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Otoplasty Sequencing The Operation For Improved Results
Otoplasty Sequencing The Operation For Improved Results
Learning Objectives: After studying this article, the participant should be able to: 1. Understand the anatomy and
embryology of the external ear. 2. Understand the anatomic causes of the prominent ear. 3. Understand the operative
maneuvers used to shape the external ear. 4. Be able to sequence the otoplasty for consistent results. 5. Understand the
possible complications of the otoplasty procedure.
FIG. 2. The surface anatomy of the external ear. Reproduced with permission from J. G.
McCarthy (Ed.), Plastic Surgery. Philadelphia: Saunders, 1990.
FIG. 5. (Above, left) Design of the posterior skin excision. (Above, right) Excision of contents of
postauricular groove. (Center, left) Undermining of the posterior surface of the ear and identification
of the tail of the helix. (Center, right) Access to the anterior surface of the ear. (Below, left) Scoring of
the cartilage. (Below, right) Placement of Mustardé sutures.
Vol. 115, No. 1 / OTOPLASTY SEQUENCING 11e
Step 4: Management of the Anterior Surface of (Fig. 5, below, right). We prefer to use 4-0 white
the Cartilage Mersilene suture on a cutting needle.
Using the access to the anterior surface of Care is taken to align the horizontal mattress
the ear noted above, a tunnel is created over suture at the proper distances from the apex of
the course of the proposed new antihelical the new antihelical fold to prevent distortion
fold by undermining with a pair of fine scis- and warping. Each suture is secured with a
sors. This tunnel will have to be wide enough single “surgeon’s” throw without knotting. All
to admit the abrading instrument (Fig. 5, sutures are placed before any are permanently
center, right); an otoabrader described by tied. Usually three to six separate sutures are
Dingman is commonly used. The cartilage is required.
scored through the perichondrium (Fig. 5, Once the desired antihelical fold is achieved,
below, left). Weakening of the cartilaginous each suture is then permanently secured, in
surface by several gentle passes with the oto- sequence, from superior to inferior, which al-
abrader will allow the cartilage to bend away lows the tension to secure the desired fold to
from the anterior plane into the desired an- be adjusted sequentially. The knots can be tied
tihelical fold. Although the antihelical fold “blindly” while observing the development of
will appear and increase its curvature with the antihelical fold from the anterior aspect.
deeper abrasion, care must be taken to avoid
scoring through the thickness of the carti-
lage. A full-thickness cartilaginous scoring in- Step 6: Management of the Helical Tail and Control
cision, when fully healed, will often produce of the Lobule
a sharp edge, instead of the desired gentle
Webster has demonstrated the role of the tail
curve. This sharp edge is a telltale sign of a
of the helix in the management of the laterally
surgical otoplasty.
displaced lobule. After the tail of the helix has
Step 5: Securing the New Antihelix been freed during the dissection of the posterior
Once the antihelical fold is scored and the cartilaginous surface (step 3), the tail can be
curvature is satisfactory, attention is turned again rotated medially over the posterior surface of the
to the posterior surface. Experience has taught concha and secured to this surface with a perma-
us that leaving the scored antihelical fold unse- nent suture (Fig. 6, left). Observing the helical tail
cured will result in gradual flattening of the cur- in several positions allows the surgeon to directly
vature, resulting in recurrence of the defect. visualize the effect of such movement on the
Thus, permanent sutures should be placed, as lobule. One or two sutures are commonly used to
suggested by Mustardé and emphasized by Elliott permanently anchor the helical tail.
FIG. 6. (Left) Securing of the tail of the helix. (Right) Placement of the concha-mastoid sutures.
12e PLASTIC AND RECONSTRUCTIVE SURGERY, January 2005
Step 7: Positioning the Ear—Repositioning the A curving incision is made as noted above.
Concha versus Resection of the Concha The dissection is completed, widely undermin-
ing the entire bowl.
The conchal-mastoid groove has previously
The cartilage is incised and the medial edge
been cleared of the fibrofatty tissue and the
is allowed to override the lateral edge (Fig. 7,
postauricularis muscle as described by Furnas.
center). With gentle pressure on the helix, the
The concha can now be positioned by gentle amount of overriding required to produce
pressure on the anterior surface of the bowl of the desired ear position can be determined.
the concha. This will produce a medial rota- The excess cartilage is resected. Stabilization of
tion of the entire ear cartilage, which results in the two edges of the cartilage is achieved by
a movement of the entire ear toward the mid- interrupted, inverted nonabsorbable sutures
line. This movement can be quantified with a (Fig. 7, right). In this location, it is important
ruler and the ear positioned at approximately that clear or white sutures be used to obviate
15 mm from the helical rim to the mastoid visibility through the thin conchal skin.
