Otoplasty - The Larrabee Center For Plastic Surgery

Pediatric Facial Plastic and Reconstructive
Surgery, editedby J.D. Smith and R. Bumsted.
RavenPress,Ltd., New York @ 1993.
CHAPTER 6
f
Otoplasty
WayneF. Larrabee,Jr.,DouglasKibblewhite,andJeanneB. Adams
HISTORY
Otoplastyis surgeryto correct protruding ears.Ely (1)
first wrote about otoplastyin 1881.In the Archivesof
boy who cameto the
a 12-year-old
OtologyElydescribed
Manhattan Eye and Ear Hospital with a complaint that
his companions ridiculed him becauseof the prominenceof his ears.Ely, through a postauricularincision,
excisedskin and cartilageto correct the protruding ear.
In 1889,Keen (2) of the JeffersonMedicalCollegenoted
Ely's contribution but describeda better approachto the
deformity. Ely had advocatedexcisingskin on the anterior aswell asthe posteriorsurface,which left an anterior
scar.Keen describedan operationsolelyremovingposterior skin and cartilageand noted that cartilageaswell as
skin must be removed to obtain an adequateresult.
Luckett(3) in 1910notedthe importanceof the antihelical fold. Writing in Surgery of Gynecologyand Obstet'
rics, this New York surgeondescribedagain the common problem of a child being teasedfor his "donkey
ears" and analyzedthe anatomy of this deformity. He
notedlack ofan antihelix in thesechildren and described
a procedure to create such an antihelix by excising a
pieceofcartilage and closingthe defect
crescent-shaped
with buried mattresssutures.In addition to delineating
the anatomicaldeformity, he very perceptivelynoted:
In an ear with a very thin flexiblecartilage,I think it
theantihelixandsetthe
to reconstruct
wouldbepossible
helix closeto the headwithout excisinga segmentor
evenincisingthe cartilage,simplyby flutingor folding
thesuturein
thecartilageat thepropersite,andpassing
sucha mannerasto maintainthefold.
W. F. Larrabee,Jr.: Department of Otolaryngology-Head
andNeck Surgery,University ofWashington,Seattle,Washington98122.
D. Kibblewhite: Department of Otolaryngology,University
of British Columbia, Vancouver,British Columbia, Canada.
J. B. Adams: Departmentof Otolaryngology,Duke University,Durham, North Carolina 27710.
Morestin(4) in 1903and Owens(5) in 1965describeda
technique of placing buried suturesto produce a controlled changein auricular shape.Mustarde (6), however,writing in the British Journal of Plastic Surgeryin
1963refinedand popularizedthis method, which is now
commonly attributedto him. Gibsonand Davis' (7) studiesof the influenceof incisionson the deformation of rib
cartilage,and, more recently,Murakami's (8) analysisof
pig ear cartilagebending createdby surgical incisions,
haveinfluencedthe applicationofcartilage scoringtechniques to otoplastyby Stenstrom(9) and others.These
authorshavedemonstratedthat incisionsmade through
perichondrium and into cartilagecausethe areaincised
to becomemore convex.
ANATOMY
Ears may be describedin terms of their form, their
proportions, and their position on the skull. Small discrepanciesin thesevariablesare immediately obviousto
the observer,but earsdo vary widely betweenindividuals.The framework of the ear is a single,complex piece
of fibrocartilageto which thin, translucent,well-vasculaized skin is tightly adherent,more so anteriorly than
on the posterior surface.With increasingage,the cartilage becomesstiffer and lesspliable, and the overlying
skin becomeslesstightly attached.
The helix is a gently curved incomplete oval, broader
at its root or spine at the external auditory canal and
thinning asit curls down toward the lobule. It is partially
concaveat its spine,becomesalmost tubular in its midportion, and flattensout againat the lobule.The antihelix oiginates at the antitragus and follows the curve of
the'helix superiorly. Approximately two-thirds of the
vertical distancetoward the top of the ear,it dividesinto
a sharp fold, the inferior crus of the antihelix, which proceedsanteriorly to dive under the overhangofthe spine
of the helix, and a lessprominent broader fold,the supe-
8 0 / C u e rrn n 6
rior crus of the antihellx,which fadesout into the area
under the superiormostpart of the helix. The areabetween thesetwo crura is the/ossa triangularis. Posterior
to the superiorcrus isthe scapha,a narrow shelfbetween
helix and antihelix.Medial to the antihelixis the kidney
bean-shapedconchalbowl, dividedby the spineofthe
helix into a superior poftion, the cymba conchae,and a
somewhatlarger inferior portion, Ihe cavum conchae'
The anteriorportion ofthe cavum conchaeis the external auditory meatus.The tragusis a firm, thick plate of
cartilagepartially coveringthe openingto the ear canal,
and is continuous posteriorly with the variably developedintertragalnotchand antitragus,which itselfblends
into the antihelix.Betweenthe tragusand the spineof
the helix the earcartilageis discontinuous'This incisura
terminalis is useful for an endauralapproachto the ear
canal,which avoidscutting cartilage.The final part of
the auricleto consideris the lobule.This dependentfibrofatty tissue lacks cartilaginous support and hangs
from the frameworkof the ear.It is variablein sizeand
shapeand in its attachmentto the skin of the cheek
(Fie. l).
