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antihelical cartilage to facilitate the creation of the antihelical fold with sutures.
However, CCTs can result in prominent contours and sharp edge deformities [10].
CSTs reduce resistance in the cartilage with partial incisions and scoring. CSTs
offer intraoperative reversibility [11]. The major advantages of these techniques are
maximum preservation of cartilage support, minimal scarring and contour irregularities, and ease of cartilage shaping with sutures [7]. CSTs are particularly easier
in ears with soft cartilage [10]. However, it may be difcult to achieve the desired
results with these techniques in rigid and thick cartilage. Mustarde (1963) is considered the pioneer of CSTs and describes the use of multiple horizontal mattress
sutures to create the antihelical fold [11]. The main objection to this technique is the
cheese-wiring effect on the cartilage at the points where the suture passes, resulting
in fragmentation of the cartilage. This cheese-wiring effect, combined with the
memory and elastic nature of cartilage, leads to recurrence. Studies have shown up
to a 40% rate of auricular retroposition in the rst postoperative year compared to
preoperative levels [12].
CSTs also use scoring to weaken the cartilage, but the incision does not go
through all layers of the cartilage [10]. After Gibson and Davis found that a fold
could be easily created after scoring the cartilage [13], Stenstrom [14] and Chongchet
[15] used this technique in otoplasty. However, scoring alone is not sufcient and
may result in sharp edges, contour irregularities, and/or recurrence in CSTs depending on the cartilage structure [16].
Furnas described the conchomastoid suture, which can be used in both cartilagecutting and CSTs and provides a solution to the depth of the conchal bowl [17]. If
the conchal bowl is too deep and there is no antihelix, conchal resection is combined
with cartilage-sparing or cutting techniques [10]. If the pathology is only conchal
hypertrophy, an elliptical excision of the cartilage from the conchal margin is
sufcient.
The successful results of CSTs and their preservation of contour deformities
have led to the development of incisionless otoplasty techniques [10]. Incisionless
otoplasty techniques were rst introduced in the literature by Fritsch’s percutaneous
permanent subcutaneous horizontal sutures [18]. In this technique, the anterior surface of the antihelical portion is scored subcutaneously with a 21-gauge needle to
create the antihelical curve. Three percutaneous Mustarde sutures are placed to
form the antihelical fold. To ensure that each stitch is subcutaneous, the needle
should be inserted at the exit point. Fritsch, the proponent of incisionless otoplasty
techniques, placed a Furnas suture subcutaneously between the mastoid and the
conchal bowl using endoscopy to treat the deep conchal bowl. Peled described
another incisionless otoplasty technique in which he added the anterior scoring
technique and operated on 20 patients with this incisionless otoplasty technique; he
reported no recurrence during the 6–30month follow-up period [19].
Due to the difculty in adjusting the distance between the helix and the scalp, the
risk of recurrence, long operative times, prolonged postoperative ear bandaging, and
potential complications with both cartilage-cutting and CSTs, Özturan etal. developed the percutaneous adjustable closed otoplasty (PACO) technique [20]. This section discusses general information about otoplasty, auricular anatomy and histology,
13 O t opla s t y
273
auricular embryology, treatment options for prominent ears, preoperative preparation, incision, closure, dressing, postoperative care, patient follow-up, complications, and revision otoplasty.
13.2 General Information
13.2.1 Auricular Anthropometry
To effectively perform auricular reconstruction and correction procedures, a thorough understanding of normal auricular anatomy is essential. This knowledge
includes the size and location of the auricle on the face and its relationship to various structures. In several studies, the auricle was measured in healthy and disabled
individuals from birth to adulthood [21–23]. Thus, an idea has been formed about
the age group in which the auricle reaches adult size. This information varies with
the patient’s gender, age, and height and inuences the surgical planning strategy [24].
Cephalometric measurements have gained importance toward the end of the last
century. In the United States, Farkas established the normalization values for ear
anthropometric measurements. This study collected manual auricular measurements from volunteers and patients [25]. In another study, standard photographs of
over 1000 normal and malformed ears were taken and analyzed using a computer
[24]. The purpose of these measurements is to appropriately plan surgery for auricular corrections.
