Outer Ear and External Auditory Canal
Otoplasty and Surgery of the External Ear
Introduction
Abnormalities of the external ear, especially protruding ears, are the most frequent malformations of the head and neck, affecting ~ 5% of the population. Therefore otoplasty is one of the most frequent procedures in facial plastic surgery and is often performed in children. It is estimated that 23,000 otoplasties are performed in Germany annually (i.e., 30 otoplasties in a population of 100,000 each year).1 Furthermore, it is (almost) the only purely aesthetic procedure performed in children and is often asked for by parents when their children are at an age when they themselves are not concerned about their “abnormality”. These are some of the unique features associated with otoplasty.
Otoplasty leads to one of the highest revision rates in facial plastic surgery, estimated to be greater than 20%.1 There are no data to explain these unacceptably high complication rates, so we can only speculate that the operative challenge is tremendously underestimated. Although several of these complications (perichondritis, othematoma, keloid) may also occur under different circumstances, their treatment will be discussed with relation to otoplasty. More than 100 different techniques can be found in the literature for performing otoplasty, indicating that no single surgical technique has been found to correct all of the different types and degrees of protruding ears and other deformities.2–4 Substantial experience in auricular surgery and adjustment to the patient′s individual anatomy are the keystones for a predictable outcome with low complication rates. This is even more important when operating on young children who have no real psychologic stress from their abnormality. For the most frequent auricular procedure, the otoplasty for protruding ears, we distinguish between five operative techniques: the four standard methods and our own combined technique.
Overview of Techniques for the Correction of Protruding Ears
The Suture Technique
This technique was reported in 1960,5 19636 and 19677 by Mustardé. It should only be used in cases where ear cartilage has been found to be very thin and soft. We frequently find that this method results in an inexact transition between the concha and antihelix, somewhat soft and indistinct contours in the scapha and occasionally an overcompensation of the helix, which, from a frontal perspective, tends to sink back behind the antihelix, the so-called “hidden helix.”
The Scoring Technique
This technique was described by Stenström in 19638 and a similar technique was reported in the same year by Ju et al,9 Crikelair and Cosman10 and Chongchet11 using a post-auricular approach and an incision in the scapha. The risk involved in using the Stenström technique is in the blind scoring of the anterior cartilage, which makes it impossible to maintain exact control over the folding of the antihelix. Excessive abrasion can lead to an uncontrolled weakening of the cartilage and bring about serious deformities or edges in the ear. This technique can also lead to serious complications, especially when accompanied by an excessive excision of postauricular skin.
The Scoring–Suture Technique
This technique was described in 1955 and 1963 by Converse and co-workers.12,13 Here, too, incorrect scoring of cartilage can lead to edges and deformations. Moreover, excessive removal of postauricular skin can cause the ear to come too close to the mastoid and the auriculocephalic sulcus may become too small.
The Conchal Set-Back
This technique was described by Furnas in 196814 especially to correct hyperplasia of the conchal cavum. Using the postauricular incision, abundant connective tissue between the conchal cartilage and the mastoid planum is removed and the auricular cartilage is rotated toward the head (= conchal set-back). It is sutured to the periosteum of the mastoid planum and by doing so the projection of the auricle is adjusted.
Malformation | Characteristics | Technique |
Antihelixhypoplasia | Very soft cartilage | Suture |
Average | Sutures and posterior scoring | |
Strong | Sutures and anterior scoring | |
Cavumhyperplasia | High antihelix | Cavum rotation |
Protruding lobule | Soft tissue tension or excess | Mattress suture Slight skin resection |
The Combined Technique
Depending on the individual anatomy we suggest that these techniques be combined ( Table 1.1 ). By doing so the particular structures that are abnormal are corrected, the forces to change the shape and position of the cartilage are distributed among various affected structures and harmony of the anatomical subunits of the auricle can be achieved. To optimize this combined technique, it is essential that a thorough analysis of all anatomical aspects and abnormalities is made preoperatively and that thorough planning is performed.
Complications
Apart from iatrogenic errors and complications there are several independent complications that can occur even after correct surgery. These include early events, which are defined as complications that occur within the first 14 days after the operation, and late complications after these first two postoperative weeks ( Table 1.2 ).
Early Complications
Pain
Postoperative pain is normal to a certain extent because of the surgical trauma per se. As the auricle is more or less immobile, pain should be low, but the individual range of perceiving pain is broad. Intensive pain could be an important symptom for other arising problems like hematoma or infection.
Early general complications | Late specific complications |
Pain | Suture extrusion |
Hematoma | Keloids |
Infection | Stenosis of external ear canal |
Pressure ulcer | “Bad” results |
A complaint of pain always requires immediate clinical control. Regular postoperative findings of wound healing with moderate pain during the first and second postoperative days should be treated with “light” analgesic medication. In cases of severe pain, hematoma and infection need to be excluded. “Inappropriate” pain—and when the surgeon is in doubt—must lead to repeated clinical control of the wound. If indicated, early revision as described below can prevent serious sequelae.
Secondary Bleeding and Hematoma
Slight secondary bleeding can be stopped by applying cold and a pressure bandage. If this is used it should only be applied for a short period of time to avoid the development of pressure ulcers.
After performing anterior scoring techniques a hematoma can develop between the anterior skin and the cartilage. In these cases, mattress sutures tightened over small pieces of gauze can be used to reposition the elevated skin and re-establish the relief of the auricle.
If pressure application is insufficient, open revision is indicated. The bleeding vessels are exposed and ligated or coagulated. If the bleeding is more or less diffuse, then hemostyptic biomaterials (e.g., Tabotamp [Ethicon Inc., Somerville, NJ, USA] or fibrin glue) might be applied into the wound.
