Combined Technique in Otoplasty

54.1 Introduction

Protruding or prominent ears are a common congenital deformity of the external ear with an incidence rate of 5% which is inherited as an autosomal dominant trait [1, 2]. Interestingly, Matsuo [3] observed that the percentage of protruding ears is 0.4% at birth and increases up to 5.5% at 1 year of age, relating the rate increase to the position of the baby head in the first days of life. He presumes that, when the baby turns its head to one side, the weight of the head keeps the ear folded thus increasing the prominent ear rate.

The normal ear develops in utero between the fifth and the ninth week: the auricular anomalies developing by the tenth week are caused by embryologic maldevelopment and are categorized as malformational auricular anomalies. Those developed in utero after the tenth week (i.e., when the ear is fully developed) or even after the birth result from deformational forces and are considered deformational auricular anomalies [4].

The first group of ear anomalies consists of true malformations with deficient and/or supernumerary auricular components, and comprises from anotia and microtia to auricular sinuses and tags.

Deformational auricular anomalies are caused by abnormal physical forces (from imbalance of the auricular muscles to abnormal positioning) that act on an embryologically normal ear structure. The deforming forces act on a malleable auricular framework,

M. Salgarello

Department of Plastic Surgery, General Surgery Institute, Catholic University of the Sacred Heart, Largo Gemelli 8, 00168 Rome, Italy

e-mail: m.salgarello@mclink.it

altering its shape. They include the less severe anomalies, which form the majority of the congenital auricular anomalies, such as prominent ears, Stahl deformity, and lop and cup ears.

From an anatomical point of view, the intrinsic and extrinsic auricular muscles stabilize the auricular cartilage. The intrinsic muscles of the anterior auricular surface are the tragicus, the antitragus, and the helicis major and minor muscles. The intrinsic muscles of the posterior auricular surface are the intrinsic transverse and oblique muscles. An interesting theory about the etiology of prominent ears postulates that the prevailing of one among the intrinsic muscles, the antitragus muscle, could exert an anterior pull on the tail of the helicis that contributes to the flattening of the antihelix [5]. These authors, examining the presence and quality of the antitragus muscle when correcting prominent ears, found an inverse correlation with the degree of antihelical folding. When the antitragus muscle was well-developed it was associated with a less-formed antihelical fold. Other Authors also believe that aberrant insertion of the auricular muscles into the auricular cartilage may lead to abnormal muscle vectors which drive to the deformation of the cartilage [3, 6].

As prominent ears have fully developed chondrocutaneous components, they can be manipulated to reach a normal shape. Auricular molding with splinting and taping is an effective way of treating this deformity if started within 3 days of birth [3] and continued for up to 6 months [7, 8]. The pliability of the auricular cartilage in this early period is probably due to the high level of maternal estrogens in the baby [9]. The nonsurgical correction usually requires 1 week in order to obtain the normal shape then it takes months to stabilize it.

Prominent ears show a combination of underdevelopment of the antihelix and overdevelopment of the concha of different degree. Moreover, prominent ears

show an increased conchoscaphal angle (over 90°) and an increased cephaloauricular distances (superior, medial, inferior). The deformity is usually bilateral, sometimes showing different degrees of the anomaly in the two sides, rarely monolateral.

During plastic surgery consultation, the surgeon has to assess the defect of each ear including the thickness of the auricular cartilage, pointing out the differences between the two sides. The discussion should involve options of correction and the fundamental element of personal motivation. As the patient perception of the deformity is usually very high, each characteristic of the anomaly has to be analyzed in detail with the patient explaining the possibility of the surgery.

At preschool age children do not note this deformity so much, thus they do not suffer from the psychological trauma yet. Moreover, 85% of the auricular growth is completed by 3 years of age, and 90–95% of adult size is achieved by 5 years of age [10, 11] making this time the ideal age for surgery.

