Practical Plastic Surgery

Figure 62.1. Surface anatomy of the human ear.

posterior surfaces of the auricular cartilage. When present, these muscles or structures are supplied by rudimentary branches of the facial nerve (CN VII).

The auricle typically measures between five and six centimeters in vertical dimenstion with a long axis which deviates approximately 20˚ from the vertical when viewed from the side. This parallels the angle of the profile of the nose. The auricle should be about half as wide as it is long with a helix to mastoid distance ranging from 1 cm superiorly to 2 cm inferiorly.

A commonly encountered ear deformity is the congenitally prominent ear, which is characterized by an increase distance from the helical rim to the mastoid scalp. It is often associated with a deep conchal bowl and may lack and antihelical fold altogether. The scaphoconchal angle is increased with flattening of the superior antihelical

crus. The cup ear deformity, also referred to as constricted ear or lop ear involves 62 cosmetically unacceptable overhang of the helix, associated with widening of the concha, flattening of the antihelix, and compression of the scapha an fossa triangu-

laris. Stahl ear, also referred to as “Spock,” “Vulcan,” or Satyr ear, is characterized by the presence of a third antihelical crus, resulting in flattening of the antihelix and angular distortion of the scapha and superior helical rim.

Preoperative Considerations

By the age of five or six years, the pinna has attained 85% of its adult height and otoplasty may be considered. In adults, surgery on the ear can generally be performed under intravenous conscious sedation supplemented with local nerve blockade or local anesthesia alone. Blood thinning medications should be discontinued including careful screening for prescription, over-the-counter and herbal medications.

Preoperative photodocumentation should include standardized frontal, lateral and oblique views with magnified views of any particular areas of interest.

Operative Technique

Due to the complex three dimensional nature of the ear, the ideal technique for otoplasty must be tailored to the particular patient’s deformity and the surgeon’s experience with various techniques. The traditional excision for correction of the prominent ear removes a fusiform ellipse of skin just lateral to the postauricular crease, although some delay committing to both limbs of the ellipse until the end of the procedure after determining precisely how much skin will need to be excised. Anterior incisions may also be employed to provide access to the anterior perichondrial surface. Skin excision alone is generally insufficient to hold an ear in position. Cartilage shaping is achieved through the placement of mattress sutures to reanchor the cartilage, scoring of the cartilage to facilitate reshaping and/or excision of excess cartilage. Sutures are placed in a mattress fashion and go through the full thickness of cartilage and perichondrium and should be fairly wide based (at least 1.5 to 2 cm) to avoid cutting through or creating an antihelix that appears too sharp. Conchoscaphoid mattress sutures (Mustarde sutures) serve to restore the normal conchoscaphoid angle of 90˚ and enhance the antihelical ridge while decreasing projection. Conchomastoid mattress sutures serve to “pin” back the concha. Both these sets of sutures are placed in a radial fashion and tied down gradually until the desired effect is achieved with evenly distributed tension.

The effect is augmented by scoring the anterior surface of the cartilage. Scoring of a cartilaginous or perichondrial surface will generally result in expansion of that surface as an assist in bending of the cartilage away from the side being scored. Patients with excessively prominent conchal bowls may benefit from resection of an ellipse of conchal cartilage. Care and experience allow the proper amount of cartilage to be removed to recreate a graceful fossa without creating an unnatural stepoff in the conchal contour. A mattress suture from the triangular fossa to the temporalis fascia can help correct any residual prominence of the superior pole of the auricle.

Prominent lobules can be addressed by extending the incision inferiorly and closing this portion of the flap in a V-Y manner resulting in reduction of the frontal appearance of the lobule. Alternatively, if the prominence of the lobule is due to an excessively long cauda helicis, simple exision of the excess cartilage and redraping of the skin will improve the deformity.

Finally the skin is redraped, excess skin is excised from the posterior surface of the ear and the wound is closed. Meticulous hemostasis is essential as hematoma

62formation can have disastrous consequences and some authors favor the placement of a small penrose type rubber-band drain to facilitate drainage. A compressive nonadherent dressing is placed and wrapped with a large turban style dressing.