The auricle should tilt posteriorly at an angle of less than 30 degrees in the mastoid plane. Any deviation from this angle, such as scars, contour changes, differences in height and length, will be easily noticeable. Since there are two ears, their
skin color, texture, and thickness are very important, and they should be in the same
position, size, and width [26].
The vertical length of the auricle is 5–6cm, while its width is about 55% of its
length. The auricle is tilted 20 degrees posteriorly relative to the vertical plane along
its long axis. The helix is usually 1–2cm away from the mastoid skin, with a protrusion angle between 21 and 30 degrees [27].
The line from the superior helix, the highest point on the long axis of the auricle,
to the anterior edge of the earlobe should be parallel to the line on the nasal dorsum
[28]. The straight line connecting the anterior helix and the earlobe should extend to
the posterior edge of the mandibular ramus. The line at the inferior end of the earlobe should be at the same level as the nasal tip. The point where the helix joins the
head should be level with the lateral canthus. The distance between the lateral helix
and the orbital rim should be approximately equal to the width of the ear. The superior apex of the helix should be level with the highest point of the eyebrow. The
external auditory canal should be at the midpoint between the eyebrow and nasal
tip. The measurements of both ears should be the same. The contours of both ears
should be the same. The posterior edge of the ascending mandibular ramus and the
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R. Dogan et al.
position of the temporomandibular joint are very important in determining ear position [24].
13.3 History
Prominent ear is the most common congenital auricular deformity [29]. Otoplasty
techniques are used to correct various auricular deformities, including prominent
ears, constricted ears, Stahl’s ear, cryptotia, and others. Various treatments and techniques (excision, adhesion, suture, carving, and auricular cartilage reshaping) have
been described to correct these deformities. Over 200 techniques have been
described for the surgical correction of prominent ears, indicating that no single
technique is sufcient to correct these problems.
The earliest known record of otoplasty techniques dates back to the seventh century in the texts of Sushruta [30]. Dieffenbach rst used the otoplasty technique for
prominent ears (post-traumatic) in 1845, using a postauricular skin incision combined with conchomastoid xation [31].
The rst aesthetic surgery for prominent ears was described by Ely in 1881, who
corrected prominent ears with a full-thickness composite resection involving the
anterior skin, cartilage, and posterior skin [32].
Morestin (1903) presented a technique that included conchomastoid sutures,
antihelical (Mustarde) sutures, antihelical incision, and thinning of the posterior
surface of the prominent cartilage. This technique was overlooked for years because
it was published in an orthopedic journal [33].
In 1910, Luckett recognized that the formation of the prominent ear deformity
was due to the congenital absence of the antihelical fold [34]. He combined skin and
cartilage excision with horizontal mattress sutures along the antihelical fold and
introduced the technique of repositioning the ear by excising the postauricular skin
to repair the deformity. Luckett made a longitudinal vertical incision in the ear cartilage to mimic and create the antihelical fold, using everting sutures to maintain the
new shapes of the scaphal and conchal cartilages. The main limitation of this method
is the creation of a sharp antihelix. His most signicant contribution to otoplasty
technique was the use of postauricular skin excision [34].
Morestin [33], Keen [35], Monks [36], Cocheril [37], and Gersuny [38] revised
the restoration of the antihelical fold initially described by Luckett in their
techniques.
In 1952, Becker described the concept of the conchal antihelical tube using a
combination of cartilage incision and suture techniques to create soft and smooth
contours in prominent ears [39]. This technique was revised and developed by
Converse in 1955 [40] and later by Converse and Wood-Smith in 1963 [41]. CCTs
were further developed by Farrior and Pitanguy in the 1960s [42, 43].
