Otoplasty: The Surgical Approach to Protuberant Ears
While prominent ears are considered a sign of good fortune in the Far East, western society looks upon prominent ears in a far less positive manner. Children with prominent ears are often the subject of verbal, and at times, physical abuse by their peers, resulting in adverse psychological effects. Otoplasty is the surgical correction of protuberant ears and ear deformities. Specifically, its aim is making the protuberant ears less apparent by restoring them to a normal form and position in a symmetrical fashion. Performed by several surgical specialties, otoplasty for the dermatologic surgeon may be an unfamiliar surgical procedure. The procedure itself, however, does not significantly differ from ear wedges or cartilage removal procedures for skin cancer — procedures with which the dermatologic surgeon is quite familiar. Historical Background In 1845, Diffenbach reported the first surgical approach for the correction of prominent ears.1 He combined simple excision from the posterior sulcus with sutures, subsequently affixing the ear cartilage to the periosteum of the mastoid. Subsequently, multiple surgical techniques have been described, with more than 170 being reported in the literature. These can be basically categorized into three groups: 1. leaving the cartilage intact and using only sutures to reconstruct the ear, as used in the permanent suture insertion of the Mustarde technique2 and the incisionless otoplasty of Fritsch3 2. incising the cartilage in order to make it more pliable, without resecting it (e.g., the Converse’s cartilage incision technique4 and the anterior approach technique described by Chongchet5 and Stenstrom6 3. a technique that includes excision of the cartilage. There is also a relative new nonsurgical approach that is effective when prominent ears are noted in infancy. The use of external temporary appliances to set the ears in a correct position for several months results in a successful permanent correction.7-9 The drawback with this method is that it takes highly motivated parents to follow the protocol. Surface Anatomy of the External Ear As with any surgery, a thorough knowledge of the anatomy of the ear is essential for performing a safe and successful otoplasty. Although compromising a small anatomic area, the surface anatomy of the external ear is quite complex (see illustration on page 44). The external ear consists of the auricle and the external auditory canal. The helix rim arises anteriorly and inferiorly from a crus, extending horizontally above the external auditory meatus, thus creating the outer frame of the auricle. The helix merges inferiorly into the cauda helices and connects to the lobule. The region located between the crura of the antihelix is referred to as the triangular fossa, while the scapha lies between the helix and antihelix. The antihelix borders medially to the rim of the concha and the concha proper. The concha is composed of the conchal cymba superiorly and the conchal cavum inferiorly, which are separated by the helical crus and meet the antihelix at the antihelical rim. The intertragal notch separates the tragus and antitragus. The lobule does not contain cartilage and displays a varying shapes and attachments to the adjacent cheek and scalp. The arterial supply of the external ear is preserved by the superficial temporal and posterior auricular arteries. The sensory innervation involves the anterior and posterior branches of the greater auricular nerve and is reinforced by the auricular temporal and lesser occipital nerves. A portion of the posterior wall of the external auditory meatus is supplied by the auricular branch of the vagus nerves. Surgical Correction Techniques External ear deformities are very diverse, protuberant ears being the most common complain by patients. Ear prominence is generally the result of one or more of the following anatomic malformations: Failure of antihelical folding, overdeveloped conchal cartilage, protrusion of the upper third of the ear and protrusion of the earlobe.10-11 For adequate surgical correction, the surgeon must recognize and address all of the anatomic malformations contributing to the patient’s ear prominence. Surgical correction of these common ear deformities will be briefly discussed. The antihelix is commonly unfolded giving the appearance of prominent ears. In this case, simple pressure in the scaphoid region toward the scalp will define the antihelix and superior crus. A further increase in pressure will elevate the conchal rim, outlining the excess conchal rim. The position of the fold is then marked on the anterior ear skin with a row of inks spots running just lateral to the antehelix from the superior pole of the superior crus down to merging point between antehelix and helix. Two ink spots are placed within the triangular fossa to mark the site of suture placement for reshaping the superior