis. These muscles provide minor struc-
tural support to the ear [ 3 ] .
The arterial supply to the auricle and external
auditory meatus is derived from the external
carotid artery through the super fi cial temporal
artery, which supplies most of the external ear
canal and parts of the anterior auricle; the poste-
rior auricular arteries provide blood fl ow to the
posterior parts of the ear.
The sensory innervation of the ear involves
several different nerves. They include the greater
auricular nerve and the lesser occipital nerve,
which are branches of the cervical plexus, and the
auricular temporal nerve, a branch of the man-
dibular division of the trigeminal nerve. A por-
tion of the posterior wall of the external meatus is
innervated by the auricular branch of the vagus
nerve [ 17 ] . Motor innervation to the external ear
is supplied by the facial nerve, although this var-
ies among individuals [ 3 ] .
Indications for Otoplasty
of Protuberant Ears
One important indication for otoplasty for promi-
nent ears is in the case of psychological illness
induced from the condition, especially in chil-
dren. Children with protuberant ears are often the
subject of verbal and even physical abuse by their
peers, causing adverse, long-term psychological
effects. It has been reported that 10 % of children
on the National Health Service (NHS) waiting
list for surgical correction of prominent ears had
been evaluated by a psychiatrist at some point
[ 18 ] . Sixty-seven percentage of children with
condition reported social distress from the condi-
tion, reported by some to start as early as the age
of 4. This psychological impact often leads to
high parental concern, which then leads to their
search for a surgical correction. It is very impor-
tant, however, that the child also desires the sur-
gical correction and voices it him or herself.
Without the child’s individual wish for correc-
tion, he or she is not a good candidate.
Another important consideration for otoplasty
is the patient’s age. As stated previously, 85 % of
the fi nal ear size is achieved by age 3. Therefore,
many physicians choose to perform otoplasty at 4
or 5 years of age or prior to school age [ 19 ] . Some
physicians choose to wait until the patient is
6 years of age to allow for children to participate
in their own postoperative care [ 3 ] . Even still,
other physicians prefer to restrict otoplasty to
adolescence or adulthood, as this age group is
more capable than young children to describe the
auricular features of concern to them and their
desire for correction [ 1 ] .

427
40 Otoplasty for the Treatment of Protuberant Ears
Once the patient and parents agree upon the
desire for surgical correction, the surgeon should
then perform a thorough physical examination
and review of medical history to assess the degree
of surgical risk, if any, to the patient. If the surgi-
cal risk outweighs the bene fi t of treatment of the
deformity, surgery should not be performed.
Anatomical Causes of Protuberant
Ears
The average Caucasian female ear is 59.0 mm in
height and 32.5 mm in width. The average
Caucasian male ear is 63.5 mm in height and
35.5 mm in width. Asians tend to have longer
ears, while Africans typically possess slightly
shorter lengths of ears. The ear’s width should be
about 50–60 % of the length in an aesthetically
ideal ear. The superior aspect of the ear should
rest at the level of the brow. On lateral view, the
slope of the ear approximates the nasal dorsum to
within 15° or lies approximately 20° posterior to
the vertical plane.
In the aesthetically ideal ear, the distance from
the helix to the mastoid is 10–12 mm in the upper
third of the ear, 16–18 mm in the middle third of
the ear, and 20–22 mm in the lower third of the
ear. The helix lies 2–5 mm laterally of the antihe-
lix on frontal view. Conchal protrusion from the
mastoid is about 12–16 mm, and the angle
between the superior helix and mastoid is 20–30°
[ 3 ] . The surgeon should keep these general pro-
portions in mind while trying to create an aes-
thetic external ear with otoplasty.
Generally, there are four main anatomical
malformations leading to ear prominence. In
order to correct protuberant ears, it is important
to understand the anatomical defects leading to
this deformity:
1. Underdeveloped antihelical fold . The under-
developed antihelical fold causes the scapha
and helical rim to protrude. This commonly
affects the upper and/or middle thirds of the
ear and presents as a winglike defect.
2. Conchal prominence and/or anterolateral
rotation . The concha may be excessively deep
and/or the auriculomastoid angle may exceed
30°–40°. This defect would cause prominence
of the middle third of the auricle.
3. Prominent helix . Excessive superior outer
helical rim cartilage can cause “elf ears” or
“spock ears,” and excessive superior helical
fold cartilage can cause “lop ears.”
4. Protruding earlobe . This defect causes promi-
nence of the lower third of the ear and can
even occur with the aging earlobe as the skin’s
elasticity decreases over time [ 20– 23 ] .
Preoperative Considerations
A careful evaluation of the defect to determine
the type of auricular anomaly or anomalies pres-
ent is the fi rst step. Only after a surgeon correctly
identi fi es the speci fi c cause of the auricular
prominence can they establish an appropriate sur-
gical plan. Most commonly, protuberant ears
result from a combination of an underdeveloped
antihelical rim and conchal prominence and/or
anterolateral rotation [ 3 ] . However, a patient may
present with all four deformities, in which case
the order of correction should be creation of the
antihelical fold fi rst, followed by conchal reduc-
tion, then helical reduction, and, fi nally, earlobe
reduction [ 1 ] .
The physical exam should also note the degree
of symmetry between the ears as well. These
fi ndings must be clearly documented in written
form and with standard photography showing right
and left lateral views, close-up right and left lateral
views, right and left oblique views, and frontal
views. Next, it is vital to set realistic expectations
for the procedure. The surgeon must discuss with
the patient what can and cannot be achieved with
surgery, and the patient must understand and have
appropriate expectations of the results.
Potential complications should be outlined
verbally and in a written consent signed by the
patient. Once the patient understands the surgery
and its potential complications, has realistic
expectations for improvement, and consents to
the surgical correction, preoperative clearance
can be obtained. This should include a thorough
physical examination, as well as a normal elec-
trocardiogram (EKG), chest X-ray, and standard

428
P. Patel et al.
laboratory tests. The patient’s age, as discussed
in depth previously, should be part of the preop-
erative considerations as determined by each
individual surgeon.
Finally, the patient should be told to avoid non-
steroidal anti-in fl ammatory agents for 2 weeks
prior to surgery to minimize bleeding and to wash
the hair the day before surgery, as this cannot be
done for several days after the procedure. A sur-
geon may consider prescribing the patient an oral
benzodiazepine to take 1 h prior the procedure to
decrease anxiety.
Surgical Techniques for Correction
of Protuberant Ears
Many of the surgical subspecialties prefer gen-
eral anesthesia in performing otoplasty, and oth-
ers may choose to utilize conscious sedation.
However, if the patient proves to be highly moti-
vated, otoplasty can easily be performed with
local anesthesia alone. Local anesthesia with a
mixture of 1 % lidocaine and 1:100,000 epineph-
rine produces adequate anesthesia while also aid-
ing in hemostasis. The age of the patient may also
dictate the type of anesthesia used, as it is rare
that a child under 10 years of age can tolerate
local anesthesia. Therefore, in younger patients,
it may become necessary to use general anesthe-
sia or conscious sedation [ 1, 2 ] .
The surgical technique for correct of the four
most common anatomical defects will be described
below.
Underdeveloped Antihelical Fold
An antihelical fold is created by lightly pressing
the scapha onto the concha. The position of the
fold is then marked on the anterior ear skin with
a row of ink spots running just lateral to the anti-
helix from the superior pole of the superior crus
down to the merging point between the antihelix
and helix. Two ink spots are placed within the
triangular fossa to mark the site of suture place-
ment for reshaping the superior crus. The last set
of ink marks run in the lateral concha just lateral
to the newly created antihelical fold, noting the
location of the placement of horizontal mattress
sutures to keep the reshaped antihelix in place.
Next, these ink marks are transferred from the
anterior to the posterior skin of the ear and its
underlying cartilage with the help of an abraded
25-gauge needle. This is done by passing the
needle through the ink marks in order and, each
time, applying methylene blue at its distal end
before withdrawing it. Next, a dumbbell-shaped
piece of skin is removed from the posterior sur-
face of the concha. The larger the protrusion of
the upper third of the ear and/or the earlobe, the
wider the excision must be at the corresponding
end and the further up and/or down along the
concha should it be placed.
Next, the posterior skin of the ear is dissected
laterally, close to the helical rim, and medially to
the postauricular sulcus and then the mastoid
periosteum. Finally, 4-0 Mersilene on a noncut-
ting needle is used to initially place and, thereaf-
ter, tie a number of horizontal mattress sutures:
one from the triangular fossa to the upper scapha
and at least four between the scapha and the lat-
eral portion of the conchal cartilage, as described
by Mustarde [ 24, 25 ] . Careful attention must be
paid to tie the sutures with enough tension so that
both the antihelical fold is more de fi ned and the
helical rim and scapha are moved posteriorly.
The surgeon must also be careful to place the
horizontal mattress sutures through the cartilage
and not through helical skin.
It may be necessary to slightly overcorrect the
defect, as studies have shown that up to 40 % of
the loss of correction may occur in the fi rst year
postoperatively [ 3 ] . The dumbbell-shaped skin
incision is then closed using absorbable 4-0
Vicryl subcutaneous sutures and nonabsorbable
5-0 Prolene running sutures on the skin.
Conchal Prominence and/or
Anterolateral Rotation
The conchal enlargement and/or anterolateral
rotation is addressed by excising an adequate
piece of cartilage from the midportion of the con-
cha, either from the posterior or anterior approach.

