Primary otoplasty and reconstruction

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CHAPTER 46 Primary otoplasty and reconstruction

Charles H.M. Thorne

Introduction

Otoplasty is an enormously rewarding procedure because good results and satisfied patients can be expected most of the time. On the other hand, traditional teaching can lead the surgeon to over-aggressive procedures and over-corrected, unnatural results. This chapter will address each of the following conditions/procedures:

1. Standard otoplasty.

2. Otoplasty for large ears.

3. Otoplasty for constricted ears.

4. Otoplasty for cryptotia.

5. Otoplasty for Stahl’s ear.

6. Correction of aging earlobes.

7. Correction of earring-related deformities.

8. Correction of facelift complications involving the ear.

History

The history of otoplasty, reviewed below, is both instructive and misleading. Understandably, the original techniques focused on changing the shape of the auricle, rather than on the nuances of aesthetics, the stage we are in today. In the author’s opinion, most classical otoplasty techniques, although essential in the evolution of the craft, are unnecessarily destructive to the ear, overly complicated in design, and excessively prone to over-correction, complications and unnatural appearing results.

Luckett recommended full thickness incisions through the cartilage along the desired location of the antihelical fold. Converse and others described the combination of full thickness incisions parallel to the desired antihelical fold, with “tubing” sutures to create the fold. Various authors have recommended weakening of the cartilage along the fold including Stenstrom who described anterior cartilage weakening in an effort to generate bending of the cartilage away from the injury. Most of these techniques included, or relied upon, skin excision in the retroauricular sulcus.

The current trend is toward less destructive methods of auricular reshaping, preservation of the retroauricular skin and concentration on natural, non-surgical appearing results. The ultimate example of this phenomenon is neonatal, non-surgical molding of the auricle which can correct many of the deformities for which an otoplasty might later be recommended. Any surgical decision represents a trade-off and this author’s approach is no exception. The approach herein incorporates the bias that under-correction, recurrence and suture complications are preferable to over-correction, unnatural contours, sharp edges and unrepairable deformities.

Physical evaluation

• Overall size and shape. Evaluate the overall size/shape of the ear: Is it prominent with an otherwise normal size and configuration, or are there abnormalities in addition to the prominence? Excessively large ears, Stahl’s ears, cryptotia, underdeveloped shell-like helical rims, postoperative deformities, cauliflower ears, elongated lobules or earring-related deformities are noted.

• Upper image. Evaluate the upper image: Is the upper pole prominent, is the antihelix/superior crus of the triangular fossa well formed, and is the helical rim well developed?

• Middle image. Evaluate the middle image: Is the concha overly deep or protruding?

• Lower image. Evaluate the lower image (lobule): Is the lobule prominent? It is important to note that even if the lobule is not particularly prominent on initial examination, it may be excessively prominent once the upper image of the ear has been corrected intraoperatively.

• Asymmetry. Asymmetry is noted, mostly because patients and families will always comment on it. In asymmetric cases it is almost always preferable to operate on both ears rather than attempt setting back only the prominent ear to match the less prominent ear.

Anatomy

While the delicate, complex contours of the ear may be difficult to create de novo (i.e. microtia), anatomic considerations are minimal in standard otoplasty. There is abundant blood supply making almost any combination of incisions acceptable without the risk of necrosis. There are no motor nerves to avoid. The terminal branches of the great auricular nerve will always be injured but normal sensory function always returns eventually.

The one anatomic structure that can be compromised in otoplasty is the external auditory canal (conchal setback narrows the meatus). Otherwise the anatomic considerations of otoplasty are those of preservation: preserve the sulcus, preserve the natural softness of the auricular contours, and avoid effacement/deformation of the normal landmarks such as the posterior wall of the concha (middle third antihelix).

Technical steps

Standard otoplasty for prominent ears of normal size

• Incision. The incision is made in the retroauricular crease.

