CME
Otoplasty: Sequencing the Operation for
Improved Results
James G. Hoehn, M.D., and Salman Ashruf, M.D.
Albany, N.Y.
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.
Correction of prominent ears is a common
plastic surgical procedure. Proper execution
of the surgical techniques is dependent on
the surgeon’s understanding of the surgi-
cal procedure. This understanding is best
founded on an understanding of the histor-
ical bases for the operative steps and the ex-
ecution of these operative steps in a logical
fashion. This article describes the concept of
sequencing the operation of otoplasty to pro-
duce predictable results combining the tech-
nical contributions from many authors. The
historical, embryological, and anatomic bases
for the operation are also discussed. Finally,
the authors’ preferred techniques are pre-
sented. Sequencing the steps in the preoper-
ative assessment, preoperative planning, pa-
tient management, operative technique, and
postoperative care will produce reproducible
results for the attentive surgeon. Careful
attention to the details of the opera-
tion of otoplasty will avoid many post-
operative problems. (Plast. Reconstr.
Surg. 115: 5e, 2005.)
The prominent ear is a source of significant
concern to the affected patient. This article will
review the significant historical contributions
to the management of the prominent ear. We
From the Division of Plastic Surgery, Department of Surgery, Albany Medical College. Received for publication March 27, 2003; revised
July 30, 2004.
DOI: 10.1097/01.PRS.0000146680.27906.90
5e
will emphasize a composite technique for cor-
rective otoplasty, which is applicable to essen-
tially all presentations of the prominent ear.
Other authors have combined operative tech-
niques such as we present, but we wish to re-
emphasize the concept proposed by Elliott that
sequencing the segments of the operative pro-
cedure provides the plastic surgeon with
greater control of the operation and predict-
ability of results.1–3
ANATOMY AND NOMENCLATURE
The normal ear consists of a convoluted
sheet of cartilage with a thin cutaneous cover.
Variations of these convoluted contours occur
in all ears, but the basic components are gen-
erally similar (Fig. 1). The usual nomenclature
is provided in Figure 2.
The helical rim of the naturally appearing
ear is located 16 to 21 mm from the temporo-
mastoid surface of the skull at the point of
maximum prominence.4 The prominent ear is
defined when this distance is exceeded. The
average ear is 6.5 cm long and 3.5 cm wide,
with significant variations. The configuration
of the ear is affected by age because gravity may
elongate the soft-tissue cover and the lobule.
The projection of the plane of the ear from the
side of the skull, as measured by the cephalo-
auricular angle, is approximately 30 degrees.
The majority of the defects that contribute
to the prominent ear are described as failure of
6e
FIG. 1. The normal-appearing ear.
the antihelix to develop its convolutions. This
deformity leads to a flattened scapha and ex-
ternal rotation of the upper pole of the ear and
a widened cephaloauricular angle. Enlarge-
ment of the concha may produce a prominent
ear even if a well-developed antihelical fold is
present. Of course, both defects may coexist.
Variations in the lobule, the tragus, and the
antitragus do occur and should be recognized
and addressed to successfully correct the
deformity.
EMBRYOLOGY
In embryonic development, the first and sec-
ond branchial arches give rise to the external
ear at about the sixth week of gestational age.
Ear development begins as six swellings known
as “hillocks” that are located on either side of
the dorsal aspect of the first branchial groove
(Fig. 3). The anterior three hillocks develop
from the first branchial (mandibular) arch and
the posterior three hillocks develop from the
second branchial (hyoid) arch. With tissue
growth, epithelial contact, mesodermal pene-
tration, and, ultimately, fusion of the hillocks,
the external ear cartilage assumes its charac-
teristic shape. The skin cover closely mirrors
the cartilage shape. The completion of the
shape has occurred by the eighth week of
gestation. By the age of 5 years, the external
ear has achieved approximately 85 percent of
its adult size.5
PLASTIC AND RECONSTRUCTIVE SURGERY, January 2005
The arterial supply of the ear arises from the
posterior auricular, the superficial temporal,
and the occipital arteries. The venous drainage
is to the posterior auricular, the superficial
temporal, and the retromandibular veins. Sen-
sation is supplied to the ears by the great au-
ricular nerve, the auriculotemporal nerve, and
the lesser occipital nerve. Nerve supply to the
concha is from the auricular branches of the
tenth cranial (vagus) nerve, which course
along the external auditory canal. The lym-
phatic drainage of the ear is divided into the
zones of the branchial arches from which they
arise. The anterior three hillocks and their
cutaneous surfaces drain to the periparotid
lymph nodes and thus into the lymphatic
chains of the anterior triangle of the neck. The
posterior three hillocks drain into the retroau-
ricular area of the neck and thus to the mastoid
and occipital lymphatic chains in the posterior
triangle of the neck.
SURGICAL HISTORY
In 1968, McDowell6 proposed the goals of a
successful otoplasty: (1) the protrusion in the
upper third of the ear should be eliminated;
(2) the helix of both ears should be seen lateral
to the antihelix from the front view; (3) the
helix should have a smooth and regular con-
tour throughout; (4) the postauricular sulcus
should not be markedly decreased or dis-
turbed; (5) the ear should not be placed too
close to the head, especially in males; and (6)
the contours and position of the two ears
should match closely but not be symmetrical.
These goals are still appropriate 35 years later
(Table I).
Ely,7 in 1881, was the first surgeon to de-
scribe a procedure for aesthetic correction of
the prominent ear. His technique involved re-
section of both skin and conchal cartilage car-
ried out in two stages. Dieffenbach8 reported a
similar procedure in 1845 to reconstruct the
traumatically deficient ear.
Luckett,9 in 1910, realized that the defect in
the prominent ear is a congenital failure to
form the antihelical fold. He was the first to
describe the setback of the prominent ear by
excision of postauricular skin. He also em-
ployed a vertical curved incision through the
length of the ear cartilage in an attempt to
create the absent antihelical fold. He main-
tained the scaphal and conchal cartilage
changes through the use of everting (“Lem-
bert”-style) sutures in the new antihelix. Unfor-
Vol. 115, No. 1 / OTOPLASTY SEQUENCING 7e