429
40 Otoplasty for the Treatment of Protuberant Ears
A crescent-shaped conchal strip is removed,
approximately 3–6 mm wide and 2.0–3.0 cm long,
extending from the midchoncha cymba down to
the incisura terminalis auris. The surgeon should
design the crescent-shaped conchal excision so
that the incision closure line will fall at the junc-
tion of the fl oor and posterior wall of the concha
so as to avoid distortion of the ear’s normal con-
tours [ 2 ] . This technique serves to reduce the
height of the concha. The conchal defect should
then be closed with 4-0 Vicryl sutures.
Conchal setback is then completed. A fusi-
form excision is made in the posterior auricular
area. The width of this excision is estimated by
pushing the concha toward the mastoid and mark-
ing the desired correction. The surgeon should
excise the minimal amount of skin needed, as
overexcision can lead to excessive tension on the
wound and hypertrophic scarring. The skin of the
concha, helix, and antihelix is then undermined
using blunt scissors.
Conchal setback is then performed by placing
multiple horizontal mattress sutures of 4-0
Mersilene between the conchal perichondrium and
the mastoid periosteum, as described by Furnas.
More speci fi cally, the horizontal mattress sutures
should be placed at the lateral third of the conchal
cavum and conchal cymba, parallel to the natural
curves of the auricle [ 3 ] . Finally, the skin is closed
with several 4-0 Vicryl subcutaneous sutures and a
running 5-0 Prolene suture on the skin [ 26 ]
Prominent Helix
Helical prominences can be divided into “spock
ears” or “elf ears,” caused by excess of the supe-
rior outer helical rim cartilage, or “lop ears,” cre-
ated by excess of the superior helical fold
cartilage. “Spock ears” or “elf ears” are treated
by excising a fusiform-shaped area on the outer
helical rim, while “lop ears” are treated by excis-
ing a fusiform-shaped area under the helical rim.
Once the fusiform-shaped skin excision is per-
formed, the surgeon should then excise any
excess underlying cartilage with a scalpel blade.
The skin is closed with nonabsorbable suture,
such as 6-0 Prolene [ 3 ] .
Protruding Earlobe
The protruding earlobe can be corrected by marking
the new earlobe with a marker before local anesthe-
sia is injected. Then, the surgeon should perform a
fusiform incision anteriorly and posteriorly, and a
wedge excision of the prominent lobe is performed.
The skin is closed with nonabsorbable suture, such
as 6-0 Prolene. The incision line should be hidden
in the inferior border of the lobule so that it is not
visible on frontal or posterior view.
Postoperative Care
After the surgical site has been cleansed, the
corrected ear or ears should be properly dressed.
The surgeon may create a molded bolster to effec-
tively stabilize the positioning of the surgically
corrected ears and avert hematoma formation.
This is created using cotton balls soaked in povi-
done-iodine and shaped to fi t the conchal bowl,
scapha, and postauricular space. The mold is held
in place with a light compression bandage. One
must be careful to avoid too much pressure from
the dressing, as this can lead to increased swell-
ing, pain, abrasion, or even necrosis of the skin.
The patient returns one day postoperatively to
have the dressing removed, and the surgeon should
examine the area for hematoma formation. If there
is no hematoma and the wound appears otherwise
unremarkable, the dressing is reapplied and fi xed
with a standard head wrap for one more week. At
this time, the nonabsorbable sutures may be
removed, and the dressing may also be perma-
nently removed. Following dressing removal, the
patient must wear an elastic headband nightly for
3–6 weeks, depending on the scope of the correc-
tive procedure. The purpose of this headband is to
inhibit the corrected ear from being pulled forward
when the patient rolls over in bed. The patient
should be informed that the headband should only
be tight enough so that it does not fall off; too tight
a headband can erode the lateral surface of the ear
and create an open wound. Postoperatively, fol-
low-up is scheduled according to the procedure
performed to allow for the early recognition of
complications and their appropriate management.

430
P. Patel et al.
Despite lack of evidence for the use of prophy-
lactic antibiotics in otoplasty, patients may be
treated with cephalexin, a fi rst-generation cepha-
losporin. Typically, the antibiotic is given as a one-
time dose intravenously at the time of surgery as a
part of the general anesthesia or conscious seda-
tion protocol. If the procedure is done with local
anesthesia only, a 1-week course of cephalexin
postoperatively is recommended. Alternatively,
cipro fl oxacin may be used in the patient allergic to
penicillin and/or cephalosporins.
Results of the authors otoplasty techniques for
the correction of protuberant ears are can be seen
in Figs. 40.1 , 40.2 , 40.3 , 40.4 , and 40.5 .
Complications
Overall, the satisfaction rate for patients undergo-
ing otoplasty for treatment of protuberant ears is
very high. However, the most common complica-
tion in otoplasty is unsatisfactory aesthetic out-
comes for the patient involving inadequate
correction, contour distortion, or an asymmetric
correction. Overcorrection or unnatural contours
is also a common complication of otoplasty. This
can result from an incomplete estimation of the
number and types of malformations contributing
to the patient’s protuberant ears or a lack of proper
postoperative care. Contours of the corrected ear
should be soft, round, and natural [ 1, 2 ] .
Even though some retroprotrusion can be
expected with most otoplasty techniques, it
appears to be more common with Mustarde’s
technique, which uses permanent sutures alone to
restructure the ear. In one study of prominent ears
treated with Mustarde’s technique, 40 % of
patients revealed a return of the ear’s position to
within 3 mm of the preoperative state at 1 year
[ 27 ] . These fi ndings support the use of cartilage
removal or incising techniques aimed at a slight
overcorrection to achieve more permanent results.
Other causes of recurrence of the original ear
deformity include insuf fi cient removal or inci-
sion of cartilage to break the cartilage spring,
failure to choose a noncutting needle to avoid
small cuts in the cartilage that make it more likely
for sutures to tear through, and patient noncom-
pliance with postoperative care.
The “telephone ear” deformity results from
overcorrection of the middle third of the ear. It is
characterized by protuberance of the inferior and
superior poles of the ear relative to its middle
portion. The use of a doughnut- or dumbbell-
shaped excision on the posterior aspect of the ear
can prevent this complication. “Reverse tele-
phone ear” deformities can occur with overcor-
rection of the superior pole and ear lobe, causing
a protrusion of the midauricle. Inadequate con-
chal setback may also produce this deformity.
The “hidden helix” deformity is created by over-
correction of the antihelix, producing the incor-
rect positioning of the helix medial to the antihelix
on frontal view. The above deformities may
require revision surgery to correct if the patient
desires [ 2 ] .
In the immediate postoperative period, hem-
orrhage or hematoma formation is the most
common complication, occurring about 2 % of
the time according to one extensive review of
the morbidity of otoplasty [ 28 ] . Studies have
shown that this complication is one of the few
early complications of otoplasty and occurs more
commonly when cartilage is disrupted though
incision or excision. Symptoms usually include
uni lateral or bilateral ear pain or tightness within
the fi rst 48 h postoperatively. The dressing should
be removed, followed by careful inspection of
the ear. A hematoma will usually present as a
tense, violet-bluish swelling in the retroauricular
space, often accompanied by ecchymosis of the
surrounding tissue. Evacuation of the hematoma
should be performed immediately to prevent per-
ichondritis and the severe ear dis fi gurement as a
result of cartilage necrosis. The patient should
also be started on antibiotic therapy to prevent
perichondritis [ 1 ] .
Infection is rare after otoplasty but should be
treated aggressively with antibiotic therapy target-
ing Staphylococcus , Streptococcus , and Pseudo-
monas aeruginosa to prevent perichondritis.
Infection usually presents on day 3 or 4 postop-
eratively. Pain and tenderness of the ears follow-
ing the surgery but unrelated to a speci fi c treatable
cause may occur up to 1 year postoperatively [ 29 ] .