Severalpointscan be definedon the ear asa wholeto
allow quantificationof the internal proportionsof the
earand its positionon the skull. The most superiorportion of the ear at the top of the curveof the helix is the
supraaurale,and the inferiormost part at the tip of the
lobuleis Ihesubaurale.Similarly,the most anteriorand
posterior points on the helix are termed the preaurale
andpostaurate(Fig.2). The attachmentof the earto the
skull is calledthe otobasion,which is a line lying anterior
to the tragus.Its superiorextentwherethe helix blends
into the skin superiorto the zygomaticarch is the otobasion superiorus,and the inferior attachment of the base
ofthe tragusto the cheekskin is the otobasioninferiorus'
The aestheticproportions of the ear are difficult to
describe,althoughdisproportionis immediatelyevident
to the casualobserver(Fig.3)' Generally,the width of the
ear,definedas its widestpart, shouldbe approximately
55%of its length. The vertical midpoint of the ear is
locatedat the root of the spineof the helix. One-thirdof
the earliesabovethe inferior crusof the antihelix'A line
drawn through supraauraleto subauralewill make an
angleof I 5o to 30oto the vertical,and about22' is ideal'
D
FlG. 1. The cartilaginousframework of the ear (see labelson diagram).A: Relationshipof lobuleto
cauda helicis.B: Laieralsurfaceear. C: Medialsurfaceear. D: Posteriorauricle.
Ororrasrv /
B1
crus
Superior
Scapha
Tuberculum
auriculae
Antihelix
Cymbaconchae
uavum concnae
Helix
AntitragusFossatrianoularis
Suoerior
crusantihelicus
Spinahelicis
Laminatragi
Cavumconchae
Fissuraantitragicohelicina
Caudahelicis
fossatriangularis
Eminentia
Transverse
sulcus(inferiorcrus)
Eminentia
cvmbaconchae
Ponticulus
Caudahelicis
cavumconchae
FlG. 2. Major contour landmarksof the ear.
FIG. 3. Proportionsof the aestheticear (Modifiedafter ref. 26).
82 / Cnerrrn 6
This posteriorangulationofthe earhasbeensaidto parallel the nasaldorsum;however,the nasaldorsumdemonstratesa great deal of individual diversity itself. The
otobasionlies at an angleof 8o to the vertical.
The ear'slocation on the skull is imporlant. ln the
vertical plane, the top of the ear lies at brow level,
whereasthe subauralelies at the level of the columella.
direction,the earshouldlie one
ln the anterior-posterior
ear-lengthfrom the lateralorbital rim (or, about6.5-7.5
cm). Finally,one must considerthe projectionof the ear
from the mastoid plane. Although this has been describedin terms of the anglethe ear makeswith this
plane,it is generallyeasierto measurethe distancefrom
the anterolateralportion of the helix. This distance
shouldbe between15 and 20 mm.
Thus the earasa wholeshouldbe positionedcorrectly
on the skull in the superior-inferiorand in the anteriorposteriorplanes,and its angleof inclination shouldbe
correct.Finally, its protrusionfrom the skull shouldbe
neither too much (bat ears)or too little (pinned-back
It is difficult to relateear positionto bony
appearance).
landmarks,but with these specificationsas a rough
guide,the eyeofthe surgeonasobservershouldbe able
to make the fine adjustmentsto producean aesthetic
placement.
EMBRYOLOGY
The precursorsto the human ear appearin the 6th
weekof fetallife in the shapeof six hillocksof condensed
ectodermand mesodermsurroundingthe first branchial
groove.Mesenchymaof the lirst and secondbranchial
archesthus createsthe externalear. About B57oof the
externaleardevelopsin the secondbranchialarchand its
derivatives.The first arch contributesonly to the anterior portion of the ear including the tragus,the helical
tragalsulcus,and the crusofthe helix.The conchalcarlilageand interlragalnotch developfrom the mesoderm
along the first branchialgrooveand do not derive directly from the auricularhillocks.The auricledevelops
in the region of the neck and later migratesto the sideof
the head.This accountsfor someofthe congenitalanomalies where the auricle is significantly displacedinferiorly. In the 8th to l2th weeksof gestationthe helix develops rapidly and therefore, projects forward and
overliesthe still underdevelopedantihelix. At this stage,
it is normal for the ear to protrude;however,if in the
succeeding12th to 16th week the antihelix fails to unfold, the helix continuesto overhangand the protrusion
will persist.At bifth, the normal ear is usually completelyformedandrestsat an angleof 30ofrom the head.
The ear continues to grow lollowing birth and attains
approximately857oof its adult sizeby 3 yearsof age.
Slow growth may continue until approximately6 years
of age,at which time the ear has reachedthe average
adult sizeof approximately6 X 3 cm. The distancefrom
the mastoidperiosteumto the helicalrim changeslittle
after 10 yearsof age,althoughthe ear may continueto
elongatemore than 1.5cm alongits verticalaxisduring
the lifetime of the individual.
SURGICAL CONCEPTS AND APPROACHES
with the
Thereis a plethoraof deformitiesassociated
quite
individbe
must
approach
any
surgical
and
auricle,
factors
that
common
some
however,
are,
There
ualized.
The threemost
in many otoplasties.
needto be addressed
common problem areasin auriculardeformitiesare (a)
the lack of an antihelicalfold, or the "unrolled" ear(Fig.
