Otoplasty techniques aim to correct a number of auricular deformities, including the prominent ear, constricted ear, Stahl’s deformity and cryptotia. The most common of these deformities is the prominent ear with an incident of approximately 5% of the general population in the United States. Although, to some degree, the perception of prominence is in the eye of the beholder, there are some characteristics that are considered as “normal”. According to these, the three-dimensional position of the auricle in relation to the face and mastoid bone is a 17-21 mm distance of the helical rim from the mastoid bone with a 20-30degree auriculo-mastoid angle. Measurements beyond these criteria aretheoretically considered as deformity. Anatomically, a prominent ear lacks the antihelix fold or his a big conchal bowl, or a combination of both .
Although the physical morbidity of the deformity is negligible, its impact on child’s psychology and socialization can be significant. A successful correction of the abnormality has been reported to improve the patient’s sense of personal happiness and confidence and would subsequently result in beneficial social and psychological changes .
There are several approaches for the correction of prominent ears: conchal excision, formation of antihelix by cartilage scoring and Mustardé’s sutures. These basic maneuvers have several modifications with each having its pros and cons. Furthermore, reported rate of residual deformities and of partial recurrence of the original deformity point out the need to ameliorate the treatment.
We present the resection of auricularis posterior muscle and adjacent soft tissue as an easy and reliable way to approximate the prominent ear reducing the auriculo-mastoid angle and providing a natural result that avoids some of the common deformities associated with other techniques.
Twenty-two patients (42 auricles) with protruding ears have been treated with the technique presented in our clinic from 2011 to 2013. Of these patients, fifteen were male and seven female with ages ranging from 5 to 40years (mean 18 years old).
Under general anesthesia, an elliptical skin excision is made in the posterior aspect of the auricle concha. (Figure 1)
Figure 1. The incision is drawn in the back of the prominent ear
Following skin excision, we dissect posteriorly through the subcutaneous plane using gentle anterior traction of the ear, aiming to identify the posterior auricular muscle. (Figure 2a)Upon identification, the muscle is meticulously dissected and detached from the ear cartilage and the mastoid fascia.
Figure 2a. Auricularis posterior muscle
The adjacent soft tissue is removed creating a pocket for the conchal cartilage to insert. (Figures 2b, 3a, 3b and 3c) 3.0 PDSTMII (Ethicon Inc.) sutures are placed through the cartilage and to the mastoid fascia, tightly securing the concha into the pocket by which the auriculo-mastoid angle is reduced and the helix mastoid distance is shortened as needed (Figure 4). The helix mastoid distance can be adjusted by putting the sutures more laterally or medially as for the specific ear dimensions. Often this maneuver alone will achieve a satisfactory result. However, if one needs tocreate an anti-helix, this can be done using any previously described method (i.e. cartilage scoring and Mustardé’s sutures). The skin is closed with 4.0 Vicryl-RapidTM (Ethicon Inc.) continuous sutures and dressings are applied.
Figure 2b. pocket created after resection ofauricularis posterior muscle and adjacent soft tissue.
Figure 3. a: auricularis posterior muscle and adjacent soft tissue, b: auricularisposterior muscle and adjacent soft tissue after dissection, c: newly formed pocket after dissection.
Figure 4. a: three 3.0 PDSTMII (Ethicon Inc.) sutures are placed through thecartilage and to the mastoid fascia tightly securing the concha into the pocket, b: the ear placed into the new position.
All patients followed a routine follow up at 1, 3 and 6 months postoperatively. No significant complications were noticed during the follow up period. No patient required revision due to relapse of ear prominence. One patient resulted with unilateral narrowing of her external auditory canal complicated by impacted cerumen requiring several outpatient clinic visits for its removal. Patients’ and parents’ satisfaction with the aesthetic results was high. (Figure 5) When looking carefully at the auricular shape after using this technique one may notice that the auricle may look somewhat wide open in comparison to cases where conchal resection was performed.
Figure 5. Preoperative (up) and postoperative (down) photos of cases treated with the presented technique. The aesthetical results were satisfying.