431
40 Otoplasty for the Treatment of Protuberant Ears
a
b
Fig. 40.1 ( a , b ) Preoperative patient with prominent ears

432
P. Patel et al.
a
b
Fig. 40.2 ( a , b ) Preoperative patient with prominent ears

433
40 Otoplasty for the Treatment of Protuberant Ears
a
c
b
Fig. 40.3 ( a–c ) Preoperative patient with prominent ears

434
P. Patel et al.
a
b
Fig. 40.4 ( a , b ) Postoperative patient after correction of prominent ears

435
40 Otoplasty for the Treatment of Protuberant Ears
Paresthesia of the ear, especially to cold tem-
peratures, may occur but typically improves over
4–6 months.
Suture extrusion and suture granuloma for-
mation can occur, particularly in the retroau-
ricular sulcus. This can be treated by simply
removing the sutures and may be prevented by
meticulous placement of the sutures by the sur-
geon. Keloids and hypertrophic scarring may
occur, particularly in individuals with a prior
history. The use of scar excision and serial
intralesional steroid injections can be used for
treatment of the condition [ 3 ] .
Conclusions
Protuberant ears are a relatively common defor-
mity. Successful surgical correction of this
deformity in both the children and adults can
produce high levels of patient satisfaction and
can help treat psychological trauma produced
from prominent ears. A thorough understand-
ing by the surgeon of auricular anatomy and
common causes of protruding ears, along with
precise planning and technique for correction,
can produce excellent cosmetic results.
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quence of surgery for prominent ears? Plast Reconstr
Surg. 1992;90(2):192–9.
17. Warmuth IP, Bader R, Scarborough D, Bisaccia E.
Otoplasty. Treatment of protuberant ears. Cosmet
Dermatol. 1999;12(4):7–8.
Fig. 40.5 Postoperative patient after correction of prominent
ears

436
P. Patel et al.
18. Bradbury ET, Hewison J, Timmons MJ. Psychological
and social outcome of prominent ear correction in
children. Br J Plast Surg. 1992;45(2):97–100.
19. Elliott RA. Otoplasty. In: Regnault P, Daniel RK, editors.
Esthetic plastic surgery. Boston: Little, Brown; 1984. p. 245–74.
20. Burres S. The anterior-posterior otoplasty. Arch
Otolaryngol Head Neck Surg. 1998;124(2):181–5.
21. Becker OJ. Surgical correction of the abnormally pro-
truding ear. Arch Otolaryngol. 1949;50(5):541–60.
22. Elliot RA. Otoplasty: a combined approach. Clin Plast
Surg. 1990;17(2):373–81.
23. Davis J. Aesthetic and reconstructive otoplasty. New
York: Springer; 1987. p. 37.
24. Spira M. Otoplasty: what I do now – a 30-year
perspective. Plast Reconstr Surg. 1999;104(3):834–40.
25. Ducic Y, Hilger PA. Effective step-by-step technique
for the surgical treatment of protruding ears.
J Otolaryngol. 1999;28(2):59–64.
26. Lavy J, Stearns M. Otoplasty: techniques, results and
complications – a review. Clin Otolaryngol Allied Sci.
1997;22(5):390–3.
27. Messner AH, Williams SC. Otoplasty: clinical proto-
col and long-term results. Arch Otolaryngol Head
Neck Surg. 1996;122(7):773–7.
28. Calder JC, Naasan A. Morbidity of otoplasty: a review
of 562 consecutive cases. Br J Plast Surg. 1994;
47(3):170–4.
29. Tan KH. Long-term study of prominent ear surgery:
a comparison of two methods. Br J Plast Surg. 1986;39(2):
270–3.

437
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_41, © Springer-Verlag Berlin Heidelberg 2013
41
Introduction
The literature has published more than 200 tech-
niques to correct protruding ears. This means that
no isolated technique brings natural and perma-
nent results in all kinds of folded antihelix defor-
mities. Many different kinds of incisions , sutures,
and cartilage-weakening procedures were cre-
ated to correct a problem that affects 5 % of the
Caucasian population. The stigma of protruding
ears not only affects the socialization of the indi-
vidual, but also leads to low self-esteem. The ears
being on the face calls immediate attention to the
problem, especially in men, since their haircuts
do not allow them to hide the ear. Although the
physiological consequences are negligible, the
aesthetic and psychological effects on the patient
can be substantial (Fig. 41.1 ).
The techniques described achieve satisfactory
results, but few obtain what can be considered a
perfect result, especially in ears with hard and thick
cartilage. The separation of the helix and scaphoid
fossa from the body of the ear (antihelix and con-
cha), completely breaking the cartilage’s inherent
spring memory, allows the use of absorbable sutures
to remodel it without any tension. This chapter is
based on work published by the author in 2010 [ 1 ] .
Modi fi cations have been made to the original con-
cept to improve the technique. A suture is introduced
to align the helix with the new antihelix. In some
ears whose deformity is in the middle and upper
thirds of the ear, the originally described incision is
used in part.
History
In 1845, Dieffenbach [ 2 ] described the fi rst treat-
ment of protruding ear (posttraumatic) through
the resection of the posterior skin and suturing of
A. S. C. Valente , M.D.
Rua Jose Negrao de lima 260 ,
Belvedere-Belo Horizonte , MG 30320280 , Brazil
e-mail: augustoscvalente@gmail.com.br
Separating the Helix from
the Antihelix: A New Concept
in Prominent Ear Correction
Augusto Sette Câmara Valente
Fig. 41.1 The stigma of having protruding ears

438
A.S.C. Valente
the auricular cartilage to the mastoid region. Ely
[ 3 ] (1881) described his technique for correcting
prominent ears by elective surgery: a postauricu-
lar skin excision, a conchomastoidal fi xation,
and conchal cartilage strip excision. Morestin [ 4 ]
(1903) recognized the need for spring breakage to
obtain de fi nitive results. In 1910, Luckett [ 5 ] dem-
onstrated that the deformity of protruding ears was
chie fl y the result of faulty folding of the antihelix.
After this, several articles with various ideas for
breaking the spring memory were published in the
literature, especially involving complete or partial
incisions of the cartilage in various forms and in
various positions of the auricular pavilion.
Becker [ 6 ] introduced the concept of creating
a tube of parallel incisions and use of sutures in
1952. This concept was rede fi ned by Converse in
1953 and 1963 [ 7, 8 ] . In 1958, Gibson and Davis
[ 9 ] published an article demonstrating the charac-
teristic of the cartilage bending on the side oppo-
site to its weakness. This concept was added to
the technique of Mustardé [ 10 ] , which used only
mattress sutures to create the fold. Stenstrom [ 11 ]
fi rst abraded the cartilage and modeled the anti-
helix with sutures, decreasing the recurrence rate
with this modi fi cation .
The concept of separating the antihelix from
the helix was fi rst described in 1963 by Chongchet
[ 12 ] ; later in 1964 came the ideas of Crikelair
and Cosman [ 13 ] , then Nordzell in 2000 [ 14 ] and
Caouette-Laberge [ 15 ] in 2000. Their techniques
exposed the anterior surface of the auricular pavilion
and weakened the cartilage with striations made by
partial incisions, drilling, and rasping. The incision
placements broke the cartilage memory, but were
not speci fi c about the design of the antihelix, creat-
ing good but not perfect results. Furthermore, the
helix was not fi rm, curving mainly on its medium
third, which sometimes left a “dog ear” appearance
as the end result.
Technique
Uncooperative patients and children receive gen-
eral anesthesia. For other patients, only local anes-
thesia, possibly with the addition of intravenous
sedation, is used. One percent lidocaine is used
with epinephrine 1:200,000, asepsis is achieved
with Betadine, and it is not necessary to cut the
patient’s hair. Local anesthesia is administered by
regional, ring -like instillation of the anesthetic
solution with subsequent in fi ltration of the entire
posterior skin of the ear and the anterior region for
designing the antihelix, facilitating making the
mattress sutures (hydrodissection) [ 16 ] .
The position of the antihelix is determined with
the push-back fi nger maneuver. The cartilage is
tattooed with methylene blue, and the needles are
introduced through the full thickness of the ear in
as many places as necessary in the superior and
posterior border of the antihelix precisely from the
beginning of the triangular fossa to the tail of the
helix. These marks de fi ne the exact location of the
posterior incision in the cartilage (Fig. 41.2 ).
A posterior skin incision is made in the form
of a dumbbell, running almost the whole length
of the ear, with two ellipses in the superior and
inferior third and a narrow bridge in the middle
third of the auricle. It is located in the projection
of the antihelix’s body that bends (Fig. 41.3 ). The
placement of the incision is important for con-
trolling the helix and the earlobe position. A nar-
row bridge incision in the middle third is
necessary to avoid overcorrection of this seg-
Fig. 41.2 Tattooing the cartilage with a needle on the
superior and lateral border of the antihelix

