Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4507_Библиотеки_им_академика_М_И_Перельмана.pdf
282
R. Dogan et al.
Based on this method, Walter and Klein (1994) developed their own technique
[75]. A semicircular incision is made behind the ear 1cm from the helical rim, ending before reaching the auriculomastoid sulcus to avoid blunting. The posterior skin
of the ear is then elevated in the supraperichondrial plane. Subsequent incisions are
made in the cartilage. Similar to the skin incision, a semicircular cartilage incision
is made, leaving 1cm of cartilage on the periphery, regardless of the presence of an
antihelical fold. These incisions are made where the cartilage meets the mastoid
bone at the top and bottom. In the caudal region, the cauda helicis is separated from
the main cartilage. The appropriate conchal height is then determined by pressing
the bowl. Continuing from the rst semicircular incision, the incision is extended
along the anterior edge of the inferior crus. Considering the appropriate conchal
height, the incision is terminated at the intertragal distance, dividing the conchal
cartilage in two. The excess of the concha is resected and removed.
However, excessive cartilage resection from the middle part of the ear can lead
to the “telephone reverse deformity.” The dividing incision at the level of the inferior crus is made on the anterior surface, over the perichondrium, and dissected
forward to reach the anterior helical ligament, where the cartilage is cut to relieve
tension and the scapha is laid back. Care must be taken not to cut the temporal artery
at this stage. The antihelical cartilage is then thinned and reshaped. An appropriate
amount of posterior ear skin is resected, and the incisions are closed [75].
The otoplasty technique of splitting the cartilage and superimposing the separated pieces was introduced by Nachlas in 1970 (78). In this procedure, a postauricular incision is made, and the area where the antihelix is to be formed is marked
with 25-gauge needles dipped in methylene blue. An elliptical skin resection of
1cm thickness is performed. Sometimes, if there is a prominent earlobe, this incision can be hourglass shaped. The needles are removed. The cauda helicis, fossa
antihelicis, scapha, and conchal cartilage are exposed through a postauricular elevation. A Cottle knife is used to make an incision in the scaphal cartilage. The incision
is made 5mm anterior to the methylene blue markings that dene the neoantihelix.
The incision is made parallel to the helix edge and inclined toward the helix apex
until 5mm remains. Triangular pieces of cartilage are removed at the upper and
lower edges of the incision. Removal of these triangles allows the cartilage segments to overlap without folding. Resection of the cauda helicis prevents the lobule
from springing out. After the cartilage incision, the anterior surface of the medial
ap is reached and a 1cm decolletage is made, then the posterior surface is thinned
with a diamond burr until a smooth and round neoantihelix is formed [76].
Pitanguy described a simple technique; he creates small cartilage islands by
making incisions parallel to the area where the desired antihelical fold will be
formed. This island is then advanced, and the open ends of the cartilage are joined
with a mattress suture to form the antihelical fold, with the island cartilage remaining in front [43, 77]. Werdin etal. used a modied version of Pitanguy’s technique
in 2007. According to the authors, Pitanguy’s technique provides good and predictable aesthetic results [1].
13 O t opla s t y
283
The posterior approach to the concha was described by Beasley and Jones. This
technique emphasizes segmental resection of the lower part of the conchal bowl
when the antitragus is prominent and there is thinning in the ponticulus [78].
Elliott and Bauer favor the anterior approach. They argue that after cartilage
excision, the excess skin will not shrink sufciently after surgery to prevent a visible
fold on the conchal oor. To achieve this, both the cartilaginous portion of the concha and the skin are excised through the anterior approach [49, 50, 61].
The goal of these procedures is to break the elastic resistance to create the antihelical fold. The preferred surgical instruments for this procedure are surgical
knives, rasps, les, and diamond burrs [79].
A large and prominent earlobe can also be a component of a prominent ear deformity. Surgery directed at the lobe is usually performed in conjunction with cutting
techniques.
A large lobule can be easily addressed at the same time as the otoplasty. Many
techniques have been described. One of the simplest is a simple crescent skin and
soft tissue excision [57].
A large earlobe is often associated with prominent ears. Unfortunately, the new
antihelical fold created by Mustarde’s technique can exacerbate this nding [80].
Therefore, special attention should be paid to the lobule in otoplasty operations. A
lobule that is not prominent before surgery may become more prominent after the
techniques used.
