OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD &

NECK OPERATIVE SURGERY

OTOPLASTY SURGICAL TECHNIQUE Caroline Banks & Mack Cheney

Otoplasty is defined as surgical correction

of external auricular deformities. Correc-
tion of the prominent ear, or Prominauris,
the most common auricular deformity with
an estimated incidence of 0.5% to 15% in
new-borns, and is the focus of this chap-
ter.1 Children and adults with auricular
deformities may suffer significant social
and psychological trauma. Dramatic psy-
chosocial improvements after otoplasty are
well-documented.2,3

Anatomy Figure 1: Anatomy of the auricle

Surgical correction of the prominent ear

requires a thorough understanding of the Superficial Temporal
complex anatomy of the auricle. The exter- Artery and Vein
nal ear is composed of fibroelastic carti-
lage covered by perichondrium. The skin is
adherent to the perichondrium anteriorly.
Posteriorly the skin is less adherent due to
Postauricular
a loose layer of areolar connective tissue Artery
above the perichondrium. The lobule does
not contain cartilage and is composed of
thicker skin and connective tissue.

The anatomic elements of the ear are the

root of the helix, helix, antihelix, superior
(posterior) crus of antihelix, inferior (ante-
rior) crus of antihelix, tragus, antitragus, Figure 2: Blood supply of the auricle
triangular fossa, scaphoid fossa, concha
cymba, concha cavum, and lobule (Figure
1).

The extrinsic muscles of the auricle are the

anterior, superior, and posterior auricular
muscles. The auricle is supplied by bran-
ches of the external carotid artery, inclu-
ding the superficial temporal and post-
auricular arteries (Figure 2).

The auricle is innervated by the great auri-

cular nerve, the auriculotemporal nerve
(V3), the lesser occipital nerve, and the
greater branch of the vagus nerve (Arnold's
nerve) (Figure 3).
Figure 3: Nerve supply of the auricle
The vertical height of the ear is 5-6cm and
should approximately match the distance
between the orbital rim and the helical
root. The width is approximately 55% of
the vertical length. The vertical axis of the
ear is inclined 15-20 posteriorly (Figure
4).

Figure 5: The superior most point of the

ear should be at the same level as the
lateral eyebrow, and the inferior part of
the lobule should be level with the
subnasale

Figure 4: The vertical height of the ear is

5-6cm. The width is approximately 55% of
the vertical length. The vertical axis of the
ear is inclined 15-20 posteriorly

The superior-most point of the ear should

be at the same level as the lateral eyebrow,
and the inferior part of the lobule should be
level with the subnasale (Figure 5).

The auriculocephalic angle, defined as the

protrusion of the auricle off of the scalp,
should range between 25-35 (Figure 6).

To assess auricular protrusion, measure-

ments are made at the most superior aspect
of the rim, the most lateral projection point
in the mid-auricle, and at a point at the
level of the inferior helical rim. The avera-
ge measurements for these points range
from 10-12mm superiorly, 16-18mm at the Figure 6: The auriculocephalic angle,
middle point, and 20-22mm at the most defined as the protrusion of the auricle off
inferior point. of the scalp, should range between 25-35

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Goals of surgery

The primary goal of otoplasty is achieve-

ment of a natural, symmetric, and aesthetic
auricle. The specific surgical goals of oto-
plasty are summarised by Litner et al 4
Correction of precise anatomic defects
Alignment of the superior and inferior
poles with the concha
Establishment of appropriate auriculo-
cephalic angles
Preserving the position of the helical Figure 7: Frontal (A) and lateral (B)
rim lateral to the antihelix photographs of a prominent ear demon-
Maintaining the postauricular sulcus strating both underdevelopment of the an-
Maintaining interaural symmetry with- tihelix (arrowhead) and increased project-
in 3 mm tion of the conchal bowl (arrow)
Ensuring that surfaces are smooth and
without visible scars using 1% lidocaine with 1:100,000 epine-
phrine. General anaesthesia is commonly
Timing of Otoplasty required for children.

