Surgical otoplasty

Surgical otoplasty

The corrective goal of otoplasty is to set back the ears so that they appear naturally proportionate and contoured, because they are harmoniously set back, without evidence or indication of surgical correction. Therefore, when the corrected ears are viewed, they should appear normal, from the:
(i) Front perspective. When the ear (pinna) is viewed from the front, the helical rim should be visible, but not set back so far (flattened) that it is hidden behind the antihelical fold.
(ii) Rear perspective. When the pinna is viewed from behind, the helical rim is straight, not bent, as if a “letter-C” (the middle-third to flat), or crooked, as if a hockey stick” (the earlobe is insufficiently flat). If the helical rim is straight, the setback is harmonious; that is, the upper-, middle-, and lower-thirds of the pinna will be proportionately setback in relation to each other.
(iii) Side perspective. The contours of the ear should be soft and natural, not sharp and artificial.
Timing otoplastic correction
The ear deformity to be corrected determines the advantageous timing of an otoplasty, for example, in children with extremely prominent ears, 4-years old is a reasonable age. In cases of Macrotia associated with prominent ears, the child’s age might be 2-years, nonetheless, it is advantageous to restrict the further growth of the deformed ear. Moreover, regardless of the patient’s age, the otoplasty procedure requires that the patient be under general anaesthesia.[19]
Ear reconstruction
Generally, for reconstructing an entire ear, or a portion of the rim cartilage, the surgeon first harvests a costal cartilage graft from the patient’s rib cage, which then is sculpted into an auricular framework that is emplaced under the temporal skin of the patient’s head, so that the skin envelope encompass the cartilage framework, the ear prosthesis. Once emplaced and anchored with sutures, the surgeon then creates a pinna (outer ear) of natural proportions, contour, and appearance. In the next months, in follow-up surgeries, the surgeon then creates an earlobe, and also separates the reconstructed pinna from the side of the head (ca. 15–18 mm), in order to create a tragus, the small, rounded projection located before the external entrance to the ear canal.
In the case of the patient encumbered with several congenital defects of the ear or who has insufficient autologous cartilage to harvest, it might be infeasible to effect the corrections with grafts of rib cartilage. In such a case, the reconstructive Antia–Buch helical advancement technique might apply; it moves tissues from behind the ear rim, and then around and forward to repair the defective front of the ear rim.[20] To perform the Antia–Buch helical advancement, with ink, the surgeon first designs the incision inside the helical rim and around the crus (shank) of the helix. Then cuts the skin and the cartilage — but does not pierce the posterior skin of the ear. The helical rim then is advanced to allow the suturing (closure), and a dog-ear-shaped graft of skin is removed from the back of the ear. The closure of the sutures advances the crus of the helix into the helical rim

Indications
The ear defect or deformity to be corrected determines the otoplasty techniques and procedures to be applied, thus, a torn earlobe can be repaired solely with sutures; a slight damage to the rim of the pinna (outer ear) might be repaired with an autologous skin graft harvested from the scalp, yet conversely, a proper ear reconstruction might require several surgeries. In the correction of infantile ear defects and deformities, the otoplasty usually is performed when he or she is about six years old, because, at that age, the healthy ear is almost adult-sized, and thus can serve the plastic surgeon as a corrective template for the auricular reconstruction.

The otoplastic technique(s) applied to correct, reconstruct, or replace a deformed, defective, or a missing ear, is determined by the indications that the patient presents; some are:
Cagot ear — A congenital defect characterized by ears without an earlobe; the name of the defect derives from the Cagot peoples of northern Spain and western France, at the Pyrenees Mountains, among whom this ear defect is genetically common.
Cat’s ear — A defect characterized by the outer edges of the ears folded forward, away from the sides of the head, and towards the face; hence the person’s feline appearance. The plastic correction anchors, and thus flattens, the ear against the head.
Cauliflower ear — An ear deformed by repeated trauma (injury) to the tissues as occurs to boxers and wrestlers; the name of deformity derives from its resemblance to a cauliflower. A hematoma might also result from an acute trauma, and, unless evacuated, the blood in the ear tends to become cartilaginous, resulting in a “cauliflower ear”, which, once fully developed, is very difficult to correct. The successful management of a hematoma might require either repeated aspirations or an incision to fully evacuate the accumulated blood. After evacuation of the blood, the management of an acute othematoma of the concha features through-and-through bolster sutures to compress the skin against the cartilage, which usually prevents recurrence.[22]
Cleft earlobe — A defect characterized by an indentation (notch) to the fleshy portion of the earlobe. The usual correction is transplantation of an autologous tissue graft.