In 1958, Gibson and Davis demonstrated that scoring one surface of the cartilage
would cause the cartilage to bend to the opposite side [44]. This nding inuenced
Chongchet (1963) [15] and Stenstrom (1963) [14], who proposed techniques to correct prominent ear deformities with anterior scoring. In these techniques, the
13 O t opla s t y
275
auricular cartilage bends towards the opposite side of the scoring and assumes its
normal position.
Chongchet’s technique used sharp scoring from the antihelix to the scaphal cartilage laterally [15]. Stenstrom presented a technique that involved multiple supercial abrasions on the anterior surface of the ear cartilage to create a new antihelical
fold. Stenstrom used a rasp to score the antihelix [14].
Gibson and Davis’ experimental observations showed that scoring one side of
the cartilage would cause the cartilage to open to the other side [44]. Stenstrom and
Heftner applied this technique to patients with an inadequate antihelical fold and
those with a deep concha [45].
In 1963, Mustardé introduced his suturing technique to create a new antihelical
fold [46]. This technique protected against the sharp and prominent edges would
result from that any cartilage cutting or removal technique. Mustardé’s technique
involved placing permanent sutures on the posterior surface of the ear cartilage to
create a soft and natural antihelical fold [47]. The limitation of this technique is that
the sutures can become loose and its effectiveness is limited in rigid cartilage. Its
most important and useful feature is its ease of application without causing contour
deformity.
In 1967, Kaye combined Stenstrom’s technique of scoring the anterior surface of
the cartilage with Mustardé’s technique of placing permanent sutures behind the ear
[24]. This combined technique, the rst of its kind, involved drawing vertical curved
lines on the anterior perichondrium to weaken the cartilage and placing mattresstype sutures behind it to create and maintain the new shape.
Furnas introduced the conchomastoid suture for the repair of prominent ears in
1968 [17, 48]. In this technique, after removing the contents of the postauricular
sulcus (postauricular muscle and adipose tissue), the concha is laid down from front
to back in the sagittal plane and secured to the mastoid fascia with permanent
sutures.
Elliot proposed concha reduction to reduce the size of the deep and wide concha
when suturing the ear from front to back was insufcient [49]. The advantage of this
technique is that it gives the surgeon easy access to the concha when needed. The
conchal reduction procedure can be performed when the surgeon feels that sutures
alone will not provide adequate correction. In this way, the conchal reduction procedure is seamlessly integrated into the otoplasty procedure.
Bauer etal. described a modication in which both the cartilage and the overlying skin are excised together [50]. This modication can be used when there is
excess skin after conchal reduction.
Webster emphasized the importance of good control of the earlobe for successful
otoplasty [51]. He noted that moving the tail of the helix medially after releasing it
from the back will change the orientation of the earlobe.
The success of CSTs has led to the development of incisionless otoplasty techniques. Fritsch described the rst incisionless otoplasty technique, explaining the
incisionless technique with permanent mattress sutures placed percutaneously at the
subcutaneous level [18]. In a series of 13 patients with a mean follow-up of 6months,
only one patient had a recurrence, which was attributed to suture failure. Peled’s
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R. Dogan et al.
approach uses a similar technique with the addition of scoring the anterior surface
of the cartilage [19]. In a series of 20 ear surgeries, no recurrences were observed at
follow-ups ranging from 6 to 30months. Although the long-term effects of this
suture technique are unknown, Fritsch emphasized that cartilage can be bent with
external splints, and these percutaneously placed sutures could have the same effect,
with long-term suture failure being clinically insignicant.
Graham and Gault’s endoscopic otoplasty approach aims to access the cartilage
of the ear from behind through the temporal scalp [52]. After weakening the posterior surface of the cartilage by abrasion, the antihelical fold is created. The antihelical fold is maintained with permanent scaphal-mastoid sutures placed through
small postauricular incisions. The displacement of the scar to the temporal scalp
region is mentioned as a way to prevent the formation of keloids or hypertrophic
scars on the ear. In their study, Graham and Gault achieved good results with this
endoscopic approach in 18 ears with prominent ear deformity, and no recurrences
were observed in these cases. Although such minimally invasive techniques currently promise good results, long-term follow-up results are needed before they can
be recommended as the preferred technique.