The majority of surgeons prefer to wait un- Surgical Technique

til patients are at least 5 years of age, as the
auricle is then 90-95% of adult size. Per- Hundreds of techniques have been de-
forming otoplasty on young children has scribed for correction of prominent ears.
the important advantage of minimising the They can be classified into 2 broad catego-
social implications of the deformity. Addi- ries i.e. cartilage-cutting and cartilage-
tionally, the cartilage in children is more sparing operations.
pliable, and ear deformities may be
corrected more easily by cartilage-sparing Cartilage-cutting techniques include inci-
methods. sions, excisions, scoring, and/or abrasion
of cartilage. The major advantage of cut-
Evaluation ting techniques is long-term stability of
results. Disadvantages include disruption
A thorough preoperative evaluation inclu- of cartilaginous support and creation of
des examination of ear symmetry, size, contour irregularities.
shape, and projection. Evaluation also in-
cludes documentation of specific anatomic Cartilage-sparing methods were develop-
abnormalities. The two most common ed to decrease the incidence of contour
auricular defects are under-development of irregularities and to maintain the structural
the antihelix and increased projection of support of the cartilage; however, longe-
the conchal bowl. These defects may occur vity of results may be decreased when
separately or simultaneously (Figure 7). compared to cutting techniques.

Anaesthesia Modern otoplasty favours a graduated

approach by combining suture techniques,
The authors prefer doing the surgery under and, when appropriate, adding cartilage-
local anaesthesia for adolescents and adults

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cutting methods in a stepwise fashion until 8A
the desired correction is achieved.4,5

Surgical Steps

The authors most commonly use a combi-

nation of Mustarde sutures 6 for shaping of
the antihelix and Furnas sutures 7 for con-
chal setback. Cartilage shaving is perform-
ed when appropriate to decrease projection
of the conchal bowl.

8B
Excising skin and soft tissue

A fusiform excision is marked based

on the postauricular sulcus, preserving
1.5 cm of free auricle (Figure 8A)
Inject the area with 1% lidocaine with
1:100,000 epinephrine
Use a 15 blade to make the planned in-
cision (Figure 8B), and sharply excise
the skin and soft tissue off the posterior
cartilaginous framework (Figure 8C) 8C
In patients with a deep conchal bowl,
elliptical shave excision of cartilage is
performed with a 15 blade until the ear
is able to be rotated to the proper
position (Figure 8D)

Antihelix Formation with Mustarde Sutu-

res

Undermine the skin posteriorly over

the free edge of the auricle to expose 8D
the area for placement of the Mustarde
sutures (Figure 9A)
Apply pressure to the ear to determine
the appropriate position of the antihe-
lical fold. Mark this position with two
30-gauge needles (Figure 9B)
To recreate the antihelical fold, place
two to three non-absorbable horizontal
mattress sutures through the posterior
perichondrium, cartilage, and anterior
perichondrium, avoiding the anterior Figures 8A-D: Excising skin and soft tissue
skin and ligate them (Figures 9C, D)

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 9A Conchal Setback

Place three non-absorbable horizontal

mattress sutures in a parallel fashion
from the concha to the mastoid perios-
teum. These sutures are passed through
the posterior perichondrium, cartilage,
and anterior perichondrium, but do not
go through skin.
The sutures are not secured until all
sutures are in place.
The first suture is placed from the con-
9B
cha cymba to the mastoid periosteum
(Figure 10A)
The second suture passes between the
concha cavum and the mastoid perios-
teum (Figure 10B)
The superior suture is placed in the
floor of the fossa triangularis, pulling
the concha posteriorly and medially
(Figures 10C, D)
Close the incision with a running 4-0
black nylon suture, taking care not to
9C disrupt the conchal setback sutures
(Figure 10E)

Cartilage-Cutting Techniques 8,9 (Figure

11)

Multiple cartilage-cutting techniques have

been described and may involve scoring,
cutting, and abrasion of cartilage. The
cartilage-cutting technique described by
Farrior 8 is a follows:
9D
Place an incision immediately lateral to
the site of the new antihelix
Elevate the anterior skin
Remove wedges of cartilage along the
axis of the antihelix from the posterior
aspect of the neo-antihelix
Tube the antihelix anteriorly and place
mattress sutures

Figures 9A-D: Antihelix Formation with

Mustarde Sutures
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10A 10D

10E

10B

Figures 10A-E: Conchal Setback

Treatment of Protuberant Lobule or

Lobule Excess

10C A protuberant lobule may be addressed

by trimming the cauda helicis
For lobule excess, the posterior auricu-
lar incision from the initial otoplasty is
extended inferiorly and a small triangle
of posterior skin is excised
A small wedge of anterior skin is also
excised
The skin is closed with 6-0 nylon inter-
rupted sutures

6
 B

A B

Figure 11: Cartilage cutting technique. A.