4); (b) a deepconchalbowl or, perhapsmore correctly,a
high conchalwall; and (c) deformities,usuallyprotrusion, of the lobule.Thesethreeproblem areasare relaindividually with a
tively distinct and can be addressed
varietyof surgicaltechniques.In this chapterwe will deand then present
scribesomeof thesebasicapproaches
the approachof two surgeonsto otoplastyto give an
exampleof how thesetechniquescan'becombined.
There are three basic approachesto remodelingthe
auricularcartilageinto a more desirableshape'The first
of theseis a suturetechniquethat usesa permanentsuture to remoldand hold the pliableauricularcartilagein
its desiredshape.The varioussuturetechniquesaremost
usefulin children and young adults whosecarlilageis
quite pliable.They can givequite naturalresults,but are
not alwayseffectivein individualswith more rigid cartilage.The best exampleof this techniqueis Mustarde's
( I 0) techniqueof otoplasty,which dependson the placement of permanentburied suturesboth to createa new
antihelicalfold and to maintainthe new shapeof the ear.
An antihelicalfold is createdby the surgeonand maintained with a bayonet forceps.Three to four points
correspondingto the proposedposition of mattresssuturesarethen markedwith methyleneblue.Thesemarks
arethen tattooedinto the earcartilagewith a needleand
methyleneblue. The actual surgicalapproachis posterior. An ellipseof skinis excisedandthe posteriorauricular carlilagemeticulouslycleanedof all fibrous tissue,
retainingthe perichondrium.The mattresssuturesare
insertedthroughthe full thicknessofcartilagebnd perichondrium usingthe dye marks for guidanceand then
tightenedto createa fold.
The problemof a prominentconchalbowl canalsobe
with a suturetechnique.This approachhas
addressed
beenpopularizedby Furnas(11) with his conchalmastoid sutures,which he usesto approximatethe conchal
cartilageto the mastoid periosteumand thus flatten the
deepconchalbowl againstthe mastoidcorexcessively
tex. Objectionsto the useof permanent,buried sutures
Oroeresrv /
FlG. 4. Cross sectionsof the normal ear (A and B) and a
prominent ear (C) resulting from increasedconchal anole
(after Converse[28]).
includeinfectiondue to the presenceofa foreignbody,
palpableor visiblesutures,and ridgingof the skin where
the suturescrossthe posteriorsulcus.
The secondbasic approachto remolding cartilage
consistsof full-thicknessincisionsor excisionsof carti_
lageto correctthe prominent ear.This is currentlyused
most commonly in the conchathrougheither an ante_
rior or posteriorapproach.One canremovesomeaspect
of the high conchalwall to allow the auricleto settleback
83
to a more normal position.Thesecartilaginousdefects
can then be suturedto obtain the desiredresult.This
typeof excisionallowsoneto reducethe sizeofthe prominent conchato changethe position of the auricle.In
general,when full-thicknessincisionsor excisionsare
madeto createan antihelicalfold, one runs the risk of
creatingsharpedgesand ridges.Most surgeonspreferto
usethe full-thicknesscartilageincision or excisiononly
in theconcha.
The third basic approachto cartilageremodelingin
otoplastydependson the tendencyof cartilageto bend
toward intact perichondrium,and to bend awayfrom a
surface where the cartilage has been scored (7,g).
Througha varietyofapproaches,
both anteriorand posterior, the cartilage is either abraded with light sandpaper,forcepsteeth,dermabraderburrs, or specialfinetoothed instruments designed specifically for this
purposein the areawherethe contour effectis desired.
Most authorsagreethat controllingthe depth of partialthicknessincisionswhen scoring cartilageis difficult,
leadingto the occasional
full-thicknessincisionwith palpable sharpedges;thus, fine abrasionis preferred.To
createa new antihelicalfold, the surgeonwill gain access
to the anterolateralcartilagesurfaceeither through an
anterioror posteriorskin incisionand lightly abradethe
perichondriumand cartilageat the point wherethe new
fold is desired.A major proponentof this approachhas
been Stenstrom(9), who has extensiveclinical experienceto show that abrasionwith a rasp of the anterior
antihelicalareawill causefurrowing and convexity to
developin this areaand, thus, createan antihelix.
Therecan be multiple deformitiesof the lobule. The
mostcommonis a protuberanceof the lobule,which can
be addressed
by eitherexcisinga smallwedgeof postauricular skin or doing some type of procedureon the
caudahelicis.Someadvocateexcisingthe caudahelicis
to producea flat lobule.Excisioncan,however,resultin
protuberantskin with no structureto pull it medially.A
cuttingand repositioningof the caudahelicisor a simple
suture placementto move it medially works better in
most cases.A lobulethat is too largeand dependentcan
betreatedby excisinga full-thicknesswedgein the preauricular crease.Similarly, a very largelobule can be reducedby simplyexcisinga crescent-shaped
pieceof skin
and subcutaneous
adiposetissuejust medialto the rim of
the lobule(12).
NEWBORN EAR TAPING
A variety of auricular deformitiescan occur prenatally
eitherfrom abnormaldevelopmentor malpositioningof
the fetusin the uterus.A largeprospectivestudy in Japan
hasshownthat approximately50Zoof thesewill spontaneouslycorrectthemselves
in the first month of life ( l3).
