28 Otoplasty and Earlobe Rejuvenation
Otoplasty, the reshaping of the ear, must be performed by recreating absent normal architecture or reducing excesses to recreate a normal size, shape, and position of the ear.
Fossa and eminence of the anterior and posterior surface of the ear need to be understood and recreated to yield a normal-appearing anatomically correct ear.
Auricular hillocks of the first and second branchial arch form the external ear, primarily the third through fifth hillocks.
Overdeveloped conchal bowl must be addressed in otoplasty through conchal reduction and setback with suturing.
Earlobe reduction in conjunction with aging face surgery creates greater harmony and can help avoid a postsurgical incongruity.
Stellate resection may be required for an earlobe reduction that addresses issues of height and width.
Otoplasty is the reshaping of the ears. This routinely refers to correcting the protruding ears or lop ear deformity. Reshaping also occurs in the form of microtia repair on a grander scale and earlobe reduction or repair of iatrogenic deformities to a more minor degree.
Otoplasty most commonly involves the reduction of protruding ears. This usually includes the re-creation of normal cartilaginous contours on the anterior surface of the ear and reduction in the depth of the conchal bowl. Contour re-creation and depth reduction of the bowl may occur in an isolated setting. However, they are most often found in association with one another and to varying degrees affect the protrusion of the ear away from the side of the head and the ideal postauricular angle or cephaloauricular angle of less than 45 degrees.1 This chapter summarizes the abnormalities producing the protruding ear and their correction and addresses relatively simple solutions for the aging lobule and postsurgical lobular deformities.
Background: Basic Science of Procedure
Embryologically, the ear arises from the first and second brachial arch in the six auricular hillocks that form within the first and second branchial arches. The first three hillocks (1 through 3) are attributed to the first brachial arch, and the second three hillocks (4 through 6) are attributed to the second brachial arch. It is the general consensus that the bulk of the ear is formed from the third through fifth hillocks, that the sixth hillock contributes to the lobule and antitragus, and that the tragus and helical crus originate from the first and second hillocks.2 Development of the pinna usually occurs during the first trimester of pregnancy, and as a consequence, deformities will have developed during this phase of embryological maturation.
The lack of development of the external ear takes varying degrees and may result in microtia, the absence of most external anatomy including the external auditory canal, and, frequently, underdevelopment of the middle and inner ear. This is considered a third-degree deformity of the ear. The cupped ear deformity is a second-degree deformity and is most often represented by an undersized ear with reduced components. The superior helical margin, superior crus of the antihelix, and scaphoid fossa are most commonly affected. First-degree deformities of the ear are deformities of excess rather than of absence and are manifested by the protruding and overly large ear.
Lop ear deformity, or protruding ears, is inherited as an autosomal dominant gene with variable penetrance, with 59% of patients having a positive family history. Protruding ears affect 5% of the Caucasian race.
Abnormalities of the ear can also arise from iatrogenic and traumatic sources. One of the most frequently occurring iatrogenic abnormalities is the pixie ear deformity, which can be the result of a face-lift ( Fig. 28.1 ). There is a similar congenital variation in the degree of attachment of the lobule to the neck that can be released, if so desired, in the same fashion as the repair of the postsurgical pixie ear.
Abnormalities that are the consequence of aging may also affect the lobule, resulting in elongation and thinning. If these are not addressed at the time of a facelift, there will be a severe lack of harmony after completion of the facial rejuvenation, which may distract from an otherwise satisfactory result.
In performing otoplasty, it is imperative to realize that for each eminence there is a fossa, and that through re-creating the normal convexities and concavities of the auricular cartilage, the surgeon can create an ear that looks normal and will persist ( Fig. 28.2a,b ).
Ears that protrude and may become the source of ridicule can be corrected as early as 5 to 6 years of age. There is evidence to suggest that teasing and harassment will begin when the patient enters elementary school. This, of course, may depend upon the degree of protrusion, the gender of the patient, and the hairstyle. The parents of males are more likely to seek correction at a younger age than those of females. There is an upper limit on the age at which an otoplasty can be performed. In the older patient, the cartilage will become more rigid and may require more aggressive surgical techniques.