At level of superior crus; B. At level of
antihelix proper

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Postoperative Care
Commercially available moulding de-
Apply Bacitracin ointment to the suture vices, such as The Earwell Infant
line, and dress the incision with non- Correction System TM (Beacon Medi-
stick gauze pads cal, Naperville IL) (Figures 12C-F)
Wrap the head with an elastic bandage
Discharge the patient home on 1 week 12C 12D
of oral antibiotics and analgesia
Instruct the patient to wear the bandage
for the first 24 hours
Thereafter the patient may shower and
gently wash the hair
A cotton headband is then placed; the
headband is worn continuously until
the post-operative appointment on Day
12
12E 12F
During this visit, sutures are removed
Instruct the patient to wear the head-
band at night for an additional 2 weeks

Non-Surgical Techniques: Ear Splinting

and Moulding

Congenital auricular deformities, including

prominent ears, are amenable to correction
with splinting and moulding, especially Figures 12 C-F: Nonsurgical techniques.
when initiated within the first three days of Commercially available Earwell Infant
life.10-12 A variety of materials have been Correction System TM (Beacon Medical,
successful 11 including: Naperville IL)
Splints made from 6-Fr or 8-Fr silicone
tubing with a 24 gauge copper wire The splint or mould remains in place 24
core, applied with Steri-Strips 10,12 hours a day, and is replaced as necessary.
(Figures 12A, B) The duration of splinting varies from cen-
ter to center, most commonly ranging from
2-12 weeks. The ear is inspected weekly
A B
for skin irritation and breakdown. Fair-to-
good results are reported in 70-100% of
patients, with better results in younger
patients.11

Complications

Complications of otoplasty may be divided

into early complications, occurring hours
Figures 12 A, B: A: Splint made from 6-Fr to days after the procedure, and late com-
silicone feeding tube with 24 gauge copper plications, occurring weeks to years
wire core; B: Splint applied to the new- later.5,13,14
born ear with Steri-Strips

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Early Complications 13B

Haematoma: Haematomas occur in up

to 3.5% of cases.14 Meticulous haemo-
stasis should be achieved at the close
of the procedure to minimise the risk of
haematoma formation. Haematomas ty-
pically present with increased or ex-
cessive asymmetric pain, bloodsoaked
dressings, bruising, and/or swelling.
Urgent evacuation of a haematoma
(Figures 13A-C) is critical to prevent
fibrosis and ultimately, permanent de-
formity of the auricle, known as cauli-
flower ear (Figure 14). Obtain careful
haemostasis during haematoma eva-
cuation, and place a drain and a pres-
sure dressing. Discharge the patient on
oral antibiotics and follow the patient
closely until the haematoma has com- 13C
pletely resolved.

13A

Figures 13 A-C: A. Postoperative auri-

cular haematoma; note fullness and
discolouration of the auricle; B. Fol-
lowing incision and drainage; C. Final
result

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 weaken noncompliant cartilage.
Inadequate correction requires revision
otoplasty.

Suture-Related Complications: Non-

absorbable sutures may extrude or
cause foreign body reactions. Braided
sutures cause more reactions as com-
pared to monofilament sutures; how-
ever, many prefer braided sutures due
to their handling properties. In cases of
inflammatory reaction or extrusion, re-
moval of the suture resolves the com-
plication, though the final result may
be compromised

Hypertrophic Scarring and Keloid:

The postauricular area may develop
hypertrophic scars or keloid (Figure
15), especially in patients with darker
Figure 14: Cauliflower ear deformity skins, younger patients, or patients
following unevacuated haematoma with a history of hypertrophic scarring
or keloid. In susceptible patients one
Infection: Wound infection occurs in should avoid unnecessary tissue trauma
< 5% of otoplasties.13 As with haema- and ensure a tension-free closure.
tomas, prompt identification and treat- Treatment of hypertrophic scarring and
ment are essential to avoid permanent keloids includes triamcinolone inject-
deformity. Infections may present with tions every 4 - 6 weeks for 6 months.14
pain, erythema, swelling, and drainage.
Management includes drainage and
irrigation of the wound, followed by
treatment with oral anti-pseudomonas
antibiotics. Patients with severe infec-
tion may require IV antibiotics.