If there is an overdeveloped cauda helicis, it will contribute to the prominent
appearance by turning the lower part of the ear cup more medially. In this case,
shaving the piece of cartilage that forms the cauda helicis would be appropriate.
However, if the lobule is overdeveloped or sagging in older patients, a lobule reduction procedure should be added. Lobule reduction techniques are described in the
literature [81–83] and may be used in combination with other otoplasty techniques.
(b) Cartilage-Sparing Techniques (CST)
CPTs were rst developed in North America [55]. Suturing techniques are simpler and preferred over sculpting techniques because they are more controlled.
These techniques prevent permanent changes in the cartilage structure and provide
reversibility [65, 84].
The advantages of these techniques include maximum preservation of cartilage
support, low likelihood of scarring, low contour irregularities, and ease of suturing
[57]. CSTs have been developed to protect against potential contour irregularities
that may result from CCTs. Suture techniques are suitable for thin or exible cartilage. They do not create contour irregularities and do not incise the cartilage.
However, when used on stiff cartilage, they may not provide adequate correction [57].
In 1963, Mustarde rst described multiple horizontal mattress sutures to create
the antihelical fold [11]. Today, it is widely used alone or in combination with other
techniques. The surgeon shapes the antihelix according to the desired correction by
applying pressure to the auricle. The surgeon places the sutures by palpation during
284
R. Dogan et al.
this external pressure thus placing the sutures without traumatizing the soft tissue.
Scaphoconchal sutures include a 4–6mm segment that encompasses the cartilage
and anterior perichondrium. The superior and inferior crura are tensioned rst. The
superior suture is placed rst, between the superior scapha and the fossa triangularis. It is then placed at the very bottom of the antihelix. As a result, a smooth-edged
antihelix is created through various interventions with the sutures. Placing the
sutures at different distances to create a contour advantage minimizes the appearance of the deformity [11]. To create the antihelix, 2–4 4–0 Polyester Mustarde-type
horizontal mattress sutures are used. Some surgeons use markers, temporary sutures,
or needles as indicators, while others use nothing [57].
The lowest suture should begin 5mm superior to the tail of the antihelix. If the
outer part of the sutures is too close to the edge of the ear, a post-like (pole-like)
deformity can occur. To avoid all these complications, it is recommended that the
lateral part of the suture passes 1cm from the free edge of the ear, and that the distance between the medial and lateral legs of the suture is 16mm. The lowest suture
should cause the cauda helicis to shift backward. The surgeon adjusts the tightness
of the sutures by looking at the ear from the front and according to the formation of
the antihelix. Finally, all sutures should be placed before tying the knots [4, 57].
Johnson (1994) argued that these mattress sutures could give a more appropriate
shape to the helix fold if they are placed obliquely rather than radially [85]. This can
better correct the upper pole and prevent excessive folding in the antihelix. Some
authors have suggested placing two temporary sutures through the anterior surface
of the antihelix before the three Mustarde sutures that are recommended [86, 87].
The conchomastoid suture was described by Furnas in 1968. The conchomastoid
suture is used to correct excess and prominence of the concha [17]. The original
technique for this suture was described by Owens and Delgado in 1955 [87]. A
retroauricular incision is made parallel to the helical rim. The procedure is continued until the mastoid region and conchal cartilage are clearly visible. Retroauricular
soft tissues, connective tissues, fat, and muscle are excised extensively to the temporal muscle fascia. The auricle is rotated dorsally. The conchal cartilage and mastoid periosteum are sutured. About 2–3 sutures are used in this procedure.
The rst suture is placed superiorly and passed between the base of the fossa
triangularis and the mastoid periosteum. The suture is clamped and left in place
until the remaining sutures are placed. This suture pulls the concha posteriorly and
superiorly, preventing the entrance to the external auditory canal from narrowing
due to pressure from the conchal cartilage. A full-thickness suture is placed, including the anterior and posterior perichondrium and cartilage, but not the skin. The
second and third sutures are placed along the vector in the cavum concha and cymba
concha, respectively. The suture placed in the mastoid periosteum provides stability
to the concha and prevents it from opening. Once all stitches are properly positioned, they are tightened in the order in which they were placed. The middle suture
can be used to adjust the superior and inferior directions. The goal here is to prevent
the telephone ear deformity that results from excessive tightening in the middle
region. After all adjustments have been made, the nal suture is tightened. There are
several important points to remember to avoid potential complications with this
13 O t opla s t y
285
technique. Tightening in the superior portion is important to minimize the pressure
of the concha on the external auditory canal. Especially in the middle suture, excessive tightening should be avoided [17].