FIG. 2. The surface anatomy of the external ear. Reproduced with permission from J. G.
McCarthy (Ed.), Plastic Surgery. Philadelphia: Saunders, 1990.

FIG. 3. Embryology of the ear. Reproduced with permission from J. G.

McCarthy (Ed.), Plastic Surgery. Philadelphia: Saunders, 1990.

TABLE I ett’s lasting contribution of the excision of the

McDowell’s Goals in Otoplasty
1. The elimination of protrusion in the upper third of the ear
2. The helix of both ears should be seen lateral to the antihelix
from the front view
3. The helix should have a smooth and regular contour throughout
4. The postauricular sulcus should not be markedly decreased or
disturbed
5. The ear should not be placed too close to the head
6. The contours and position of the two ears should match closely,
but not be symmetrical
tunately, the Luckett procedure tended to cre-
ate an abnormally sharp antihelix, particularly
in the region of the superior crus, giving the
appearance of a “surgically altered” ear. Luck-
postauricular skin, however, became an inte-
gral part of many subsequent otoplasty
techniques.
Stenstrom,10 using a basic plastic surgical
principle described first by Gibson and Davis,11
proposed a technique to establish the gentle
fold of the natural antihelix through multiple
superficial abrasions of the anterior surface of
the auricular cartilage to create a new antihe-
lical fold. The experimental observations of
Gibson and Davis demonstrated that cartilage
incised (scored) on one surface would bend
away from the plane of the incisions. Stenstrom
and Heftner12 applied this technique to both
8e
insufficient folding of the antihelix and exces-
sive cupping of the concha.
In 1963, Mustardé13 introduced his suture
technique to create the new antihelical fold.
This technique avoided the sharp visible mar-
gins that result from any of the techniques that
incised or excised cartilage from the antiheli-
cal fold. Mustardé’s eponymous technique uti-
lized the placement of permanent sutures on
the posterior surface of the ear cartilage to
create a soft, gentle antihelical fold.14 These
scaphoconchal sutures must be precisely
placed. Suture management during knot set-
ting must be done gently to avoid suture “fa-
tigue.” A drawback to this technique is the high
tension under which the sutures may be
placed, which can lead to suture failure. The
technique is also not easily used in the heavy
cartilage found in adult male ears.
In 1967, Kaye15 combined the anterior scor-
ing technique of Stenstrom with the posterior
suture placement technique of Mustardé. This,
the first of several composite techniques, in-
volved the vertical curvilinear striations of the
anterior perichondrium to weaken the cartilag-
inous “spring” followed by the creation and
securing of the new antihelical fold by place-
ment of posterior mattress sutures.10 Kaye also
advocated the use of nonabsorbable sutures to
avoid recurrence secondary to knot failure.
Kaye also proposed the anterior placement of
the mattress sutures, but frequent visual prom-
inence of the knot beneath the thin antihelical
skin is a problem and few other surgeons have
adopted anterior placement for routine use.
Furnas, in 1968, introduced the technique of
correction of prominent ears by conchal-
mastoid sutures.16,17 After removal of the con-
tents of the postauricular groove (postauricu-
laris muscle and fibrofatty tissues), the concha
is rotated in a sagittal plane from posterior to
anterior and anchored to the mastoid fascia
with nonabsorbable sutures.
Elliott2 proposed a procedure for conchal
reduction that reduces the enlarged concha
when suture setback alone is insufficient to
correctly position the ear relative to the side of
the head. The advantage of this technique is
the ease of implementation that it provides to
the surgeon. The choice of conchal reduction
may be made when the surgeon determines
that a setback with sutures (after Furnas) will
be insufficient to correct the ear prominence.
In this way, surgical reduction of the concha
may be threaded into the otoplasty seamlessly.
PLASTIC AND RECONSTRUCTIVE SURGERY, January 2005
Elliott’s conchal reduction utilizes an anterior
incision placed within the “shadow zone” of
the conchal margin. The skin of the anterior
surface of the concha is widely undermined.
The lateral edge of the conchal cartilage is
incised from the top of the conchal margin to
the bottom. Gentle pressure is exerted on the
helix. The excess conchal cartilage that
projects through the incision is resected. The
incised cartilage edges are approximated with
a nonabsorbable suture for stability. The skin
incision is closed and the excess skin is ab-
sorbed over time by contraction.
Recently, Bauer et al.3 described a modifica-
tion in which the cartilage and its overlying
skin are resected together. This option can be
instituted to manage excess conchal skin when
necessary at the conclusion of conchal
reduction.
Webster18 added to the successful otoplasty
by drawing attention to the control of the ear
lobule. He noted that the “tail” of the helix,
when cleared on its posterior surface, can be
repositioned medially with a change in orien-
tation of the lobule.
Elliott2 is credited with the operative colla-
tion of techniques from Luckett, Stenstrom,
Mustardé, and Furnas, which provides repro-
ducible results in most ears. His description of
“sequencing” of the otoplasty also increases the
predictability of the operation.
PREFERRED SURGICAL TECHNIQUE
In most patients, a sequential approach to
the surgical correction of the ear is desirable.
The major steps include (1) preoperative as-
sessment and surgical planning; (2) skin exci-
sion and management of the postauricular
groove; (3) preparation of the postauricular
surface and identification of the tail of the
helix; (4) management of the anterior carti-
lage surface; (5) securing of the new antihelix;
(6) management of the tail of the helix to
TABLE II
Sequencing the Otoplasty
1. Assessment and surgical planning
2. Skin excision and management of the postauricular surface
3. Preparation of the postauricular surface and identification of the
tail of the helix
4. Management of the anterior surface of the cartilage
5. Securing of the new antihelix
6. Management of the helical tail and control of the lobule
7. Positioning of the ear—repositioning of the concha versus
resection of the concha
8. Skin closure and postoperative dressings
Vol. 115, No. 1 / OTOPLASTY SEQUENCING 9e
control the lobule; (7) positioning of the ear—
repositioning of the concha versus resection of
the concha; and (8) skin closure and postop-
erative dressings (Table II).