84 /
Cseprnn 6
The processis actuallymore complexwith about45Vaof
earsnormal at birth and 84Vonormal at I year.Lop ears,
for example,are presentin 38Voof babiesat birth and
only 6Voat 1 year,whereasthe incidenceofprotruding
earsactuallyincreasesfrom 0.4Voat birth to 5.5Voat 1
year.The protrudingear may be causedby mechanical
factorsin the first year of life (14).Although many ears
that are abnormal at birth will return to normal by I
year,thereis no way to predictwhich oneswill. Thus,the
simplenonsurgicalcorrectiondescribed
belowis applicable in everycase.
Recentreportshavedemonstrated
that deformitiesinvolvingmalpositionof a formedauriclecanbe corrected
nonsurgicallyby splintingthe earin the correctposition
within a few daysof birth (14,15).The new position is
maintained for the first 2 weeks.On removal of the
splint,the earremainsin its newposition(Figs.5 and 6).
The physiologicexplanationfor the ability of newborn
auricularcartilageto be permanentlyremodeledin the
immediate newborn period is unclear.Cartilageis an
avascularnetwork of chondrocytesembeddedin a type
II collagen-proteoglycan
matrix. The proteoglycanmatrix is stabilizedby hyaluronicacid,a singlepolymer of
which mav be linked with asmany as 100proteoglycan
monomers(16).The very high estrogenlevelsthat exist
in the neonateat birth and for the first few days of life
levels( I 7).
directlyincreasehyaluronidicacidsynthetase
The enzymeaffectsthe productionof hyaluronidicacid,
possiblyallowingremodelingof the cartilagein the new
position. Relaxin, a polypeptidehormone involved in
parturition, also demonstratesvery high serum levelsin
the immediate pre- and postpartum period. Relaxin has
a profound effecton the fibroblastsand collagenofthe
pubic ligament,and hasbeenrecentlyshownto havea
demonstrableeffect on skin during tissue expansion
( I 8). This effectis thoughtto occurthrougha disruption
of the cross-linkingof collagenin the extracellularmatrix. High relaxin levelsmight also allow the auricleto
remodelin the immediatepostpartumperiod. Clinical
experienceshowsthat, whateverthe underlyingcause,
the splint must be appliedin the first few daysafter birth
to be effective.
FtG.5. View of a congenitalauriculardeformity.A: Auriculardeformityin a newborn.B: Ear conformed
over a wax stent. C: Ear taped over stent. D: Two months postoperation.
Oropresry
/ 85
viewsof an infanttreatednonsurgically
FlG.6. Pre-andpostoperative
at birthwithstent.
TWO INDIYIDUALIZED
TO OTOPLASTY
APPROACHES
Multiple techniquesare availableto addressthe anatomical problemsseenin the deformedear. Surgeons
tend to selectthosetechniquesthat work best in their
hands.To obtain a practicalapproachto otoplasty,two
individualsurgeons'approaches
will be discussed.
Obviously,eachsurgeon'stechniqueis an amalgamationof
the individual creativecontributionsof the pioneersin
this field.
In our practice(W.F.L.)a carefulanalysisof the earis
firstperformedto describethe specificanatomicaldeformity that needscorrection.In general,the ear or ears
involvedhave somecombinationof a prominent concha,a lack of an antihelix,and a malpositionof the lobule.The earwith a prominentconchaonly canbetreated
quite easilywith the conchalsetbackor conchalreduction procedure,which is describedbelow.The ear with
solely a lack of an antihelix is treated with a Mustarde
suturetechniqueonly. For the majority of earsthereare
a combination of thesetwo problemsand both techniques are utilized. Problems with the lobule are adindependently.In the physicalexaminationcardressed
tilage pliability as well as symmetry is noted. Any
specificdeformity in the areaof the lobule is described.If
there is a tendencytoward a "telephoneear" where the
midportionof the earis closerto the headthan the superior and inferior portions that is noted. Standardphotographsare taken. Thesegenerallyinvolve frontal, posterior, and lateral views. Measurementsof the distance
from the mastoid skin to the helix are made on both
sides.
The procedurecan be performedunder either general
or local anesthesia.Children arebestdone under general
anesthesiaand adults can usually be managed quite
nicely with local. Children are not operatedon until age
5 to 6. A subcutaneousfield block is all that is required
for the anesthesia.Careful aseptictechnique is used
throughoutthe procedure.The patient is usuallygiven
prophylactic antibiotics due to the incision of cartilage
and the permanentsuturesplaced.A stockinettedressing is placedover the entire headwith openingscreated
for the earsand face.A plasticeyesheetdrape is usedto
maintain sterility of the operative field. If a conchal
prominenceis present,one first manuallyplacesthe ear
in an appropriatepositionand placesa few dots in the
postauricularsulcus to define where the new sulcus
shouldbe located.Thesedotsgeneratea smallwedgeof
tissuefor excision.It is important not to overexcise
skin
in this areaand not to createtoo shallowa postauricular
sulcus.Incisionsare then made perpendicularto the
mastoidcortexand perpendicularto the perichondrium
of the posterioraspectof the auricularconcha,and all
interveningsoft tissueis removed(Fig. 7). In childrenit
is important to usecarebecauseof the more superficial
locationof the facialnerve.Simply removingthe excess
softtissueallowsthe earto lie in a more naturalposition.
