Introduction

The plethora of otoplasty techniques that have appeared in the literature over the past century makes it a unique study in our field. More than 200 techniques to correct the lopear deformity have appeared since Ely’s description of this procedure in 1881. ¹ As with all facial plastic surgical techniques, the modern themes of conservatism and minimalism have dominated recent studies.

Otoplasty is the surgical correction of the lopear deformity. Analogous to rhinoplasty, achieving the optimal result begins with a threedimensional analysis of the deformity. Surgical correction requires relating the components of the auricle to the underlying bony skeleton. Furthermore, these components—the helix–antihelix, concha, tragus–antitragus, and lobule—must be evaluated preoperatively and placed in harmony intraoperatively to maintain a natural auricular appearance.

Until the past decade, we traditionally separated otoplasty techniques into two general but somewhat overlapping categories. There were the suture-based techniques, epitomized by the Mustarde procedure, and there were the cartilage-altering techniques, most involving incisions through the auricular cartilage to try to recreate the antihelix or more aggressively set back a protruding conchal bowl. Naturally, the overlapping techniques addressed the limitations of both with some cartilage scoring assisting the suture techniques, and vice versa. With the advent of additional approaches, we can now expand these categories to four. The two additional categories would include nonoperative methods (which have been described for decades, but are gaining increasing interest) and incisionless techniques. Given the heterogeneity of auricular deformities, there appears to be an appropriate use for more than one of these approaches.

Historical Overview

Deformities of the auricle have inspired much creative analysis over the years. In fact, certain characteristics (e.g., prominent Darwin’s tubercles and flattened helical margins) have been suggested as predisposing to criminal behavior. ² The particular deformity addressed in this chapter is actually a group of deformities that have a common overall appearance of the prominent auricle. This may result from the classic absence of the antihelix, from overprojection of the concha, or from a combination of these deformities. Less frequently, a twisted or overprojected lobule may exacerbate the deformity.

Since the 19th century, techniques have been described to restore the normal relationship of the auricle to the scalp and underlying mastoid bone. The first written description of otoplasty is attributed to Ely, who reduced a prominent ear by excising a throughandthrough piece of auricle consisting of anterior auricular skin, auricular cartilage, and posterior auricular skin. ¹ Similar techniques followed (Haug, Monks, Joseph, Ballenger, and Ballenger), all involving a reduction approach to otoplasty that attempted to reduce prominent ears by the removal of skin or cartilage.

In 1910, Luckett correctly attributed the classic lopear deformity to the absence of the antihelical fold. ³ This new revelation as to the correct anatomical defect enabled him and subsequent authors to devise correction techniques. Earlier techniques involved incisions in the auricular cartilage anterior and posterior to the desired antihelix position. In Luckett’s technique, a crescent-shaped excision of skin and cartilage was performed at the site of the intended antihelix. The remaining cartilage edges were then sutured. Becker’s technique also included anterior and posterior incisions around the intended antihelix. He then formed the new antihelix with fixation sutures and posterior abrasion. ⁴ A further variation is seen in the technique of Converse, whereby the anterior and posterior incisions were followed by suturing the antihelical segment to form a tunnel. ⁵

Modern techniques stress the importance of avoiding the surgical appearance. Visible edges of cartilage are to be avoided, and a smooth, pleasantly shaped auricle in normal relation to the skull is desired. We discuss the pertinent anatomy and embryology, and then outline the basic approaches to congenital auricular deformity—cartilage suturing and cartilage sculpting—and the multiple variations that have been developed for both techniques.

Anatomy and Embryology

The external ear is a cartilaginous structure except for the lobule, which contains no cartilage ( Fig. 29.1 ). This flexible elastic cartilage is covered with skin, which is closely adherent anteriorly and more loosely attached posteriorly. The plate of cartilage has a definite shape and may be described as a combination of ridges and hollows incompletely surrounding the bony external auditory canal.

The normal auricle protrudes 20 to 30 degrees from the skull ( Fig. 29.2 ). When measured from the lateral edge of the helix to the mastoid skin, this distance is usually 2 to 2.5 cm. When analyzed from a superior viewpoint, the angulation is seen to result from a combination of a conchomastoid angle of 90 degrees and a conchoscaphalic angle of 90 degrees. The average length and width of the male auricle are 63.5 mm and 35.5 mm, respectively. Corresponding measurements in the female are 59 mm and 32.5 mm. ⁶ , ⁷

Analysis of the convolutions of the normal auricle begins with the helix and antihelix. They begin inferiorly at the level of the tragus and diverge as they extend superiorly. They are separated through their course by the scaphoid fossa. As the antihelix is followed superiorly, it divides into a smoother, wider superior crus and an inferior crus, which characteristically is narrower and sharper. The fossa triangularis lies between the superior crus and the inferior crus. From the frontal viewpoint, the helix forms the most lateral extent of the auricle superiorly and should be just visible behind the antihelix and superior crus.

