The importance of conchal resection in correcting the prominent ear

Treatment of an Overcorrected Ear After Previously Performed Otoplasty

No single otoplasty technique can be applied to all prominent ear deformities. The factors determining the type of operative method are based on the surgeon's preference for and confidence in the technique as well as long-term results. However, all cutting or scoring techniques include a risk of development of undesired edges, defects, or deformities on the ear being operated on. One of the patients' complaints and dissatisfactions after otoplasty is an overcorrected ear in its upper half. This condition leads to the loss of helix and prominent and conspicuous crus superior and antihelix. The article presents a simple and successful surgical procedure for correction of the condition.

Open Otoplasty Through Ventral Skin Incision and Abrasion of the Antihelix Under Vision

BACKGROUND

Common otoplasties through incisions behind the ear with blind scoring or scratching the anterior perichondrium often leave an irregular surface of the antihelix.

METHOD

To avoid these tiny side effects, a skin incision along the ventral antihelical fold (scapha) is used to thin and fold the flat antihelix under vision. After local anesthesia of the ventral ear skin, an incision along the scapha allows its blunt lifting toward the concha and to expose the cartilaginous antihelix. Its future shape is marked and the thickness of the cartilage is thinned with a dermabrader by approximately half or until one sees the gray of the inner cartilage. The now missing perichondrium causes the antihelix to fold by itself with an absolute smooth surface and is fixed with three absorbable mattress sutures.

RESULTS

The technique has been developed in 1985 in Frankfurt and has since been performed on over 1000 patients with optimal results and a low complication rate. The skin flap is so well perfused that no skin necrosis and only 5.7% wound healing problems were experienced.

CONCLUSION

This approach from ventral is safe, timesaving, and avoids contour irregularities of the antihelix often seen after traditional techniques. It can be left to beginners in plastic surgery without hesitation. The fear of hypertrophic scars or even keloids can be dispelled with the fact that ear keloids only occur after wound infection.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Otoplasty: The Belfast Experience. A 10-Year Review of 2333 Ear Outcomes

BACKGROUND

"Prominent ear" remains one of the most common referrals to pediatric plastic surgery. The perceived deformity has been corrected using a multitude of techniques for over a century, and significant variation in practice still exists. Recent studies suggesting that cartilage-scoring techniques are associated with more major complications than suture techniques may have led to an adverse international perception of the technique. Thus, waning use of anterior scoring prominent ear correction appears to be occurring. For appropriate cases, the authors have used anterior scoring for over 20 years, with high patient satisfaction and low complication rates. They present a review of all cases and outcomes from 2005 to 2015. The authors believe this is the largest case series of anterior scoring otoplasty published to date.

METHODS

All pediatric cases undergoing prominent ear correction from 2005 to 2015 were included in this retrospective case note analysis and follow-up study. Patient demographics, operative details including early and late complications, and postoperative results were analyzed.

METHODS

Over a 10-year period, 1199 otoplasties were performed (1134 bilateral, 65 unilateral), for a total of 2333 ear corrections. A total of 1575 ears were corrected using the anterior scoring technique. The remaining cases underwent correction by means of suture only, cartilage reduction, or combination techniques. There was a significantly lower all-cause reoperation rate for anterior scoring compared to suture-only techniques ( P = 0.0039; significant at P < 0.025). There were no reported cases of cartilage necrosis.

CONCLUSIONS

This study demonstrates that in appropriately selected patients, anterior scoring otoplasty is a low-morbidity procedure. In the authors' institution, when compared to suture techniques, it was associated with a lower rate of complications and reoperation rate than suture-only techniques.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Comparative study of the effectiveness of the surgical technique with and without preservation of the conchal cartilage in otoplasty through the measure of the cephalo-auricular and scapho-conchal angles

OBJECTIVES

Prominent ear abnormalities affect 5% of the population. A prospective, double-blind study of patients who underwent otoplasty procedures to correct these abnormalities was conducted to compare two surgical techniques. They diverge by the preservation or not of conchal cartilage.

METHODS

The two techniques were compared by measuring the cephalo-auricular and scapho-conchal angles. Measurements were performed in pre and 6-months post-operative periods using alginate molding. Twenty patients were randomly assigned to two groups (with and without cartilage preservation) with 10 participants each. Student's t-test, Covariance Analysis Model (ANCOVA), and non-parametric Mann-Whitney were used in the statistical analyses.

RESULTS

A significant reduction in the average of the cephalo-auricular and scapho-conchal angles was observed in both surgical procedures (p<0.001). However, no significant difference was found between them (p=0.887).

CONCLUSION

The two techniques analyzed in this study fulfilled their objectives. Therefore, further comparative studies are needed to confirm the superiority of one over the other.

LEVEL I

Evidence obtained from at least one properly designed randomized controlled trial.