Step 1: Preoperative Assessment and

Surgical Planning
During the preoperative consultation, a fo-
cused history and physical examination are
conducted. With children, it is important to
assess their drives and desires so that attention
may be paid to the real reasons for the surgical
consult. Often, the parents desire the opera-
tion and the child is indifferent. In most in-
stances, however, teasing and ridicule that have
been endured by the child has become a
strong motivating factor.
It is preferable to direct the discussion of the
surgical procedure to the child in language
that the child can understand, so that the child
and the parents are familiar with the goals and
the objectives of the surgery. Prehospital prep- FIG. 4. Protection of the external auditory canal and an-
aration includes a thorough shampoo the tihelical markings.
night before surgery. Special haircuts in the Step 2: Skin Excision and Management of the
operative area are not necessary. No hair is Postauricular Surface
shaved in the operating room.
Anesthesia. General anesthesia is preferred The posterior skin excision (Luckett) is cen-
in children and is supplemented with local an- tered over the depth of the postauricular
esthesia as noted below. In adults, local anes- groove (Fig. 5, above, left). The incision may be
thesia utilizing 1% Xylocaine with 1/100,000 ovoid or slightly “dumbbell” shaped and
parts of epinephrine may be used alone. A “di- should taper gently to a narrow “v” to allow
smooth closure. Excision of the skin may con-
amond block” of the entire ear is performed
veniently include the subcutaneous tissue and
with a local infiltration of the conchal cup to
the contents of the postauricular groove—the
anesthetize the auricular branch of the vagus
postauricularis muscle and the fibrocollag-
nerve. enous tissue surrounding it (Fig. 5, above,
Sequencing the otoplasty: Preoperative preparation right). Care should be taken to identify the
of the operative site. The cleansing of the exter- posterior surface of the cartilaginous portion
nal ear and the external auditory canal is per- of the external auditory canal, to prevent inad-
formed with agents of the surgeon’s choice. vertent injury. Hemostasis is secured.
The head is draped to allow visualization of
both ears. An ophthalmologic adhesive vinyl
drape is placed over the ear for additional field Step 3: Preparation of the Postauricular Surface and
isolation and hair control. A small cotton ball is Identification of the Tail of the Helix
placed in the external auditory canal to prevent The skin of the posterior surface of the ear is
blood from accumulating on the tympanic widely undermined to the outer border of the
membrane (Fig. 4). helical rim (Fig. 5, center, left). The helical car-
The desired ear contours are again pro- tilage prominence is then followed inferiorly
duced by exerting gentle digital pressure on until the tail of the helix is encountered. Me-
the helix to determine the desired antihelical dial to the tail is a “slot” in the edge of the
fold, which is marked on the skin (Fig. 4). cartilage that allows access to the anterior sur-
Through-and-through markings with a needle face of the ear (Fig. 5, center, left). Dissection to
and India ink are not necessary, so potential free the tail of the helix anticipates the use of
tattooing of the cartilage is avoided. the tail to control the position of the lobule.
10e PLASTIC AND RECONSTRUCTIVE SURGERY, January 2005

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
Step 4: Management of the Anterior Surface of
the Cartilage
Using the access to the anterior surface of
the ear noted above, a tunnel is created over
the course of the proposed new antihelical
fold by undermining with a pair of fine scis-
sors. This tunnel will have to be wide enough
to admit the abrading instrument (Fig. 5,
center, right); an otoabrader described by
Dingman is commonly used. The cartilage is
scored through the perichondrium (Fig. 5,
below, left). Weakening of the cartilaginous
surface by several gentle passes with the oto-
abrader will allow the cartilage to bend away
from the anterior plane into the desired an-
tihelical fold. Although the antihelical fold
will appear and increase its curvature with
deeper abrasion, care must be taken to avoid
scoring through the thickness of the carti-
lage. A full-thickness cartilaginous scoring in-
cision, when fully healed, will often produce
a sharp edge, instead of the desired gentle
curve. This sharp edge is a telltale sign of a
surgical otoplasty.
Step 5: Securing the New Antihelix
Once the antihelical fold is scored and the
curvature is satisfactory, attention is turned again
to the posterior surface. Experience has taught
us that leaving the scored antihelical fold unse-