Since the ear reaches approximately 90% of the adult dimensions by theage of 3, we can correct the deformity early in child’s life. It is therefore advisable to proceed with surgical intervention at the age of 3 to 6 years, before the onset of school, to avoid the psychological distress during child’s socialization period . Furthermore, until the age of 6, the elastic properties of ear cartilage allow easier manipulation and less recurrence rates than at adolescent or adulthood .
Correction of prominent ears is a challenging procedure with many parameters to be taken into account. Projection of the ear should be established at multiple levels. The helix-to-mastoid distance should be 10 to 12 mm at the superior helix, 16 to 18 mm at the midpoint, and 20 to 22 mm at the lobule. The auriculo-cephalic angle is a more difficult parameter to recommend because of the wide variability in the reported literature. The angle should be less than 35o , preferably between 21o and 25o , with females demonstrating less projection in general. Symmetry between the two ears is acceptable within the limit of 3mm. Dieffenbach (1984) first reported a successful correction of prominent ears. Ever since, nearly 200 various techniques have been described. These techniques can be roughly divided in two main categories: cartilage-cutting techniques and cartilage-weakening procedures.
Cartilage-cutting techniques are often preferred in the presence of stiff and thick cartilage . The incisions are made from the front and/or rear aspect of the antihelical cartilage and cutting the auricular cartilage breaks its elastic resistance in order to form an antihelical curve. The tubular form is secured in place with sutures. Although the concept of cartilage-cutting techniques is simple and the procedure is technically less demanding, it potentially subjects the ear to irreversible distortion created by wound contracture and cartilage remodeling. The results are therefore less predictable. Irregularities, sharp edges and overcorrection are usual and difficult to treat complications of the cartilage-cutting approach. The unpredictability of these changes challenges the goals of form and symmetry . Furthermore, conchal cartilage excision commonly results in some excess of skin in the anterior side of the ear. Although this visible fold in the conchal floor will, in most cases, spontaneously resolve, it can add some level of distress to the patient and family during the post-op period.
Cartilage-weakening techniques are based on the observation that cartilage tends to warp away from an injured surface . Cartilage weakening techniques are more suitable for patients with less stiffness. The cartilage resistance is reduced by means of partial incisions or scorings allowing for maximum protection of cartilage support. These techniques minimize scar risk and contour disorders and allow easy suturing of cartilage. An antihelical curve is achieved with multiple horizontal mattress sutures, first introduced by Mustardé in 1967 . With cartilage-weakening techniques, permanent changes in cartilage structure are avoided and reversibility is ensured . However, the result from a given degree of cartilage abrasion depends on several factors and can be difficult to predict, rising the residual deformities requiring revision to a rate of 10% to 30% . Furthermore, sutures may slice through tissue like a wire slicing through a block of cheese and this cheese-cutting effect can erodethe cartilage and result in recurrence .
In the technique presented, we resect the auricularis posterior muscle as well as the adjacent soft tissue in order to create a pocket for the conchal cartilage to insert. The pocket ensures that the cartilage is secured in a newly formed anatomical position and the cartilage is tension-free sutured in its new position with absorbable threads. Since neither cutting, nor scoring of the cartilage is required, the risk of chondritis is minimized. Creating a pocket to insert the concha offers an easy and efficient way to correct the angle and, at the same time, makes conchal cartilage excision redundant. Furthermore, in cases where the desired correction of the auriculo-mastoid angle cannot be achieved with the presented technique alone, Mustardé’s sutures can be additionally used but without the need to apply them as pronounced as we would normally do, thus allowing for more natural looking results.
However, this technique can only correct prominent ears and the degree of correction is limited to the depth of the pocket created. It is therefore important for the surgeon to combine this procedure with cutting or scoring cartilage techniques if the desired degree of remodeling is not achieved and to perform additional manipulation if supplementary ear deformities are present.
We believe that the resection of the auricularis posterior and adjacent soft tissue for the correction of prominent ears to be a straight forward, technically undemanding technique that can be performed even by less experienced surgeons with satisfying results.
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