439
41 Separating the Helix from the Antihelix: A New Concept in Prominent Ear Correction
ment. The amount of posterior skin resection
(size of the ellipses) de fi nes the exact position of
the helix and the earlobe.
The incised skin is removed, undermining the
posterior surface of the cartilage. Hemostasis
must be rigorous. After total exposition of the
posterior side of the cartilage, the methylene blue
marks are identi fi ed, and another mark is made
on the cartilage line to be incised (Fig. 41.4 ). The
complete incision in the cartilage includes the tail
of the helix, going by the posterior border of the
antihelix until the triangular fossa. At this point,
the index fi nger is positioned at the anterior aspect
of the ear, with the thumb holding the skin hooks
to force the cartilage forward, facilitating the
incision. When there is a normal positioning of
the earlobe and the tail of a helix (the prominence
involves only the middle and superior third), a
partial incision is made as originally described,
starting in the middle third of the antihelix and
proceeding to the triangular fossa (Fig. 41.5 ).
This modi fi cation allows shortening of the surgi-
cal time and reducing the trauma, but maintains
the original idea and results.
Anteriorly, the antihelix’s body is undermined
with Stevens scissors to expose this structure
completely. Three 4-0 polyglycolic acid mattress
sutures are applied to reshape the new antihelix.
It is not necessary to employ a nonabsorbable
suture because the antihelix has lost its spring
strength. The fi rst suture is placed in the superior
part of the antihelix, and this knot is tied with
more slack than the second one, which is placed
next to the fi rst in the middle third of the antihe-
lix. The third suture is placed more inferiorly in
the region between the antitragus and the conchal
Fig. 41.3 Bielliptical posterior skin incision with a nar-
row bridge in the middle third of the ear. The narrow
bridge is very important to avoid overcorrection. The sizes
of the superior and inferior ellipses are determined based
on the degree of ear prominence and are important for the
correct helix and earlobe position
Fig. 41.4 Cartilage with marked tattooing points

440
A.S.C. Valente
cartilage to maintain the curve of the antihelix
(Fig. 41.6 ). A fourth suture [ 17, 18 ] is applied to
position the tail of the helix if there is an impor-
tant lateral projection of this structure and the
lobule. In cases in which the cartilage is very
thick, it is necessary to make a parallel 10-mm
incision to weaken the spring and facilitate the
fold by suturing next to the antitragus region.
The alignment point between the helix and the
antihelix should be determined accurately to avoid
distorting the anatomy of the ear (Fig. 41.7 ).
Finally, as a re fi nement, a small strip of the carti-
lage is excised from the superior part of the lateral
border of the newly shaped antihelical fold, close
to the scaphoid fossa, to avoid any unexpected
posterior projection of the cartilage at the back
edge of the ear. This excision functions to simulate
the natural shape of the antihelix, too (Fig. 41.8 ).
Great care should be taken in the reconstruc-
tion of the ear to obtain a perfect result with no
recurrence.
The conchal cartilage should be operated upon
only if a high degree of hypertrophy is present. In
the author’s view, the best way to do this is to set
it back with a mastoid fi xation [ 19 ] or an ellipti-
cal resection of the concha in the portion close to
the cranium.
Fig. 41.5 Partial incision in the outer border of the anti-
helix, used in cases of superior and middle third promi-
nence, as a modi fi cation of the original technique in these
speci fi c cases
Third suture
Second suture
First suture
Helix totally free
a
b
Fig. 41.6 ( a , b ) Three
absorbable mattress sutures
to reshape the new antihelix

441
41 Separating the Helix from the Antihelix: A New Concept in Prominent Ear Correction
The ear dressing consists fi rst of wet cotton
soaked in 70 % alcohol, which is carefully molded
into the concavities of the new ear’s fold; a larger,
dried portion of cotton is applied with a bandage
placed around the head, which is kept in place for
4 days (Fig. 41.9 ). Because of the extensive
undermining of the fl aps, the dressing should
never be tightened, thus preventing the occur-
rence of epidermolysis/necrosis.
Discussion
The strength and memory of the cartilage spring
are the most dif fi cult problems to solve in
otoplasties, particularly when the cartilage is
thick. Many authors have focused their efforts on
weakening this region (the antihelix) and
described a number of innovative ideas that have
led to good, though not always perfect results.
Moreover, the previously described procedures
were time consuming, and some cases of irregu-
larities in the antihelical fold were reported.
The general engineering of the ear spring
results in a very strong and stable structure. The
spring strength is determined by the complex
strength of the fi bers’ distribution and continuity,
which begins in the conchal region and is sus-
tained in the helix. The helix acts as a frame-
work, sustaining that structure to maintain the
original position of the ear and the strength of
the spring. If this distal continuity is broken, the
spring loses strength because it has lost its sup-
port. A global view of the problem led the author
Fig. 41.7 The alignment
point
Fig. 41.8 A small strip of cartilage is cut off from the superior part of the lateral border of the antihelix to avoid pos-
terior projection after surgery and simulates the natural shape of the antihelix

442
A.S.C. Valente
to conceive of another way to reshape this struc-
ture by deconstructing the ear, rebuilding it, and
placing it in a new position to heal. This is the
key point of this technique.
The separation of the helix/scaphoid fossa
from the antihelix/concha breaks the spring force
of the cartilage completely, facilitating the mak-
ing of a new antihelix and the repositioning of the
helix and the earlobe.
The precise location of the incision exactly
according to the design of the antihelix creates
two separate structures, the helix and the sca-
phoid fossa, from the antihelix and concha . The
former is completely free for positioning in its
proper position. The latter, now free from its dis-
tal support, tends, with its radial beams, to bend
the antihelix. We use the cartilage spring strength
in our favor (Fig. 41.10 ).
The techniques using sutures and weakening
work well on fi ne cartilage, but the angle created
at the outer edge of the antihelix is rounded and
not 90°, as it would be a normal ear (Fig. 41.11 ).
When bending to the antihelix, the helix also
tends to bend, especially in its most cranial seg-
ment, because they are united. Thus , retaining
part of the spring force predisposes to partial or
total relapse.
Fig. 41.9 Dressing. Cotton soaked in 70 % ethyl alcohol inside the ear’s convolutions and a large dry cotton bandaged
head to maintain the head’s position at bedtime and to protect the new auricular pavilion
Fig. 41.10 Separating the helix from the antihelix. Black
arrow (helix), green arrow (antihelix), and yellow arrow
(tail of the helix). Notice how the posterior border of the
antihelix is free to be folded