Constricted ear — In mild cases of constricted ear, the crus (shank) of the helix is advanced out of the concha, and into the helical rim in order to increase its circumference. In severe cases of constricted ear, some of the cartilage is discarded and a complete reconstruction of the pinna is performed, as in the procedure for correcting microtia.
Cryptotia — The hidden ear features the rim of the helix cartilage buried under the skin of the scalp in the temporal region. After making an incision, the upper portion of the ear is exposed by outward traction on the pinna, after making an incision around the visible helical rim. Then, the medial surface of the freed helical-rim cartilage is resurfaced either with a skin graft or with a skin flap. In most cases of Cryptotia, the upper-ear cartilage that is buried under the scalp is developmentally normal, but occasionally, it is abnormal and might also require correction.
Darwinian ear — A defect wherein the rim cartilage of the conchal bowl of the ear is flat, rather than folded inwards; it is an evolutionary remnant from when the human head muscles permitted the person to voluntarily prick up the ears in a given direction. The Darwinian ear eponym derives from Charles Darwin (1809–1882), the British biologist and evolutionary theoretician. (see Darwin's tubercle)
Lop ear — A protruding ear characterized by the defects of a too-small helix (the cartilage-stiffened rim of the pinna) and a large, central depression around the auricular canal (ear opening); the combined effects of the deformations produce a “cup ear” appearance. The usual plastic correction is enlargement of the helix and closer anchoring to the head.
Macrotia — Ears that are proportionately oversized to the person’s head; the surgeon reduces them by making an incision on the lateral surface of the pinna, just inside the helical rim. The scapha (elongated hollow) is reduced, and a segment of the helical rim is excised, and the incision is closed primarily to avoid redundancy.
Microtia — A congenital defect characterized by either the severe underdevelopment or the absence of the pinna (outer ear). At one end of the spectrum is a pinna slightly smaller than normal, but of normal appearance, and at the other end of the spectrum is anotia, the absence of the pinna. The Nagata classification correlates the ear deformity with the surgical approach thus: (i) Lobule type — The patient has an ear remnant and malpositioned lobule, but no concha, acoustic meatus, or tragus. (ii) Concha type — The patients presents an ear remnant, malpositioned earlobe, concha (with or without acoustic meatus), tragus, and antitragus with an incisura intertragica. (iii) Small concha type — The patient presents an ear remnant, malpositioned lobule, and a small indentation instead of a concha. (iv) Anotia — The patient presents either no ear remnant, or a minute, ear remnant. (v) Atypical microtia — The patient presents deformities of the ear that are not comprehended in the four preceding Nagata classifications.[23]
Question mark ear — A rare congenital defect characterized by a protuberant pinna (external ear) with a cleft (indentation) between the earlobe and the outer cartilage rim, between the fifth and sixth hillocks. This deformity also is known as Cosman ear, after Dr. Bard Cosman (1931–1983), the American plastic surgeon who identified it. The degree of anatomical deficiency is variable, and usually can be corrected with a cartilage graft and a V-Y advancement-flap of retroauricular skin, harvested from the back of the ear, because there often is excess skin in the upper-third of the ear being corrected. To reconstruct a Question mark ear featuring a severely deformed pinna, the otoplastic procedure for correcting microtia is applied.
Scroll ear — A congenital defect characterized by the outer edge of the ear curling forward, inwards (like a curled scroll), and towards the head.
Skin cancer and malignant melanoma — Cutaneous malignancies of the helical rim can be excised and closed with the Antia–Buch helical advancement technique. Cancerous lesions in the concha or over the antihelix can usually be excised and skin grafted. If the cartilage is involved, it can be excised and the graft placed directly on the posterior skin. Malignant melanomas should be excised with the same margins as melanomas of the equivalent depth in other parts of the body. Melanoma in situ does not require a full-thickness excision, and is excised with a 5-mm margin, to preserve the perichondrium, and then covered with a skin graft. Invasive melanomas of the helical rim require wedge resection to achieve adequate margins; these defects might be large and require secondary reconstruction as in Figure 30.11.