Late Complications

Loss of Correction or Relapse of

Auricular Deformity: This occurs
more commonly after cartilage-sparing
techniques. There are multiple techni-
cal causes of inadequate correction,
including pulling of sutures over time,
improper placement of sutures, failure
to correct deformity during surgery,
failure to anchor sutures firmly on the
mastoid periosteum, or failure to Figure 15: Postauricular keloid
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 Telephone and Reverse Telephone 3. Bradbury ET, Hewison J, Timmons
Ear Deformities: Telephone ear defor- MJ. Psychological and social outcome
mity occurs with overcorrection in the of prominent ear correction in chil-
middle third of the ear and relative un- dren. Br J Plast Surg. Feb-Mar
dercorrection of the superior and infe- 1992;45(2):97-100
rior poles (Figures 16A, B). Reverse 4. Adamson PA, Litner JA. Otoplasty
telephone ear deformity occurs when technique. Otolaryngol Clin North
the middle third of the auricle remains Am. Apr 2007;40(2):305-18
prominent relative to the superior and 5. Petersson RS, Friedman O. Current
inferior poles (Figure 16C). Both de- trends in otoplasty. Curr Opin
formities are avoidable with correct Otolaryngol Head Neck Surg. Aug
placement of the conchal set-back 2008;16(4):352-8
sutures. 6. Mustarde JC. The correction of promi-
nent ears using simple mattress sutu-
res. Br J Plast Surg. Apr 1963;16:170-
8
7. Furnas DW. Correction of prominent
ears by conchamastoid sutures. Plast
Reconstr Surg. Sep 1968;42(3):189-93
8. Farrior RT. Modified cartilage inci-
sions in otoplasty. Facial Plast Surg.
1985;2:109-18
9. Manz RW, B. Otoplasty: Surgical
Correction of the Prominent Ear. In:
Cheney MH, T.A., ed. Facial Surgery,
Plastic and Reconstructive: CRC
Figures 16 A-C: Normal anatomy (A), Press; 2014
telephone ear deformity (B), and 10. Petersson RS, Recker CA, Martin JR,
reverse telephone ear deformity (C) Driscoll CL, Friedman O. Identifica-
tion of congenital auricular deformi-
Narrowing of External Auditory ties during newborn hearing screening
Canal: This may be seen after conchal allows for non-surgical correction: a
setback with improperly placed sutu- Mayo Clinic pilot study. Int J Pediatr
res. When placing Furnas conchal set- Otorhinolaryngol. Oct 2012;76(10):
back sutures, care must be taken to pull 1406-12
the concha superomedially to avoid 11. van Wijk MP, Breugem CC, Kon M.
canal narrowing. Non-surgical correction of congenital
deformities of the auricle: a systematic
review of the literature. J Plast
References Reconstr Aesthet Surg. Jun 2009;62
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1. Weerda. Surgery of the Auricle: 12. Tan ST, Shibu M, Gault DT. A splint
Tumors, Trauma, Defects, and for correction of congenital ear defor
Abnormalities. 1st ed. New York: mities. Br J Plast Surg. Dec 1994;47
Thieme; 2007 (8):575-8
2. Macgregor FC. Ear deformities: social 13. Adamson PA, Litner JA. Otoplasty
and psychological implications. Clin technique. Facial Plast Surg Clin
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18, vii NECK OPERATIVE SURGERY
www.entdev.uct.ac.za

Authors

Caroline A. Banks, M.D. The Open Access Atlas of Otolaryngology, Head &
Neck Operative Surgery by Johan Fagan (Editor)
Clinical Fellow [email protected] is licensed under a Creative
Division of Facial Plastic and Reconstruc- Commons Attribution - Non-Commercial 3.0 Unported
License
tive Surgery
Department of Otolaryngology/Head and
Neck Surgery
Harvard Medical School/Massachusetts
Eye and Ear Infirmary
Boston, Massachusetts, USA
[email protected]

Mack Cheney, M.D.

Director, Office of Global Surgery and
Healthy
Division of Facial Plastic and Reconstruc-
tive Surgery
Department of Otolaryngology/Head and
Neck Surgery
Harvard Medical School/Massachusetts
Eye and Ear Infirmary
Boston, Massachusetts, USA
[email protected]

Editor

Johan Fagan MBChB, FCORL, MMed

Professor and Chairman
Division of Otolaryngology
University of Cape Town
Cape Town
South Africa
[email protected]

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