443
41 Separating the Helix from the Antihelix: A New Concept in Prominent Ear Correction
The techniques that use complete incisions in
the cartilage break the spring, but should be posi-
tioned exactly on the outer edge lateral and supe-
rior to the antihelix. The incision should be in
exactly positioned to deconstruct the ear without
leaving sharp edges at the postoperative site and
maintaining the helix in a fi rm position for attach-
ment to the scaphoid fossa.
The double incisions (parallel) in cartilage in
techniques such as the Converse create short
beams. The spring is extremely strong, and
sometimes even a suture as thick as nylon 2–0 is
unable to maintain the folding structure. This
mainly occurs in thick cartilage. With another
incision close to the concha, the opportunity is
lost to use the leaf spring leaving the concha for
our purposes. The advantage is to facilitate
bending. The angle created by the incision in the
region of the antihelix with the concha creates
an angle that is not natural with sharp edges
(Fig. 41.12 ).
All the techniques that use weakening of
the cartilage – scoring, rasping, and especially
partial incisions – are time consuming and can
cause visible irregularities. With the incision
described in this chapter, this becomes unnec-
essary. The modi fi cation added to the origi-
nal technique proved fundamental when the
Before
a
b
After
Smooth conchal-antihelix
angle
90° scapho-antihelix angle
c
d
Fig. 41.11 ( a – d ) The leaf spring before and after applying the technique to create new and natural antihelix angles
with the adjacent structures. The new angle is 90° with the scapha and helix smooth with the concha

444
A.S.C. Valente
author’s cases no. 61 showed a misalignment of
the two structures formed and an almost com-
plete recurrence of the upper pole of the ear,
the fi rst time this has occurred (Fig. 41.13 ).
It was clear that in certain patients resection
of the upper skin ellipse was not enough for
adequately positioning the helix and scapha.
The alignment point was designed to solve this
problem (Fig. 41.14 ).
In ears with prominence only in the region of
the middle third and upper pole (Fig. 41.15 ), par-
tial incision is extremely ef fi cient (Fig. 41.16 ).
The postauricular incision associated with
posterior undermining throughout obtained opti-
mal results with an imperceptible scar.
The postoperative results followed the pre-
cepts of McDowel [ 20 ] and La Trenta [ 21 ] for
aesthetic otoplasty (Fig. 41.17 ). The results are
Fig. 41.12 Operated with
the Converse technique. Note
the unnatural angles created
in the conchal-antihelix-
scaphal region and the sharp
edges. Also note the very
short and strong leaf spring
that lost its curvature, which
was created with sutures
with time
a
b
Fig. 41.13 ( a , b ) Complete
recurrence of upper pole
and a lack of alignment of
the new antihelix in relation
to the helix

445
41 Separating the Helix from the Antihelix: A New Concept in Prominent Ear Correction
very natural looking, with the helix appearing
straight and seeming to be beyond the antihelix
from the frontal view. The antihelix contours
appear smooth, round, and without irregularities,
instead of being sharp, straight, or unnatural
(Figs. 41.18 , 41.19 , 41.20 , and 41.21 ).
Complications
Complications are the same as described in the lit-
erature – small hematomas, epidermolysis, retroau-
ricular keloids, and late hypersensitivity – and the
author has not experienced any cases of infection
a
b
c
Fig. 41.14 ( a ) Preoperative 25-year-old. ( b ) Ten months postoperatively. ( c ) One month after reoperation
Fig. 41.15 Preoperative 14-year-old male. Note the
prominence in the middle third and upper pole and the
normal position of the inferior third and earlobe
Fig. 41.16 One year after surgical correction. The result
is very natural with partial incision

446
A.S.C. Valente
or dehiscence. All low rates are compatible with
those reported in the literature [ 22 ] . Recurrences ,
which occurred mainly in the upper pole at the
beginning of the series, have not occurred again so
far in the last 26 patients since starting to use an
alignment point. One patient presented with an
unnatural, tube-like result (Fig. 41.22 ) caused by
the sutures being very close to each other.
In a total of 86 patients , the satisfaction rate
was 97.66 %. Very good results were achieved
in 75 patients (87.22 %), good results in 9
patients (10.46 %), acceptable results in 1
patient (1.16 %), and a bad result in 1 (1.16 %)
(Table 41.1 ).
Conclusions
Surgery for correction of prominent ears may
at fi rst seem to be a simple and easy procedure
when we think that it only corrects the sca-
phocephalic angle to 30° in the preoperative
Fig. 41.17 ( Left )
Preoperative. ( Right )
Postoperative immediately
after surgery
a
b
Fig. 41.18 ( a ) Preoperative
25-year-old male.
( b ) Eighteen months after
correction of protruding ears

447
41 Separating the Helix from the Antihelix: A New Concept in Prominent Ear Correction
and postoperative front view photos as a
parameter of outcome. But if we think of the
precepts of McDowell, La Trenta, and others,
and the lateral and oblique views, the perfection
of the structures becomes dif fi cult to obtain
because the ear is formed entirely of cartilage.
This structure has a very powerful spring
memory, and any incision or stitches made the
a
b
Fig. 41.19 ( a ) Preoperative
25-year-old female. ( b ) Three
years after ear correction
Fig. 41.20 ( Left ) Preoperative 15-year-old male. ( Right ) Five months after surgery

448
A.S.C. Valente
Fig. 41.20 (continued)

449
41 Separating the Helix from the Antihelix: A New Concept in Prominent Ear Correction
Fig. 41.21 ( Left ) Preoperative 18-year-old female. ( Right ) Postoperative

450
A.S.C. Valente
wrong way can result in a deformity or change
in the expected result.
The various techniques described currently
use weakening (several types), sutures, and
incisions of the cartilage. Based on what has
been presented, complete incision of the
cartilage breaks the spring memory, and this
eliminates the need to weaken it. The placement
of this incision should be speci fi ed in the design
of the antihelix to create a new structure exactly
as it should be, looking for that perfect result.
Only the use of sutures with or without
weakening works well in thin cartilage, but it
still does not de fi ne the correct angle created
between the antihelix and helix/fossa scaphoid
at 90°, which would be the most natural and
furthermore may cause a fold in the cranial
part of the helix since there is no physical sep-
aration between the two.
The cartilage incision in the region between
the antihelix and concha creates an unnatural
angle in this region and furthermore breaks the
continuity of the beams’ spring, which comes
from the conchal region and ends at the free
edge of the new antihelix, preventing the use of
strength and the spring’s memory in our favor.
The dressing should never be tight, because
the detachments necessary to perform the tech-
nique leave the fl aps sensitive and susceptible
Fig. 41.22 Unnatural tube-like antihelix
Fig. 41.21 (continued)

451
41 Separating the Helix from the Antihelix: A New Concept in Prominent Ear Correction
to compression. We believe that this technique
is reproducible, and the results are natural-look-
ing and have a very low rate of recurrence.
Every surgeon should handle the ear carti-
lage with care. Any incision made out of place
may become visible and interfere with the
results, which should not have signs of being
an “operated” ear (Fig. 41.23 ).
References
1. Valente ASC. Separating the helix from the antihelix.
A new concept in prominent ear correction. Aesthet
Surg J. 2010;30(2):139–53.
2. Dieffenbach JE. Die operative Chirurgie. Leipzig: F.
A. Brockhause; 1845.
3. Ely ET. An operation for prominent auricles. Arch
Otolaryngol. 1881;10:97–9 (reprinted Rogers BO. Ely’s
1881 operation for correction of protruding ears. A med-
ical “ fi rst”. Plast Reconstr Surg. 1968;42(6):582–6).
4. Morestin MH. De la reposition et du plissement cos-
metiques du pavillon de l’oreille. Rev Orthop. 1903;4:
289–303.
5. Luckett WH. A new operation for prominent ears
based on the anatomy of the deformity. Surg Gynecol
Obstet. 1910;10:635–7.
6. Becker OJ. Correction of protruding deformed ear. Br
J Plast Surg. 1952;5(3):187–96.
7. Converse JM, Nigro A, Wilson FA, Johnson NA.
Technique for surgical correction of lop ears. Plast
Reconstr Surg. 1955;15(5):411–8.
8. Converse JM, Wood-Smith D. Technical details in the
surgical correction of the lop ear deformity. Plast
Reconstr Surg. 1963;31:118–28.
9. Gibson T, Davis W. The distortion of autogenous car-
tilage grafts: its cause and prevention. Br J Plast Surg.
1958;10:257–74.
10. Mustardé JC. The correction of prominent ears using
simple mattress sutures. Br J Plast Surg. 1963;16:170–8.
11. Stenstrom SJ. A “natural” technique for correction of
congenitally prominent ears. Plast Reconstr Surg.
1963;32:509–18.
12. Chongchet V. A method of antihelix reconstruction.
Br J Plast Surg. 1963;16:268–72.
13. Crikelair GF, Cosman B. Another solution for the
problem of the prominent ear. Ann Surg. 1964;160:
314–24.
14. Nordzell B. Open otoplasty. Plast Reconstr Surg.
2000;106(7):1466–72.
15. Caouette-Laberge L, Guay N, Bortoluzzi P, Belleville
C. Otoplasty: anterior scoring technique and results in
500 cases. Plast Reconstr Surg. 2000;105(2):504–15.
16. Brent B. Hydrodissection as key to a natural-appearing
otoplasty. Plast Reconstr Surg. 2008;122(4):1055–8.
17. Webster GV. The tail of the helix as a key to otoplasty.
Plast Reconstr Surg. 1969;44(5):455–61.
18. Beernink JH, Blocksma R, Moore D. The role of the
helical tail in cosmetic otoplasty. Plast Reconstr Surg.
1979;64(1):115–7.
19. Furnas DW. Correction of prominent ears by con-
chamastoid sutures. Plast Reconstr Surg. 1968;42(3):
189–93.
20. McDowell AJ. Goals in otoplasty for protruding ears.
Plast Reconstr Surg. 1968;41(1):17–23.
21. LaTrenta GS. Otoplasty. In: Rees TD, LaTrenta GS,
editors. Aesthetic plastic surgery. 2nd ed. Philadelphia:
Saunders; 1994. p. 891–921.
22. Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast
Reconstr Surg. 2005;115(4):60e–72.
Table 41.1 Satisfaction index
Satisfaction
Very bad
Bad
Acceptable
Good
Very good
Total
0 (0 %)
1 (1.16 %)
1 (1.16 %)
6 (10.46 %)
75 (87.22 %)
86 (100 %)
Fig. 41.23 The results are very natural looking, with the
helix appearing straight and seeming to be beyond the
antihelix on the frontal view. The antihelix contours
appear smooth, round, and without irregularities