Note
The best “treatment” of postoperative bleeding is its avoidance by meticulous intraoperative hemostasis. In addition, a small drain left in place for 1 day can help to avoid a hematoma.
Allergies
Before the operation, allergies to suture material or to topically applied ointments may be unknown. Although rare, allergic reactions can be avoided in most patients through taking careful note of the medical history. Removing the ointment and applying corticosteroids locally will alleviate an allergic reaction. Systemic administration of corticosteroids might be considered in severe reactions.
Infections
Otoplasty should be a sterile operation that does not generally require antibiotic prophylaxis. Nevertheless, short-term or one-shot perioperative antibiotic prophylaxis might reduce the risk of infection. Antimicrobial ointments (e.g., Betadine [providone–iodine], Mundipharma Laboratories Gmbh, Basel, Switzerland) and systemic antibiotics with high diffusion into cartilage (e.g., clindamycin) should be applied immediately and for a relatively long period because cartilage has hardly any cellular protective mechanisms.
Pressure Ulcers and Necrosis
The anterior auricular skin is one of the thinnest and most vulnerable of the whole body. In addition, it is located directly on cartilage, a tissue that has no blood supply of its own and therefore cannot “help” the skin to survive in a critical situation. Too much pressure from below due to a hematoma or from above due to the bandage can interrupt its flat, horizontally structured blood supply and lead to necrosis even after a few hours. Prophylaxis includes the avoidance and treatment of hematomas as discussed above and a meticulous bandage technique that avoids inadequate pressure on the auricular skin. We carefully cover the surface of the auricle with ointment and mold its contours with multiple pieces of gauze. To secure this we have developed a special foam dressing that is taped around the auricle to prevent it from being accidentally dislocated. It also has a special foam cap that fits exactly on to the taped foam and prevents pressure on the auricle from outside (Spiggle & Theis Medizintechnik Gmbh, Overath, Germany).
If necrosis has occurred it is often no longer a small, easy-to-treat issue. Up to a size of ~ 2 to 3 mm it might be closed directly; otherwise the necrotic tissue has to be removed and the defect of the auricle needs to be reconstructed according to the individual situation. We have described details of those reconstruction techniques in more detail elsewhere.15–20
Late Complications
Late complications are more common than early ones. They can “just happen” without being caused by any surgical mistake or they can be late sequelae of surgical deficiencies. This is influenced by the unique anatomy of the auricle with its very thin anterior skin, which can lead to prolonged periods of swelling over irregularities, sometimes for many months, and in the long-term can show up any deficiencies in reconstruction.
Suture Fistulae and Granulomas
There has been a long and still ongoing discussion as to whether sutures should be used, and if so, what type, for the remodeling of the cartilage. If a technique that does not purely rely on scoring (i.e., a suture or combined technique, as we prefer) is used then one must understand the aim and mechanism of suturing. Sutures in the cartilage have to reshape and stabilize it. Cartilage is a bradytropic tissue—meaning that the speed of remodeling of its fibers is very slow. It takes many months for the turnover of its collagen before it is stable in its new shape on its own. This is much slower than the resorption of all kinds of nonpermanent sutures. If the sutures resorb while the corrected form is not stable, the cartilage will have a tendency to move back into its previous abnormality.
The only way to avoid a recurrence like this is to use permanent sutures. Otherwise a relapse—depending on the amount of tension in the cartilage—will occur. So if we use permanent sutures—and we suggest doing so in most cases of average or strong cartilage—they should be sufficiently covered by soft tissue. This can only be achieved when the sutures do not go all the way through the cartilage coming to lie directly under the very thin anterior skin, and posteriorly are covered sufficiently with the relatively thick skin that should not be sutured under tension. If sutures are exposed or lead to local irritation or infection they have to be removed. The wound should be cleaned carefully, granulation tissue also has to be removed and we apply some local antimicrobial treatment (e.g., framycetin).
Stenosis of External Ear Canal
The entrance to the external ear canal can become too narrow if the cavum rotation is performed in an anterior direction. To prevent this, it is much better to pull the auricle slightly posteriorly with the rotation suture. These sutures should not only pull the auricular cartilage toward the head, but also pull it slightly posteriorly. If the rotation has not been performed in this way, a stenosis of the entrance to the external ear canal might occur. This is caused by the cartilage of the conchal cavum, which might be pushed into the external ear canal. To widen it, cartilage and skin must be removed.
We prepare an H-flap with its central incision directly over the apex of the stenosis ( Fig. 1.1a ). Two U-flaps are then elevated to expose the cartilage ( Fig. 1.1b ). A crescent-shaped piece of cartilage is removed, and the skin flaps are appropriately trimmed and sutured back in place ( Fig. 1.1c ). This relatively small procedure is performed under local anesthesia in most patients.
Hypertrophic Scars and Keloids
Hypertrophic scars are thickened scars in the area of the previous wound. Keloids show a tendency to grow beyond the scar and develop a more or less unlimited growth. They can become huge and grow like a tumor, destroying the surrounding cartilage ( Fig. 1.2 ). Sometimes they only start to develop years after surgery.
Many factors are thought to influence the development of keloids but none of these are the sole explanation.21 Risk factors are individual disposition, race (more frequent in dark and Asian races), tension on the scar leading to increased activity of fibroblast with up to 12 times greater production of collagen in comparison to normal wounds and three times higher production of collagen in comparison to hypertrophic scar, localization of the wound (more frequent in ear, chest, and shoulders), and inflammation, which stimulates the liberation of growth factors. The latter causes can be influenced by the surgeon to a certain extent.
Note
Avoidance of tension along the wound closure is the most important advice. The position of the auricle should not rely on the skin sutures but on the remodeling of the cartilage. The resection of excess skin should be performed very conservatively, taking into account that, especially in young patients, folds will flatten over time.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