• Dissection. No skin is excised except a small triangle from the medial surface of the lobule (not from the retrolobular skin), taking care to preserve enough tissue for a normal earlobe and retrolobular sulcus. The cartilage is exposed on its posterior surface and soft tissue is excised from deep to the concha. In the region of the earlobe, deep dissection is performed under the concha in preparation for lobule repositioning.

• Correction. (Fig. 46.1). Mustarde concha-scapha and triangular fossa-scapha sutures are placed using 4-0 clear Nylon sutures. The number of sutures depends on how far into the middle image of the ear the antihelical deficiency extends. These sutures are used to create a soft curvature to the antihelix and no attempt is made to correct the prominence at this point. A small crescent of cartilage (3 mm or less at its widest point) is excised from the posterior wall of the concha, at its junction with the conchal floor. The defect is closed primarily using numerous 4-0 Nylon interrupted sutures. A conchal setback is performed using a single 3-0 PDS suture between the concha and the mastoid fascia. This combination of a small conchal resection and a small conchal setback avoids the distortion of a large conchal resection and the unreliability of a large conchal setback. The earlobe is repositioned employing a method similar to that described by Gosain. Two 5-0 PDS sutures are placed which not only approximate the skin where the skin excision was performed, but incorporate a bite of cartilage on the undersurface of the concha (Fig. 46.2). The sutures are tightened until the lobule is slightly over-corrected.

• Endpoint. Otoplasty is all about the endpoint. How do you know how tight to make the Mustarde sutures? How do you know how tight to tie the Furnas conchal-mastoid sutures. How do you know how sharp to make the antihelical fold? The answers to these questions are apparent if the surgeon remembers what the ear is supposed to look like: (1) When viewed from the front, the helical rim should be visible, poking out from behind the antihelix. (2) When viewed from the side, the contours should be round and soft, never sharp. (3) Finally, and most helpful to the surgeon who is sitting behind the patient intraoperatively: When viewed from behind the patient, the contour of the helical rim should be a straight line, not a “C” or a “hockey stick” or any other shape. If there is one lesson to take from this chapter, this is it. The final position of the ear should be over-corrected minimally to allow for some relapse, but not enough to create an unsatisfactory result if no relapse should occur.

• Closure. The skin is approximated using 5-0 plain gut, without excising more skin.

image

Fig. 46.1 Technique for standard otoplasty. The combination of Mustarde sutures, conchal resection/closure and conchal-mastoid sutures is shown. A, Suture placement. B, Sutures tightened and tied appropriately. C, Position of sutures as shown from the surgeon’s vantage point.

image

Fig. 46.2 Lobule repositioning. The technique for lobule repositioning is shown. A triangle of skin is excised on the earlobe, never compromising the appearance of the lobe or the ability for the patient to wear earrings. Sutures are placed close to the skin defect while catching a bite of the concha deep in the closure.

Otoplasty for large, prominent ears

• Incision. An incision is made on the lateral (visible) surface of the ear, just inside the helical rim (or where the helical rim would be if it is underdeveloped).

• Dissection. The incision is extended through the cartilage to achieve the posterior surface of the auricle where the cartilage is exposed.

• Correction. The scapha cartilage and skin are trimmed to the desired size and shape, taking care to excise more cartilage than skin (Fig. 46.3). An incision is added in the retroauricular sulcus and, if lobule repositioning will be necessary, skin is excised from the medial surface of the lobule. Otoplasty techniques are then performed as described above for prominent ears of normal size.

• Closure. The helical rim is then reapplied to the scapha, but it will be too long for the reduced scapha. A wedge of helical rim and posterior skin is excised. The helical redundancy can be removed wherever the surgeon feels the small incision in the rim will be least visible. In the case of a helical rim which is flat and lacking in overhang, slight tension on the helical rim closure will correct this deformity.

image

Fig. 46.3 Ear reduction. The technique of ear reduction is shown.

Redrawn from Argamaso RV. Ear reduction Plast Reconstr Surg 1990; 85(2):316, Fig. 2.