The situation changes when the children start social or school activities and the prominent ears become a source of teasing from the other children. At this age the anatomic deformity of the ear can cause such a psychological alteration (personality vulnerability, emotional instability, and very low self-esteem) to recommend the prompt surgical correction [12]. In the adolescence, during which psychological instability can be worsened by an aesthetic deformity such as the prominent ear, and in the adults, where the protruding ears could represent the trauma of an uncomfortable adolescence or even childhood, the psychological perception of the deformity makes the motivation and expectation of surgery very high. It may leave a patient dissatisfied even in case of successful operation from a surgical point of view. Therefore, the surgical correction is now encouraged before school-age without fear of interfering with the growth of the operated ear [13, 14]. Instead, in the majority of cases, they are treated surgically during childhood or even adolescence.

Otoplasty is the surgical correction of the prominent ears, with the aim to restore the normal anatomic features. It has to produce:

1.A smooth, rounded, and well-defined antihelix fold, with the helical rim slightly protruding beyond the antihelix (i.e., being slightly visible from the front view)

2.A concho-scaphal angle of 90°

3.Reduction of conchal excess and reduction of the angle between concha and mastoid

Table 54.1 McDowell and Wright’s goals of otoplasty (McDowell, Richards)

ssAll trace of protrusion in the upper one-third of the ear must be corrected. (Some remaining protrusion in the middle third or lower portions may be acceptable, provided the superior aspect is thoroughly corrected; however the reverse does not hold true)

ssFrom the front view, the helix of both ears should be seen beyond the antihelix (at least down the midear and preferably all the way)

ssThe helix should have a smooth and regular line throughout

ssThe postauricular sulcus should not be markedly decreased or distorted

ssProtrusion should measure between 15 and 20 mm from the helix to the head

ssPosition of the two ears (i.e. distance from the lateral border to the head should be within 3 mm at any given point)

4.Reduction of the cephaloauricular distances

5.Correction of abnormal position of the lobule (if the lobule projection is beyond the helical rim)

The analysis of the outcome after the surgical correction of the prominent ears can follow one or more of the following criteria:

ssObjective assessment such as McDowell and Wright’s goals of otoplasty [15, 16] (Table 54.1)

ssSubjective assessment by the surgical team, the patients, their parents

Innumerable surgical techniques have been proposed for the treatment of prominent ears. The multitude of surgical approaches indicates that there is not one definitive technique able to correct all the degrees of the deformities of prominent ears. The ideal technique should be simple, effective, adaptable for the correction of every deformity, successful and with a low complication rate. The technique presented here follows these parameters: it combines elements of various techniques in a graduated approach that is based on anatomical demand [17].

54.2 Technique

The preoperative assessment of the characteristics of the malformation, especially in terms of shape and consistency of the ear cartilage on both sides, is important because it allows the technique to be individually adjusted for each ear.

According to what is needed, surgery can be performed on one ear alone or on both ears, and the surgical techniques can be different on the two sides. In case of severe deformity on one side with minimal anomaly on the other side, we prefer to operate on both sides to achieve a more symmetrical result.

Prophylactic antimicrobacterial agents are used at the beginning of the operation. The surgery is usually done under local anesthesia with sedation. In young children a general anesthetic may be required. In each case infiltration with Xylocaine 1% and adrenaline 1:100,000 is performed on the posterior surface of the ear and on the anterior surface over the antihelix and the concha. This is for a bloodless field and makes undermining of the skin easier.

The helical rim is folded back against the head to visualize the area of the new antihelix which is marked with methylene blue (Fig. 54.1). A linear surgical incision is done on the posterior surface of the ear on the posterior projection of the new antihelical fold, 1–1.5 cm above the retroauricular fold, without removing any skin (Fig. 54.2). In fact, it is not necessary to excise the skin to affect the correction of the auricular cartilage. Cutaneous undermining of the posterior surface of the ear is performed up to the tail of the antihelix inferiorly and laterally toward the helical rim to widely expose the auricular cartilage. The wide exposure helps in positioning of the sutures in order to bend the cartilage of the antihelix.

