ANOTHER SOLUTION FOR THE PROBLEM OF THE PROMINENT EAR

A retrospective analysis of complications and surgical outcome of 1380 ears: Experience review of paediatric otoplasty

AIM OF THE STUDY

The psychological benefits of successful surgery for prominent ears have been emphasised. However, there are few comprehensive reports in the literature on the incidence of complications. The aim of this retrospective study is to present the postoperative outcome and possible recurrence of prominent ears after otoplasty in a University Hospital Center.

METHODS

A total of 705 patients were followed after otoplasty. We carried out a retrospective review of the file that included all children who had been treated for prominent ears following the same surgical technique from January 01, 1993 to December 31, 2017, and made a descriptive analysis of the data.

MAIN RESULTS

Our study confirmed the prevalence of females in operative treatment of PE, as well as the predominance of the bilateral form of this anomaly. Postoperative complications were recorded in 3.7% of the children (n = 26). 16 patients (2.2%) developed hypertrophic scar complications that required surgical revision in all cases, classifying them as 3b according to the Clavien-Dindo classification. Nine patients (1.3%) required surgical revision for recurrence (Clavien-Dindo 3b). Recurrence, unlike scarring complications, seems to be dependent on the surgeon's experience. A family history was noted in 20% of cases.

CONCLUSIONS

The otoplasty technique showed here is safe and has a low rate of the complications commonly described in the literature. A prospective study with a survey of complications and degree of satisfaction with the results will follow.

Helix free otoplasty for correction of prominent ear

BACKGROUND

Prominent or bat ear is not uncommon deformity as it affecting 5% of population. Plenty of procedures were reported for its correction. Being plenty means it is still a subject of research. The current procedures could be summarized as cartilage sparing and cartilage splitting ones.

METHODS

During a period of 35 months a total of 31 patients were presented with bilateral prominent ears so the included a total of 62 ears. Their average age was 8 years (ranging from five to 18 years). All deformities were corrected using helix free otoplasty technique which included skin paddle excision, separation of helical cartilage (hence the name helix free), anterior scoring, backward folding, mattress and simple suturing of the folded cartilage, proper definition of antitragus and earlobe and concha-mastoid sutures. Outcomes including patient's and/or guardians' satisfaction were determined.

RESULTS

The postoperative period was uneventful except two cases that developed early postoperative hematomas, one case shows late postoperative antihelical fold irregularity in one ear and other case developed ill defined superior helix in one ear. The average follow up period of two years shows no recurrences. Almost all patients (96.85%) and their guardians were satisfied with the aesthetic results while only one (3.2%) was dissatisfied.

CONCLUSION

Helical free otoplasty technique addresses the deformity through a posterior approach with under vision correction. It has very low incidence of complications, high patient's satisfactions, no visible scars and no recurrences. It is a simple, short duration procedure, reliable and good option for correction of prominent ear.

Prominent Ear Correction: A Comprehensive Review of Fascial Flaps in Otoplasty

Over the last 100 years, more than 200 different methods have been described to correct prominent ear deformity. These techniques revolved around various combinations of postauricular incision, cartilage scoring, and strategic suture placement to reapproximate the antihelical fold and correct angular deformity. In the last two decades, fascial flap techniques have become prominent in otoplasty. This article gives a comprehensive review of the different surgical techniques employed to construct fascial flaps and their contributions to otoplasty.

Complications after prominent ear correction: A systematic review of the literature

BACKGROUND

There is great diversity in reported post-operative outcomes for otoplasty, with the incidence of haematoma or infection ranging from 0% to 15.6% and 0%-10%, respectively. With such variability, it is difficult to determine an overall 'average' incidence of common post-operative complications.

METHODS

A systematic review of the most relevant medical databases was conducted for studies available in English published between January 1, 2000, and December 31, 2015. Using the dataset, pooled estimates for the incidence of the primary and secondary outcomes were calculated for all included studies. The primary outcome was haematoma and/or bleeding incidence, and the secondary outcomes included infection, skin/wound healing problems, suture-related problems, scarring, pain and itching, and revision surgeries/recurrence. Comparable sub-group analysis of studies was also performed using calculated pooled proportions.

