Synopsis
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Analysis. Analyze the problem in thirds.
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Endpoint. Know what normal looks like, so you know your surgical endpoint.
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Do not be destructive. Do not do anything to the ear that cannot be reversed.
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Skin is precious but weak. Preserve skin in the sulcus, and do not rely on skin tension to maintain ear position.
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Lobule. Consider lobule setback in every case.
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Asymmetry. In asymmetric cases, operate on both ears most of the time.
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Facelifts are otoplasties. Do not deform the tragus, lobule, or sulcus.
Keywords
Ear, Otoplasty, Prominent, Setback, Cartilage
Synopsis
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Analysis. Analyze the problem in thirds.
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Endpoint. Know what normal looks like, so you know your surgical endpoint.
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Do not be destructive. Do not do anything to the ear that cannot be reversed.
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Skin is precious but weak. Preserve skin in the sulcus, and do not rely on skin tension to maintain ear position.
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Lobule. Consider lobule setback in every case.
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Asymmetry. In asymmetric cases, operate on both ears most of the time.
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Facelifts are otoplasties. Do not deform the tragus, lobule, or sulcus.
Brief introduction
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“Otoplasty” refers to surgical changes in the shape or position of the ear.
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The most common indication is the patient with prominent but normally shaped ears.
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The single most important exercise for the surgeon, before performing any procedure in the otoplasty spectrum, is to have the characteristics of a normal ear firmly in his/her mind. With proper choice of technique, the surgeon can usually avoid the uncorrectable problems of overcorrection and unnatural contours ( Figs. 5.1 and 5.2 ).
Figure 5.1
Anatomical structures of the ear. The tubercle of the helix is synonymous with Darwin’s tubercle.
(Reprinted with permission from Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg. 2005;115(4):60e–72e.)
Figure 5.2
Main components of the prominent ear.
(Reprinted with permission from Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg. 2005;115(4):60e–72e.)
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It has also never been shown that an otoplasty retards auricular growth.
Preoperative considerations
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Otoplasty is unique in that it is perhaps the only cosmetic procedure that can be performed in childhood, and both parents and grandparents may be involved in surgical decision making for the patient who cannot yet express himself or herself.
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The overall size and shape of the ear is evaluated to determine if the ear is prominent with an otherwise normal size and configuration, or if there are abnormalities in addition to the prominence.
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The upper third of the ear is evaluated to determine if it is prominent, if the antihelix/superior crus of the triangular fossa is well formed, and if the helical rim is well defined.
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The middle third of the ear is evaluated to determine if the concha is overly deep or protruding.
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The relationship between the antihelix and the helix is examined to determine if any underdevelopment of the antihelix/superior crus in the upper third extends into the middle third or if it is confined to the upper third.
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The lobule is evaluated to determine if it is prominent.
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Even if the lobule is not particularly prominent on initial examination, it may become prominent once the upper two-thirds of the ear have been corrected.
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Asymmetry is noted, mostly because patients and families will always comment on it.
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In asymmetric cases, it is usually preferable to operate on both ears rather than attempt to set back only the prominent ear to match its less prominent counterpart (see Fig. 5.1 ).
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The degree of prominence/deformity and the age at presentation will determine when a surgical recommendation is made.
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For young children with very prominent ears and whose parents desire early correction, otoplasty is recommended as early as age 4 years.
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Four years of age can be viewed as a minimum for most otoplasty procedures.
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When the entire ear requires reconstruction, as in microtia, this author prefers to wait until approximately 10 years of age.
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In some cases, the parents may want the child to participate in the decision process, and that will necessitate later intervention.
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It is common to have patients present at approximately 18 years of age, when they are legally independent, or later when they have earned the money for the procedure.
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It is not unusual for adults at almost any age to request correction, either because they have wanted it all their lives or because their desire to have other procedures (e.g., a facelift) has led to the realization that their ears are also prominent.
Anatomical/technical pearls
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While the delicate, complex contours of the ear may be difficult to create de novo (i.e., microtia), anatomic considerations are minimal in standard otoplasty.
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There is abundant blood supply, making almost any combination of incisions acceptable without the risk of necrosis.
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There are no motor nerves in the neighborhood. The terminal branches of the great auricular nerve will always be injured, but normal sensory function usually returns.