If the patient presents with a series of anomalies, the concha should be addressed
rst to minimize tightening with the Mustarde suture. The conchal depth should be
less than 2.5cm to effectively use the Furnas technique with the conchomastoid
suture [17, 68]. To minimize the number of stitches, strong bites should be taken
from the mastoid fascia. To minimize rotation or narrowing of the external auditory
canal, sutures should be placed in a posterior–superior direction [68].
If Furnas sutures are placed too far back on the concha or too far forward on the
mastoid, the conchal bowl will rotate outward and forward, reducing the diameter
of the external auditory canal [73]. Spira and Stal modied this technique by using
a lateral-based conchal cartilage ap and then suturing it to the mastoid periosteum.
This maneuver is necessary to bring the concha closer to the scalp and reduce the
protrusion. This technique offers the advantage of a thick cartilaginous ap, which
provides a more durable and precise suture to the periosteum and reduces the tendency to block the external auditory canal [88].
Conchal correction should be performed rst in the operation as less antihelical
correction is needed once the conchal position is established [60].
Although cartilage scoring techniques damage cartilage, they are considered
CSTs in the literature because they do not involve full-thickness incisions [87].
In 1958, Gibson and Davis showed that cartilage can bend in the opposite direction to the scored side [44]. They demonstrated this in their studies of costal cartilage. Fry later adopted this view and showed that scoring one side of the
perichondrium causes the cartilage in the auricle to bend toward the opposite side
[89]. Stenstrom [14] and Chongchet [15] developed this theory and applied it to
otoplasty. Chongchet made a longitudinal transcartilaginous incision on the posterior surface of the scapha to include the perichondrium on both sides laterally to the
desired antihelix. He then made scorings parallel to the antihelix on the anterior
surface, involving the perichondrium and partially the cartilage. This technique is
one of the preferred otoplasty techniques today [15]. The Stenstrom technique used
anterior scaphal scoring to create the antihelical fold. He later modied it by adding
a posterior approach [45] (Fig.13.2).
Trenite (1990) proposed a modication of Chonchet’s technique by adding three
mattress sutures through the perichondrium with 4–0 Vicryl to guarantee the results.
Another modication made by Trenite was to perform the dissection on the anterior
surface in a subperichondrial plane, which reduces the risk of skin color changes
and hematomas often seen in the rst operation. The procedure begins with an elliptical skin excision behind the ear, avoiding coming closer than one centimeter to the
free edge of the scapha and the retroauricular sulcus. Needles are inserted medially
and laterally to the desired antihelix region, an incision is made on the posterior
surface of the scapha perichondrium and cartilage passing through the lateral needles, then subperichondrial scoring is performed on the anterior surface, and nally,
three mattress sutures are applied as in the Mustarde method. One of the advantages
286
Fig. 13.2 Using
monopolar cautery to
soften the antihelix
R. Dogan et al.
of anterior scoring is that it can be effective in cases with thick cartilage where
Mustarde’s method is difcult to apply [90].
Staindl (1980) proposed a modication of Stenström’s technique. Here, scoring
is performed through tunnels opened in a subperichondrial plane with a posterior
incision, and mattress sutures are applied to the scored cartilage for stabilization
[91]. Ju etal. suggested scoring after making an anterior skin incision and lifting the
ap. They argue that scoring half of the cartilage in this method allows for more
effective and observable scoring [92]. Pilz etal. [93], Brenda etal. [12], and Vital
and Printza [94] scored the posterior part of the cartilage. According to these
authors, scoring the anterior surface in Stenstrom’s study creates step deformities in
the cartilage, resulting in a poor appearance. These three authors also used mattress
sutures, stating that the sutures help to curl the cartilage and reduce tension on the
sutures as the cartilage weakens. Various instruments have been used for scoring:
scalpel, les, elevators, diamond burrs, Adson-Brown forceps, subcutaneous needles, and bipolar cautery [95].