453
M.A. Shiffman (ed.), Advanced Cosmetic Otoplasty,
DOI 10.1007/978-3-642-35431-1_42, © Springer-Verlag Berlin Heidelberg 2013
42
Introduction
Otoplasty need not be as challenging an artistic
endeavor as other facial cosmetic surgeries.
A straightforward and systematic strategy as
outlined in this chapter can help guide a surgeon
to attain reproducible and aesthetically appeal-
ing outcomes. By dividing the ear into vertical
thirds, a surgeon can identify the causative aes-
thetic problem and thereby correct it in a tailored
and targeted manner. The upper third of the ear
when prominent typically signi fi es the pres-
ence of a lop ear deformity in which the anti-
helical fold is diminished or altogether absent.
Correction of this deformity involves Mustarde
sutures to create a proper antihelical fold. The
middle third of the ear, if prominent, usually
re fl ects the overexuberant presence of the con-
chal cartilage, creating a cup ear deformity,
which would mandate excision and reduction
of the conchal bowl. Often neglected, the lower
third of the ear can also manifest an enlarged,
prominent, or protruding lobule that if ignored
can lead to an unbalanced result with a nonaes-
thetically protruding lobule. Various strategies
to reduce the lobule that will be discussed are a
V–Y setback and cauda helicis fi xation to the
conchal bowl. This chapter will aim to describe
the aesthetic principles, systematic planning, and
surgical technique to create a balanced, natural,
and aesthetic otoplasty result.
Principles and Strategy
All ears are not created equal. Besides the above
considerations, ears can be asymmetrically pro-
truding, differently shaped, and of different sizes.
When trying to prioritize what would be the most
important dimension to fi x, the author tends to
recall the time of performing reconstructive ear
surgeries for skin cancer conditions. Whenever a
cancer had to be removed, the ultimate goal
would be focused on how the ears would look
straight on from the frontal view, i.e., how much
protrusion they would have off the head and to try
to ensure that both ears would be protruding
about the same degree. With bad technique, one
ear could easily cup forward and protrude unnat-
urally. No other dimension was as important as
how the ears appeared from the frontal view.
Many times patients can become obsessed with
the relative size differences of their ears or the
fact that one ear shape is slightly or grossly dif-
ferent from the other ear. However, keeping in
mind that the only time that both ears can be
viewed at the same time is from the frontal view,
it is not as important that the two ear shapes be of
the same size and proportion because the viewer
will never be able to see the two ears side by side
to compare.
S. M. Lam , M.D.
Willow Bend Wellness Center, Lam Facial Plastic
Surgery Center and Hair Restoration Institute ,
6101 Chapel Hill Boulevard, Suite 101 ,
Plano 75093 , TX , USA
e-mail: drlam@lamfacialplastics.com
Balanced Otoplasty: Dividing
the Ear into Vertical Thirds
Samuel M. Lam

454
S.M. Lam
After ensuring that the ears are protruding to the
same degree, the second most important element to
consider is how the shape of the ear itself looks from
the side view. Because one size of the ear cannot be
easily compared with the other size of the ear, size
differences are not important. Instead, when look-
ing at an ear from the side view, the ear should look
like an ear, i.e., it should possess all the normal con-
stituent elements of an ear like the helix and antihe-
lix. So long as the protrusion from the frontal view
is not compromised, the shape of the ear as viewed
from the side takes secondary precedence.
An important element would be that the size of
one ear should be similar to the size of the other
ear. This size difference albeit dif fi cult to appreci-
ate can be deduced somewhat from the frontal
view if grossly different in size and possibly with
rapid turning of the head as the viewer sees one ear
and then the other one. Despite this attribute rank-
ing third in importance, it is actually almost impos-
sible to fi x without taking undue risk in violating
the fi rst two principles of normal protrusion and
normal shape. As with cancer operations, tissue
can be borrowed from the lobule and slid upward
by making incisions along the inside of the helix,
but this technique is more appropriate for skin can-
cer cases than for cosmetic reductive otoplasty.
How do these principles play out when working
on real-case scenarios? Think of when one ear pro-
trudes more than the contralateral side. When pull-
ing the ear that is protruding out farther backward
to match the other side, the antihelical fold some-
times can be deeper recessed due to the need for
greater recession. This shape will obviously look
different from the other side upon careful inspec-
tion, especially when the head is rotated to the side.
Nevertheless, if we follow the principle that the ear
should be as symmetrical as possible from the
frontal view, i.e., the degree of protrusion should
be as symmetrical as possible, then we are okay to
ignore this slight difference. This limitation should
be pointed out to a patient before surgery so that
there is nothing unexpected afterward.
The term “telephone deformity” is well known
and suggests that the ear is tucked too far back-
ward to the cranium in the middle pole. An “anti-
telephone deformity” refers to pulling the upper
pole too far back during a lop ear reduction. It is
important that the ear not appear fl at against the
head no matter how much the patient is desirous of
doing this, as it will appear unnatural. The ear
should be resting 20°–30° naturally off of the mas-
toid. With experience, the surgeon need not mea-
sure the degree of protrusion on one side compared
with the other but merely eyeballs the degree of
setback and symmetry during the procedure.
For those just starting in the practice of oto-
plasty, more rigorous guidelines can be offered.
Using Castroviejo calipers, the superior aspect
of the helix should be approximately 10–12 mm
from the cranium; the crural junction, at
16–18 mm; and the top of the external auditory
canal, at 20–22 mm.
Another important concept that is overlooked
is the relative position of the helix and the antihe-
lix from the frontal view. When viewing an indi-
vidual straight on, the helix should be ever so
slightly lateral to the antihelix, i.e., the helix
should not be hidden behind the antihelix. This
problem can occur when the sutures are tied down
too aggressively in a lop ear correction such that
the antihelical fold dominates and covers the vis-
ibility of the helix from the frontal view. When
tying down sutures during the procedure, the sur-
geon should always reference how the ear is
shaping up from the frontal view as the fi rst and
foremost priority.
The sole exception when the antihelix can be
tied down so that the helix is partially obscured is
in an individual whose cartilage is very thick and
would tend to rebound over time as the sutures
relax and the ear begins to protrude slightly over
time. The author believes that through-and-
through cuts through the cartilage in the proposed
region of the antihelical fold are verboten because
it will frequently lead to the visibility of cut
cartilage edges over time. Accordingly, a slightly
overcorrection of the degree of setback of the ear
is done when correcting a lop ear deformity
because invariably there is some visible relax-
ation that can occur over time. This is especially
true if the cartilage is stiff, rigid, and thick, as
mentioned above. As always, it is important to
explain this to a patient preoperatively so he or
she does not perceive the surgery as a failure with
some relaxation that is bound to occur.