Postoperative Care

In teenagers or adults, otoplasty can easily be performed as an outpatient procedure with a responsible relative or friend available for overnight observation. After the dressing is removed at the first postoperative visit, patients should be instructed to continue to wear lightly supportive tennis or skiing headbands or ear wraps to take tension off of the reconstruction for an additional 6-8 weeks. Hypertrophic scarring or keloid formation can be treated with injection of steroids with or without excision as dictated by the severity of the scar.

Complications

Along with the ubiquitous risks of bleeding and wound infection, the most common sequelae involve an unsatisfactory cosmetic result. Over-correction or, more commonly, under-correction or reversal of the correction with time are the most common complaints. Avoid asymmetry by measuring the helix to mastoid distance. Over-correction of the conchal prominence without addressing superior pole projection and an excessive lobule results in the “telephone ear” deformity. Conversely, over-correction of superior pole and lobule projection with insufficient correction of conchal excess results in the so called “reverse telephone ear.” Failure to anchor conchomastoid sutures in a posterior vector can lead to compromise of the external auditory meatus by occlusion with redundant conchal cartilage. Inadequate hemostasis and failure to recognize a postoperative hematoma can lead to catastrophic loss of the cartilaginous architecture of the auricle, requiring far more complex reconstruction, potentially requiring rib cartilage. Infection should be promptly treated with systemic antibiotic therapy and surgical drainage.

Pearls and Pitfalls

•The biggest disaster is ischemia of the ear. This can lead to cartilage necrosis and a resulting misshapen ear. It can be caused by folding of the ear from too tight a dressing or poor placement of the ear in the dressing due to numbness from anesthesia. Severe postoperative pain is an indication for removal of the dressing and evaluation of the ear.

•Tie the Mustarde mattress sutures first and then look and measure the two ears to achieve as much symmetry as possible. Ears are typically not identical preoperatively.

•Over-correction or an ear that lies flat against the head will not typically improve with time.

•Correction of the antihelix without treating a deep conchal bowl results in an odd deformity requiring revision.

•There are very few occasions when both auricles are seen simultaneously in the course of normal daily activities. Therefore, perfect symmetry from side-to-side is less critical than the correct anatomical harmony of each auricle viewed alone. As an example, this can be very useful when repairing traumatic defects of the ear which require removal of tissue from the helix. The precise size matching of the two auricles is of secondary importance to achieving a balanced, harmonious, natural appearing ear.

1.Kelley P, Hollier L, Stal S. Otoplasty: Evaluation, technique, and review. J Craniofac Surg 2003; 14(5):643.

2.Stenstrom SJ, Heftner J. The Stenstrom otoplasty. Clin Plast Surg 1978; 5(3):465.

3.Dingman RO, Peled I. Corrective cosmetic otoplasty: A simple and accurate technique. Ann Plast Surg 1979; 3(3):250.

4.Elliott Jr RA. Otoplasty: A combined approach. Clin Plast Surg 1990; 17(2):373.

Figure 63.1. Upper eyelid anatomy.

baggy upper lids. The orbital septum lies deep to the orbicularis. It hangs from the superior orbital rim and joins the levator aponeurosis at the superior border of the tarsal plate. Weakening of the septum with aging, hereditary predisposition, or trauma may cause protrusion of the orbital fat. The upper lid contains two fat pads: medial and central (the lateral space is occupied by the lacrimal gland). The medial and central compartments are separated by the superior oblique muscle. The medial fat pad is lighter in color (similar to butterscotch), firmer in consistency, and usually requires more local anesthesia during resection than the central compartment. The medial compartment also contains the terminal branch of the ophthalmic artery; we find that attending surgeons will take an extra second to ensure that this vessel is satisfactorily coagulated during fat resection.