Kaye [24] and Tramier [96] used the anterior approach to place mattress sutures
to contour the auricle. They believed that this approach eliminated the need for
extensive ap dissection thereby minimizing postoperative discomfort and reducing
the risk of infection and bleeding. Pilz etal. prefer a modied version of the technique originally described by Stark and Saunders. This technique combines postauricular skin excision with controlled abrasion of the posterior cartilaginous
surface [93].
Messner and Crysdale [6] reported a loss of correction in the superior pole in
their otoplasty technique using the Mustarde and Furnas techniques along with
sutures between the fossa triangularis and the temporal fascia as CPTs. One-third of
their cases returned to the preoperative position, and another third had a nal appearance between preoperative and postoperative. Despite this loss of correction, 85%
of patients were satised with the results. Georgiade etal. highlighted the permanent prominence in the superior region in suture techniques [97]. To avoid this problem, they recommended placing scoring or a high vertical suture superior to
the helix.
13 O t opla s t y
287
Another cartilage-sparing method described by Horlock etal. is anterior cartilage scoring, posterior suturation, and posterior fascial ap with posterior suturation
in otoplasty [98]. Studies have shown that placing the suture under the posterior
fascial ap is effective in preventing suture extrusion [98, 99]. According to a comparative study of the postauricular fascial ap, the results are a low recurrence rate,
minimal complications, and the best cosmetic outcome [98].
Today, those who deal with prominent ear aesthetics rely mostly on suturing
techniques. They also use scoring and shaving when necessary to correct protrusion [57].
The main objection to suture techniques is that they can cause recurrence and
possibly cut or tear the cartilage. To avoid this complication, a suture can be placed
to encompass both the cartilage and the perichondrium. However, suturing is difcult due to the thin anterolateral ear skin, lack of subcutaneous tissue, and adhesion
of the perichondrium. Therefore, hydrodissection is used to open the space between
the subcutaneous perichondrium and prevent the suture from touching the skin [89].
There are studies showing that scoring in addition to suturing can lead to more
effective results. A study by McGarry KM etal. followed prominent ear outcomes
for 10years and concluded that anterior scoring is a low morbidity procedure in
appropriately selected patients. In this study, anterior scoring + suturing showed
lower complication rates and lower revision rates compared to suturing alone [99].
A current technique used to create the antihelical fold is the Chong-Chet anterior
scoring technique. In the modied Chong-Chet technique, elevating the perichondrium in this region and using it for xation in addition to anterior scoring has been
reported to produce longer lasting and better results [100]. Lemperle suggests making a hidden incision in the helix region. This ventral incision allows maximum
visibility of the antihelical region. Instead of abrasion or cutting the antihelix, he
recommends using dermabrasion. He states that this abrasion provides good results
by avoiding sharp edges and unwanted cartilage appearance [101]. A study by
Unverdi etal. suggests the use of the posterior auricular muscle complex ap technique. In this technique, the adipoperichondrial ap-assisted posterior auricular
muscle complex can be used to correct prominent ear deformities [102].
Current applications of CSTs include the medial-based perichondro adipodermal
ap technique. In a study by Mandour etal., this technique was used in 34 patients,
and they concluded that the technique is simple and safe with advantages such as a
natural-looking antihelical fold and minimal tissue stress. The use of a medial or
proximal-based adipodermal ap was mentioned to help reduce recurrence rates
and suture extrusion [103].
(c) Minimally Invasive Techniques
CSTs have been developed to protect against the complications of techniques
that involve cartilage. The success of CSTs has led to the development of incisionless otoplasty techniques [56].
Incisionless otoplasty was rst described by Fritsch in 1995 [18]. Fritsch
described his own incisionless technique using percutaneous permanent
288
R. Dogan et al.
subcutaneous horizontal mattress sutures. He used this method in 13 patients and
followed them for 6months, with only one patient having a recurrence. In this technique, the anterior surface of the area planned as the antihelical fold is scored subcutaneously with a 21-gauge needle. Sutures must be successfully placed. To ensure
that each is buried under the skin, the needle must enter the skin exactly where it
exits. Three percutaneous Mustarde sutures are then placed to create the antihelical fold.
Fritsch developed his technique to not only create the antihelix but also to retract
the concha and reshape the earlobe [104]. Recently, Fritsch combined his incisionless technique with conchal resection [11]. Peled’s technique is a simple suture
technique that includes anterior cartilage scoring [19]. He has operated on 20 ears
and observed no recurrence in 6–30months of follow-up.