Accurate hemostasis is performed. Now, a mosquito is inserted at the level of the antitragus–helical fissure (i.e. the fissure located between antitragus and tail of the helix) (Fig. 54.3) to bluntly elevate a tunnel

Fig. 54.1 The helical rim is folded back against the head to shape the new antihelix that is marked with methylene blue

Fig. 54.2 A linear surgical incision is done on the posterior surface of the ear, about 1 cm above the retroauricular fold, without removing any skin

Fig. 54.3 A mosquito is inserted in the antitragus–helical fissure (i.e. the fissure located between the antitragus and the tail of the helix)

from the posterior aspect of the ear toward the anterior surface of the ear. The Stenström otoabrader (Fig. 54.4) is inserted in this tunnel (Fig. 54.5) and is directed toward the anterior surface of the ear in the subcutaneous plane, where the corresponding antihelix is to be formed (Fig. 54.6). Here the perichondrium and cartilage of the antihelix and scapha are rasped making the cartilage more pliable to achieve the correct curve. A careful scoring of the tail of the antihelix and medially scoring toward the concha weakens the cartilage at this level, which is thicker than in the upper third of the ear. This maneuver allows to medialize the tail of the antihelix and to turn the ear lobe toward the mastoid.

Fig. 54.5 The Stenström otoabrader is inserted at the level of the antitragus–helical fissure to be directed toward the anterior surface of the ear

Fig. 54.7 A straight needle dipped in methylene blue is passed through and through the cartilage to mark the inferior pair of points at the tail of the antihelix

Fig. 54.8 Three straight needles dipped in methylene blue are passed to mark three pairs of points on the skin of the anterior surface of the ear

Fig. 54.6 The Stenström otoabrader has been inserted in the subcutaneous plane of the anterior surface of the ear, where the corresponding antihelix is to be formed

The helix of the ear is now pressed toward the mastoid to create the correct fold of the antihelix.

Straight needles dipped in methylene blue are passed through and through to mark the cartilage posteriorly with three pairs of points starting inferiorly

(Fig. 54.7): the inferior pair of points are set through the tail of antihelix, on the scaphal and on the conchal side, the intermediate points are put down the bifurcation of the antihelix, on the scaphal and on the conchal side, the upper pair of points are placed between the triangular pit and the scapha to delineate the crus lateralis of the antihelix (Figs. 54.8 and 54.9). These pairs of points indicate the position of the mattress sutures that will be tied on the posterior surface of the antihelix to form the antihelix itself.

Three 3–0 Vicryl sutures are now passed through the posterior surface of the cartilage with partial thickness bites (Fig. 54.10) and tied, determining the bending of the antihelix (Fig. 54.11).

Fig. 54.9 The three pairs of points already tattooed are visible on the posterior surface of the ear

Fig. 54.10 Three sutures are passed through the posterior surface of the cartilage with partial thickness bites

Fig. 54.11 The three sutures have been tied to determine the curve of the antihelix

Fig. 54.12 Three transfixion sutures over gauze pads are placed on the anterior surface of the ear to stabilize the curve of the antihelix

It is important to overcorrect the tail of the antihelix moving it medially toward the concha, thus decreasing the conchoscaphal angle and reducing the medial and inferior cephaloauricular distances. It helps in shaping the antihelix and is mainly important to control the positioning of the lobule thus preventing its possible protrusion. The correct positioning of these mattress sutures represents the key point of the operation, because if properly positioned they allow the reorientation of the ear.

If it is necessary to correct a very deep concha, this is done by excising a small crescent of full thickness cartilage ( width between 2 and 6 mm) at the junction of the floor and posterior wall of the concha. The edges

of this crescent are widely undermined to move them closer. No sutures are needed.

The incision on the posterior surface of the ear is closed with interrupted sutures allowing blood drainage in case of small bleeding.

The curve of the antihelix is then stabilized with transfixion sutures over gauze pads on the anterior surface of the ear (Fig. 54.12). These help in further molding of the cartilage and in maintaining the cartilage in its new position for 10 days before they are removed. An elastic band is worn for about 2 weeks, for compression and prevention of hematomas, so that the patient does not make unintentional movements during sleep that can jeopardize the surgical result [18, 19].