Özturan recently described the latest incisionless otoplasty technique,
Percutaneous Adjustable Closed Otoplasty (PACO) [20]. This technique has been
shown to be particularly suitable for soft cartilage; it is incisionless, easy to perform, allows easy adjustment of the ear-to-auricular distance, has low complication
rates, and is effective and reliable. A comparative study of CSTs and PAKO has
been performed by the same hands [53].
13.4 Anatomical Basis ofProminent Ears
To be successful in otoplasty, it is necessary to understand the anatomical structure
of both the normal ear and the prominent ear. This knowledge allows for better preoperative evaluation, surgical planning, and patient satisfaction.
The main causes of prominent ears are:
1. Conchal hypertrophy or excess (high polarity, low polarity, or both)
2. Antihelical fold insufciency (central part of the antihelix, superior crus, inferior
crus, or all)
3. Conchoscaphal angle greater than 90 degrees
4. Combination of conchal hypertrophy and underdevelopment of the antihe-
lical fold.
Other causes include cranial abnormalities, lobular protrusion, and anterolateral
displacement of the helical tail [51]. It is important to note that prominent ear deformity is bilateral. However, as Spira etal. pointed out, different deformities can be
present in each ear [54].
Egloff etal. classied the anatomical deformities associated with prominent ears
[55]. According to this classication:
13 O t opla s t y
Type-1: Absence of antihelix and presence of conchal hypertrophy
Type-2: Presence of antihelix and presence of conchal hypertrophy
Type-3: Absence of antihelix and normal concha
Type-4: Lateral lobule with one of the above types
277
13.5 Objectives inCorrecting Prominent Ears
The purpose of otoplasty is to create normal anatomical features, permanently position the auricle in its anatomical position, and provide a natural aesthetic appearance [56].
As with other facial aesthetic procedures, the goal of this surgery is to create an
ear with natural-looking proportions, a strong aesthetic structure, and a ne aesthetic structure. Successful correction is achieved by making the contours of the
helix and antihelix symmetrical with the opposite ear [57].
The specic surgical goals of otoplasty include the following [58, 59]:
1. To denitively correct anatomical defects such as an underdeveloped antihelical
fold, increased conchal height, and other contour abnormalities.
2. The concha should be aligned with both the superior and inferior pole.
3. The increased auriculocephalic angle and distance should be corrected.
4. The lateral helical rim should not be posterior to the middle part of the auricle
compared to the dorsal part of the antihelix.
5. The postauricular sulcus should continue.
6. Asymmetry between the ears should be 3mm or less.
7. There should be no irregularities, scar tissue, or sharp edges on the anterior and
posterior surfaces.
13.6 Preoperative Evaluation ofProminent Ear Patients
Preoperative analysis and identication of various anatomic deformities are critical
to successful outcomes [1, 59–61].
Specic anatomic deformities should be systematically recorded during the initial evaluation of the patient. Inadequate preoperative observation is the most common cause of surgical correction failure and postoperative dysfunction. Therefore,
a systematic approach should be used to note the general symmetry, size, shape,
projection, and contour of the ear. This process should be performed with the participation of the patient or the patient’s family [57]. The preoperative systematic
evaluation of patients with prominent ears should be performed in the following
order [57]:
1. Degree of antihelical fold.
2. Depth of the conchal bowl.
3. Flatness and deformity of the lobule.
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R. Dogan et al.
4. Angle between the helical rim and the mastoid.
5. Stiffness and inclination of the auricular cartilage.
To evaluate auricular protrusion, the distance between the auricle and the scalp is
measured both preoperatively and postoperatively. These measurements are used to
safely compare the ears bilaterally.
Adamson et al. [57] demonstrated this evaluation by taking measurements at
three points:
1. The top of the rim
2. The most lateral point of the middle part of the rim
3. One point from the level of the intratragal incisura
In these measurements, the ideal ranges are 10–12 mm for the superior part,
16–18mm for the middle part, and 20mm for the level of the caudal helix [57].
