Synopsis of Otoplasty

In this issue of Facial Plastic Surgery we have put together several aspects of otoplasty, particularly for protruding ears, which is the most common malformation of the auricle. Depending on the definition, 5% of all newborns suffer from this purely esthetic abnormality. They have no hearing impairment or any other functional disorder, but they are-or might be in the eyes of their parents-at risk of being teased. This is why they ask for our help. Mostly we deal with kids coming in with their parents for correction. Only some, whose parents thought it would be better to wait until the children can decide on their own, come in as adults. The latter patients have suffered from this stigma all their life and want to fulfill their dream.

We can help them, and we do so with the highest professionalism, care, and commitment possible. It is, fortunately, a minor deformity, but we should never underestimate its psychosocial effect-being teased might be very hard to stand when the patient is young. From an objective standpoint it is easy to say “It is not important for life,” but from a subjective perspective it is hard for a sensitive character to deal with.

As good doctors, we have to anticipate this and to help our patients. As in many areas of facial plastic surgery, we have to understand and accept the psychology behind the patient's desire, keep it in mind, and then proceed to the pragmatic, manual, surgical task.

I have the feeling it might be confusing for a more inexperienced reader to learn about all the different techniques to correct protruding ears, as it was for me in the beginning. Also, it would be more puzzling than helpful for my residents if I taught them a variety of different techniques at once. We could have presented many other techniques here in this monograph, but because this is not a review of the literature on otoplasty techniques, I limited the discussion to a few techniques. The selection is subjective, and I hope that colleagues who use different techniques are not upset with me. Facial plastic surgery, in its vast majority of techniques, is far from being evidence based. Instead, it is a science based on experience, as medicine has always been.

At the end of this monograph I wish to present to you a synopsis of the techniques that have been useful during the last 20 years of my practicing facial plastic surgery and that I try to teach to the residents of my clinic. Whenever a patient with protruding auricles comes into our clinic, I ask my residents to analyze the cause of the protrusion. “What anatomical structures make the ear stand out? Is it the hypoplasia of the antihelix? Or is it a hyperplasia of the helix or of the cavum conchae? Or is it only (?) the lobule?”

There is no way to plan your specific technique unless you exactly analyze the malformation. This examination might be performed by anthropometric measurements-which is good and exact-but it also might be done by experience and esthetic “feeling” after some time of experience. Nevertheless, you should record it by exact measurements and photography for reasons of documentation and quality control, and you should never forget palpation. Getting the feeling for tissues, in this task especially for the cartilage, is mandatory for high-quality surgery. Feel how the cartilage, the crucial framework of the auricle, is. Is it thick or thin? Does it have calcification and areas of stiffness in it? While you feel it, think: “How can I modify it? Am I sure that my sutures will hold it in position? Are they stable enough in the long term? Do I have to soften the cartilage-and where?” You look at the skin of the auricle, but you need an understanding of its structure. You must imagine what is beyond the surface.

I have seen surgical teachers who had clear concepts but were far from being perfect in adapting their ideas to the individual situation, and I am lucky to have had teachers that actually could not explain what they were doing but had a fascinating sensitivity for the tissue. I think both these attitudes should be combined to a certain extent. You need a certain understanding, and with increasing experience, the subconscious evaluation becomes more dominant. For teaching purposes, nothing can replace a clear concept, as experience can never be taught.

Thus I would like to present my-very subjective-synopsis of otoplasty for protruding ears (Table [1]). In most-but surely not in all cases-anthelixhypoplasia is a major cause of protruding ears. It has to be corrected in a manner chosen based on the stability of the cartilage, which is established by palpation.

Table 1 Synopsis of Otoplastic Procedures for Protruding Ears Malformation Characteristics Technique Anthelixhypoplasia Very soft cartilage Suture (Mustardé) Average cartilage Sutures and posterior scoring (Converse) Strong cartilage Sutures and anterior scoring (Crikelair modif.) Cavumhyperplasia High anthelix Cavum rotation Protruding lobule Prominent helix Scoring Soft tissue tension Mattress suture and slight skin resection

If the cartilage is very soft, only sutures to modulate the cartilage might be sufficient, but be careful: If you rely purely and exclusively on sutures, you must make sure that they are firmly fixed to the cartilage and are not pulled through over the relatively long time the cartilage needs to remodel its fibers, which might take up to more than a year, and that they are not resorbed before the cartilage is stable in its new form.

Therefore, we use nonabsorbable sutures whenever we really have to rely on their stability over a long time. Nevertheless, we only rarely trust the pure suture technique. Instead, in most cases we prefer to weaken the cartilage in the appropriate regions, so we score it in the regions of maximum tension after bending-at least on the posterior side-which is more or less the Converse technique. This is the technique for changing the anthelix that we perform most often.

Only if the cartilage is very sturdy do we take the additional steps of incising all the way through the scapha and mobilizing it on its anterior surface to score it here as well. Because of the very thin anterior skin, a deep incision into the cartilage should be avoided because it might lead to visible edges. Instead, numerous superficial scores help to accentuate the anthelix. This is, more or less, the Crickelair technique.

It is also very important to consider the height of the cavum conchae. Often this contributes to the protrusion of the auricle and also has to be corrected. In most cases, rotating the whole cavum toward the head (i.e., the mastoid plane) is sufficient. To get the necessary space, soft tissue between the mastoid planum and the conchal cartilage has to be removed, and then the cartilage can be shifted medially and fixed to the periosteum with sutures. These sutures only have to hold the cartilage in position until a soft tissue scar has developed, which is incomparably faster than the remodeling of cartilage; resorbable sutures are adequate for this task.

Sometimes protrusive areas of cartilage, and in particular of the posterior auricular spine, have to be removed with a scalpel. Hardly ever does the cavum cartilage have to be excised completely. Because this excision includes the risk of visible edges, it should be avoided whenever possible.

The treatment of the protruding lobule is different, as it is a unique structure of the auricle. Its protrusion requires a separate and distinct approach that is described in another chapter. The special mattress suture following extended mobilization is what we have been relying on successfully for an extended period of time.

Having this synopsis as a guide, correcting a protruding auricle is neither difficult nor magical at all. Have established a meticulous analysis and the correct differential diagnosis, delicate surgery can be performed by any skilled plastic surgeon, leading to very satisfying results for both the patient and the surgeon.