The extent of the dissection implies the amount of postoperative edema: to reduce it the patient has to rest with the head on two pillows, and Arnica medication is used for 2 weeks postoperative.

54.3 Complications

Complications of otoplasty can be divided into early and late groups; each of them may be categorized as major or minor ones. Overall complication rates of otoplasty are low, and when they occur tend to be minor.

Early complications (from hours to days) include major complications such as hematomas, skin necrosis, wound infection, and infection of cartilage. All of these are dreaded ones and require prompt intervention. Minor complications such as a bleeding from the wound a few hours after surgery often require reoperation for exploration. Pain has to be prevented by the use of routine prophylactic analgesics, but excessive pain is a warning symptom as it may indicate a significant auricular hematoma, mandating immediate wound inspection. Pressure wound along the newly formed antihelix and especially at the tail of it may be caused by a too firm bandage and has to be avoided.

Late complications reveal themselves after weeks to months; they include recurrence or residual deformity often due to undercorrection, malposition of the superior crus of the antihelix due to overcorrection, keloids (Fig. 54.13) or hypertrophic scars, and suture extrusion. A peculiar surgical deformity is the telephone ear, due to failure to correct a prominent ear lobule while hypercorrecting the concha (Fig. 54.14) or to removing excessive skin from the middle third of the ear [20].

The most common late complication in the adult patient is patient dissatisfaction [21]. In case the surgery has been properly performed, it may be related to excessive expectation from surgery due to a peculiar psychological status. The preoperative discussion should have emphasized the possibility of slight asymmetries on side-to-side comparison that are considered acceptable.

In case we face a true recurrence of the deformity, it has to be reminded that the cartilage elasticity decreases with advancing age, which may give a higher risk of prominent ear recurrence at this age, thus demanding a more aggressive treatment of the cartilage in patients undergoing otoplasty as adults.

Fig. 54.13 Small keloid at the retroauricular scar

Fig. 54.14 Telephone ear deformity, possibly due to excessive excision of conchal cartilage

Many complications tend to be technically dependent ones. Acute crests and irregular contours along the fold of the antihelix with a tendency to overcorrection are typical deformities seen with the techniques that interrupt the continuity of the cartilage [2, 20] (Figs. 54.15 and 54.16)..These residual deformities

Fig. 54.15 Sharp cartilage edge on the upper part of the antihelical fold after correction of prominent ears with a cartilage cutting technique

Fig. 54.16 Many acute crests and irregular contour are visible along the antihelix fold after correction of prominent ear with a technique that interrupts the continuity of the cartilage

require secondary correction surgery. They occurred in the past in up to 24% of cases [22], and are rarer today as the interruption of the cartilage is rarely performed.

Suture-related techniques were reported to have suture extrusion in 12.5% of cases [16], and a higher recurrence rate [2, 23]. As suture extrusion is related to the use of permanent sutures, the author’s combined technique is recommended since scoring the cartilage helps to weaken it, thus allowing the use of not-perma- nent stitches for molding the cartilage and extrusion is rare. At present, many Authors agree that the combined techniques show a high success rate with a low complication rate [24].

54.4 Discussion

Over 200 otoplasty techniques have been described since the first otoplasty which is credited to Dieffenbach who used postauricular skin excision to correct prominent ear [25].

Surgical techniques can be grouped into procedures to create the antihelical fold, to correct the concha defect, and to control the position of the lobule. Those addressing the correction of the antihelix keep the fundamental step to correct the prominent ear. They can be grouped into cartilage-cutting techniques and carti- lage-sparing techniques. With the cartilage-cutting techniques the cartilage may be incised either full thickness or partial thickness in the anterior or posterior side. They include the ancient methods of fullthickness incisions: a single incision in the posterior surface of the ear at the location of the proposed antihelical fold [26]; two parallel incisions on the posterior surface of the ear behind the antihelix to tube the island of cartilage in between that is secured with sutures to create the antihelical fold [27]; a scaphal incision on the posterior face of the ear to undermine the anterior surface of the cartilage in order to expose it for direct scoring of the antihelical cartilage, then folding the cartilage back and fixing it with buried sutures [28]; two parallel incisions on the posterior surface of the ear behind the antihelix to create a crescent of cartilage, the edges of the adjoining remaining cartilage are undermined and sutured together just under the cartilage crescent to create the antihelix [29, 30]. These methods retain the risk of creating visible contour irregularities and/or sharp edges.

The scoring techniques are partial-thickness methods based on the original observation of Gibson and Davies that cartilage bends away from the side of injury [31]. Following them Stenstrom [32] scored cadaveric auricular cartilage on one side and observed the cartilage curving away from the direction of the scoring. Thus he described scoring the anterior surface of the ear cartilage to create the antihelical fold. He also showed that deeper furrowing resulted in more profound bending.