crus. The last set of ink marks run in the lateral concha just lateral to the newly created antehelical fold, noting the location of horizontal mattress sutures to keep the reshaped antehelixes in place. Next, these inks marks are transferred from the anterior to the posterior skin of the ear and the underlying cartilage with the help of an abraded 25-gauge needle. This is done by passing the needle through the ink marks in order, and each time applying methylene blue at its distal end before withdrawing it. Next, a dumbell-shaped piece of the skin is removed from the posterior surface of the concha. The larger the protrusion, the wider the excision must be at the corresponding end and the further up and/or down along the concha it should be placed. Then, the posterior skin of the ear is dissected laterally close to helical rim and medially to the postauricular sulcus and then the mastoid periosteum. Finally, we use 4-0 Mersilene on a non-cutting needle to initially place and, thereafter, tie a number of horizontal mattress sutures: one from the triangular fossa to the upper scapha and at least four between the scapha and the lateral portion of the conchal cartilage.11 Conchal enlargement represents another common ear deformity. The excess conchal cartilage is excised from the midportion of the concha. Conchal set back is completed by placing multiple horizontal mattress sutures of 4-0 Vicryl between the conchal perichondrium and the mastoid periosteum. Finally, the skin is closed with several 4-0 Mersilene subcutaneous sutures and a running 5-0 Prolene suture on top, all of which is done in a tensionless fashion. The removal of the excess cartilage in the appropriate areas, resolves the abnormal contour of the ear.11 The auricle and the earlobe generally meet the adjacent scalp tissue at an angle of about 30 degrees. Usually, an angle greater than 40 degrees results in protrusion of the ear. To achieve proper correction, the skin of the posterior earlobe and posterior auricle, as well as the skin over the mastoid, needs to be dissected and then sutured together. Dissection of the lobule skin alone will change the anatomy of the lobule, without improving protrusion of the ear. Complications The most common immediate post-operative complication of otoplasty is the formation of a hematoma, requiring immediate, meticulous treatment.12 Generally, if a patient complains of increasing, persistent pain under the dressing, a hematoma has to be suspected. If a hematoma is present, immediate evacuation should be performed, and the patient should be started on oral antibiotic therapy in order to diminish the incidence of perichondritis. Inadequate correction, contour distortion or an asymmetric correction is the most common untoward outcomes of otoplasty.13 Even though some degree of retroprotrusion can be expected with most otoplasty techniques, it appears to be particularly common and significant when permanent sutures alone are use to reconstruct the ear.14 For that reason and in order to obtain optimal cosmesis, we favor the technique that includes excision of cartilage. This is a simple surgical procedure that provides the best and most reliable results, making the deformity less apt to recur. A Simple Surgical Procedure Children with protruding ears are often the subjects of verbal, and at times, physical abuse by their peers, resulting in adverse psychological effects. These psychological concerns often cause parents to be the first to initiate the steps toward surgical correction of the prominent ears. However it is very important to have the child voice his desire for surgery, as the child is best able to judge the degree of distress this condition imposes. Nevertheless, the patient’s age plays an important role in the decision for or against surgery. Eighty five percent of the final size of the ear is achieved by age three, and surgery prior to school age could result in marked inhibition of auricular growth. For these reasons we prefer to limit otoplasty in our office to patients who have achieved adolescence or adulthood without completely adjusting to their appearance, as they are more capable than young children to describe the auricular features of concern to them and their desire for correction. Otoplasty is a simple surgical procedure that the dermatologic cosmetic surgeon should be familiar with. It is performed in an outpatient setting and under local anesthesia with or without conscious sedation. With minimum complications and risks, a successful otoplasty can be of significant help to a patient’s social life and self-esteem. Dr. Bisaccia is professor of clinical dermatology with the Department of Dermatology at Columbia University College of Physicians & Surgeons in New York, NY. Drs. Lugo and Johnson are fellows in cosmetic surgery with Affiliated Dermatology. Dr. Scarborough is with the Division of Dermatology at Ohio State University Hospital in Columbus, OH.