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The one anatomic structure that can be compromised in otoplasty is the external auditory canal (conchal setback narrows the meatus). Otherwise, the anatomic considerations of otoplasty are those of preservation:
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Preservation of the sulcus.
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Preservation of the natural softness of the auricular contours.
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Preservation of the normal landmarks such as the posterior wall of the concha (i.e., the middle third of the antihelix).
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Otoplasty surgery is all about the endpoint. The right endpoint can be achieved with a thorough knowledge of a normal ear. If the surgeon remembers the following regarding how the ear should look from various vantage points, it will aid tremendously in the intraoperative decision making:
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From the front, the helical rim should be visible, poking out from behind the antihelix.
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From the side, the contours of the ear should be round and soft, never sharp.
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From behind (and this is the most helpful to the surgeon who is sitting behind the patient intraoperatively), the contour of the helical rim should be a straight line, not a “C”, or a “hockey stick”, or any other shape. If the helical contour is a straight line, it almost ensures that a harmonious correction will be achieved.
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Regardless, if the ultimate correction is slightly under- or slightly overcorrected, a harmonious correction will read as “normal” to the outside world, and almost all patients will be happy. This is perhaps the single most important lesson from this chapter.
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The last judgment is how close to the head the ear should be placed. The final position of the ear should be overcorrected minimally to allow for some relapse, but not enough to create an unsatisfactory result if no relapse should occur.
Operative techniques
Standard otoplasty for prominent ears of normal size
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The incision is made in the retroauricular sulcus.
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In the upper third of the ear, it can be extended up to the back of the ear to provide adequate exposure to place Mustarde sutures between the triangular fossa and scapha.
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No skin is excised, except a small triangle from the medial surface of the lobule (not the retrolobular skin), taking care to preserve enough tissue for a normal earlobe and retrolobular sulcus.
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This skin excision on the lobule is frequently necessary for repositioning of the lobule at the end of the procedure.
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The cartilage is exposed on the posterior (medial) surface of the ear, and soft tissue is excised from deep to the concha.
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In the region of the earlobe, deep dissection is performed under the concha in preparation for lobule repositioning. Branches of the great auricular nerve will be seen and divided.
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Mustarde concha–scapha and triangular fossa–scapha sutures are placed using 4–0 clear nylon sutures on an FS-2 needle ( Fig. 5.3 ) .
Figure 5.3
Technique for the standard otoplasty. The combination of Mustarde sutures, conchal resection/closure, and concha–mastoid sutures is shown. (A) Suture placement. (B) Suture tightened and ties appropriately. (C) Position of sutures as shown from the surgeon’s vantage point.
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The number of sutures depends on the how far into the middle third of the ear the antihelical deficiency extends.
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These sutures are placed in order to create a soft curvature to the antihelix, and no attempt is made to correct the prominence of the ear at this point.
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The Mustarde sutures are not parallel to each other but, instead, are arranged like spokes on a wheel, all pointing toward the top of the tragus (center of the wheel).
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Care is taken to create a superior crus that curves anteriorly such that it terminates almost parallel to the inferior crus.
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If the superior crus is created such that it is a direct, cephalad extension of the antihelix (straight line), the result will appear unnatural and amateurish.
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A small crescent of cartilage (≤3 mm at its widest point) is excised from the posterior wall of the concha at its junction with the conchal floor.
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The defect in the concha is closed primarily using numerous 4–0 nylon sutures.
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It is important that the conchal resection be placed precisely, as lack of attention to the placement of the conchal resection is a common cause of complications.
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If the resection is too large or if it is too far up the posterior conchal wall, then it will irrevocably deform the antihelix.
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If the resection is too far anterior in the floor of the concha, it will not decrease the height of the posterior conchal wall, and the closure may be visible.
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A conchal setback suture (Furnas suture) is then placed between the reduced concha and the mastoid fascia using a single 3–0 nylon or 3–0 PDS suture.
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This combination of a small conchal resection and a small conchal setback avoids the distortion of a large conchal resection and the unreliability of a large conchal setback.
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This author avoids conchal setback alone in all but the mildest cases, as it can narrow the external auditory meatus to the point of significant stenosis ( Fig. 5.4 ) .