The depth of the soft tissueis frequently underestimated
and as can be seenin Fig. 8, it is considerable.Simply
removingthis softtissuein many caseswill provideadequate setback.Once the auricle is in position againstthe
mastoidperiosteum,the surgeoncan then removecartilageas neededfrom the conchato createthe desiredear
position.By usinga #l I blade,one can carefullyshave
small segmentsof the apex of the concha (actually the
eminentia)until the ear is appropriatelyplaced(Fig. 9).
By shavingparallelto the earwith the fingeron the anterior surface,an automatic contouring is performed so
that no sharpedgesarevisible.This part ofthe operation
is quite straightforwardbut must be individualized with
variable amounts excised from the different prominences,dependingon the patient. The eminentia cymba
concha,eminentia cavum concha,and eminentia fossa
triangularisareindividually treatedto achievesymmetry
and appropriate position of the ears. Once the appro-
CHeprnn 6
FlG. 7. A postauricularincisionis made to excise equal
amountsof skin on the postauricularand mastoidareaspreservingnormalpostauricularsulcus.
- N_rsil illtnJ .fi tl lr$c
'
lrl.,!rt,afdil,,.{,,\
til^',1'ul i"""llii""'.
.(,L,dl
hl,i,
$!)
r{.IhithNrItrr!
Iirt. ttcs4,iil
isuP-trHd )
nxt.grtr# kl lnu. h.sd)Choidrttnrpnnir.*
lh!i'i!.r
Pilti! iL&kllc
FfG. 8. A: Cadavercross-section.(From ref. 29, with permission.)B: Radiographdemonstratesthe
amountof soft tissuebetweenthe skin and mastoidcortex'
Ororlesrv
FlG. 9. The eminentia of the concha (fossa triangularis,
cymbaconchae,cavum concha)are shavedfrom posteriorly
to placethe ear in a naturalposition.
/
87
priate amount of setbackhas been achieved,attention
can be turned to the antihelix. With the Mustarde suture
technique,usually three horizontal mattresssuturesare
used to define the antihelix. Mustarde originally describedthe techniqueusingwhite silk sutures.We prefer
4-0 Mersilene,asit is lessreactive.It alsohasgoodholding characteristicswhen the knots are snuggedindividually.As seenin Fig. 10,threesuturesareusuallyplacedto
createthe antihelix; more or fewer may be required in a
given case.To facilitate suture placement, it is sometimes helpful to fold the antihelix with the forcepsinto
the desiredposition and then to mark the proposedsuture sitesexternallyon the skin. Using a2}-gaugeneedle
with methylene blue dye, one can perforate through
these holes and mark the underlying cartilage for the
suture sites.From the postauricularincision one can
then carefully dissectthe skin flap up to the helix and
visually seethe dye marks where the suture should be
placed.It is crucial to removeall soft tissueattachments
from the perichondriumto allow remodelingof the fold.
Suturesare bestplacedfrom the postauricularapproach
with onefingeron the anterioraspectofthe earto ensure
proper level of the needle. The needle should pass
throughthe posteriorperichondrium,cartilage,and the
anteriorperichondrium(but obviouslynot through anterior skin),and then back in the samefashion.It is quite
important to passthroughthe anterior perichondrium or
FlG. 10. Placementsitesfor the horizontalmattresssutures,as describedby Mustarde.lt is important
to place the more superiorsuture so that one createsan anteriorcurve to the antihelixand does nor
createa straightantihelix.
88 /
CHeernn6
posithe suturemay tear through and not maintain its
placed
is
suture
mattress
tion. After a singlehorizontal
and tied with a surgeon'sknot, it is snuggedand visually
examinedto seeif it is creating the fold of the desired
positionand contour(Fig. I l)' This individual sutureis
ihen loosenedand the other suturesplaced'Ifthe sutures
are tied after each individual placement, it becomes
quite difficult to placethe sequentialsutures'Once all of
tlhesutureshavebeen placed,they are sequentiallytied
from superiorto inferior while the ear is held in its new
positionexternally.Careis taken not to include any unneededsofttissuein the suturesthemselves'The contour
ofthe antihelixis then carefullyinspectedand ifthere are
anyasymmetriesor problemsthe suturesare replacedat
thistime.
Themajorityof the problemswith the antihelixcanbe
quite niceiy handledby the simple Mustardetechnique'
ih.r, ur., however,times when the cartilageis thickened and will not easily conform with a suture technique. We are preparedat the time of surgeryin these
to proceedwith an abrasionofthe anteriorsurface
cases
of the antihelix similar to that describedby Stenstrom
(9).Stenstromdescribedthe mechanicaltendencyof the
earto curl away from the area where perichondrium is
periexcised.Thus, by using a small rasp to abradethe
anterior
the
on
slightly
cartilage
the
ihin
and
chondrium
part of the antihelix, one can facilitatebendingwith the
Mustarde sutures if the cartilage appears somewhat
intransient.
The ear is then set back into its new position against
the mastoid cortex and three conchal mastoid sutures
passedfrom the mastoid periosteum to the perichonirium of the auricle(Fig. l2). It is a technicalerror to
excisetoo much of the conchalbowl when doinga combinedconchaland antihelical procedurebecauseit may
leavetoo little conchalbowl to obtain adequatepurchase
for the Mustardesuture.