cured will result in gradual flattening of the cur-
vature, resulting in recurrence of the defect.
Thus, permanent sutures should be placed, as
suggested by Mustardé and emphasized by Elliott
FIG. 6. (Left) Securing of the tail of the helix. (Right) Placement of the concha-mastoid sutures.
11e
(Fig. 5, below, right). We prefer to use 4-0 white
Mersilene suture on a cutting needle.
Care is taken to align the horizontal mattress
suture at the proper distances from the apex of
the new antihelical fold to prevent distortion
and warping. Each suture is secured with a
single “surgeon’s” throw without knotting. All
sutures are placed before any are permanently
tied. Usually three to six separate sutures are
required.
Once the desired antihelical fold is achieved,
each suture is then permanently secured, in
sequence, from superior to inferior, which al-
lows the tension to secure the desired fold to
be adjusted sequentially. The knots can be tied
“blindly” while observing the development of
the antihelical fold from the anterior aspect.
Step 6: Management of the Helical Tail and Control
of the Lobule
Webster has demonstrated the role of the tail
of the helix in the management of the laterally
displaced lobule. After the tail of the helix has
been freed during the dissection of the posterior
cartilaginous surface (step 3), the tail can be
rotated medially over the posterior surface of the
concha and secured to this surface with a perma-
nent suture (Fig. 6, left). Observing the helical tail
in several positions allows the surgeon to directly
visualize the effect of such movement on the
lobule. One or two sutures are commonly used to
permanently anchor the helical tail.
12e
Step 7: Positioning the Ear—Repositioning the
Concha versus Resection of the Concha
The conchal-mastoid groove has previously
been cleared of the fibrofatty tissue and the
postauricularis muscle as described by Furnas.
The concha can now be positioned by gentle
pressure on the anterior surface of the bowl of
the concha. This will produce a medial rota-
tion of the entire ear cartilage, which results in
a movement of the entire ear toward the mid-
line. This movement can be quantified with a
ruler and the ear positioned at approximately
15 mm from the helical rim to the mastoid
surface. The concha can be permanently se-
cured in this position with nonabsorbable su-
tures (Fig. 6, right). Two or three sutures are
usually required.
If excessive medial rotation is required to
achieve adequate set back, the tragus will be
forced to rotate in a lateral direction, which
produces an unsightly prominence and, occa-
sionally, a deformity of the tragus. In this situ-
ation, a conchal reduction is required.
Conchal reduction. The anterior surface of
the concha is marked for incision just inside the
edge of the antihelix (Fig. 7, left). The natural
“shadow line” will mask the residual scar.
The bowl of the concha is infiltrated with
similar Xylocaine local anesthesia containing
epinephrine. If the anesthesia is injected in the
subperichondrial plane, the resultant hydrodis-
section will elevate the conchal skin.
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.
PLASTIC AND RECONSTRUCTIVE SURGERY, January 2005
A curving incision is made as noted above.
The dissection is completed, widely undermin-
ing the entire bowl.
The cartilage is incised and the medial edge
is allowed to override the lateral edge (Fig. 7,
center). With gentle pressure on the helix, the
amount of overriding required to produce
the desired ear position can be determined.
The excess cartilage is resected. Stabilization of
the two edges of the cartilage is achieved by
interrupted, inverted nonabsorbable sutures
(Fig. 7, right). In this location, it is important
that clear or white sutures be used to obviate
visibility through the thin conchal skin.
Skin closure of this conchal incision can be
the surgeon’s choice. A well-healed scar can
become almost invisible, as healing in this area
is usually good. Our preference is for 6-0 nylon
or silk removed by the third postoperative day.
Adjunctive procedures. Removal of Darwinian
tubercles on the helical rim can be approached
from the posterior incision with a small amount of
additional undermining. Reduction of the lobule
can be done at the conclusion if indicated. Several
surgical flap designs have been proposed.5 Man-
agement of transverse bars can be accomplished
by reversed anchoring cartilaginous flaps.19
Step 8: Skin Closure and Postoperative Dressings
Postauricular skin closure is the surgeon’s
choice. This anatomic area is cosmetically “si-
lent” but should be closed with the same atten-
tion to detail that is given to any other wound.
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. 10. Late protection of the ear.

