The social implications of auricular deformities for the developing child are well documented. Apart from being aesthetically displeasing, protruding ears, or prominauris , are a frequent source of ridicule by peers and may contribute to a range of developmental abnormalities including social phobias and outright behavioral disturbances. Techniques for correction of these deformities have spanned millennia, with the first known recording found in Sushruta’s texts from the seventh century . The history of otoplastic technique has been detailed elsewhere . Modern otoplastic techniques can be categorized broadly as cartilage-cutting and cartilage-sparing varieties. Cutting techniques are still widely favored, more so in Europe, as they are purported to better maintain enduring corrections. These techniques may encompass cartilage incisions, wedge excisions, scoring, or abrasion of either the anterior or posterior cartilaginous surface, designed to eliminate the inherent elastic spring of the unfurled antihelical fold. Preferred instruments for such maneuvers include surgical blades, burrs, rasps and, more recently, a diamond-coated file . The correction is temporarily maintained during the healing period via tension dressings, surgical tapes, or tissue adhesives.
Cartilage-sparing methods have evolved primarily in North America in response to the anterior contour irregularities sometimes seen with more aggressive cartilage handling. Advantages of these techniques include maximal preservation of cartilaginous support, decreased incidence of scarring or contour irregularities, and allowance for easy suture adjustment, at the expense of arguably inferior stability of the correction. Every otoplastic surgeon is familiar with those suture techniques credited to Mustarde and Furnas for restoration of aesthetic scaphoconchal and cephaloconchal angles, respectively. Webster , in fact, should be credited for providing what is now a commonplace eclectic approach to surgical amelioration of the protruding ear. His techniques include some admixture of posterior skin excision, conchal resection, cartilage scoring, and placement of antihelical mattress sutures to achieve a natural refinement of the auricular contour. The authors, too, prefer a graduated approach principally relying on suture techniques, with occasional cartilage scoring or shaving as necessary to promote appropriate correction.
Clinical assessment
Patients may be considered for otoplasty as early as age 5, when auricular growth is near completion but before any lasting emotional upset has been created by the deformity. At this age, the auricular cartilage is characteristically pliable; however, elasticity decreases with advancing age, often demanding more aggressive treatment of the cartilage in patients undergoing otoplasty as adults.
The precise anatomic deformities should be recorded systematically during the initial patient evaluation. Whereas antihelical unfurling often features prominently, conchal excess or protrusion is a common coexistent deformity. Failure to observe this preoperatively is a frequent source of surgical undercorrection and postoperative aesthetic dissatisfaction. A systematic evaluative approach is advised so that such contributing factors go unmissed. Overall symmetry of auricular size, shape, projection, and contour should be noted with patient or parental attention called to any asymmetries. Inadequate folding may occur throughout the antihelical course or at the superior or inferior crus alone. Isolated superior pole prominence may often result from a poorly developed inferior crus. Excessive prominence or unfurling of the helical rim may also be present. The auricle is occasionally laterally displaced by a hyperpneumatized mastoid bone. Less common deformities include an outstanding lobule or cauda helicus, prominent tragal or antitragal cartilage, or the presence of a Darwinian tubercle.
During the assessment, auricular protrusion is specifically measured at three points of interest: (1) the most superior aspect of the rim, (2) the most laterally projecting point of the mid-rim, and (3) a point level with the intertragal incisura. Such measurements can be reliably reproduced bilaterally for precise interaural comparison. Ideal measures for these points are roughly 10 to 12 mm superiorly, 16 to 18 mm in the middle third, and about 20 mm at the cauda helix. The helical rim should be seen roughly 2 to 5 mm lateral to the antihelical ridge from the frontal view. Appropriate auriculocephalic angles are from 25° to 35°. In abnormally protruding ears, this angle typically exceeds 40° to 45°. The conchal-mastoid angle is between 45° and 90°, whereas the conchal-scaphal angle is normally less than 90°.
Gentle pressure on the helical rim can be seen to highlight antihelical folding so that the desired amount of surgical correction can be demonstrated. Likewise, pressure on the conchal bowl with a cotton-tipped applicator may simulate conchal setback so that the relative redundancy of the post-auricular skin can be estimated for the purposes of surgical planning. The cartilage pliability is also assessed. Finally, standard preoperative photographs are taken, including a frontal view in addition to bilateral full and magnified lateral views.