After the ear has been placedinto its new position
promithe lobule is evaluated.If the lobule is slightly
of
wedge
a
excising
by
corrected
be
nent, it can usually
promiif
the
or
adequate
not
is
If
this
skin posteriorly.
,r.n.i i, quite significant, a suture is placed from the
cauda helicis to the more medial soft tissueto pull the
cauda helicis and thus the lobule medially' Although
the caudaheliciscan be excisedin thesecases,it sometimes leavesthe lobule still protuberant with no firm
structure with which to mobilize it' Other problems of
the lobule such as excessivelobule size are then adat this point in the operation'
dressed
After obtaining hemostasiswith the bipolar cautery,a
rubber-banddrain is placedin the postauricularareaand
the incisionmeticulouslyclosedusinga subcuticular5-0
nylon or Prolene.The subcuticularsutureis left long,so
that it can be pulled out at a later date without pulling
the earforward.After the secondearis recontoured,careful examination is performed to ensure symmetry between the two ears and any corrections are made as
needed. Although it is not necessaryto significantly
overcorrectthe ear, there is usually some minor overcorrectioninitially asthe eardoestend to uncurl slightly
from the scalp over the first few weeksafter surgery'A
dressingis then placed over the ear. Mustarde initially
usedwet lamb's wool, which when dry would form a stiff
castfor the ear.We usually pack the ear with bacitracinimpregnatedcotton. This is packedanatomicallywith a
deepeipieceof cotton in the conchalbowl and a more
suplrficial roll lying betweenthe antihelix and the helix'
A final, singlepieceof cotton is placedoverthis' A mastoid dressingis thenplacedoverboth ears'Thoughmany
in placefor-4 or 5 daysor
surgeonsleavethesedressings
-o-r", ,". routinely changethem on the first day to inspectthe earsfor hematomasor other problemsand then
replacethe dressing.The secondmastoid dressingis left
irrplace for about 5 days.The sutureis removedatl to
placementto create an antihelix'
FlG. 11. Cross sectionof the principleof the Mustardesuture
Ororlesrv
/
89
FlG. 12. A, B: After placementof the Mustardesuturesto createthe antihelix,conchamastoidsutures
are placedfrom the perichondriumof the auricleto the mastoidcortex.
10daysby simplypullingout the subcuticularnylon.We
ask the patient to wear a simple headbandat night for
another4 to 6 weekspostoperativelyto ensurethe areais
not accidentallydamagedduring sleep.
This combinationof techniques-the conchalsetback
and/orreduction,Mustardesuturetechnique,and occasional raspingof the anterior antihelix-is adequatefor
Typithe vastmajorityof cosmeticauricularprocedures.
cal casesareseenin Figs.l3 and 14.The Mustardetechnique is especiallygood in youngerchildrenwherethe
ear cartilageis pliable and easilymolded. It is more difficult in older patients.We havehad very occasionalepisodeswherethe ear haspartially unfurled at somestage
after the operation,usuallymonths or yearslater. It is
relatively straightforwardto replacethe suture in those
cases.Conservatismis essentialwith the conchalsetback
techniqueto avoid the all too common "telephoneear"
appearancewith the midportion of the ear being further
back against the head than the superior and inferior
poles.A major advantageof the techniquedescribedis
that individual minor variations in the antihelix, concha, or lobule can be addressedwithout difficulty at the
time of surgery.
The approachof Feuersteinand Adams(19) is somewhat differentand demonstratesthat variousapproaches
can be used to achieve similar results in otoplasty
surgery.
The anesthesiaemployed dependson the age of the
patient. Most parentsor guardiansof children under l0
years of age requestgeneral anesthesia,whereasolder
children and adults may comfortably be operated on
under local anesthesia.The periauricularhair is not cut.
Following surgical preparation of the skin, towels are
sutured around the ear. An auricular-mastoid pedicle
flap is then created(Fig. 15), but no skin is removed
initially. Skin excisionshouldbe reservedfor the conclusionofthe proceduresothat carefultailoringofthe postauricular skin can help prevent formation of the "telephoneear." That is, one may wish to leavea wider strip
of postauricularskin in the middle third, and this need
may not be appreciated until the very end of the
procedure.
Next, one attemptsto createtwo auricular "compartments." That is, an incision shouldbe made alongthe
margin betweenthe conchaand the antihelix, startingat
the mastoid-conchalarea inferiorly and continuing upward, carefullyfollowing the conchalcurvaturejust medial to the antihelix into the inferior crus and then along
the lower margin of the inferior crus to the level of the
crus helicis.At this point the helical rim should be separated from the inferior crus by excision of a segmentof
of the
cartilage(Fig. 16).One effectscompleteseveranc'e
concha from the antihelix so that the antihelix with its
scaphoidportion and superior crus will easily fold and
angleto a normal 90'. Bethe conchal-scaphal
decrease
causean adequatefold of the superiorcrus may still not
90
Csaprnn 6
folds,but prominentconchaseenbeforeand afterexcision
FlG.13. A teenageboy with goodantihelical
of excessconchaand placementof conchamastoidsutures.
tn
be attained,further manipulationmay be necessary
of
a
The
use
the
antihelix.
and
body
of
the superiorcrus
may
be
useful
cartilage
wire
to
thin
the
brush
rotating
(Fig.17).