Graham and Gault [52] have developed an endoscopic approach to otoplasty. In
this technique, the cartilage of the ear can be accessed from the posterior surface by
entering through the temporal region of the scalp. The antihelical fold is created
after abrasion and weakening of the posterior surface of the cartilage. Maintenance
of the antihelical fold is ensured with permanent scaphomastoid sutures placed
through small postauricular incisions. They mentioned that moving the scar to the
temporal region of the scalp could prevent the formation of keloids or hypertrophic
scars on the ear. In their study, Graham and Gault applied this endoscopic approach
to ears with prominent ear deformity and reported successful results without
recurrence.
Due to the difculty in adjusting the distance between the helix and the scalp in
cartilage-cutting and sparing techniques, Özturan developed the percutaneous
adjustable closed otoplasty (PACO) technique [20]. In this technique, 3–4 pieces of
3–0 white polyester sutures are placed in a horizontal mattress style between the
scapha and mastoid periosteum without making an incision on the ear to create the
antihelix and bring the auricle closer to the medial side. The distance between the
auricle and the scalp can be adjusted by tightening the knots as needed. The results
are satisfactory in these cases. This method, preferred when the cartilage is soft,
may be insufcient when the cartilage is stiff and contracted. In combined pathologies, the conchal hypertrophy can be corrected with an anterior approach at the
beginning of the operation, and then the PACO technique can be used to improve
cases with prominent ears with both pathologies. This technique is very suitable for
children with soft cartilage. The surgery takes an average of 20 minutes per ear
(Fig.13.3). It can be performed under local anesthesia in appropriate cases. No
pressure dressing is required after surgery. Patients can see the results immediately
when they return to their beds from the operating room. The effectiveness of the
PACO technique has been demonstrated in a comparative study with CST [53].
A study by Kang etal. states that the EarfoldTM implant, which assists in the
creation of the antihelix, can be used in selected cases [105]. It is mentioned that this
product can be used in combination with cavum concha reduction in selected
cases [106].
A study by Edafe etal. used the incisionless otoplasty technique in 32 patients
and found that this technique has high success and satisfaction rates at long-term
13 O t opla s t y
Fig. 13.3 PACO (Percutaneous adjustable closed otoplasty) technique
289
follow-up. Complications of this technique include early postoperative edema,
swelling, and uid collection [107].
(d) Combined Approach
In otoplasty techniques, a simple method is sought after proper evaluation to
achieve the desired result. For example, in a patient with an absent antihelical fold,
the cartilage must be weak and exible to achieve successful results with mattress
sutures. If the only deformity is the depth of the conchal bowl, an elliptical excision
is made along the edge of the concha. A conchomastoid suture can be placed
depending on the situation.
Today, many surgeons combine CCTs with CSTs to achieve the desired
results [56].
Webster [51] takes an eclectic approach to correcting prominent ears. His technique involves creating a natural-looking auricle using posterior skin excision, conchal resection, cartilage scoring, and antihelical mattress sutures.
Using a posterior approach, Stenström scored the anterior cartilage with an otodebrider and placed Mustarde-type horizontal sutures. In the presence of a deep
conchal bowl, full-thickness conchal rim cartilage excision was added to the treatment. This technique has been observed to have a high success rate and low morbidity [108].
In otoplasty techniques, although a posterior approach is generally recommended, some advocate an anterior approach alone, which reduces the operative
290
R. Dogan et al.
time to half an hour and has a much lower likelihood of keloid formation compared
to the posterior approach, or a combined approach [109, 110]. In Erol’s approach,
conchal cartilage excision, anterior scoring, and mattress sutures can be performed
through an incision on the anterior surface of the concha [110].
Burres etal. described the “antero-posterior otoplasty” technique (52). Here, the
conchal setback is performed through a posterior incision with helix sutures, and the
lateral conchal resection is performed through a series of incisions opened on the
anterior surface of the scapha [50]. Burres etal. rst perform conchal cartilage excision from a posterior approach, then perform anterior scoring and mattress suture
application through an incision on the anterior surface [110].
Bauer etal. [50] begin their combined techniques with an incision similar to
Erol’s on the anterior surface of the ear, perform skin and cartilage excision from
there, and close the incision. They then approach the antihelix from behind the ear
with a squid-style incision.