455
42 Balanced Otoplasty: Dividing the Ear into Vertical Thirds
Although
through-and-through
incisions
through the proposed antihelix is unwise, partial
scoring of the posterior aspect in the region of the
antihelix truly can help reduce the tendency to
relapse after a lop ear reduction. Technique will
be explained in detail in the following section.
When the cartilage is particularly rigid, it becomes
imperative that the surgeon takes his time to score
the posterior aspect of the cartilage in a deliberate
and almost exhaustive manner to thin the carti-
lage down as much as possible.
Relaxation typically does not occur with cup
ear reductions because I believe that some carti-
lage excision in the conchal bowl is critical to
achieve the desired result. The precise technique
will be described below. In the past, the author
would not excise conchal cartilage but try to take
the conchal bowl either back onto itself or onto
the mastoid periosteum without predictable
results. This is especially true when the conchal
bowl cartilage is truly excessive in quantity, mak-
ing a tack back to the mastoid virtually futile in
the ability to achieve a durable result.
In general, even if there is some degree of con-
chal bowl excess but not a lot, the author will still
prefer to excise a little bit of conchal bowl to break
the recoil of the cartilage in an area that I deem
safe, i.e., that should not create visible cut carti-
lage edges as would be visible by cutting along the
region of the proposed antihelix. This is especially
helpful when dealing with very thick, resilient car-
tilage in which the fear is that there would be total
relaxation of the Mustarde sutures over time.
To determine how much lop ear deformity
(absence of the antihelix), cup ear deformity
(conchal excess), and lobular protrusion exist in a
particular patient, the surgeon can stand in front
of the individual and push back the top, middle,
and bottom of the ear, respectively, to evaluate
the relative contribution of each part of the ear to
the observed deformity. Doing this is also very
helpful in explaining to a patient what the precise
mixture of aesthetic issues presents and how the
surgery would be tailored accordingly. Also by
doing this, sometimes the lobule that seemed to
be okay becomes obviously protuberant when
pushing back the upper two-thirds of the ear. In
this case, a lobular reduction should be planned.
The two ways that are reliable methods to
reduce the lobule include a V-to-Y setback and
tacking the cauda helicis to the conchal bowl. Both
methods can be combined as well when needed.
When the lobule itself is too large and protrusive,
the V-to-Y setback allows some reduction of the
tissue from the posterior aspect of the lobule, per-
mitting the ear to be reduced in size and somewhat
retrodisplaced. When the ear lobule is just protrud-
ing out, securing a suture between the cauda helicis
and the conchal bowl is a secure method of retro-
setting the lobule and can be adjusted depending on
how tight the suture is tied down. This is a more
reliable method of lobule setback when the conchal
cartilage is not resected as in a cup ear reduction.
Sometimes both methods are helpful when used
together to attain adequate lobular reduction.
In the past, the author would use 4-0 braided
polyester fi ber suture (Mersilene) for all otoplasties.
However, there was a higher extrusion and infec-
tion rate noted with this braided suture. Further,
when removing the suture in the of fi ce, it was quite
painful for the patient and a more labor-intensive
chore, pulling out a braided suture from the ear.
Today, the author prefers 4-0 clear polypropylene
(Prolene) suture as it is almost as easy to tack down
as Mersilene with a much lower incidence of extru-
sion and infection, and when the suture extrudes,
suture removal is almost entirely painless and easy
to perform. The patient is always counseled that
extrusion can occur but not to remove the sutures
but to allow the author to do it, as needed. Typically
the author does not like removing any sutures
unless they are truly problematic prior to 6 months
when I believe most of the scar tissue has become
mature to hold the ear more durably in position.
Technique
Sedation, Preparation, and Anesthesia
When performing a reduction in the three vertical
divisions of the ear, the author almost always pro-
ceeds with reducing the center (cup ear), then the
top ear (lop ear), and then the lobule in that order.
The technique will be described according to that
sequence.

456
S.M. Lam
For children who would not tolerate intravenous
sedation, then general anesthesia may be preferred.
However, an increasing percentage of adults are
now seeking reductive otoplasty later in life and
can tolerate simple intravenous sedation with mida-
zolam and fentanyl. Despite using sedation, the
initial ring block can still be quite uncomfortable,
so we make it a point to apply topical anesthetic
cream for an hour circumferentially around the ear
and directly on the ear (anteriorly and posteriorly)
in order to minimize the potential discomfort.
The postauricular skin island planned for exci-
sion should be marked out before the patient is
prepared and draped and after the anesthetic cream
has been thoroughly removed. In a person with an
obvious need for reductive otoplasty, a fusiform
shape is removed running from 1 cm below the
superior helix to 2 cm above the lobule, fanning
from 5 mm superiorly to 1 cm at its greatest
dimension (situated at the upper one-third of the
planned excision) tapering downward to 2–5 mm
inferiorly (Fig. 42.1 ). It is important to match the
width on one side meticulously with the contralat-
eral side using Castroviejo calipers. When per-
forming nuanced, subtle otoplasty reductions, a
proportionate degree of reduction in total amount
of skin removed should be undertaken so that the
ear is not inadvertently overpinned.
The patient is then prepared with povidone-
iodine solution to include both ears, the periau-
ricular region, and the entire face. The reason for
this extensive sterile preparation is that it is easy
to touch the central face accidentally when per-
forming bilateral otoplasty. The patient is draped
with a sterile blue towel as a head wrap with both
ears left exposed and remaining dressings applied
circumferentially to maintain a sterile fi eld. The
patient has intravenous sedation administered.
A 10-mL syringe containing a 50/50 mixture of
1 % lidocaine/l:100,000 epinephrine and 0.25 %
bupivacaine is in fi ltrated as a ring block around
each ear, i.e., 10 mL per each ear, taking care to
be symmetrical in how the ring block is applied
(Fig. 42.2 ). Additionally, 2–3 mL of 1 %
lidocaine/l:100,000 epinephrine is in fi ltrated
directly along the posterior aspect of the ear in
the planned area of skin excision and the sur-
rounding area (Fig. 42.3 ). Ten minutes is allowed
to transpire for proper hemostasis and anesthesia
to be established. It is critical not to in fi ltrate
anesthesia along the anterior surface of the ear,
which can lead to distortion and thereby inability
to read what is going on during the procedure.
Fig. 42.1 The postauricular skin island planned for
excision should be marked out before the patient is pre-
pared and draped and after the anesthetic cream has been
thoroughly removed. In a person with an obvious need for
reductive otoplasty, I remove a fusiform shape running
from 1 cm below the superior helix to 2 cm above the lob-
ule, fanning from 5 mm superiorly to 1 cm at its greatest
dimension (situated at the upper one-third of the planned
excision) tapering downward to 2–5 mm inferiorly
Fig. 42.2 A 10-mL syringe containing a 50/50 mixture
of 1 % lidocaine/l:100,000 epinephrine and 0.25 % bupi-
vacaine is in fi ltrated as a ring block around each ear, i.e.,
10 mL per each ear, taking care to be symmetrical in how
the ring block is applied