Normallythis crus has a gentlecurve,which blends
thelevelof theconcha.
with theinferiorcrusasit reaches
incisionsin this recartilage
not
allow
the
One should
gion to extendthroughto the perichondriumon the lateralsurface.Suchcarewill preventformationof "sharp"
lines,telltaleevidenceof otoplasticsurgery.
Followingcompletemobilizationof the conchaland
antihelical auricular components, one must decide
whetherburiedsuturesof the Mustardetype arerequired
for further correction.It is recommendedthat such suturesbe usedonly to hold the repositionedcartilagein
placeuntil sufficientscartissuehas formed. Figures18
and 19demonstratethe insertionof two typesof,sutures.
The first demonstratesthe conchal mastoid suture,
which is indicatedwhen a conchalsetbackis required;
this suture passesfrom the conchal cartilage into the
mastoid periosteum.The secondsuture demonstrates
the vertical mattressedMustardesutureplacedalongthe
Oroeresrv /
9l
FlG. 14. A teenageboy with an adequate
antihelixon the rightbut an inddequate
antihelix on the left, who underwent bilateral
conchal reduction plus a Mustarde procedure on the left to create an antihelix.
FlG. 15. Two separate "compartments"
are createdby an incisionat the conchal-an
tihelicaljunction extending into the inferior
crus untilit meetsthe crus helicis.A triangular segmentof cartilageis excised(T).This
maneuvercompletely"breaks" the auricula
spring.
FlG. 16. The removalof triangular segment of cartilageat
Oroelesrv
/
93
FlG. 17. A: Triangularstrips of auricularcartilageremoved.
Theseincisionsdo not extendcompletelyto the perichondrium
on the lateralsurface.B: Use of dermabrasionsteel-wirebrush
to weaken "spring" of excessivelyfirm superiorcrus'
Oroplesrv
/
93
FlG. 17. A: Triangularstrips of auricularcartilageremoved'
Theseincisionsdo not extendcompletelyto the perichondrium
on the lateralsurface.B: Use of dermabrasionsteel-wirebrush
to weaken "spring" of excessivelyfirm superiorcrus'
94 /
CHnprnn6
FlG.18. Placement
of conchalmastoidsutures.
antihelixand its superiorcrus.As mentionedpreviously,
it may be preferableto utilize a strongabsorbable
suture
to obviatefuture "spitting" of sutures,granulomaformation, and secondaryinfection.
On completionofthe otoplasty-procedure,
oneshould
carefullyevaluatethe frontal appearanceofthe auricleto
determinewhetherthereis excessive
residualprotrusion
of the antitragusor lobule. Antitragal prominencecan
readily be reduced by excision of a wedge of cartilage
from the apexthrough the postauricularwound.The lobule may be accuratelytailored to balancewith the remainder of the ear by appropriate resection of skin
wedgeson the posterioraspectof the lobule. Actually the
initial postauricularincision may be extendedinto the
FlG. 19. Placementof verticalmattressedMustardesutures,
which securethe undersurfaceof the antihelixto the "cut"
edge of the concha.This suture maintainsthe desiredposition of the antihelix,camouflagingthe incisedconchalcartilage untilfibrosisand fixationoccur.
Oroelasrv
s
:,:,l:l;i:*!i*
i,
FlG. 20. Otoplastywith techniqueof Adams and Feuerstein.A: Preoperativefrontal.B: Postoperative
frontal.C: Preoperativelateral.D: Postoperativelateral.
/
95
96 / CHeernn6
FlG. 21. Otoplastywith the techniqueof Adgms and FeuersteinA:
B: Postoperativefronta|.c: Postoperative|at.
Preoperative.fronta|'
eral view.
Ororr-esrv / 97
lobule.During surgeryall bleedingvessels
shouldbe carefully cauterized.Use of fine bipolar cauterypreventsexcessivedamage to the cartilage. In addition, a small
Penrosedrain insertedthrough the inferior aspectofthe
postauricular incision should be used routinely. The
drain may readily be removedin 24 hr.
Interrupted silk suturesare recommended.The useof
absorbablecatgut for skin closure,although it obviates
the necessityfor removing sutures,is not suggestedbecauseof the increasedincidence of keloid formation.
Nonabsorbablesutures,suchas silk or nylon, should be
used.They may be removedin 8 to 10 days.A soft cotton and gauzedressingmoistenedwith warm saline is
usedto maintain proper mobilization of auricular cartilage during the postoperative period. The dressing
shouldroutinely be changedin 24 hr and the auricular
skin examinedfor its color and any evidenceof hematomaformation.If, indeed,a hematomahasformed,the
woundmust be openedand the hematomaevacuated
Two typical patients treated with this technique are
seenin Figs.20 and2l.
Thereare multiple other individualizedapproachesto
otoplastysurgerybut thesetwo showthe diversity possible and demonstratethe basicconcepts.Readersare referredto the original works of those who have created
thesetechniques,particularly Mustarde (6,10), Stenstrom(9,20)Furnas(l l,2l), Elliott (22,23),Davis(12),
and Becker(28).
