------------------------------------------------------------------------------- TITLE: OTOPLASTY SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds DATE: November 9, 1994 RESIDENT PHYSICIAN: Kelly D. Sweeney, M.D. FACULTY: Karen H. Calhoun, M.D. DATABASE ADMINISTRATOR: Melinda McCracken, M.S. ------------------------------------------------------------------------------- "This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." I. Introduction Lop ear deformity (protruding ears) is a common malformation with frequent associated psychological disturbances. Children with this deformity are often the subject of ridicule. Because of the potential psychological consequences during the elementary school years, it is best to correct this problem when the child is between four and six years old. By this age, the ear growth is essentially complete. The most common (60%) defective structure is the lack of development of the normal antihelical and superior crus folds, causing the contour of the concha to flow more or less directly into the surface of the scapha. The second most common (30%) deformity is that of over development of conchal cartilage which can be present in the upper 1/3, lower 1/3, or both. This excess must be evaluated fully before any surgical removal of the cartilage rim because this cartilage governs the concho- scaphal angle and the vertical angle made by the ear and skull. This deformity can occur alone or with deficient antihelical folding. The primary goal of otoplasty is to restore the ear to a more natural appearance without obvious signs of surgical intervention. II. Embryology The external ear begins to develop during the third week of gestation from the otic placode. By six weeks, six mesenchymal proliferations are evident at the dorsal ends of the first and second branchial arches surrounding the first branchial cleft. These auricular hillocks of His are responsible for the development of the auricle. The three cranial hillocks develop from the first branchial arch (mandibular) and the three caudal hillocks develop from the second branchial arch (hyoid). These hillocks ultimately form: 1st hillock = tragus 2nd hillock = crus helicus 3rd hillock = helix 4th hillock = antihelix 5th hillock = antitragus 6th hillock = lobule From the eighth to twelfth weeks of gestation, the skin and helix grow rapidly, resulting in the helix overlying the underdeveloped antihelix. The antihelix then furls during the twelfth to sixteenth week. Failure of this furling to occur will result in a protruding ear. III. Anatomy The basic structure of the auricle consists of delicate, intricately shaped elastic cartilage with a thin, closely adherent layer of skin covering the antero- lateral surface. The posterior auricular skin tends to be more loosely adherent. A. Blood Supply 1. Arterial a. Superficial Temporal b. Posterior Auricular c. Occipital 2. Venous a. Posterior Auricular b. External Jugular c. Superficial Temporal d. Retromandibular B. Lymphatics Drain to parotid nodes anteriorly and upper cervical nodes posteriorly. C. Muscles 1. Intrinsic a. Major and Minor Helices b. Tragicus c. Antitragicus d. Transversus e. Oblique 2. Extrinsic a. Anterior Auricularis b. Superior Auricularis c. Posterior Auricularis D. Innervation 1. Sensory a. Greater Auricular (C2,C3) b. Lesser Occipital (C2,C3) c. Auriculotemporal (V3) d. Arnolds nerve (X with some fibers from VII) 2. Motor a. Temporal branch of VII b. Posterior auricular (VII) IV. Growth and Development At age one, the ear measures approximately five centimeters vertically. By the age of three, 85% of auricular growth has occurred. By age five to six, it is essentially complete. This permits surgical correction before the child starts school without fear of altering the growth potential of the ear. The adult ear measures approximately six centimeters vertically. V. Aesthetic Parameters The vertical axis of the ear should be inclined 20' posteriorly. The vertical height is usually equal to the distance between the lateral orbital rim and the root of the helix (approximately six centimeters). The width of the ear should be approximately 55% of the height. The superior aspect is usually level with the brow. The helix should be visible on the frontal view two to five millimeters laterally behind the antihelix. The fossa triangularis should face laterally, not forward. The helical rim should be symmetrically located to within one to two centimeters of the scalp (auriculocephalic angle) with and angle of protrusion of 25-30'. VI. Pre-Operative Evaluation Before performing otoplasty, it is extremely important to communicate openly and honestly with the patient and family to determine precisely