Stahl’s ear deformity — A pointed-ear defect characterized by an abnormal folding of the skin and cartilage of the pinna, which produce an “elfin ear” characterized by an ear-rim with a pointed upper-edge, rather than a rounded upper-edge.
Wildermuth’s ear — A congenital defect characterized by a backwards-oriented helix (the pinna’s curved, cartilage border), which deforms the ear by protruding the ante-helix (inner ridge of the pinna). The eponym derives from Hermann A. Wildermuth (1852–1907), the German neurologist who identified the defect.

Surgical procedures
Otoplastic surgery can be performed upon a patient under anesthesia — local anesthesia, local anesthesia with sedation, or general anesthesia (usual for children). In order to correct a lop ear with a small helix (the cartilage-supported outer rim of the pinna), an incision to one side of a flat cartilage piece leaves unopposed elastic forces on the opposite side, which permits the evolution of the ear contour; thus, a small incision on one side of the lop-ear cartilage, along the new anti-helical fold, can be a technical element of the corrective ear surgery. Yet, when done without an incision, the procedure is deemed an incisionless otoplasty, wherein the surgeon places a needle through the skin, to model the cartilage and to emplace the retention sutures that will affix the antihelix and conchal bowl areas.
Surgical otoplasty techniques
Depending upon the auricular (pinna) defect, deformity, or reconstruction required, the surgeon applies these three otoplastic techniques, either individually or in combination to achieve an outcome that produces an ear of natural proportions, contour, and appearance:
I. Antihelical Fold Manipulation
(a) Suturing of the cartilage. The surgeon emplaces mattress sutures from the scapha and the triangular fossa, or both, to the concha (as described by Mustarde), and is tied with sufficient tension to increase the definition of the antihelical fold, thereby setting back the helical rim and the scapha.
(b) Stenstrom technique of anterior abrasion. The abrasion (roughening) of the anterior (front) surface of the antihelical fold cartilage causes the cartilage to bend away from the abraded side (per the Gibson principle), towards the side of intact perichondrium, the membrane of fibrous connective tissue.
(c) Full-thickness incisions. One full-thickness incision along the desired curvature of the antihelix permits folding it with slight force, thereby creating an antihelical fold (as in the Luckett procedure). Yet, because such a fold is sharp and unnatural in appearance, the technique was modified as the Converse–Wood-Smith technique, wherein two incisions are made, running parallel to the desired antihelical fold, and tubing sutures are emplaced to create a more defined fold of natural contour and appearance.
II. Conchal Alteration
(a) Suturing. The surgeon decreases the angle (-25 degrees) between the concha and the mastoid process of the head with sutures emplaced between the concha and the mastoid fascia (as described by Furnas).
(b) Conchal excision. From either an anterior or a posterior approach, the surgeon removes a full-thickness crescent of cartilage from the posterior wall of the concha (ascertaining to neither violate nor deform the antihelical fold), to thereby reduce the height of the concha. Moreover, to avoid producing a noticeable surgical scar in the concha, the surgeon meticulously closes the conchal defect with sutures. The design of the cartilage-crescent excision means to produce a closing incision will lay at the junction of the conchal floor and the posterior conchal wall — where it is least noticeable, and causes minimal distortion of the normal contours of the ear.
(c) Combination. The surgeon applies a corrective technique that combines the pertinent technical aspects of the Furnas suture technique and of the conchal excision techniques.
III. Correction of Earlobe Prominence
Repositioning the earlobe is the most difficult part of the otoplasty, because when a pinna (external ear) that has been repositioned in its upper two-thirds, and that yet retains a prominent lobule (earlobe) will appear disproportionate to and malpositioned upon the head — as it did in the original, uncorrected deformity. The otoplastic technique most effective for lobular repositioning is the Gosain technique (or a variant), wherein the surgeon cuts the skin on the medial surface of the earlobe, and, in suturing it closed, takes a bite of the conchal undersurface to pull the earlobe towards the head.