The cartilage is attached to the skull by three ligaments. The anterior ligament attaches the helix and tragus to the zygomatic process of the temporal bone. The front portion of the cartilaginous external auditory canal is free of cartilage but is bridged by a ligament passing from the tragus to the helix.

The ear has both intrinsic and extrinsic muscles supplied by the seventh cranial nerve. These small muscle masses form in definite areas and create soft tissue thickness with an associated increase in blood supply. These muscles have essentially no function, although some people can wiggle their ears.

Fig. 29.3 depicts the arterial blood supply of the auricle. Contributions are primarily from the superficial temporal artery and the posterior auricular artery, although some branches also feed from the deep auricular artery. Venous drainage is via the superficial temporal and posterior auricular veins. Lymphatic drainage is to preauricular and superficial cervical nodes.

Sensory innervation to the external ear is derived from multiple sources ( Fig. 29.4 ). The auriculotemporal branch of the mandibular division of the fifth cranial nerve supplies the anterior limb of the helix and part of the tragus. The remainder of the anterior auricle is supplied chiefly from the greater auricular nerve, whereas the posterior surface receives its innervation from the lesser occipital nerve. Minor contributions are also made from the 7th, 9th, and 10th cranial nerves.

The hillocks of His refers to a description by that author of six visible protruberances in the 39-day embryo that develop into the auricle. Although His originally traced the origin of the first three hillocks to the first branchial arch and that of the second three hillocks to the second branchial arch, subsequent studies have challenged this theory. It now appears that only the tragus may be traced to the first branchial arch and that the remainder of the auricle is derived from the second branchial arch ( Fig. 29.5 ). This is supported by the location of congenital preauricular pits and fistulae located along the anterior incisura and incisura intertragica. Because these regions anatomically represent the dividing line between the first and second branchial arches, these anomalies would therefore arise from the first pharyngeal depression. ² , ⁸ , ⁹ The majority of auricular deformities are inherited in an autosomal dominant pattern. ¹⁰ Similar inheritance patterns are also seen in preauricular pits and appendages.

Function

The function of the auricle in lower animals has been extensively studied. ⁴ Sound localization and protection against water entry are two of the documented functions. Water protection is afforded by apposition of the tragus and antitragus. These physiologic functions are not documented in humans.

Preoperative Evaluation

Like all facial plastic surgical procedures, otoplasty requires precise preoperative evaluation and analysis. Each ear must be evaluated separately because the deformity or deformities present may be very different between the two ears. The auricle should be evaluated as to its size, its relationship to the scalp, and the interrelationship between its four components (helix, antihelix, concha, and lobule). Typical measurements recorded during the preoperative examination include the following:

1. 
   

   The mastoid–helical distance as measured at the superior aspect of the helix

   
   
2. 
   

   The mastoid–helical distance as measured at the level of the external auditory canal

   
   
3. 
   

   The mastoid–helical distance as measured at the level of the lobule

Additional measurements included by some authors are the distance from the top of the helical rim to the junction of the inferior and superior crus, and the distance from the helical rim to the antihelix ( Fig. 29.6 ).

Preoperative photographs include an anterior fullface view, a posterior full-head view, and close-up photographs of the involved ear(s) with the head positioned so that the Frankfort plane is parallel to the floor.

The abnormality most commonly observed in the protruding ear is the overgrowth or protrusion of the conchal cartilage. Such deformities are not corrected by otoplasty techniques designed to re-create the antihelix. These ears require an alteration of the relationship between the concha and the mastoid cortex. Protuberant lobules may be the only deformity present in an otherwise normal ear. This may be secondary to an abnormally shaped cauda helicis ( Fig. 29.7 ).

Approaches to the Congenital Auricular Deformity

Traditional otoplasty literature cites the 4- to 5-year-old patient as the ideal age for otoplasty correction. The reasoning behind this age window was that the ear was fully developed and the child had not yet entered school where he or she might be subject to peer ridicule. Case reports as early as the 1980s suggested that these deformities would be better served if addressed at birth. ¹¹ , ¹² In 2010, Byrd reported on 488 patients treated shortly after birth with nonoperative compression. ¹³ The EarWell Infant Ear Correction System was used to treat a variety of commonly seen deformities, including the absence of the antihelix and the overprotrusion of the conchal bowl. When treated in this fashion, successful correction was achieved in 90% of patients. ¹³ This is consistent with the experience of other proponents of early auricular molding. ¹⁴ , ¹⁵ Even though some of these anomalies may self-correct, early intervention appears to provide the optimal chance for avoiding the need for surgical correction. The ideal age for ear compression treatment is the first weeks of life. Although successful correction through nonoperative compression has been reported in children up to 5 years of age, it is generally thought that this therapy works best when done no later than 6 weeks of age. ¹⁶ , ¹⁷ This may have to do with higher estrogen levels in neonates, allowing for cartilage being more responsive to molding. ¹³

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