Otoplasty is a surgical technique that is commonly performed for the child or young adult who has protruding ears. Although parents often seek advice early for a child with prominent ears, it is frequently the young adult who independently presents for clinical evaluation. In the case of a child who is brought in for otoplasty consultation, there are two lines of consideration regarding the timing of surgery. One school of thought suggests that the children should reach an age in which they are able to participate in the decision of whether or not they wish to have otoplasty performed. This timing further allows the parents to see whether this is a social issue for the child among the peer groups. The other school of thought feels that it is better to perform the operation correcting protruding ears before the child is aware of this as an issue and before social pressures are encountered. Unfortunately, there have been no definitive studies to current date to determine the proper timing of the otoplasty procedure.

From a purely surgical point of view, the tradition is that otoplasty should not be performed before the age of 6. This is based upon two general concepts: The first is that the auricle is 80% to 90% of the adult size by the age of 6 and anticipated future growth is of minimal concern. The second is that most 6-year-old children will cooperate with the postoperative care and will wear their dressings and headbands for weeks after the surgery without putting up too much of a fuss.

This chapter is devoted to the treatment of the protruding ear with an absence of the antihelical fold and a deep conchal bowl and does not address issues such as microtia or a constricted or lop ear, which occurs when the ear is foreshortened and the vertical dimension is folded over the helical edge. Techniques for this type of reconstruction can be found in other sections of this textbook.

As with all surgical patients, the usual questions about the onset of the condition, past surgical interventions, trauma, and hereditary factors are reviewed. The history of the patient’s general health is obtained and includes cardiac, pulmonary, hepatic, and renal systems. Two key points of a child or young adult undergoing surgery should focus on a family history of bleeding disorders and/or connective tissue disorders. These two elements are of considerable importance with regard to the quality of healing.

The most important lines of questioning are directed toward the social aspects of the protruding ear. One must be certain that the family or the young adult patient has appropriate expectations and reasons for doing the surgery and does not consider the surgery a completely life-changing event. There is no reason to delay or avoid surgery on patients who wear eyeglasses as the eyeglasses can be worn postoperatively except for 1 or 2 days during the postoperative period. Even then, bandages can be tailor-made so that eyeglasses can be incorporated into them.

Photographs are to be taken of all patients preoperatively. Anterior, posterior, lateral, and oblique views should be taken with the hair pinned back. A submental view can also be quite helpful. Measurements of the distance between the mastoid skin and the superior, middle, and lobular portion of the ear should be recorded preoperatively for each ear so that these measurements can be compared with postoperative and intraoperative findings. The external ear should be examined for any obstruction to the ear canal and tympanoscopy should be accomplished to rule out middle ear disease. Although an actively draining ear would be a contraindication to surgery, the presence of ventilating tubes or recurrent otitis media is not a contraindication to otoplasty.

This procedure may be done under local for adults, MAC, or general; the latter is typically reserved for children. Long hair is placed into multiple small ponytails or braids without shaving the hair. The ears and face are prepped and draped in standard sterile fashion. The surgical prep is to include both ears and the face so that the head can be turned side to side during the procedure without reprepping and draping. Preoperative broad-spectrum skin antibiotic prophylaxis is given.

Measurements are made on both sides of the distance from the mastoid skin to the superior portion of the auricle, the middle portion, and the lobule. These recordings are labeled right and left side on the back table or by the circulating nurse. Using a sterile marking pen, a dumbbell-shaped incision is marked on the medial
surface of the auricle. A fusiform excision can also be performed, but this does not give as much skin resection at the superior and inferior portion of the ear as the dumbbell excision does. The skin excision is completely on the medial surface of the auricle and does not go into the postauricular crease, nor does it extend up to the helical rim. The wide portions of the dumbbell excision inferiorly and superiorly are about 1 to 1.5 cm and the narrow neck in between is about 0.5 cm. The postauricular skin is injected with 1% lidocaine with 1:100,000 epinephrine and allowed to set for 8 minutes. The skin and underlying tissues that were marked are excised down to the level of the perichondrium and the surrounding soft tissues are raised from the helical rim to the mastoid underneath the postauricular crease (Fig. 38.2). When dissecting down to the mastoid bone, one must incise the postauricular muscle and it is common to find mastoid emissary veins that must be cauterized.