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.

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