which features of the patients ears they find objectionable and to develop a clear understanding of their expectations from the procedure. A comprehensive medical history is important to rule out the presence of any bleeding diathesis, medical diseases HTN, diabetes, etc...), or the tendency towards formation of keloids or hypertrophic scars, which could complicate the procedure and cause disastrous results. In order to plan the best method of correction of the ear deformity, a careful pre-op evaluation and analysis of the deformity must be performed. This evaluation must include inspection of the position, size, and proportion of both ears in relation to each other, to other facial features, and to the head. The ears should be manually manipulated to a medialized position to determine the consistency of the cartilaginous framework, redundancy of skin in the posterior auricular sulcus, and the desired alteration of the individual ear components. Darwinian tubercles and other skin tags should be noted and pointed out to the patient and may need to be removed during the procedure. Careful measurement of the excursion of the helical rim from the surface of the head must be made for each third of the auricle. A pre-op checklist is often helpful and will ensure that important details are not overlooked (Appendix 1). Photographic documentation is an extremely important aspect of the pre-operative assessment. Views must include frontal, right lateral, left lateral, oblique, rear view, and close up's of each auricle. A headband is often needed to secure the patients hair in order to obtain good photos. Photos should be repeated at six and twelve months post-op for accurate documentation. VII. Surgical Techniques A. Mustarde Technique The protruding ear is folded back to produce an antihelix and the summit of the fold is marked in ink. The position of the mattress sutures are also marked on the skin at least 7 mm from the summit line to prevent forming too narrow of a fold. The markings on the concave side of the concha are closer together than those on the convex side. Next, through and through punctures are made with a 25 gauge needle and marked with methylene blue dye which will leave marks on the cartilage when the needle is pulled through. An ellipse of skin about 3-4cm by 1cm is removed from the postauricular area. The soft tissue is then elevated off the perichondrium to expose the dye marks. Mattress sutures (3 minimum) are placed with 3.0 clear prolene in a horizontal fashion. These should be full thickness through both perichondrium and the cartilage, making sure the anterior skin is not violated. The sutures are then tied with one hitch, starting with the middle suture. The position of the auricle is then adjusted until the desired look is achieved. These sutures are then tied securely in this position. The excessive skin created by this medial displacement on the medial surface of the auricle is then excised in a fusiform fashion, and the postauricular skin incision is closed under no tension in order to prevent obliteration of the normal auriculocephalic crease. Cotton wool soaked in glycerin is then applied to both sides of the auricle to produce a molding effect to the new auricle as it dries. The advantages of this technique is that it creates a very normal-appearing antihelical fold with sutures which can hold indefinitely. The sutures also can help to create a good superior and inferior crus. This technique is also relatively easy to learn and can be used successfully by even inexperienced surgeons (i.e. residents!). The disadvantages of this technique is that an incorrectly placed suture can cause problems post-op (protrusion, infection, or deformity), and this technique is not applicable for work in the conchal bowl area. B. Converse Technique The ear is folded back and the antihelix is marked. The postauricular incision is made and the antihelix cartilage is incised creating an island of cartilage. Sutures are placed to protrude this island of cartilage anteriorly, which retracts the ear as the antihelix is formed. The advantages of this method is that the island of cartilage creates a more natural, softer fold, more permanent retraction of the auricle is facilitated, and because the island of cartilage is not sutured, a more gentle curve to the antihelix is created. However, this technique requires a more experienced surgeon. C. Farrior Technique: Once the perichondrium is exposed posteriorly, then incisions are made through the cartilage on the conchal rim only. Longitudinal wedges of cartilage are removed at the level of the superior crus and future antihelical fold. An incision is made through the cartilage at the level of the