Conchal Excision Techniques in Otoplasty: A Literature Review

Prominent ears are a common congenital deformity of the head and neck. Correcting concha hypertrophy is an important step in otoplasty. Despite the risk of postoperative deformity due to the sharp edges created by excision, removing a section of cartilage is sometimes the only method to obtain a satisfying and long-lasting result. Multiple conchal excision techniques have been reported in the literature, with significant differences in approach, outcome evaluation, and complication classification. The objective was to review cartilage excision-based otoplasty procedures to offer plastic surgeons’ insights into current data on outcomes and complications of conchal excision techniques.

Prominent Ear Repair Surgery: Retrospective Review of Long-term Results

PURPOSE

Prominent ear is common in the White population at a rate of 5%. Many surgical incision and suture techniques have been described for its correction. The purpose of this article was to report the results of the prominent ear surgeries applied in our clinic for the last 5 years and to show the details of the surgical technique, to evaluate long-term results, complications, revisions and to compare them with previously published studies.

MATERIALS AND METHODS

A total of 27 patients were included in the study. The patient age ranged from 7 to 60 at the time of surgery (mean age: 18.7). Of the 27 patients, 13 were female (48.2%) and 14 were male (51.8%). The procedure was bilateral in 19 cases (70.4%) and unilateral in 8 cases (29.6%). The patients were treated with the same technique by three surgeons. Aesthetic results were evaluated by patient and surgeon surveys.

RESULTS

The follow-up was between 1 and 5 years (mean: 3 years). The patients very satisfied with the overall appearance of the ears, and the symmetry of the ears was rated as excellent by all patients, parents, and surgeons.

CONCLUSION

Regardless of the technique used, patient satisfaction appears to be high. To reduce negative results and prevent recurrence, the authors recommend that the ear is preoperatively evaluated and the treatment algorithm is used accordingly.

A New Cartilage-Sparing Procedure for Correction of the Prominent Ear Deformity: Dermal Anchor Technique

BACKGROUND

Although the literature is replete with surgical techniques described for correction of the prominent ears, new techniques are still needed to minimize the recurrence rates and postoperative complications.

OBJECTIVE

Here, the author presents a new and simple otoplasty procedure, namely, the dermal anchor technique (DAT), in which a wide planar adhesion between the opposing dermal surfaces of the deepithelized antihelical groove is used as a biological anchor for long-term maintenance of the antihelical fold without any cartilage manipulation.

MATERIALS AND METHODS

For 12 years, this new procedure was used for correction of 76 prominent ears in 44 patients, with 17 being female and 27 being male. The ages of the patients ranged from 5 to 37 years. In 28 patients, the DAT was combined with conchal excision and/or concha-mastoid sutures as required, whereas it was used alone in the remaining 16 patients. The preoperative and postoperative distance between the ear and the head was measured at 4 points (superior helical point, superior conchal attachment, inferior conchal attachment, and lobules).

RESULTS

All patients healed uneventfully. Except mild edema and pain, there was no postoperative problem. The mean follow-up time was 4½ years (4 months-10 years). During this time, there was no patient with surface irregularities and/or suture-related complications. Two patients required revision because of unilateral lateralization of the upper pole by time (recurrence rate, 2.63%). When the preoperative and postoperative superior helical point, superior conchal attachment, inferior conchal attachment, and lobule measurements for both ears of the patients who were operated on were compared, postoperative values were determined to be significantly decreased (P < 0.001).

CONCLUSIONS

The DAT provides predictable and aesthetically satisfactory long-lasting results with a minimal risk of complications. Because it does not harm the cartilage tissue, it avoids the potential problems resulted from cartilage manipulations such as surface irregularities and chondritis. Covering the suture knots with a thick soft tissue layer, it eliminates the suture-related complications. Moreover, it offers a direct approach and does not require anterior dissection. Thus, it requires a shorter operative time, minimizes the risk of anterior skin necrosis and hematoma, and causes less postoperative pain, edema, and ecchymosis.

Proposal of a Classification System for the Assessment and Treatment of Prominent Ear Deformity

BACKGROUND

Prominent ear is the most common external ear deformity. To comprehensively treat prominent ear deformity, adequate comprehension of its pathophysiology is crucial. In this article, we analyze cases of prominent ear and suggest a simple classification system and treatment algorithm according to pathophysiology.

METHODS

We retrospectively reviewed a total of 205 Northeast Asian patients' clinical data who underwent an operation for prominent ear deformity. Follow-up assessments were conducted 3, 6, and 12 months after surgery. Prominent ear deformities were classified by diagnostic checkpoints. Class I (simple prominent ear) includes prominent ear that developed with the absence of the antihelix without conchal hypertrophy. Class II (mixed-type prominent ear) is defined as having not only a flat antihelix, but also conchal excess. Class III (conchal-type prominent ear) has an enlarged conchal bowl with a well-developed antihelix.

RESULTS

Among the three types of prominent ear, class I was most frequent (162 patients, 81.6%). Class II was observed in 28 patients (13.6%) and class III in 10 patients (4.8%). We used the scaphomastoid suture method for correction of antihelical effacement, the anterior approach conchal resection for correction of conchal hypertrophy, and Bauer's squid incision for lobule prominence. The complication rate was 9.2% including early hematoma, hypersensitivity, and suture extrusion. Unfavorable results occurred in 4% including partial recurrence, overcorrection, and undercorrection.