The upper lid tarsus is a fibrous plate that is approximately 10 mm wide in the central upper lid, narrowing medially and laterally. The tarsal plates extend from the lateral commissure to the punctum, and it contains numerous meibomian glands that empty into the ciliary border. There are two muscles responsible for opening the upper 63 eyelids: the levator muscle (primary lid elevator) and Müller’s muscle. The levator muscle originates at the apex of the orbit, just superior to the superior rectus. At the orbital aperture, it is supported by Whitnall’s ligament, which functions to translate

the horizontal force of this muscle into the posterior and vertical motion necessary for lid elevation. The levator muscle becomes aponeurotic as it passes Whitnall’s ligament. The anterior interdigitation of the aponeurosis with the orbicularis muscle fibers leads to the formation of the supratarsal fold. Müller’s muscle originates from the posterior aspect of the levator aponeurosis and travels inferiorly, closely adherent to the conjunctiva, to insert on the superior border of the tarsus. Müller’s muscle is sympathetically innervated. The conjunctiva is the inner most layer of the upper lid.

Lower Eyelids

The lower eyelid is often described as being composed of three lamellae (Fig. 63.2). The anterior lamella consists of the skin, orbicularis oculi (orbital, preseptal and pretarsal) muscle, and preseptal suborbicularis oculi fat (SOOF). The middle lamella is the orbital septum. The septum is a continuation of the orbital periostium that extends from the inferior orbital rim (arcus marginalis) to the inferior border of the tarsus. It provides the anterior border of the medial, middle and lateral fat compartments. Although these compartments are more imaginative than anatomic, the inferior oblique (most commonly injured during blepharoplasty) separates the medial and middle compartments; the arcuate expanse divides the middle from the lateral fat pad. The medial fat pad tends to be whiter than the middle and lateral pads.

The posterior lamella is composed of the tarsus, lower lid retractors and the conjunctiva. The lower lid tarsal plate is only about 4.5 mm wide at the mid-pupil. The lower eyelid retractor system originates as a fascial extension of the inferior rectus muscle (capsulopalpebral head). This fascial system splits to encapsulate the inferior oblique muscle and then reunites to form a dense fibrous sheet (capsulopalpebral fascia) that inserts onto the inferior tarsal border. The inferior tarsal muscle is the smooth muscle analog of the upper lid Müller’s muscle. The inferior tarsal muscle originates in the inferior fornical area and extends toward the inferior tarsal border but does not insert on the tarsal border as does its counterpart in the upper eyelid. The inferior tarsal muscle provides sympathetic innervation to the lower eyelid, and interruption of its innervation results in a slightly elevated position of the lower eyelid margin, as observed in Horner syndrome. Otherwise, the inferior tarsal muscle has little pathologic significance.

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Figure 63.2. Lower eyelid anatomy.

Asian Eyelids

There are a number of anatomic differences between Asian and Caucasian eyelids. In the Asian upper eyelids, the skin and subcutaneous fat tend to be thicker. The ROOF is heavier. The orbital septum is weaker and thinner and it tends to drape below the upper border of the tarsal plate. The levator aponeurotic dermal extensions are weak or nonexistent. The paucity of levator-dermal extensions is responsible of the low-lying or absent supratarsal fold. Epicanthal folds cover the medial angle and lacrimal caruncle. Trichiasis is caused by the overhanging upper eyelid skin pushing down on the eyelashes. Collectively, these features give the Asian eyelid more fullness, a lower lid crease and a narrower palpebral fissure.

Canthal Tendons

Medially, the superficial heads of the upper and lower pretarsal muscles join to form the medial canthal tendon (Fig. 63.3). This tendon is firmly attached to the anterior lacrimal crest. The superficial heads of the preseptal muscles attach to the medial canthal tendon. The deep heads of the preseptal and pretarsal muscles attach to the posterior lacrimal crest, just behind the lacrimal sac. Laterally, the upper and lower pretarsal muscles join to form the lateral canthal tendon, which inserts just posterior to the orbital tubercle. The upper and lower preseptal muscles join laterally to form the lateral palpebral raphe, which is attached to the skin.