surface. The concha can be permanently se- Skin closure of this conchal incision can be
cured in this position with nonabsorbable su- the surgeon’s choice. A well-healed scar can
tures (Fig. 6, right). Two or three sutures are become almost invisible, as healing in this area
usually required. is usually good. Our preference is for 6-0 nylon
If excessive medial rotation is required to or silk removed by the third postoperative day.
achieve adequate set back, the tragus will be Adjunctive procedures. Removal of Darwinian
forced to rotate in a lateral direction, which tubercles on the helical rim can be approached
produces an unsightly prominence and, occa- from the posterior incision with a small amount of
sionally, a deformity of the tragus. In this situ- additional undermining. Reduction of the lobule
ation, a conchal reduction is required. can be done at the conclusion if indicated. Several
Conchal reduction. The anterior surface of surgical flap designs have been proposed.5 Man-
the concha is marked for incision just inside the agement of transverse bars can be accomplished
edge of the antihelix (Fig. 7, left). The natural by reversed anchoring cartilaginous flaps.19
“shadow line” will mask the residual scar.
The bowl of the concha is infiltrated with Step 8: Skin Closure and Postoperative Dressings
similar Xylocaine local anesthesia containing Postauricular skin closure is the surgeon’s
epinephrine. If the anesthesia is injected in the choice. This anatomic area is cosmetically “si-
subperichondrial plane, the resultant hydrodis- lent” but should be closed with the same atten-
section will elevate the conchal skin. tion to detail that is given to any other wound.
FIG. 7. (Left) Marking the anterior surface of the concha for incision. (Center) Dissection of conchal cartilage. (Right)
Stabilization of the lateral and the medial conchal edges.
Vol. 115, No. 1 / OTOPLASTY SEQUENCING 13e
We have preferred a running, locked 4-0 chro-
mic suture that is bathed starting on the sev-
enth postoperative day and dissolves very
shortly thereafter. It obviates the discomfort of
suture removal, especially in children.
Control of the new ear contours in the early
postoperative period is very important. The
effects of shear, especially in the younger pa-
tient, can be disastrous.
We use a single layer of Xeroform gauze over
the postauricular suture line. Then a fluffed,
dry, all-cotton gauze dressing is wetted and
carefully placed into the new antihelical folds
and the concha (Fig. 8). This gauze is contin-
ued to the posterior surface over the Xeroform
dressing; it also supports the ear in the desired
relationship to the mastoid surface of the skull. FIG. 9. Securing the dressings.
Dry, fluffed, all-cotton gauze is then placed
over the wet gauze. In a short period, the mois-
ture from the wet gauze is absorbed into the
dry gauze, leaving a soft mold of the desired
shape to support the new contours. Drains
should not be needed if adequate hemostasis
has been achieved.
The gauzes are held in place with cling wrap
and finished with an Ace bandage (Fig. 9). This
dressing is left in place for 7 days. At the first
postoperative visit, the entire dressing is re-
moved. The patient is then instructed to wear an
ear protector (either a skier’s ear protector or a
tennis sweat band) each night for a month to
prevent accidental stresses on the ear during
sleep (Fig. 10). Vigorous activities such as sports
and dancing are permitted 1 month from the day
of surgery. After the dressing is removed, showers
FIG. 12. (Above, left) Preoperative anterior view. (Above, right) Postoperative anterior
view. (Below, left) Postoperative left lateral view. (Below, right) Postoperative right lateral
view.
Conforming dressings, if applied too tightly, scar tenderness, and (3) no racial predilec-
however, can obstruct the venous circulation in tion. Management with serial intralesional
the subdermal plexus, with resulting loss of steroid injections will usually control the
skin in the involved area. This complication overgrowth of scar tissue.
can be avoided with appropriate dressings. Keloid formation can occur in African Ameri-
cans. The clinical diagnosis of keloid scarring is
Abnormal Scar Formation made by the clinical triad of (1) scar enlarge-
In approximately 2 percent of patients, ment extending outside the operative site (invad-
scar tissue hypertrophy of the postauricular ing otherwise normal tissue), (2) no scar tender-
suture line occurs. Hypertrophic scars are ness, and (3) predilection for people of Negroid
clinically diagnosed by the triad of (1) scar descent. Management is more difficult and often
enlargement in the confines of the original consists of intralesional excision and steroid in-
wound (does not invade normal tissue), (2) jections followed by cutaneous irradiation in der-
16e PLASTIC AND RECONSTRUCTIVE SURGERY, January 2005
mal doses. Recurrence of keloid scars, even after REFERENCES
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jhoehn1@nycap.rr.com February 22, 2003.