RESULTS

After screening, 28 articles involving 3493 patients were included in the study. Pooled proportions revealed that haematoma and/or bleeding incidence was 2.5% (95% CI: 1.4-3.8%), infection 0.8% (95% CI: 0.4-1.3%), skin/wound healing problems 3% (95% CI: 1.4-5.1%), suture-related problems 1.8% (95% CI: 0.8-3.2%), scarring 1.6% (95% CI: 0.8-2.6%), pain and itching 13% (95% CI: 5.4-23.1%) and revision surgeries/recurrence 5% (95% CI: 2.9-7.7%).

CONCLUSIONS

By pooling proportions of reported complications, the results of this study could be useful in the personal audit of practice and will be a point of reference for comparing novel surgical techniques in the future.

Malformation and plastic surgery in childhood

Malformations of the head and neck show a huge variety of clinical symptoms with functional and esthetic consequences. Often times its rehabilitation requires multi-staged and multi-disciplinary procedures and concepts. These must consider eating, speech, mimic expression, hearing and "esthetics" or at least "normality". A survey of the most common head and neck malformations and their treatment options are presented here.

Correction of protruding ears (Weerda grade I deformity) using knotless bidirectional barbed absorbable sutures

OBJECTIVE

To introduce a variant of the Furnas technique using a knotless bidirectional barbed absorbable suture for the correction of Weerda grade I prominent ears.

STUDY DESIGN

Comparative study between groups of patients and literature review.

SETTING

Tertiary care teaching hospital.

SUBJECTS AND METHODS

Review of 25 patients who underwent otoplasty by the technique described by Furnas and 23 patients who underwent otoplasty by this modified technique using knotless bidirectional barbed absorbable sutures. Postoperative complications and level of satisfaction were measured.

RESULTS

The postoperative complication rate was low regardless of the suture technique used. We observed statistical significance in relation to the pain caused by the suture knots (P < .001). The reoperation rate was on the limit of statistical significance (P = .051). In the group with bidirectional barbed absorbable sutures, no reoperation was required. In the group with classic sutures, reoperation was necessary in 5 cases to correct recurrence and in 1 case to correct asymmetry. Furthermore, in 4 cases of this group, sutures were removed due to pain or extrusion. The overall long-term satisfaction rate was 91.6% in the group operated with classic suture techniques and 95.7% in the group operated with knotless bidirectional barbed absorbable sutures.

CONCLUSION

The use of knotless bidirectional barbed absorbable sutures in the Furnas technique is simple and fast and presents few complications. The major advantages that we obtained with the use of this technique were the absence of discomfort caused by the type of suture and the fact that no reoperation was required to correct relapses.

Separating the helix from the antihelix: a new concept in prominent ear correction

BACKGROUND

For over a century, various otoplasty techniques for correction of the prominent ear have been attempted. Nevertheless, cartilage memory strength, mainly in the thick cartilage (and consequently the recurrence of the prominence), still remains a problem. An additional difficulty relates to the antihelix irregularities caused by attempts to weaken the cartilage spring, which are time-consuming and in some cases lead to an unnatural-looking result.

OBJECTIVE

The technique reported in this article represents a new approach to otoplasty that deconstructs the auricular pavilion with a single full incision in the antihelix. This approach makes it easier to rebuild the antihelical fold with dissolving sutures and allows repositioning of the helix and earlobe with a posterior bielliptical incision and a narrow bridge skin resection.

METHODS

Between 1999 and 2009, the author performed otoplasty for correction of the prominent ear in 60 patients, including 32 men (53.3%) and 28 women (46.7%). A single incision was made in the superior and lateral borders of the antihelix from the triangular fossa down to the tail of the helix, to completely separate the antihelix from the helix. Three postauricular sutures were applied with nonpermanent side-to-side mattress sutures, with a fourth suture placed to reposition the tail of the helix. A posterior bielliptical incision with a narrow bridge skin resection was performed.

