11 Otoplasty

Since Ely’s 1881 original description of cosmetic otoplasty,1 numerous surgical techniques have been described in the literature over the past century to correct a congenital lop ear, or prominent auricle deformity. In general, the techniques can be categorized as cartilage sculpting techniques versus suture placement techniques, or a combination of the two methods. The purpose of otoplasty is to give the auricle a more natural appearance in relation to the underlying mastoid bone. To achieve optimal results, accurate understanding and assessment of the deformity is paramount.

A lop ear deformity is classically described as a syndrome of deformities related to an undeveloped antihelical fold and an overprojected concha, resulting in a prominent auricle. Luckett is credited with first correct attribution of the deformity to the absence of the antihelical fold.² Davis has further described the important elements of the deformity related to the upper third of the ear: (1) reduction in the vertical height of the auricle, (2) reduction of the fossa triangularis, (3) reduction of the scapha, (4) reduction or absence of the superior crus of the antihelix, and (5) lid-like turning down of the helix.³

In Ely’s description of cosmetic otoplasty, a full-thickness skin and cartilage wedge excision of the conchal bowl was performed to reduce the prominence of the ear.¹ A visible scar was left along the front and back side of the ear. Various modifications involving a reduction approach by excising skin and cartilage have been described. By using the same technique, Keen preserved a strip of skin along the front of the ear, thereby preventing a visible scar from appearing.⁴ Monks believed that cartilage excision was not always necessary depending on the stiffness of the cartilage and advocated excision of an ellipse of posterior auricular skin alone was adequate.⁵ In Luckett’s modification, a crescent-shaped excision of the skin and cartilage was performed at the site of the intended antihelix.³ The remaining edges of the cartilage were then everted anteriorly and sutured to recreate the antihelix. Converse further modified the technique in recreating an antihelix by suturing the antihelical segment of the cartilage to form a tunnel.⁶ In an important contribution, Mustarde described and popularized the suture technique, which uses permanent mattress sutures to maintain the superior crus of the antihelix.⁷ Furnas is credited with the description of conchal mastoid sutures to correct prominent conchal deformities.⁸ The use of various suture techniques remain popular today, given the trend toward more minimalistic approaches in the surgical correction of a lop ear deformity. Modern innovations have included “incisionless” techniques, where, for example, the ear can be shaped using permanent sutures placed through the skin by carefully positioning the suture needle into the same needle hole without creating an incision with a scalpel.

Embryology and Anatomy

The development of the auricle occurs during weeks 6 to 16 in utero. The hillocks of His refer to the six visible protuberances in the 39-day embryo, as described by that author. He originally referred the origin of the first three hillocks to the first branchial arch and the second three hillocks to the second branchial arch. Alternatively, Streeter believed that the first arch hillocks contribute only to the tragus, crus helices, and helix, while the second arch hillocks ares responsible for approximately 85% of the auricle.⁹ In further contrast to the original embryological description by His, Wood-Jones and I-Chuan believed that the first branchial arch contribution is limited to the tragus and the remainder of the auricle is derived from the second brachial arch.¹⁰ This is supported by the location of congential preauricular pits and fistulae along the anterior incisure and the intertragic incisure. These anomalies arise from the first pharyngeal depression, which anatomically is the dividing line between the first and the second pharyngeal arch.

The key topographical landmarks in a normal ear include the helix, antihelix, scapha, conchal bowl, and tragus. The helix and antihelix start at the tragus and diverge as they extend superiorly, separated by the scapha. Superiorly, the antihelix divides into a wider superior and a sharper inferior crus. The fossa triangularis is the depression between the superior and the inferior crus. The conchal bowl is composed of the cymba concha superiorly and the cavum concha inferiorly. Flexible elastic cartilage provides the framework and structure to the external ear. Cartilage is absent from the ear lobule. Anteriorly, the skin is closely adherent to the cartilage, whereas posteriorly, the skin is more loosely attached.

The intrinsic muscles associated with the external ear are the major and minor helices, tragus, antitragus, oblique, and transverse muscles. The external muscles are the anterior auricularis, superior auricularis, and posterior auricularis muscles. The muscles are innervated by the seventh cranial nerve.

The external ear receives blood from the superficial temporal, posterior auricular, and occipital arteries. The venous drainage involves the posterior auricular, external jugular, superficial temporal, and retromandibular veins. The lymphatics of the ear drain into the preauricular and superior cervical lymph nodes. Sensory innervation to the anterior limb of the helix and tragus is supplied by the auriculotemporal branch of the mandibular division of the fifth cranial nerve. The greater auricular nerve supplies the remainder of the anterior auricle. The lesser occipital nerve supplies the posterior auricle. Arnold nerve, a branch of the tenth cranial nerve, supplies the concha.

Appropriate preoperative counseling with the patient and/or their family is essential. Realistic postoperative expectations and wound care need to be addressed. For children, otoplasty is typically performed between 4 and 6 years of age. By this age, the auricle is nearly fully developed. Furthermore, given the concern for peer ridicule and the effect it may have on a child’s self-image, otoplasty is often requested by parents before the child enters school. Gosain et al have suggested that otoplasty performed before 4 years of age can be safely considered without adversely interfering with the growth of the operated ear.11

Relative contraindications to otoplasty include unrealistic patient expectations; patients unwilling or unable to cooperate with postoperative care instructions, wound healing disorders, and cartilage disorders; and patients with a history of hypertrophic scarring or keloids.

Surgical Techniques

Otoplasty is indicated for the correction of prominent ears (Fig. 11.1). The goal is to achieve symmetry and balance of the face. The surgical technique used is dependent on the preoperative analysis and the experience of the surgeon. One may need to correct conchal protrusion, an antihelical deformity, or a combination of the two deformities. At present most techniques incorporate a combination of sutures and cartilage-modifying maneuvers to correct auricular deformities.

The traditional conchal setback technique using permanent conchal mastoid sutures, as originally described by Furnas, is commonly used for conchal protrusion.⁸

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