Surgical goals
As with other facial aesthetic procedures, the absolute surgical ideal is the achievement of a natural and durable aesthetic postoperative appearance. In otoplasty, this constitutes provision of a gracefully arcing curvature to the helical and antihelical contours that is symmetric to the opposing ear. Specific surgical goals should include the following: (1) Precise anatomic defects should be corrected, including an unfurled antihelix and excess conchal height, as well as other contour abnormalities; (2) alignment of the superior and inferior poles with the concha should be achieved; (3) appropriate auriculocephalic angles and distances should be maintained; (4) position of the helical rim lateral to the antihelical ridge should be preserved at least down to the mid-auricle; (5) the postauricular sulcus must be maintained; (6) interaural symmetry of protrusion must be within 3 mm; and (7) anterior and posterior surfaces should be free of sharp edges, ridges, creases, and visible scars.
To achieve favorable outcomes consistently, the authors proceed with otoplasty in a systematic and graduated stepwise fashion with reliance on cartilage-sparing techniques via a postauricular approach. This approach entails a logical progression, beginning with conchal setback and proceeding to antihelical contouring, with cautious assessment and correction of each deformity along the way. Intraoperative overcorrection is required, as postoperative recovery of elastic recoil will result in loss of as much as 40% of correction . We find that overcorrection is better tolerated than is undercorrection, which is more commonly perceived as a surgical failure by patients. Anticipation of such recoil, particularly at the superior pole, will often prevent an unsatisfying result. Even in the setting of a unilateral deformity, bilateral surgery is advantageous as corresponding forces of recoil should act equivalently on both ears to result in a symmetric postoperative outcome.
Surgical goals
As with other facial aesthetic procedures, the absolute surgical ideal is the achievement of a natural and durable aesthetic postoperative appearance. In otoplasty, this constitutes provision of a gracefully arcing curvature to the helical and antihelical contours that is symmetric to the opposing ear. Specific surgical goals should include the following: (1) Precise anatomic defects should be corrected, including an unfurled antihelix and excess conchal height, as well as other contour abnormalities; (2) alignment of the superior and inferior poles with the concha should be achieved; (3) appropriate auriculocephalic angles and distances should be maintained; (4) position of the helical rim lateral to the antihelical ridge should be preserved at least down to the mid-auricle; (5) the postauricular sulcus must be maintained; (6) interaural symmetry of protrusion must be within 3 mm; and (7) anterior and posterior surfaces should be free of sharp edges, ridges, creases, and visible scars.
To achieve favorable outcomes consistently, the authors proceed with otoplasty in a systematic and graduated stepwise fashion with reliance on cartilage-sparing techniques via a postauricular approach. This approach entails a logical progression, beginning with conchal setback and proceeding to antihelical contouring, with cautious assessment and correction of each deformity along the way. Intraoperative overcorrection is required, as postoperative recovery of elastic recoil will result in loss of as much as 40% of correction . We find that overcorrection is better tolerated than is undercorrection, which is more commonly perceived as a surgical failure by patients. Anticipation of such recoil, particularly at the superior pole, will often prevent an unsatisfying result. Even in the setting of a unilateral deformity, bilateral surgery is advantageous as corresponding forces of recoil should act equivalently on both ears to result in a symmetric postoperative outcome.
Surgical technique
Preparation and incision
The authors usually find general anesthesia preferable, but adolescents or adults may choose local anesthesia with intravenous sedation for this procedure. A conservative amount of hair is trimmed in the postauricular area. Both ears are prepped and draped simultaneously into the field to allow intraoperative comparison. The more involved ear is operated on at the outset of the procedure, as final adjustment of the less involved ear is found to be least problematic in achieving acceptable symmetry. Before local infiltration and associated tissue distortion, the area of redundant postauricular skin to be excised is estimated by gentle manipulation of the ear and traction in the desired position.
Postauricular skin excision
An eccentric fusiform excision based in the postauricular sulcus and extending onto the posterior concha is marked ( Fig. 1 ). The apices of the excision are maintained at least 1 cm from the superior and inferior poles so that the resultant scar will fall directly into the preserved crease and away from view. The auricular and mastoid soft tissues are then extensively infiltrated with a solution of equal parts 1% lidocaine with 1:100,000 epinephrine and 0.5% bupivacaine with 1:200,000 epinephrine to aid in vasoconstriction and hydrodissection. The skin excision is then accomplished in continuity with variable amounts of mastoid soft tissues down to periosteum to permit the desired degree of conchal retrodisplacement. The posterior auricular skin is then widely undermined, and a lateral releasing incision may be undertaken at this juncture to facilitate suture placement. Hemostasis is meticulously maintained with bipolar electrocautery.