Many instruments were then used for anterior scoring including rasp, abraders, Adson-Brown forceps, and hypodermic needle [33]. Posterior scoring has been described too by dermabrasion to weaken the cartilage, combined with mattress sutures [34]. The validity of this approach was confirmed by the Weinzweig’s studies [35] on rabbits that showed that anterior perichondrium rasping initiated a cartilage regeneration process over the convex surface of the newly created fold.

The cartilage-sparing techniques were developed to avoid the contour irregularities of the cartilage-cutting ones. They basically imply the use of sutures and the cartilage is not incised. Mustarde horizontal mattress sutures for antihelical folding date back to 1963 [36] and Furnas chonchal-mastoid suture for the concha set back and for derotating the ear was introduced in 1968 [37]. It consists of the use of a full-thickness mattress suture placed in the conchal cartilage sutured to the mastoid fascia.

Conchal hypertrophy may be corrected by Furnas suture, by repositioning the posterior auricular muscle [38], through an excision of a crescent of cartilage of the lateral wall, through scoring its anterior surface [2], or by a combination of techniques.

The lobule is the lower noncartilaginous portion of the auricle, the position of which is related to the position of the caudal helix to the conchal bowl. Lobule set back is a difficult objective [2, 23] and may be addressed through a fishtail skin excision [39], wedgeexcision, and a deep dermis to scalp periosteum suture [40]. The author’s approach to correct the lobule protrusion is through a medial repositioning of the caudal helix toward the concha by scoring the tail of the helix and then fixing it to the adjacent concha with the lower mattress Mustarde suture. This maneuver serves to retropose the lower third of the ear and to medialize the ear lobule as well.

From an historical point of view, after the description of the basic techniques, the combination of

techniques to address the deformity started. In 1959, Farrier combined anterior scoring through two cartilaginous incision perpendicular to the antihelix with horizontal mattress sutures and conchal-mastoid suture after weakening the concha through the shaving of an elliptical disk of cartilage [41]. In 1967, Kaye combined cartilage anterior scoring with placement of mattress sutures through three longitudinal stab incisions in the anterior skin [42]. In 1982, Francesconi otoplasty combined anterior scoring with Mustarde sutures and extended the superficial scratching and mattress suture to the helical tail for the retropositioning of the ear lobe [43].

Nowadays, otoplasty techniques are continuously modified and refined, and the more recent trend today is the use of a graduated approach that combines elements of various techniques to address the ear deformity [24]. Moreover, as in each person the two ears are neither equal nor symmetric, the surgical technique needs to be individualized.

With the technique presented here the author has attempted to overcome many drawbacks. It is a combined procedure, using the closed anterior scoring technique along with mattress sutures to the posterior cartilage, as it has already been described by some other authors such as Francesconi [43], and Bulstrode [33]. The abrasion of the anterior cartilage represents the best way to obtain a natural and harmonious profile of the ear. Then, the internal mattress sutures combined with external transfixed stitches are used for molding the antihelical fold, for long lasting stabilization and to avoid overcorrection or malposition.

As the author’s approach is a graduated one which can be tailored to prominent ear of any grade, it also allows the correction of cup ears of mild degree. In case of cup ear, the feasibility of the technique is tested by bending the antihelix with digital pressure to create the new antihelical fold. If this maneuver corrects the deformity, it is possible to apply the technique for achieving the correction of the defect (Fig. 54.17).

Some technical points render the author’s approach peculiar. The avoidance of postauricular skin excision helps in reducing the possibility of cheloids as the skin suture is tension-free. Skin preservation has also been advocated by Kelley et al. [23] to compensate the excessive skin retraction that can obliterate the postauricular sulcus or draw the midhelix into a hidden position on the front view. The use of the Stenstrom

otoabrader that is a standard surgical instrument, makes the anterior scoring safer and more predictable than the modified needle used by Bulstrode and Martin or the Adson Brown forceps used for scoring of the Farrior technique. The use of methylene blue to accurately mark and tattoo the position of the mattress sutures is a useful addition that Francesconi did not describe. It also helps to standardize the method and makes the result more predictable.

Another important point of note is the anterior scoring of the tail of the antihelix and the anterior concha and the inferior mattress suture to derotate the inferior ear. It also turns the ear lobe toward the mastoid allowing a certain degree of repositioning of the ear lobe (Fig. 54.18). This technique allows us to obtain a harmonious antihelical contour with a smooth and well-rounded fold, avoiding cartilage irregularities or sharp edges (Figs. 54.19 and 54.20). It usually leaves the patients very satisfied.

Preoperative 21-year-old woman showing lobule protrusion. (b1, b2) Eight months postoperative after lobule set-back by scoring of the tail of the antihelix and the anterior concha and positioning of the inferior mattress suture to derotate the inferior ear

M. Salgarello