Another prominent-earlobe correction technique is suturing the helical-cartilage tail to the concha, yet, because the tail of the helix does not extend into the lobule, setting it back does not reliably correct the set back of the earlobe proper; other techniques involve skin excision and sutures, between the fibrofatty tissue of the lobule and the tissues of the neck.
IV. Alteration of the position of the auricular upper pole
Depending upon the pre-surgical degree of prominence of the upper-third of the pinna, the surgical creation of the antihelical fold might be inadequate to fully correct the position of the helical rim, near the root of the helix.[24]
Types of otoplastic correction
Ear augmentation, addressing Microtia (underdeveloped pinna) and Anotia (absent pinna) involves adding structural elements to replace the missing structures. The cartilage tissue grafts for such extensive reconstructions usually are harvested either from the ear (auricular cartilage) or from the rib cage (costal cartilage).
Ear pinback — An otopexy that “flattens” protuberant ears against the head (ca. 15–18 mm), wherein the surgeon makes an incision to the natural crease behind (retroauricular sulcus) the external ear, and cuts a small tunnel along the front of the poorly folded antihelix. Once the cartilage is loosened, the concha (bowl) is moved closer to the head, after removing the excess skin and cartilage from the ear rim, and is sutured to reshape the antihelical fold, to balance the ear lobe (lobule) with the proportions of the pinna. The corrected ear then is emplaced and sutured closer to the head. Surgical ear pinback can be performed upon an anesthetized patient (local or general anesthesia), and usually is performed as an outpatient procedure that allows the patient to convalesce at home. The post-operative bruising and swelling usually subside within two weeks, and the narrow, surgical scars are hidden in the posterior skin folds of the ear; yet the outcome is not fully noticeable until the swelling and bruising have gone. Historically, otopexy dates from 1881, when Edward Talbott Ely first performed ear pinback plastic surgery at the Eye, Ear, and Throat Hospital, Manhattan, New York City.[25]
Ear reduction, addressing Macrotia, might involve reducing one or more of the components of oversized ears; the incisions usually are hidden in, or near, the front folds of the pinna.
Post-surgical recovery
The internal sutures usually are permanent (non-absorbable), but the surgical wound or wounds can be sutured with either absorbable sutures or with non-absorbable sutures that the plastic surgeon removes when the surgical wound has healed. Depending upon the deformity to be corrected, the otoplasty can be performed either as an outpatient surgery or at hospital; while the operating room (OR) time varies between 1.5 to 5.0 hours.
For several days after the surgery, the otoplasty patient wears a voluminous, non-compressive dressing upon the corrected ear(s), during which convalescent period, he or she must avoid excessive bandage pressure upon the ear, lest it cause pain and increase swelling, which might lead to the abrasion (rubbing), or even to the necrosis of the ear’s skin. After removing the dressing, the patient then wears a loose headband whilst sleeping, for a 3–6-week period; it should be snug, not tight, because its purpose is preventing the corrected ear(s) from being pulled forward, when the sleeping patient moves whilst asleep. Hence, a tight headband can abrade and erode the side surface of the ear, possibly creating an open wound.[26]
Complications
Hematoma. This otoplasty complication is immediately addressed when the patient complains of excessive pain, or when the surgical wound bleeds. The dressing is immediately removed from the ear to ascertain the existence of a hematoma, which then is immediately evacuated. If the surgical wound is infected, antibiotic therapy helps avoid the occurrence either of abscess or of perichondritis (inflammation).
Infection. Cellulitis is rare after otoplasty, but it is treated aggressively, with antibiotics in order to avoid chondritis — which might require debridement, and permanently disfigure the ear.
Suture complications. The most common otoplastic complication is suture extrusion in the retroauricular sulcus, (the groove behind the ear). Such extruded sutures are easy to remove, but the extrusion occurrence might be associated with granulomas, which are painful and unattractive. This complication might be avoided by using absorbable sutures; to which effect, monofilament sutures are likelier to protrude, but have a lesser incidence rate of granulomas; whereas braided sutures are unlikely to protrude, but have a greater incidence rate of granulomas.
Overcorrection and unnatural contour. The most common, but significant, complication of otoplasty is overcorrection, which can be minimized by the surgeon’s detailed attention to the functional principles of the surgical technique employed. Hence, function over form shall minimize the creation of the unnatural contours characteristic of the “technically perfect ear”.