Conchal setback
The authors proceed with first setting the appropriate vertical position and angulation of the concha relative to the skull and secondarily adjusting the antihelix relative to the now-fixed conchal position. Too often, proceeding in the reverse order will lead to misguided antihelical overcorrection and conchal undercorrection. After conchal setback, one may commonly find manipulation of the antihelix to be unwarranted. As a rule, the authors use three Furnas-type horizontal mattress 4-0 Mersilene sutures to secure the concha, placed in a particular sequence. The first suture is placed in the superior-most aspect of the floor of the fossa triangularis and through the mastoid periosteum. It is clamped and left untied until the remaining sutures are placed. With this suture, the bowl is drawn posteriorly and superiorly so that the external auditory canal is not encroached by the compressed conchal cartilage. A full thickness bite is taken, consisting of posterior and anterior perichondrium and intervening cartilage but not skin. A second and third suture is placed along the identical vectors in the inferior bowl (cavum concha) and midbowl (cymba concha), respectively. A substantial bite of mastoid periosteum is taken to ensure superior stability. Once all sutures are positioned appropriately, they are tightened in the same order in which they were thrown. In this way, the midbowl can be adjusted to align with the superior and inferior aspects. This aids in preventing overzealous tightening within the midbowl region and a resultant “telephone ear” deformity. Only once final suture adjustments have been made are all of the knots fully tightened.
There are several points of critical importance in avoiding potential complications related to this technique. The superior vector of pull on the concha is essential to minimize infringement on the ear canal. Similar conchal distortion or ear canal compression may occur by too high placement of a suture on the conchal wall with subsequent forward displacement of the bowl. Overtightening of the conchal sutures, particularly of the middle bowl, is expressly avoided.
Occasionally, it may be advisable to reduce an excessively deep conchal bowl by shave excisions of the ponticulus, triangular, and conchal eminences. This maneuver can be very effective in allowing the concha to be further retrodisplaced into the surgically deepened sulcus.
Antihelix repositioning
When the conchal position is set, there is often less need for antihelical correction than originally anticipated. Treatment of the antihelix is via two to four precisely placed 4-0 Mersilene Mustarde-type horizontal mattress sutures. Although some surgeons advocate use of ink, temporary sutures, or needle fixation to guide suture placement, the authors do not use these tools. Instead, the desired correction is manually simulated and the surgeon applies external pressure using his fingernail at the preferred site on the anterior auricular surface. The surgeon can position the suture accordingly through palpation of this external pressure. In this way, sutures can be placed unhindered by external devices while soft tissue trauma is also minimized. These scaphaconchal sutures require a 4- to 6-mm bite through cartilage and anterior perichondrium. As with the conchal setback, a specific sequence is applied, whereby the superior and inferior crura are set as the initial maneuver.
The superior suture is placed first, extending from the superior scapha to the fossa triangularis. Next, a scaphoconchal suture is placed at the most inferior portion of the antihelix. Finally, intervening sutures are variably and obliquely placed as needed to achieve a natural and continuous curvature of the midportion of the antihelical fold. Again, all sutures are first placed and then tightened in the same sequence to achieve the desired correction. Rather than place additional sutures equidistantly, suture placement is customized to achieve maximal contour advantage while minimizing chances for development of a “vertical post” deformity. Once the conchal and helical position is set bilaterally, measurements are once again performed to ensure symmetric corrections. Target auriculocephalic distances at the mid-auricle are roughly 15 to 18 mm in the intraoperative period.
Supplementary maneuvers
Additional sutures may be placed as necessary to correct any remaining deformities. A persistently cupped superior pole may be addressed using suture placement from the fossa triangularis to the temporal fascia. Likewise, an equivalent prominence of the inferior pole may be remedied by suturing the cauda helicus to the mastoid. Lobular protrusion is improved by placing a single cauda-conchal anchoring horizontal mattress suture. The authors rarely resort to scoring or rasping of cartilage, although this is sometimes prudent in the extraordinarily stiff adult ear, wherein the anterior antihelical surface may be scored to encourage folding. This is done via tunnel access beneath the anterior perichondrium. Whenever in question, it is best to avoid such maneuvers as they are disposed to postoperative surface irregularities.
Closure and dressing
Once the conchal and antihelical positions are established, the postauricular incision is closed with interrupted, buried intracuticular 4-0 chromic gut sutures. The loose closure allows for egress of fluids, obviating the need for surgical drains. The wound is copiously irrigated with a clindamycin bath before closure. The skin should readily drape into the postauricular sulcus without any attendant wound closing tension. After completion of additional procedures as needed, bolsters of cotton soaked in equal parts hydrogen peroxide and mineral oil are carefully molded to the folds of the auricle. Plentiful soft fluff dressing is used followed by application of a compressive mastoid dressing. Extreme care is taken to avoid any pressure points that might predispose to skin necrosis.
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