457
42 Balanced Otoplasty: Dividing the Ear into Vertical Thirds
The surgeon begins on one ear, incising
the fusiform skin paddle with a Bard-Parker
No.15 blade and discarding the removed skin
(Fig. 42.4 ). Hemostasis is achieved with bipo-
lar cautery before proceeding. Medium-wide
double-hooked retractors are enlisted to retract
the ear, as the surgeon uses curved tenotomy
scissors to spread and separate the skin from
the underlying postauricular cartilage along
the entire expanse of the postauricular surface
(Fig. 42.5 ). Again hemostasis with bipolar cau-
tery is attained as needed before proceeding.
Cup Ear Reduction
Twenty- fi ve-gauge needles are used to penetrate
the skin from the anterior to posterior side of the
ear along the lateral curved edge of the conchal
bowl to mark out the conchal bowl along the pos-
terior aspect of the ear. Gentian violet can be used
to connect the points along the posterior aspect to
guide the fi rst through-and-through incision
through the conchal cartilage, taking care not to
violate the anterior skin surface (Fig. 42.6 ).
Approximately 2–4 mm of cartilage is then cut in
a parallel arc medial to the previous incision and
the ends joined to facilitate removal of this carti-
lage excess (Fig. 42.7 ). The curved tenotomy scis-
sors are used to undermine under both cartilage
edges approximately a centimeter on both sides so
that the skin does not appear bunched up when the
cartilage edges are closed together (Fig. 42.8 ).
The cartilage is then closed with 2–3 interrupted
4-0 polypropylene sutures (Fig. 42.9 ).
Lop Ear Reduction
Multiple 25-gauge needles are placed through
from the anterior to posterior side of the ear on
both sides of the proposed antihelical fold to
Fig. 42.3 Additionally, 2–3 mL of 1 % lidocaine/l:100,000
epinephrine is in fi ltrated directly along the posterior
aspect of the ear in the planned area of skin excision and
the surrounding area
Fig. 42.4 The surgeon begins on one ear, incising the
fusiform skin paddle with a Bard-Parker No.15 blade and
discarding the removed skin
Fig. 42.5 Medium-wide double-hooked retractors are
enlisted to retract the ear, as the surgeon uses curved teno-
tomy scissors to spread and separate the skin from the
underlying postauricular cartilage along the entire expanse
of the postauricular surface

458
S.M. Lam
correlate with where the mattress sutures will be
placed. Typically 6–8 needles are placed to cor-
respond with 3–4 sutures that will be used to rec-
reate the antihelical fold with Mustarde sutures
(Fig. 42.10 ). With the needles in place and the
postauricular surface in view, the territory
between the needles is scored in a partial thick-
ness manner using a No.15 blade running verti-
cally, horizontally, diagonally in one direction,
diagonally in the opposing direction, and across
until the cartilage is suf fi ciently weakened
without fully penetrating with the knife to the
other side (Fig. 42.11 ). In addition, the belly of
the blade can be used to scrape the cartilage in the
partially scored region of cartilage to further
soften the cartilage to limit recoil. When the sur-
geon believes that the cartilage is suf fi ciently
weakened, he can then progress with the suture
placements.
Starting from the top, the 4-0 polypropylene
suture is placed through the cartilage in a full-
thickness manner ensuring that the needle pene-
trates all the way through the anterior
perichondrium but not through the anterior skin.
Fig. 42.6 Gentian violet can be used to connect the
points along the posterior aspect to guide the fi rst through-
and-through incision through the conchal cartilage, taking
care not to violate the anterior skin surface
Fig. 42.7 Approximately 2–4 mm of cartilage is cut in a
parallel arc medial to the previous incision and the ends
joined to facilitate removal of this cartilage excess
Fig. 42.8 The curved tenotomy scissors are used to
undermine under both cartilage edges approximately a
centimeter on both sides so that the skin does not appear
bunched up when the cartilage edges are closed together
Fig. 42.9 The cartilage is closed with 2–3 interrupted
4-0 polypropylene sutures

459
42 Balanced Otoplasty: Dividing the Ear into Vertical Thirds
The same needle is then passed through the cor-
responding 25-gauge needle point on the other
side of the proposed antihelical fold in the same
manner but backhanded to complete the mattress
(Fig. 42.12 ). The suture is not tied down but
tagged with curved or straight clamps. The two
25-gauge needles that were used as guides for the
fi rst suture are then removed. The same technique
is continued along the entire length of the pro-
posed antihelical fold, tagging but not tying down
any of the sutures. The middle suture is then tied
down with a surgeon’s knot until the ear is posi-
tioned at about 80 % of the desired position and
secured with remaining knots. The excess suture
tails are then cut, saving the remaining needle
and suture for use on the contralateral side if pos-
sible. Each additional mattress suture is tied down
sequentially until the antihelical fold is fully
formed, the ear is well positioned by inspecting
the ear from a frontal view, and as mentioned
before the helix is not entirely obscured by the
antihelical fold from the frontal view.
Lobular Reduction
At this point, any lobular excess can be properly
identi fi ed. If the lobular size is too large and protu-
berant, a V-to-Y closure can be done to draw the
lobule backward and to reduce the size of the lob-
ule somewhat. If the lobule is truly too large, a
wedge excision may need to be undertaken, but
this risks a visible incision from the frontal view
that in most cases is not worth it. If the lobule is
just somewhat protrusive relative to the reduced
Fig. 42.10 Multiple 25-gauge needles are placed through
from the anterior to posterior side of the ear on both sides
of the proposed antihelical fold to correlate with where
the mattress sutures will be placed. Typically 6–8 needles
are placed to correspond with 3–4 sutures that will be used
to recreate the antihelical fold with Mustarde sutures
Fig. 42.11 With the needles in place and the postauricu-
lar surface in view, the territory between the needles is
scored in a partial thickness manner using a No.15 blade
running vertically, horizontally, diagonally in one direc-
tion, diagonally in the opposing direction, and across until
the cartilage is suf fi ciently weakened without fully pene-
trating with the knife to the other side
Fig. 42.12 Starting from the top , the 4-0 polypropylene
suture is placed through the cartilage in a full-thickness
manner ensuring that the needle penetrates all the way
through the anterior perichondrium but not through the
anterior skin. The same needle is then passed through the
corresponding 25-gauge needle point on the other side of
the proposed antihelical fold in the same manner but back-
handed to complete the mattress

460
S.M. Lam
upper two-thirds of the ear, then a 4-0 polypropyl-
ene suture can be passed through the cauda helicis
(Fig. 42.13 ) and tacked back somewhere to the
conchal bowl (Fig. 42.14 ) and tightness adjusted
as the lobule begins to retrude backward. As a
point of clari fi cation, the cauda helicis is de fi ned
as the small appendage-like cartilage that signi fi es
the very caudal border of the helical cartilage. It
oftentimes needs to be dissected sharply with scis-
sors to be readily identi fi ed, using palpation as a
guide.
Skin Closure and Drain
When the ear looks good from a frontal position,
i.e., the helix is not tucked too far back and the upper,
middle, and lower poles look to be in alignment and
in proportion, then the skin can be closed. A running
5–0 chromic suture is used to close the incision,
leaving a small gap at the inferior aspect for a cut red
rubber catheter tube that is left in place over night.
Contralateral Side
The contralateral side is approached in the exact
same manner, taking care that when the head is
turned to the other side, the recently operated-on
ear is not bent and pinned unfavorably against the
headrest/table. Some additional gauze padding
can be secured to buttress the previously operated-
on ear as it now presses more against the bed after
the head is turned. When all of the Mustarde
sutures have been tagged and are ready to be tied
down, the surgeon should stand up and look down
on the patient to evaluate the position of the ear
relative to the other side when tying each knot
down to ensure symmetry and similarity in curva-
ture. In the past, the author would use calipers to
measure the distance from ear to mastoid but has
found that my eye is more accurate than these
measurements can afford. It is imperative that the
frontal view shows as symmetrical a result as pos-
sible. Sometimes that means bending one ear back
more than the other ear to attain that frontal sym-
metry. However, it is also important to make sure
that by bending one ear back farther than the other,
the shape of the antihelix does not appear to be too
distorted when pulled farther back than the other.
A slight degree of greater curvature is accepted if
it permits better frontal symmetry. Again, it is
essential that the patient know that the ears may
look different from a side or % view due to this
fact in order to get a frontal view that looks more
symmetrical. This limitation should be expressed
in the preoperative encounter not ideally after the
surgery has been completed. The difference
between an education and an excuse is that an edu-
cation is provided before the surgery and an excuse
is offered afterward (Figs . 42.15 and 42.16 ).
Fig. 42.13 If the lobule is just somewhat protrusive rela-
tive to the reduced upper two-thirds of the ear, then a 4-0
polypropylene suture can be passed through the cauda
helicis and tacked back somewhere to the conchal bowl
and tightness adjusted as the lobule begins to fall
backward
Fig. 42.14 This photograph shows the second pass of the
lobule setback suture shown in Figure 42.13

461
42 Balanced Otoplasty: Dividing the Ear into Vertical Thirds
g
f
cb
a
Fig. 42.15 ( a ) Preoperative 36-year-old gentleman. ( b ) One year after reductive otoplasty of a cup and lop ear
deformity with good aesthetic improvement and improved symmetry in the result