RESULTS

Complications occurred in six of the 60 patients (10%) who underwent bilateral otoplasty. A discrete recurrence occurred in the superior pole in six patients (10%) and was unilateral in all cases. Follow-up ranged from three months to 10 years. There were no major recurrences in this series. The satisfaction rate was 98.3%. The antihelix looked smooth, without marks or irregularities; the helix seemed straight and well placed. The posterior scar was inconspicuous.

CONCLUSIONS

The present technique introduces a new concept in otoplasty that avoids handling the antihelix cartilage. A single incision of the antihelix breaks the cartilage spring memory completely and allows rebuilding of the antihelical fold without resorting to techniques such as rasping, drilling, excision, or complete incision, all of which are time-consuming and may result in irregularities. Sutures are placed to create the new antihelix in the desired shape easily and without tension. The helix and earlobe are repositioned with a specific posterior skin resection and with the tail of the helix's replacement.

Reconstruction of the auricle

Reconstructive and aesthetic surgery of the auricle is one of the most challenging and diverse tasks in plastic head and neck surgery. Injuries, defects and malformations require multiple different techniques, some of which are standardized, other situations require huge experience and artistic creativity. It is a specialty that will never become monotone.

Complications of auricular correction

The risk of complications of auricular correction is underestimated. There is around a 5% risk of early complications (haematoma, infection, fistulae caused by stitches and granulomae, allergic reactions, pressure ulcers, feelings of pain and asymmetry in side comparison) and a 20% risk of late complications (recurrences, telehone ear, excessive edge formation, auricle fitting too closely, narrowing of the auditory canal, keloids and complete collapse of the ear). Deformities are evaluated less critically by patients than by the surgeons, providing they do not concern how the ear is positioned. The causes of complications and deformities are, in the vast majority of cases, incorrect diagnosis and wrong choice of operating procedure. The choice of operating procedure must be adapted to suit the individual ear morphology. Bandaging technique and inspections and, if necessary, early revision are of great importance for the occurence and progress of early complications, in addition to operation techniques. In cases of late complications such as keloids and auricles that are too closely fitting, unfixed full-thickness skin flaps have proved to be the most successful. Large deformities can often only be corrected to a limited degree of satisfaction.

Otoplasty - techniques, characteristics and risks

The protruding ear as a minor ear abnormality is found in approx. 5% of the German population and may give rise to serious emotional problems in children and also in adults. In general, the procedure used for the surgical correction of protruding ears (otoplasty) is a combination of incision, scoring and suture techniques. The choice of the surgical procedure is based on the severity of the ear abnormality and the individual characteristics of the auricular cartilage. In children up to the age of ten years, a soft, elastic or easily pliable auricular cartilage is often still present. In this situation, gentle suture techniques, such as a suturing technique described by Mustardé, are frequently enough to achieve a cosmetically good and lasting result. In adults, the auricular cartilage has already become stiff. Therefore, a combination of incision, scoring and suture techniques is usually required. Apart from reducing the cephaloauricular angle to 15-20°, emphasis on the antihelical fold and a smooth rim of the helix without interruption of the contour are desirable outcomes of this operation. Occasionally, surgical fixation (lobulopexy) may be required to treat protruding lobules or, in rare cases, an additional conchal reduction may become necessary in cases of conchal hyperplasia. Since postoperative complications can often result in severe auricular deformities, as a matter of principle, each ear should be analysed individually regarding its problem areas, and the surgical approach that causes the least injury to the cartilage should be used.

[Techniques in otoplasty]

A great number of surgical techniques for the correction of protruding ears have been developed. Their basic concepts originate from Mustardé's suture, the scoring technique described by Chongchet, Stenström, and Cricelair, and the combined suture and scoring technique described by Converse. Techniques for cavum rotation and lobuleplasty have also been presented. Indication, diagnostics, selection of method, the operative technique itself, and postoperative care are described. Advantages and risks of each technique are discussed, and a therapy algorithm is proposed.