antihelical fold, creating an island of cartilage. This island should widen from inferior to superior producing a gentle bend to the antihelix. Then sutures are placed as described above to retract the ear and form the anti- helix. This technique primarily crates a more gentle bend to the antihelix. This technique requires a more experienced surgeon. D. Pitanguy Technique: This operation is very similar to the Converse procedure. An island of cartilage is created and sutures are used to protrude the island forward while the auricle is retracted. Again, an experienced surgeon is required. E. Furnas Technique: Using a cotton-tipped applicator, the conchal bowl is pushed posteriorly until the ear is no longer prominent. The level of reflection is then marked on concha with a pen. A posterior auricular segment of skin is excised and the concha is dissected anteriorly. The posterior auricular muscle is divided. A segment of the soft tissue overlying the mastoid fascia is removed and the deep fascia over the mastoid process is exposed. Three sutures of 4.0 clear nylon are used to approximate the cartilage to the thick mastoid periosteum. Once the desired look has been achieved, the sutures are tightened and the final knots are welded with the bovie. The skin is then closed, and a mild pressure dressing is applied for 7-10 days. The advantages of this technique are that when excessive conchal cupping is the only cause of the prominence of the ear, then concha-mastoid sutures can produce an exceptionally natural-appearing ear, permanent retraction can be achieved, and this procedure can be easily done in combination with the above antihelical producing procedures. The disadvantage with this technique is that partial closure of the external auditory canal can occur if the mastoid sutures are placed too far forward. However, this will usually be noticed during the procedure and can be corrected before closure. F. Stenstrom Technique: A posterior ellipse of skin is excised in an hour glass fashion. An incision is made along the lateral most aspect of the cartilage at the site of the future antihelix. Dissecting about the tail of the helix allows for an entire anterior skin flap to be elevated for exposure to the anterior surface of the auricular cartilage. The cartilage is then scored in a longitudinal fashion over the future site of the superior crus and antihelix. The posterior incision is then closed causing a retraction and posterior reflection of the auricle. This technique provides direct visualization of the anterior surface of the cartilage and produces weakening of the cartilage without actual excision. This results in a more natural curve to the auricle and antihelix. The disadvantage of this technique is that no permanent sutures are used to hold the ear in place which can lead to recurrence of the problem post-op. Also, possible irregularities are visible on the anterior surface and hematoma formation is increased. G. Correction of Lobular Defects Excessive protrusion of the lobe can be corrected by identifying the cauda helicis from the posterior approach and placing a permanent horizontal mattress suture from it to the concha. This allows the lobe to be drawn in just the right amount. Excessive lobule can be reduced in size by a curvilinear excision of inferior skin. H. Scapha Reduction This should be avoided if at all possible due to the excessive scarring and deformity which can occur. However, if this is necessary to correct an extremely large scapha, an inverted pentagonal offset wedge excision may be used. I. Darwinian Tubercles A prominent darwinian tubercle may be excised via an incision hidden in the helical fold anteriorly. The excess skin can be tailored prior to closure. A long incision is preferred over a short incision to help avoid dog-ears. VIII. Complications A. Early 1. Hematomas Caused by dissection outside the tissue plane, inadequate hemostasis, inadequate dressing, HTN, and rebound vasodilation from local anesthetic. This complication should be suspected if the patient complains of excessive post-op pain or if bleeding is evident through the dressing. If a hematoma is suspected the dressing should be removed and the ear inspected. The postauricular space will be tense, bluish, and swollen with ecchymosis. The treatment involves returning to the OR, opening the wound under sterile conditions, cauterize bleeders with needle tip bovie, place a small drain, and reclose with interrupted sutures. The patient should be placed on broad spectrum antibiotics. If this complication is missed, perichondritis or cartilage necrosis can occur. 