Armamentarium

History of the Procedure

The protruded ear is a common esthetic problem, affecting approximately 5% of the population. Common causes of a protruding ear include:

• •

  Effacement of the antihelical fold

• •

  Deep concha bowl

• •

  Excessive helical root

• •

  Cup ear deformity

• •

  Excess fold of cartilage causing Stahl’s ear, or a pointed ear

• •

  Macrotia

• •

  Overprojected lobule

• •

  Prominent Darwin’s tubercle

Surgical correction of the protruded ear is reported in the literature as far back as 1845, with excision of the retroauricular skin and conchomastoid fixation. However, this approach corrected only the cephaloauricular angle; relapse was high because this method did not correct the underlying cartilage deformity. Since 1845, more than 100 techniques have been described. The Mustarde technique was developed in 1963 and continues to be the most popular approach for creating an antihelix with permanent conchoscaphal mattress sutures and without excision of cartilage. Furnas described a simple correction of the prominent ear with a well-formed antihelical fold but protruding conchal bowl using a conchal bowl–to–mastoid periosteum suture. These techniques are often used together because a prominent ear is often the result of a lack of an antihelical fold and the presence of a large conchal bowl.

Alternatives to the cartilage-sparing techniques include cartilage-cutting or scoring methods, which have become more popular in recent years as a way to mold the cartilage and avoid using permanent suture material. Surgeons weaken the anterior cartilage with abrasion, rasping, cutting, or needle scoring so that they can mold the tissue. Care must be taken not to disrupt the blood supply to the cartilage, causing necrosis. Studies comparing cartilage-sparing with cartilage-cutting techniques do not show an improved outcome or increased complication rate for one method over the other.

Nonsurgical treatment of otoplasty has been discussed in the literature. Because otoplasty generally cannot be performed until the patient is 6 to 10 years of age and because of the possible complications associated with the surgery, nonsurgical treatment must be considered in the evaluation of a newborn. If prominent ears are detected within the first 48 to 72 hours after birth, splinting has been proven to correct the deformity. After 3 to 4 days, the cartilage begins to harden, making the ears less pliable, and the patient then is not an optimal candidate for nonsurgical otoplasty. Other authors have discussed the fact that many infants are born with normal-appearing ear projection, but the ears become more prominent after the age of 1 year, which is too old for nonsurgical correction.

History of the Procedure

The protruded ear is a common esthetic problem, affecting approximately 5% of the population. Common causes of a protruding ear include:

• •

  Effacement of the antihelical fold

• •

  Deep concha bowl

• •

  Excessive helical root

• •

  Cup ear deformity

• •

  Excess fold of cartilage causing Stahl’s ear, or a pointed ear

• •

  Macrotia

• •

  Overprojected lobule

• •

  Prominent Darwin’s tubercle

Surgical correction of the protruded ear is reported in the literature as far back as 1845, with excision of the retroauricular skin and conchomastoid fixation. However, this approach corrected only the cephaloauricular angle; relapse was high because this method did not correct the underlying cartilage deformity. Since 1845, more than 100 techniques have been described. The Mustarde technique was developed in 1963 and continues to be the most popular approach for creating an antihelix with permanent conchoscaphal mattress sutures and without excision of cartilage. Furnas described a simple correction of the prominent ear with a well-formed antihelical fold but protruding conchal bowl using a conchal bowl–to–mastoid periosteum suture. These techniques are often used together because a prominent ear is often the result of a lack of an antihelical fold and the presence of a large conchal bowl.

Alternatives to the cartilage-sparing techniques include cartilage-cutting or scoring methods, which have become more popular in recent years as a way to mold the cartilage and avoid using permanent suture material. Surgeons weaken the anterior cartilage with abrasion, rasping, cutting, or needle scoring so that they can mold the tissue. Care must be taken not to disrupt the blood supply to the cartilage, causing necrosis. Studies comparing cartilage-sparing with cartilage-cutting techniques do not show an improved outcome or increased complication rate for one method over the other.

Nonsurgical treatment of otoplasty has been discussed in the literature. Because otoplasty generally cannot be performed until the patient is 6 to 10 years of age and because of the possible complications associated with the surgery, nonsurgical treatment must be considered in the evaluation of a newborn. If prominent ears are detected within the first 48 to 72 hours after birth, splinting has been proven to correct the deformity. After 3 to 4 days, the cartilage begins to harden, making the ears less pliable, and the patient then is not an optimal candidate for nonsurgical otoplasty. Other authors have discussed the fact that many infants are born with normal-appearing ear projection, but the ears become more prominent after the age of 1 year, which is too old for nonsurgical correction.

Indications for the Use of the Procedure

Otoplasty is most commonly used for surgical correction of prominent ears that may involve an underdeveloped antihelix or an enlarged conchal bowl. Surgical correction may be indicated for grade I (mild) deformities, grade II (moderate) deformities, and grade III (severe auricular) deformities.

An understanding of the normal auricular anatomy is paramount in determining the best surgical approach to the prominent ear. Protruding ears are the most common grade I deformity; however, a careful examination must be performed to distinguish deformity from a misshapen auricle. Numerous criteria have been proposed to define the normal ear

:

McDowell has proposed the following goals for otoplasty:

Limitations and Contraindications

There are very few contraindications to otoplasty. The best timing for otoplasty continues to be a topic of debate. In the past, surgeons have delayed correction for optimal auricular development and social matriculation to around 6 to 7 years of age, when ear growth is nearly complete and the cartilage has not yet stiffened. The ears grow rapidly in the first decade; 95% to 97% of the total growth is complete by age 10. However, at age 5 the child begins primary school, and starting school with protruding ears or some other ear deformity can have a considerable psychosocial impact on the patient. Gosain et al. along with Balogh and Millesi have demonstrated that early surgical intervention does not negatively affect the growth of the ear.

Surgeons are hesitant to perform surgery on a young patient whose parents are pushing for surgery before the child is cooperative. Additionally, surgeons will not perform surgery on a patient who has unrealistic expectations for the outcome.