Otoplasty for constricted ears

The constricted ear tends to be prominent, but unlike standard prominent ears, they are prominent because the helical circumference is inadequate. In other words, the ear cannot lie flat because the excessively short helical rim draws the auricle into a cup. Any attempt to setback a constricted ear must be accompanied by elongation of the helical rim. The most common technique for elongating the helix is by mobilizing the crus of the helix and recruiting it out of the concha and into the helix.

• Incision. An incision is made within the helical rim (as in large ears, above) and continued around the crus of the helix and back up in the preauricular region to the junction of the ear and the temporal scalp. The crus of the helix, consisting of three layers (skin, cartilage and skin), is fully mobilized.

• Correction. The otoplasty is performed as in the case of standard ears which will recruit the crus of the helix into the helical rim.

• Closure. The donor site in the concha is closed primarily, as if the crus of the helix had been taken for a composite graft to the nose. The incision in the scapha is closed with a running absorbable suture. Any excess or unusable crus of the helix is discarded.

Otoplasty for cryptotia

A detailed description of the surgical correction of cryptotia is beyond the scope of this chapter but a few guidelines will be outlined. The term cryptotia is used to describe the condition where the upper portion of the ear is buried beneath the temporal scalp. The ear can literally be pulled out of the scalp to examine it. Correction involves pulling the ear out of its bed in the scalp, incising around it in order to release it fully, and resurfacing the defect behind the upper pole of the ear with a skin graft or a local flap. If the shape of the auricular cartilage is abnormal, in addition to being buried, then additional cartilage maneuvers are indicated.

Otoplasty for Stahl’s ears

As in cryptotia, a detailed description of the available techniques is beyond the scope of this chapter. The deformity consists of a third crus, in addition to the superior and inferior crura of the triangular fossa, which extends towards the helical rim. The deformity is variable. In mild cases the extra crus is barely noticeable and can be ignored and the otoplasty performed as if it were a standard case. In more severe cases the crus is more prominent and may cause a deformity of the auricular shape with a pointed, “Dr. Spock” appearance. In the most severe cases, in addition to the pointed shape of the ear, the superior crus of the triangular fossa is absent. Correction involves resection of the abnormal crus. There are a variety of opinions on what to do with the resected cartilage, from turning it upside down to using it to replace the absent superior crus. While the Stahl’s ear deformity can be improved significantly, it is important to manage expectations in the severe cases where the result will fall short of a completely normal ear (Fig. 46.4).

image

Fig. 46.4 Correction of Stahl’s ear. One technique is shown.

Redrawn from Kaplan HM, Hudson DA. A novel surgical method of repair for Stahl’s ear: a case report and review of current treatment modalities. Plast Reconstr Surg 1999;103:566–569.

Reduction of aging or elongated earlobes

Earlobe reduction can be a magical procedure in a patient with droopy, inelastic, elongated earlobes. The procedure can be performed concomitantly with a facelift or as an isolated procedure. A number of techniques have been described. The anatomy of the individual patient dictates the design. The most commonly used procedure in this author’s hands; however, is amputation of a wedge from the caudal border of the lobule. This procedure is trickier and more time consuming than the neophyte might imagine.

• Incision. The ideal contour is drawn on the earlobe. The wedge is designed asymmetrically so that the incision is made caudal to this line on the lateral surface and cephalad to it on the medial surface. The idea is to create a longer skin flap on the lateral surface of the lobe. This lateral flap is thinned so it is also more mobile than its medial counterpart.

• Closure. When closed, the incision will be located on the medial surface of the lobule so it is less visible. The ends of the wedge excision are placed slightly on the medial surface of the lobule, which also encourages the final scar to roll under where it is not visible. Numerous sutures, meticulous tapering and some patience are required for the best outcome.