Messner and Crysdale [6] have demonstrated this evaluation by taking measurements at four points, believing that this would provide a better evaluation of the
auricle.
1. The level of the upper end of the helix (Superior point)
2. The level where the crus of the helix attaches to the head (Superior line)
3. The level of the upper end of the tragus
4. The level of the intertragal sulcus
The ideal distances for these measurements are 8–10mm, 10–12mm, 16–18mm,
and 20–22mm, respectively [62].
Gentle pressure on the helix can reveal the antihelical fold, helping to understand
the desired amount for surgical correction. This can also be used to assess the compliance of the cartilage. Similarly, the amount of conchal setback can be understood
by applying pressure to the top of the conchal bowl with a cotton applicator. Finally,
standard preoperative photographs should be taken; including bilateral full and
enlarged lateral views, as well as frontal, rear, and oblique views [61].
13.7 Timing oftheRepair
The ear is 66% of adult length and 76% of adult width at birth [27].
The goal is to correct the deformity prior to the socialization process to minimize
the patient’s exposure to peer ridicule. The literature indicates that this deformity
causes signicant psychosocial distress and that there are improvements in many
psychosocial parameters, such as postoperative psychosocial distress, following
otoplasty [7, 63, 64].
Determining the most appropriate time for otoplasty is based on auricular size
and school age. The general consensus is that prominent ears should be repaired
13 O t opla s t y
279
between the ages of 3 and 6, before the child enters school, to avoid peer pressure [65].
Studies have shown that performing otoplasty on children between the ages of
ve and eight years does not interfere with ear growth and development [66], Gosain
etal. [62] have shown that otoplasty is safe and does interfere with auricular the
growth even in children between the ages of 9months and 4years. The advantages
of performing otoplasty at these early ages are that the ear cartilage is easier to
shape, CSTs can be safely used, and there is less need for CCTs [62]. Balogh and
Millesi have shown that growth of the ear continues after surgical correction in 76
patients who underwent prominent ear otoplasty with cartilage excision [8].
However, many surgeons also indicate that it is necessary to wait until the deformity
is established, and the child can express themselves, in accordance with the nature
of the cosmetic and the cooperation of the patient [65, 67, 68].
The choice and timing of the procedure depend on the patient’s maturity, appropriate ear development, the psychosocial burden of the deformity, and the pliability
of the developing ear cartilage. Abnormalities in the size of the external ear are usually present at an early age. To minimize potential psychosocial stress, many surgeons recommend correction before the child begins to socialize. Although
correction of the deformity is the primary motivation for correcting negative social
effects, additional factors leading to the decision for surgery should also be considered. In many cases, the child is expected to be mature enough to actively participate in postoperative care [69].
13.8 Treatment Methods forProminent Ears
It has been approximately 133years since the rst description of the correction of
prominent ears in 1881. During this time, the various procedures used to correct this
pathology have been among the most discussed methods. Our primary goal in correcting this pathology is to reshape the ear, correct the contour, and thus prevent it
from attracting attention. To this end, more than 200 surgical techniques have been
described. This situation indicates that there is no single and simple method that is
effective for all ear deformities.
The techniques used to correct prominent ears can be divided into two main
categories:
1. Conservative treatment
2. Surgical treatment
(a) Cartilage-cutting techniques (CCT)
(b) Cartilage-sparing techniques (CST)
(c) Minimally invasive techniques (incisionless otoplasty)
(d) Combined techniques
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R. Dogan et al.
13.8.1 Conservative Treatment
Matsuo etal. reported in their study that all cases of prominent ears treated with
surgical tape within 3days of birth showed complete correction at 6weeks with no
recurrence observed [70]. However, there is a lack of data regarding the exact timing
of taping. According to Matsuo etal., the incidence of prominent ears increases
from 0.4% at birth to 5.5% at one year of age, resulting in the development of a
prominent ear deformity [70].