CONCLUSIONS

To reduce unfavorable results and avoid recurrence, we propose the use of a classification and treatment algorithm in preoperative evaluation of prominent ear.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Using bilaterally fascioperichondrial flaps with a distal and a proximal base combined with conventional otoplasty

Prominent ears are the most common aesthetic abnormality of the external ear. Mustardè sutures and conchal setback are usually used for otoplasty, additional various cartilage-manipulation methods are also presented. One adjunctive technique that is often used involves the elevation of a fascial flap beneath which is sutured for additional cover, potentially reducing the risk of complications and recurrence. In the literature, this flap is traditionally raised with a proximal or distal base but it can be raised both distally and proximally with a number of advantages as we demonstrate. This article presents a technique to raise the fascioperichondrial flap with both a proximal and a distal base as an addition to conventional otoplasty. One hundred consecutive patients, followed up for at least 12 months, have been reviewed. One hundred ninety otoplasties were performed in 100 patients (10 unilateral), 65 women and 35 men. The mean age was 20.6 years, and the mean follow-up time was 16.3 months, respectively. No patient has developed skin necrosis or suture extrusion. In two patients (One bilateral and one unilateral for a total of three ears) a further procedure has been required to improve symmetry (1.5%). Using the retro auricular fascioperichondrial flap combined with other techniques offers good results and can be used as a standard procedure in the surgical treatment of prominent ears.

Creating a neoconchal complex using the adjustable conchal sliding technique in prominent ear correction

An oversized aural concha plays a significant role in prominent ear deformities and should be taken into consideration during preoperative examination. In the current study, we present a procedure known as the conchal sliding technique as an alternative to more disruptive methods. Twenty-four patients (9 females and 15 males; 47 ears in total) underwent a conchal sliding procedure between 2006 and 2010. During the surgery, a wide subperichondrial dissection is performed after a posterior elliptical incision. After the concha is exposed as a hemisphere, it is split along its long axis to reveal the medial and lateral cartilage segments. These segments are gently scrolled upon each other. Transposition of the lateral segment posteriorly to the medial segment replaces the whole ear toward the posterior direction. Three mattress sutures (4-0 polypropylene) reliably secure the repositioned and setback conchal bowl. If needed, an antihelix can be formed using neoconchal-scaphal mattress sutures. Median follow-up period was 24.3 months (range, 6-48 mo). A unilateral hematoma developed in 1 patient and an anterior step deformity occurred in another. No recurrence, infection, necrosis of the skin, distortion of the auditory canal, or formation of keloid was observed in any of the patients. The median cephaloauricular angle was measured as 46 degrees before the surgery and 26 degrees after the surgery, whereas the distance between the helix and the mastoid was 23 mm before the surgery and 11 mm after the surgery. All the patients were satisfied with the results. This technique provides stable and natural results by creating a safe neoconchal complex. It may be a safe and reliable solution to an oversized aural concha, enabling natural-looking and positive cosmetic results.

Revision otoplasty: an algorithm

BACKGROUND

The purpose of this study was to propose a surgical algorithm for revision otoplasty, based on an evaluation of patient concerns, desires, and clinical findings. A series of instructive cases is presented.

METHODS

Thirty-six patients with an average age of approximately 15 years (range, 6 to 61 years), who underwent revision otoplasty between 2006 and 2011, were included. Demographic data, complications, indications for revision surgery, and operative details were retrieved from case notes and preoperative and postoperative photographs. Aesthetic outcomes were assessed by three independent plastic surgery consultants using a survey with 15 questions.

RESULTS

Indications for revision otoplasty included recurrent prominence/undercorrection, distortion of scaphoid fossa, distortion of antihelical fold, hypertrophic conchal bowl, and telephone ear. The relevant surgical technique was performed according to the patient's concerns and aspirations in line with the proposed protocol of treatment and included the following: posterior suturing, conchal bowl reduction, reconstruction with conchal cartilage, or reconstruction with costal cartilage.

CONCLUSIONS

Otoplasty is performed frequently in young patients, and unsuccessful surgery can have a negative impact on their quality of life. Suturing techniques are safer than sculpting techniques, which can cause permanent ear deformity. Complications after sculpting techniques can lead to ear reconstruction. The proposed algorithm for revision otoplasty addresses the whole variety of ear deformations, providing the surgical options available to address these abnormalities.

Understanding the unfavorable result after otoplasty: an integrated approach to correction

The correction of an unfavorable outcome after otoplasty requires a thorough understanding of the anatomy of prominent ear and recognition of the spectrum of secondary deformities and their origin. The goal of this article is to describe the causes of postotoplasty deformity, including both undercorrection and overcorrection. The latter presents the more complicated reconstructive problem, as both skin shortage and permanent cartilage disruption need to be addressed. The authors propose an algorithm for revision otoplasty based on clinical findings and patient concerns. Finally, a case with overcorrection secondary to both skin deficiency and cartilage disruption is illustrated showing the sequential steps needed for optimal correction.