Otoplasty: anterior scoring technique and results in 500 cases

Corrective otoplasty is a commonly performed procedure to change the shape of the auricular cartilage. Many techniques use permanent sutures to maintain the cartilage folding, whereas other techniques rely on cartilage incisions (partial thickness or full thickness). At this institution, a cartilage cutting and anterior scoring technique has been used for more than 30 years with pleasing results. The surgical techniques published in the past have been reviewed and compared with the procedure used at this institution to point out the advantages, disadvantages, and differences of these various techniques. Also reviewed were 500 consecutive cases operated on under local or general anesthesia between January of 1993 and December of 1995 to determine the incidence of early and late complications. The patients were contacted by mail to return for a follow-up examination or answer a questionnaire, at least 2 years after the procedure. Early complications were bleeding in 13 cases (2.6 percent) and hematoma in 2 cases (0.4 percent). There were no infections or ear necrosis. A small cutaneous wound was present on the anterior skin in three patients (0.6 percent), and there was one wound dehiscence (0.2 percent). Late complications were keloids in two cases and inclusion cysts in three cases. Residual deformity was noted in 22 cases and asymmetry in 28 cases. Secondary surgery was performed in six cases. The questionnaire was answered by 387 patients (77.4 percent response rate): pain when the ear is touched was present in 22 cases (5.7 percent), hypesthesia in 15 cases (3.9 percent), occasional cutaneous irritation in 38 cases (9.8 percent), asymmetry in 71 cases (18.4 percent), and abnormal ear shape in 17 cases (4.4 percent). Twenty-nine patients (7.5 percent) also noted that the ear was more sensitive to cold or touch. The satisfaction rate was 94.8 percent: very satisfied, 74 percent; satisfied, 20.8 percent; dissatisfied, 4.2 percent; and very dissatisfied, 1 percent. These results were compared with other published series of complications and late results after otoplasty; the complication rates are similar or lower in this study. Therefore, it can be concluded that the cartilage cutting and anterior scoring technique otoplasty is a safe procedure with a high patient-parent-surgeon satisfaction rate.

A simple, direct correction of the constricted ear

A simple approach to correct the constricted ear is described using a V-Y advancement to lengthen the periphery. Then through a posterior incision, an anterior exposure allows the creation of cartilaginous folds with scoring and sutures under direct vision.

The correction of the prominent ear

The prominent ear was first noted in the medical literature to be a social and psychological disturbance in 1881, when Ely suggested the first technique for the correction of this condition. Since Ely many surgeons have tried to find the best solution for this deformity; however, because of the specific cartilagenous architecture of the auricle, no one has yet designed an acceptable and secure technique. The successful reconstructured auricle should be the result of tackling all components of the deformity, namely, the absence of the antihelix and the aloofing of the concha from the mastoid. Mustarde's technique and the various anterior scoring methods do not deal with the conchal component of the protruded ear, nor do they give a fully satisfactory formation of the antihelix when one of these methods is used alone. This article presents the author's preferred technique for reconstructing the auricle, simultaneously using Mustarde's mattress sutures, Cochrane's anterior scoring of the antihelix, and the approximating of the concha to the mastoid.

Prominent ears--Pitanguy's island technique: long-term results

Through the analysis of 300 cases of prominent ears operated by Pitanguy's technique with a follow-up of 1-15 years we observed the preservation of the aesthetic aspect as well as the cephaloauricular angle. We call attention to its easy performance and almost no incidence of early or late complications.

Otoplasty: Excision of conchal floor cartilage

In 10 consecutive otoplasties, conchal floor cartilage was excised to facilitate rotating prominent ears back against the head. The procedure is most effective in aural prominence due to deep conchae. Cosmetic improvement is as good as that achieved by excision of posterior wall cartilage, and recontouring of the antihelix fold is needed less often. The amount of cartilage to remove is easily determined, matching of asymmetrically prominent ears is simplified, and concha-mastoid sutures can be placed without tension. The corrections have been followed 1-2 years without recurrence of the deformity.