Ear splinting is a simple, effective, and inexpensive treatment for congenital
auricular deformities. Correction should ideally be performed within the rst 3days
after birth when the auricular cartilage is soft and elastic [71]. These splinting techniques are remarkable, especially in the neonatal period, as many cases can be
treated without the need for surgical correction [56].
Non-surgical correction of prominent ear deformities generally has poor results
in older children. Non-surgical treatment within the rst ve days of life is usually
sufcient. Tan et al. followed patients who underwent auricular molding from
3 days after birth to 6 months and reported excellent results. The success rate
decreases when the treatment is delayed. Tan pointed out that the pliability of the
cartilage is related to the decrease in estrogen levels after birth [71, 72].
Estrogen levels are high in the rst 3days after birth and return to normal levels
by week 6 [70, 71]. High maternal estrogen levels during this period make the auricular cartilage vulnerable to external forces [71].
Early ear casting is not yet common practice in neonatal care, but it has excellent
results with very few complications. This technique should be recommended to all
families with infants with ear deformities. Audiologists performing newborn hearing screening should also be aware of this issue.
13.8.2 Surgical Treatment
(a) Cartilage-Cutting Techniques (CCT)
CCTs were the rst techniques used to repair prominent ears. CCTs include cartilage incision, wedge excision, scoring, and abrasion. The goal of these techniques
is to eliminate the natural elasticity of the cartilage with incisions to ensure longlasting surgical results [56].
CCTs are used in cases of stiff and thick cartilage. Full-thickness or halfthickness incisions are made from the anterior and/or posterior surface of the cartilage. Cartilage can be removed to assist in the reshaping of the ear. Any
cartilage-cutting technique carries the risk of creating visible contour irregularities
and sharp edges. These risks may affect aesthetic acceptability [56].
Excisional techniques reduce conchal hypertrophy. These techniques can be
divided into two categories: those that involve excision of cartilage only and those
that involve excision of both cartilage and skin. Posterior approaches are used in
cartilage-only techniques. When both cartilage and skin are to be removed, an
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281
anterior approach is used. There is no proven difference between the anterior and
posterior approaches. The choice of approach is a matter of personal preference [73].
Ely used CCT in the rst aesthetic surgery he described. This procedure involved
a full-thickness resection of the anterior skin, cartilage, and posterior skin [32].
Luckett emphasized the importance of restoring the underdeveloped antihelical fold
in the prominent ear deformity in 1910 [34]. In Luckett’s original procedure, a semilunar segment was excised from the posterior cartilage, and the remaining surfaces
were sutured back together to form a new antihelix. However, this creates an unnatural-looking sharp edge. As a modication of this single-incision technique, a new
antihelix was created by making longitudinal parallel incisions on either side of the
antihelix. When these edges are folded back, they take on a tubular appearance.
Later, a round, natural-looking antihelix is formed by smooth suturing [74]. CCTs
were developed by Backer, Converse, Farrior, and Pitanguy in the 1940s and 1960s
[39–42].
Converse’s technique is a classic example of a complex CCT [40, 41] (Fig.13.1).
In this technique, injection needles are inserted full-thickness from the anterior to
the posterior surface of the skin to dene the area where the antihelix will form. The
needles are then stained with ink or methylene blue to mark the cartilage. The skin
is elevated by dissection over the perichondrium. Medial and lateral incisions are
then made in the areas marked by the needles without damaging the anterior perichondrium. To better form the superior antihelical arch, a separate incision is added
parallel to the cephalic helical contour and between the two previous incisions. It is
important that these three incisions are not connected. The posterior surface of the
antihelical region is then smoothed and shaped with a diamond burr. A new antihelical fold is created by forming a tubular structure and suturing [40, 41]. Postauricular
tension sutures maintain the shape of the newly formed antihelix.
Another method, rst introduced by Becker (1949), is characterized by dividing
the auricle into two segments to reduce tension in the cartilage. In Becker’s technique, incisions are made on the anterior and posterior surfaces of the antihelix, and
a new antihelix is formed with posterior abrasion and xation sutures [39].
Fig. 13.1 Converse
technique