2. Cellulitis Usually due to Staph, E. Coli, or Pseudomonas. This usually occurs five days post-op. This can be prevented by a dose of IV Ancef perioperatively, strict adherence of sterile technique, irrigation prior to closure, and placement of antibiotic ointment over incisions. Treatment involves evacuation of any fluid collections or hematoma, culture and sensitivity, warm saline compresses, and broad spectrum antibiotics until C&S returns. 3. Perichondritis This rare complication occurs in less than 1% of cases. It may follow and undetected hematoma or cellulitis. The ear will appear red, swollen, and tender. Treatment involves hospitalizing the patient, broad spectrum IV Abx, and returning to the OR for debridement of necrotic tissue and cartilage. 4. Cartilage necrosis This is rare and usually due to injudicious dissection of skin flaps, excessive use of bovie, poor application of post-op dressing with ear bent, post-op hematoma, or infection. This devastating complication can result in a very poor post-op result, but can be potentially avoided by close post-op care. 5. Allergic reaction This can be caused by chromic sutures or neomycin antibiotic ointment. Pain and pruritis usually occur. Treatment involves removing the dressing, inspecting the wound, removing the ointment, and possibly steroids. B. Late 1. Suture granuloma The incidence of this may be as high as 8%. This was usually seen with the use of silk and occurs less frequently with newer monofilament sutures. Treatment is to remove the suture after three to four months. 2. Suture extrusion This is much less common with the use of monofilament sutures. If this occurs, remove the suture tag and apply ointment. 3. Hypertrophic Scars and Keloids These are more common in younger or deeply pigmented patients. This is usually related to excess postauricular skin excision with a skin closure under tension. These may resolve over time or may be treated with kenalog injections. 4. Hypesthesia This is due to injury of the greater auricular nerve while excising deeper tissue for conchal set back technique. This is not usually a major problem but the potential for this complication should be discussed pre-op. 5. Susceptibility to cold temperature This is due to disturbance of the auricular blood supply and can result in frost bite in these patients. It is important to caution patients so that they may watch for this in the winter. IX. Unsatisfactory Results A. Recurrence of deformity This is the most frequent cause of surgical failure and need for revision surgery. This will usually be evident by 3 months post-op. The most common reasons are: improper placement or insufficient number of sutures, cartilage too strong to be controlled by sutures alone, persistence of excessive conchal wall projection, and failure to mobilize the auricle at the inferior crus. Reassessment of the entire ear with appraisal of each component is mandatory. It is important to inquire about post-op trauma and to rule out a localized infection or suture abscess. Corrective surgery can be conducted at any time as long as there is no infection present. B. Telephone ear deformity This is caused by overcorrection of the middle third of the ear. This deformity may follow excessive removal of skin in the middle third posteriorly, excessive resection of mastoid soft tissue, excessive removal of conchal cartilage, or excessive tightening of concha-mastoid or scapha-conchal sutures. This can be prevented by double checking the tension on all sutures during the procedure and adjusting the tension accordingly. C. Conchal deformities The high conchal wall can cause protrusion of the auricle and may be overlooked in the presence of prominent antihelical folding. This can be corrected by using the Furnas set back procedure. X. Conclusion Otoplasty is usually a mutually gratifying procedure for both the patient and the surgeon. Correction of protruding ears prior to the elementary school years can help prevent psychological problems later in life. A thorough preoperative evaluation including photographic documentation is essential. Meticulous surgical technique and careful postoperative care are of utmost importance for preventing possible complications and obtaining a satisfying result. --------------------------------------------------------------------------- BIBLIOGRAPHY Bailey, Byron J., ed. Head and Neck Surgery - Otolaryngology. Philadelphia, PA: J. B. Lippincott Co., 1993 Cummings, Charles, ed. ibid Krause, Charles J., ed. Aesthetic Facial Surgery. J. B. Lippincott Co. 1991 McCarthy, Joseph G. Plastic Surgery. Philadelphia, PA: W. B. Saunders Co. 1990 Reese, Thomas D. Aesthetic Plastic Surgery. Philadelphia, PA: W. B. Saunders Co., 1980 ---------------------------------END---------------------------------------