Preoperative Considerations

During the complete medical history, one should inquire about a history of diabetes, hypertension, coagulopathy, hypothyroidism, hyperthyroidism, renal disease, cardiopulmonary disease or glaucoma; each of these diseases can have a role in eye symptomatology and effect postoperative recovery. Patients with a history of collagen vascular diseases, such as scleroderma, systemic lupus erythematous, periarteritis nodosa, Wegener’s granulomatosis, Stevens-Johnson syndrome, rosacea, rheumatoid arthritis, or secondary Sjögren syndrome have a higher risk of postoperative dry eye syndrome. Finally, elicit an ophthalmologic history. This includes previous eyelid surgery, eyelid trauma, eyelid infection, eyelid allergy, eyelid swelling, the use of glasses or contact lenses, and changes in visual fields and/or visual acuity.

The physical examination first includes looking at the full face. Note facial appearance, asymmetry and wrinkles. Examine the periorbital area for crow’s feet, fine wrinkles (at rest and with smiling), and the appearance of the globes, infraorbital

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Figure 63.3. Canthal tendons.

rims, cheeks and malar bags. Assess for negative vector (in the lateral view: anterior most projection of the globe, the lower eyelid margin and the malar eminence). A negative vector is one which angles posteriorly and indicates an absence of support for the lower lid). Patients with a negative vector are at higher risk for postoperative dryness. Note any pseudoherniated orbital fat and hypertrophied orbicularis muscle. Pressure on the upper eyelid and globe causes pseudoherniated orbital fat in the lower eyelid to be more evident. Having the patient look upward can help to delineate the lower eyelid fat pockets. Examine the eyelids for discoloration, hypertrophied skin and skin lesions. Excessive skin produces a crepe-like quality in the lower eyelid skin. Also, note the position of the lacrimal gland, in particular whether or not it has fallen from the lacrimal fossa. Assess for Bell’s phenomenon. The Schirmer’s I test may be performed by placing a 5 x 35 mm strip of #41 filter paper between the lower lateral lid and globe for 5 minutes. This test measures both basic and reflexive tear production. Less than 10 mm of moisture on the paper suggests that the patient may be at risk for postoperative dry eyes. The Schirmer’s II test measures only basic tear secretion by blocking reflex secretion with a topical anesthetic. The snapback test is performed by grasping the lower eyelid skin and pulling the lid away from the globe. The rapidity with which the lid snaps back against the globe gives an estimate of the probability of postoperative ectropion.

Surgical Technique

Upper Blepheroplasty

Begin the procedure by marking the lower border of the skin resection with the patient in the upright position. This curvilinear line is usually located 10 mm above the lid margin in the natural eyelid crease. The upper border of the skin resection is usually estimated by a pinch test; there should be 15-18 mm of skin between the upper border of the skin resection and the eyebrow. Infiltrate local anesthetic evenly throughout the upper eyelid. Excise the skin and achieve hemostasis with pinpoint electrocautery. Resect a sliver of orbicularis oculi muscle to reveal the preaponeurotic fat. The preaponeurotic fat is resected as desired, and the orbital septum is opened in defined points at the medial and central fat pads or along its length. Excess orbital fat is estimated by applying gentle pressure to the globe. This excess fat is resected with care taken to ensure hemostasis. The skin then is reapproximated, and the procedure is complete.

Lower Lid Blepharoplasty, Subciliary

At the start of the subciliary blepharoplasty approach, a Frost suture can be placed

63in the gray line lateral or medial to the limbus to facilitate retraction and protect the globe. Alternatively, a lubricated corneal shield may be inserted. An incision is made just lateral to the lower lid margin. A scissors is used to develop a subcutaneous plane across the subciliary margin and complete the skin incision. Care is taken to protect the lashes. A skin-only or skin-muscle flap can be created to gain access to the orbital fat. If a skin-only flap has been elevated, the orbicularis is opened by incisions over the medial, central and lateral compartments. If a skin-muscle flap is chosen, all three fat compartments are in plain view. The inferior oblique muscle is identified between the medial and middle fat pads, and it is protected easily. The lateral compartment is slightly higher than the middle and should be identified carefully because it is the most common compartment to be overlooked. After resecting the orbital fat, a conservative skin excision is performed and the skin is closed.