OTOPLASTY COMPLICATIONS
Otoplastycomplicationsmay be divided into postsurgicalcomplications,and into a categoryof the unfavorablecosmeticresults.
SurgicalComplications
Infection
Postoperative
wound infectionsin otoplastyare uncommon,and occuron the 3rd to 5th postoperative
day
as in other soft tissueinfections.They are usually the
sequelto an unrecognizedor inadequatelytreatedhematoma. The most significantsymptom is pain, occurring
as early as 12 hr postoperatively.Erythema, swelling,
and purulent drainagemay be noted on removal of the
dressing.Removal of skin suturesshould be considered
to provideadequatedrainagefor necroticdebris,ifpresent,and antibiotic therapyinstituted on the basisof cultureandsensitivity.Hospitalizationfor severeor progressivesymptomsmay be warranted.Delay in treatmentor
a rapidly progressiveinfection may lead to chondritis
and deformity. Infections are relatively uncommon,
probablybecausethe auricle,like the face,is a relatively
privilegedareasurgicallywith its rich blood supply and
extensiveanastomoticnetwork.
Chondritis
The most significantsequelaof infection is chondritis.
Oncestarted,it is difficult to eradicate,probablybecause
cartilageis avascularand antibiotic therapycannot penetrate to the locus of infection. Sequestraof dead infectedcartilageform, leadingto the necessityfor potentially deformingdebridements,and prolongedantibiotic
treatment basedon culture and sensitivities.Someprogresshasbeenmadein the local delivery of antibioticsto
problem areassuch as infected bone or cartilage.Fibrin
glue, bioresorbablepolymer beads, and other devices
havebeenusedasvehiclesthat releasethe antibioticin a
controlledfashionovertime, and areimplantedinto the
infected areaat the time of sureicaldebridement.
Hypertrophic Scarsand Keloid Formation
Unsatisfactoryscarsare uncommon on the ear.They
can be preventedto someextentby adheringto the principle of tensionless
skin closure,and, onceformed,they
are treated in standard fashion with intralesional steroids,and on occasionexcisionand reclosure.Recombinant human interferon-7 injected intralesionallyhas
beenusedwith success
in keloids(25).
Suture Complications
Most suturecomplicationsmay be avoidedby the appropriatechoiceof suturematerial and by correctplacement. A relatively unreactivematerial such as a nonabsorbablemonofilament synthetic may be placed such
that the knots are hidden under the thicker skin cover
posteriorly.Most suture complicationssuch as visible
bridging, granulomata, and extrusion may be treated
with removal of the offendingsutureat a time when the
ear has healedinto its new position and is unlikely to
move, usually after 2 months.
Hypoesthesia
Decreasedsensationoverthe auricleis a common postoperativecomplaint. Return of sensationusually occurs
over a period of months as fine sensorynerve endings
from the rich circumauricular network grow back in to
replacethosesectionedat surgery.
UnfavorableCosmeticResult
Shurp Ridges
'
Thesemay be producedby the cartilagecutting techniques;they arepermanentand shouldbe avoided.Stenstrom's(9,20)work hasshownthat gentleabrasionofthe
anterior perichondrium alone is enoughto createa ten-
98 /
Cneprnn 6
dency of the cartilageto curve toward the intact perichondrium ofthe posteriorsurface.This tendencycan
be enhancedand reinforcedwith Mustarde-Furnas-type
sutures.
goalsarea natural appearanceand symmetry.Conservatism in cartilage excision is the rule and the operated
look should be avoided.Newbornswith auricular deformities can be successfullytreated with simple molds in
the first few daysof life.
Deformities of the Antihelix-Helix Curvature
REFERENCES
The placementof suturesis donein a radialfashionto
recreate the normal antihelical curvature. Failure to
create a cosmeticallyappropriate curve may lead to a
"vertical post" deformity where the ear appearsfolded
back about a verticalline. The suturesneedto be tightenedsequentiallyand equallyto ensurethat the setback
of the newantihelixis uniform from superiorto inferior'
The new antihelix may be placedanywherein the scapha
by current surgicaltechniques,and thus the procedure
shouldbe designedsuchthat the antihelix lies in a natural position with a scaphaof the appropriatewidth. The
actual roll of the antihelix may be made too wide or
narrow dependingon the amount of cartilagespanned
by the sutures.
Position
Ideallythe ear shouldlie approximately18 mm from
the mastoid as measuredfrom the lateral surfaceof the
helix;thus,an ear may be incompletelycorrected,overcorrected ("pinned-back" appearance),or asymmetric
from sideto side.
Obliteration of the PostauricularSulcus
skin exciBluntingof the sulcusis a resultof excessive
sion,producingtensionon the wound closureand allowing tentingof the skinacrossthe sulcus.Evidently,avoidanceofthe problemis achievedby excisingonly the skin
that is in excess.
TelephoneEar and ReverseTelephoneEar
Theseare wonderfully descriptiveterms that refer to
an abnormally pinned-back-appearingconcha in the
confirst case,and an abnormallyprominent-appearing
ofeither
because
occurs
It
usually
case.
cha in the second
over-or undercorrectionofa deepconchalbowl.
SUMMARY
Otoplastyis a challengingprocedure.The techniques
available-cartilage excision,sutures,and cartilagescoring or rasping-must be creativelycombined to address
the specific problems of each individual patient. The
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