Treatment of earring-related complications

Earring-related complications are extremely common. Complications related to piercing of the cartilage of the ear, especially in its upper portion, are beyond the scope of this chapter. Remarks will be confined to the lobule. While a number of procedures have been described for repair of elongated ear piercings, the author has found that simple excision and closure is most effective. This technique applies to both elongated earring holes and those that have torn completely through the lobule margin. In the latter case, a Z-plasty can be added in an effort to avoid a notch. In reality, an everted closure using a horizontal mattress suture seems to yield equivalent results at the lobule margin. The medial and lateral skin are closed with Nylon sutures, and no deep, absorbable sutures are used. The earlobes can be re-pierced in 4–6 weeks, depending on how stiff and fibrotic they are after the repair. Avoiding absorbable sutures in the subcutaneous tissue of the lobe seems to minimize the inflammation and shorten the recovery and the waiting period before re-piercing.

Treatment of facelift deformities of the ear

After 20 years of hard labor in this area, this author has concluded that a facelift is just one type of otoplasty. Facelift deformities of the ear are frequently unfixable, leading to lesson number one in facelifting: avoid them. When confronted with such problems however they fall into the following categories:

1. Deformities of the earlobe (pixie ear).

2. Deformities of the tragus.

3. Deformities of the retroauricular sulcus.

4. Unsightly, hypertrophic or poorly placed periauricular scars.

Earlobe deformities

Earlobe deformities after facelifting are the result of excessive anterior and inferior traction on the lobe due to inexpert trimming of the facelift flap. The facial skin should be trimmed so that the ear can barely be pulled out from beneath it. In other words, it is far better to have the facelift flap tucked up under the earlobe (even elongating the earlobe), than to have it too low where the closure will deform the earlobe. As anyone with experience can tell you, secondary lifting may generate a disappointing amount of skin advancement and a pixie ear may only be partially improvable. Be careful about promising a patient that you can repair it entirely.

Tragal deformities

Tragal deformities consist of either anterior traction of the tragus, amputation of some of the tragal cartilage or excess facial skin which hides the bottom of the tragus and is an across-the-room surgical signature. There is little that can be done for the first two conditions: anterior traction and amputation of the tragal cartilage. In fact further lifting attempts may make them worse: When the facial skin is rotated cephalad, there may be even less cutaneous coverage for the tragus than there was originally. The latter deformity, lack of definition of the caudal tragus, however, can be improved dramatically by a minor procedure to remove a triangle of skin and reveal the normal anatomy in this region.

Retroauricular deformities

Surgeons seem to feel that it is necessary to place the facelift incision up on the back of the ear. If that is done a few times, guess what? There is no ear skin left. The incision can be placed within the sulcus, or if you insist, just on the auricular cartilage, and it will not migrate if the flaps are trimmed judiciously. Once the deformity is created there is no solution except release of the ear and placement of a full thickness skin graft. Most such deformities are not that severe and the author has only performed the above release/graft maneuver once in 20 years.

Scars

Unsightly scars can frequently be improved by excision and additional facelifting maneuvers as long as no tension is placed on the closure. Although axiomatic in facelifting it bears repeating: the facelift flap should be redraped and trimmed so the edges are touching. While a few sutures are placed, no sutures should really be necessary in the preauricular region or the post-auricular sulcus. Hypertrophic scars are more problematic. If they are due to tension, they can be improved. If they are due to the patients’ intrinsic scar forming idiosyncrasies, they won’t be. The problem is that the surgeon doesn’t know in advance which category the scars fit in. The surgeon should approach the revision of such scars with great trepidation.

Postoperative care

A soft bulky dressing is placed. The purpose of the dressing is to protect the repair and to absorb drainage, not to put pressure on the ears. A doughnut of gauze is placed around each ear specifically to avoid pressure on the auricles. This author has seen significant abrasions of the ear from dressings that were excessively tight, in one case an ulceration with visible auricular cartilage.

The dressing is left in place 3–5 days depending on when the most convenient day for an office visit occurs. No further dressings are used. Since absorbable skin sutures are used, no sutures require removal in the standard otoplasty case. In the case of ear reduction, there are 1–3 Nylon sutures in the helical rim that require removal.

The patient or family is instructed to wear a loose headband at night only. The goal is to have no pressure on the ear during the day and only enough at night to prevent inadvertent pulling forward of the repaired auricle. The nocturnal head band is continued for 4–6 weeks. Remember, the headband should be only tight enough that it does not fall off.