Technical Aspects of Procedure
Lop Ear Deformity
Correction of the lop ear deformity takes many forms and has been covered extensively in the past.3–6 This section summarizes the author′s preferred techniques and offers an explanation for these choices Video 28.1. Any technique must be customized to address the deformities that exist and neither over-nor undertreat.
In the author′s practice, there is a 93% occurrence of absence or underdevelopment of the superior crus of the antihelix in patients with protruding ears. This may present in isolation, resulting in the protrusion of the superior pinna, or in conjunction with the absence or underdevelopment of the antihelix along its entire length; this occurs in 75% of the patients and will result in the protrusion of the entire helical margin. Protrusion of the entire helical margin in the absence or underdevelopment of the antihelix is almost universally associated with a prominent cauda helices, contributing to protrusion of the lobule. A deep conchal bowl that further exacerbates the protrusion occurs in ~ 45% of the author′s patients.
Absence of the superior crus is the most straightforward deformity and the most consistently encountered. It is addressed through the excision of an ellipse of skin on the posterior surface of the ear over the desired fossa of the superior crus of the antihelix. This is determined by folding the ear to re-create the superior crus and identifying the corresponding position on the posterior surface. This can be accomplished by the placement of Keith needles through the ear from the anterior surface. Needles are placed at the junction of the superior and inferior crus of the antihelix in the fossa triangularis, the lateral conchal bowl at the junction of the superior and inferior crus, and the anterior margin of the scaphoid fossa ( Fig. 28.3a,b ). These are used as guideposts for the scoring of the posterior surface of the ear in the antihelical fossa, while avoiding incisions that would cross the inferior crus, a devastating error. After scoring, horizontal mattress sutures are placed from the scaphoid eminence to the eminence triangularis and the lateral conchal bowl, sequentially. These sutures are performed with a 4–0 Mersilene suture and are tightened to the desired projection, which is having the helical margin 1.5 to 2 cm off the mastoid at the junction of the superior and inferior crus.7,8
When absence of the antihelix in the entirety is present, the posterior skin excision is extended as an elliptical dumbbell inferiorly until the beginning of the lobule ( Fig. 28.4 ). After skin excision is complete, the skin is dissected off the posterior surface of the cauda helices. Then 5 to 7 mm of the distal lateral margin of the skin is resected obliquely ( Fig. 28.5 ). The scoring is then performed, extending down the entire length of the antihelix ( Fig. 28.6 ). Horizontal mattress sutures of 4–0 Mersilene are placed from the scaphoid eminence to the lateral conchal bowl ( Fig. 28.7 ). The sutures all radiate from the external auditory canal. When one is placing the sutures, care is taken to avoid the skin on the anterior surface.
In the presence of a deep conchal bowl, conchal reduction or conchal setback needs to be executed. The author has found that conchal reduction is more reliable and results in much less postoperative pain and discomfort. With conchal setback alone, there is no re-creation of the antihelix in its absence.
To perform conchal reduction, the posterior surface of the cartilage is marked with transauricular Keith needles corresponding to the previously described locations, in addition to the placement of a needle at the lateral conchal bowl even with the antitragus ( Fig. 28.3a,b ). The index or middle finger is placed in the conchal bowl to palpate the deep surface of the conchal incision, and an ellipse of lateral bowl cartilage is resected, with the width dependent on need ( Fig. 28.8 ). This defect is then incorporated into the posterior suturing. The additional sutures are placed from the scaphoid eminence in a horizontal fashion to the lateral, and subsequently, medial margin of the conchal bowl as a vertical suture ( Fig. 28.7 ).
The postauricular incision is closed with a running locked 5–0 plain gut suture. Antibiotic ointment is applied to the incision, and mineral oil–impregnated cotton is placed in the postauricular sulcus, fossa triangularis, scaphoid fossa, concha cavum, and concha cymba ( Fig. 28.9 ). Fluffed cotton 4 × 4 gauze is secured over the ears with a circumferential dressing encompassing both ears.
Appropriate applications of elliptical dumbbell excision of posterior auricular skin, cauda helicis trimming, conchal reduction, posterior scoring, and mattress suturing will lead to excellent, anatomically correct–appearing ears with little to no evidence of surgical correction. The margins of the cartilage are realigned when cartilage excision is performed. The incision is on the medial surface of the protruding portion of the pinna and is invisible to observers ( Fig. 28.10 ; Fig. 28.11a,b ).