In the study by Olgun etal., a combination technique (Mustarde suture, concha
resection, and Furnas suture) was used. Since the goal of otoplasty is to create symmetrical ears with smooth contours, the use of graduated techniques rather than a
single technique is recommended. It has been reported that the combination of
Mustarde suture to create the antihelix, conchal resection, and conchomastoid
suture to reduce the concha has been used with satisfactory results [18].
13.9 Preparation andIncision forSurgery
General anesthesia is usually preferred for otoplasty. However, in adolescents and
adults, this procedure can be performed and is preferred under intravenous sedation
with local anesthesia. A limited amount of hair shaving may be required in the postauricular area. The procedure begins with the more prominent ear. Then the less
problematic ear is made symmetrical by comparing it to the other ear. Before the
tissue is reshaped under local anesthesia, manual manipulation of the ear scapha
should be performed to plan the amount of tissue to be removed behind the ear [57].
If an incisional technique is to be used, an eccentric fusiform excision centered
on the antihelix is planned. The limits of the excision are set at 1cm between the
superior and inferior poles. Local anesthetic (1% lidocaine with 1:100,000 epinephrine and 0.5% bupivacaine with 1:200,000 epinephrine) can be inltrated into the
auricular and mastoid soft tissues for vasoconstriction and hydrodissection. Skin
excision is initially performed conservatively. Additional skin excision may be
required at the end of the procedure. The postauricular skin is extensively weakened, and a lateral incision can be made at this point to facilitate suture placement.
Hemostasis should be carefully achieved with a bipolar cautery [2].
During otoplasty, the constant interference of hair in the surgical area of the ear
and scalp is a particular problem. Covering, adhesion, and the use of a silicone cap
can be used to address this [111].
13 O t opla s t y
291
13.10 Closure, Dressing, andPostoperative Care
Closure, dressing, and postoperative care vary with the technique used. With incisionless otoplasty techniques, closure, dressing, and postoperative care are simpler,
faster, and less inconvenient. In cartilage-cutting and sparing techniques, the postauricular incision is closed with 4–0 sutures after the conchal and antihelical positions are established. The closure should be loose to allow uids to drain without the
need for drainage. The wound can be irrigated with copious amounts of clindamycin prior to closure. There should be no tension when closing the wound edges.
After completion of any additional procedures, if necessary, the ear folds can be
carefully wrapped in a mold with cotton evenly soaked in antibiotic ointment. After
applying a mastoid pressure dressing, a soft dressing is applied. We must choose the
pressure points with extreme care to avoid skin necrosis [57].
Various techniques have been described for postoperative dressing. Dressing
techniques differ for adults and children. The purpose of the dressing is to maintain
the desired postoperative shape and position. Other goals of the dressing are to prevent hematoma and to maintain tension. The classic ear dressing is described as
either covering the ear with a cotton pad or maintaining the position of the ear with
a vaseline gauze. The head is usually wrapped with an elastic bandage. Postoperative
problems with ear dressings include tension (especially at night), postoperative discomfort, and skin necrosis [112–114].
It is advantageous to remove the dressing on the rst postoperative day. This
facilitates early detection of skin ischemia or early hematoma formation. A lighter
dressing is applied and left in place for four days. This second dressing can be
applied in adults or cooperative children. After the dressing is removed, patients
wear a sports headband for 2weeks. Then they wear it only at night for another
2weeks [57].
If the patient is a child, they should stay away from toys or harmful substances.
These can inadvertently cause trauma. Half of the cases requiring revision surgery
have been found to be related to a history of external trauma [115].
13.11 Patient Follow-Up
Variable follow-up periods and different methods of data collection make comparisons difcult. The nature of follow-up periods is more often completed than frequent. Ideally, both subjective and objective methods should be used in postoperative
evaluation. However, follow-up is often incomplete because satised patients do not
return for periodic examinations. Surveys are often used to compensate for this situation. Relying on patient surveys to obtain nal results is usually favorable because
patients are usually satised with the correction of prominent ears and may not be
able to evaluate the situation from a surgeon’s critical perspective [116, 117]. In
addition, satised patients are less likely to return for follow-up [118]. The difference in complication rates between studies is due to the length and type of followup. This is especially true for late complications [119].