Complications

The technique described above largely eliminates the worst of the otoplasty complications: over-correction, sharp edges, unnatural contours, inharmonious setback, telephone deformity, and infection.

On the other hand, suture complications are common. The nylon Mustarde sutures may eventually protrude through the posterior skin. This may occur within the first few weeks or not for years. In some cases the sutures are associated with inflammation of a granuloma. Suture removal immediately cures any apparent infection and does not seem to lead to recurrence of the prominent ear.

The second complication that is more common with this technique is under-correction or recurrence. While this is not ideal, it is far better in this author’s opinion than over-correction or distortion.

Pearls & pitfalls

Pearls

• Less is more. Don’t do anything to the ear that can’t be reversed by removing a few sutures and lysing some scar tissue.

• Endpoint, endpoint, endpoint. Knowing what the auricle is supposed to look like will dictate when to stop tightening, setting back, correcting etc.

• Assess the ear, and determine plan, in thirds: upper, middle and lower image.

• Include earlobe setback (or at least consider it) in every otoplasty.

• Operate on both sides in asymmetric cases.

Pitfalls

• Don’t perform cartilage scoring, weakening or burring, especially in young children with thin, weak cartilage.

• Don’t remove skin except behind earlobe

• Don’t rely on conchal setback without conchal excision unless very mild correction.

• Don’t rely on large conchal excision. Combine with conchal setback.

• Don’t deform the tragus, lobule or sulcus when performing a facelift.

Summary of steps for standard otoplasty

1. Incision. The incision is made in the retroauricular crease.

2. Dissection. No skin is excised except a small triangle from the medial surface of the lobule (not from the retrolobular skin), taking care to preserve enough tissue for a normal earlobe and retrolobular sulcus. The cartilage is exposed on its posterior surface and soft tissue is excised from deep to the concha. In the region of the earlobe, deep dissection is performed under the concha in preparation for lobule repositioning.

3. Correction. Mustarde concha-scapha and triangular fossa-scapha sutures are placed using 4-0 clear nylon sutures. These sutures are used to create a soft curvature to the antihelix and no attempt is make to correct the prominence at this point. A small crescent of cartilage is excised from the posterior wall of the concha, at its junction with the conchal floor. The defect is closed using numerous 4-0 nylon interrupted sutures. A conchal setback is performed using a single 3-0 PDS suture between the concha and the mastoid fascia.

4. The earlobe is repositioned: Two 5-0 PDS sutures are placed which not only approximate the skin where the skin excision was performed, but incorporate a bite of cartilage on the undersurface of the concha. The sutures are tightened until the lobule is slightly over-corrected.

5. Endpoint:

• When viewed from the front, the helical rim should be visible, poking out from behind the antihelix.
• When viewed from the side, the contours should be round and soft, never sharp.
• When viewed from behind the patient, the contour of the helical rim should be a straight line, not a “C” or a “hockey stick” or any other shape. If there is one lesson to take from this chapter, this is it.

6. Over-correction: the final position of the ear should be over-corrected minimally to allow for some relapse but not enough to create an unsatisfactory result if no relapse should occur.

7. Closure. The skin is approximated using 5-0 plain gut, without excising more skin.

Further reading

Argamaso RV. Ear reduction with or without setback otoplasty. Plast Reconstr Surg. 1990;85(2):316.

Gosain AK, Recinos RF. A novel approach to correction of the prominent lobule during otoplasty. Plast Reconstr Surg. 2003;112(2):575–583.

Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg. 2005;115(4):60e–72e.

Kaplan HM, Hudson DA. A novel surgical method of repair for Stahl’s ear: a case report and review of current treatment modalities. Plast Reconstr Surg. 1999;103(2):566.

Kelley P, Hollier L, Stal S. Otoplasty: evaluation, technique and review. J Craniofac Surg. 2003;14(5):643–653.

Spira M. Otoplasty: what I do now – a 30 year perspective. Plast Reconstr Surg. 1999;104(3):834.

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