and shampooing are allowed. Gentle scrubbing

FIG. 8. Dressing the postoperative ear.
of the postauricular suture line is necessary to
encourage suture dissolution. Postoperative pho-
tographs are taken at the 2-month visit.
COMPLICATIONS
Complications Related to Appearance
Most of the problems after otoplasty relate
to undesirable appearance deformities of the
operated ear (Fig. 11). Several of these prob-
lems deserve discussion to reflect on meth-
ods of prevention.
Recurrence of the Deformity
In young children, the deformity recurrence
rate has been reported to range from 1.8 percent
14e
FIG. 11. Undesirable result (note severe irregularities of
helical contours).
to 3 percent. Most often it is caused by failure of
a Mustardé postauricular suture or knot. In rare
cases the suture may fatigue and break under
stress, but more commonly the knot loosens and
becomes untied. The latter situation can be pre-
vented with the technique described above: a
surgeon’s knot with two visualized square knots.
In adults, recurrence of the flat scapha is caused
by too shallow abrasion of the anterior cartilage
or posterior suture failure. This problem usually
requires reoperation to correct.
Telephone-Ear Deformity
Telephone-ear deformity is caused by over-
aggressive setback of the middle third of the
helical rims by creation of a severe antihelical
fold without attention to correction of the po-
sition of the lobule and with or without incom-
plete correction of the uppermost pole of the
helix. If a conchal reduction has been per-
formed, overaggressive resection of the conchal
bowl may be the causative factor. Correction usu-
ally requires reoperation and replacement of the
Mustardé sutures to establish the desired antihe-
lical fold and conchal position.
Postsurgical Appearance
The postsurgical ear appearance occurs
when the antihelical fold has a vertical orien-
tation instead of a gentle anterior curve. The
appearance of the antihelix may seem abnor-
mally elongated and harsh. The deformity may
PLASTIC AND RECONSTRUCTIVE SURGERY, January 2005
be the result of inaccurate placement of the
Mustardé sutures or incorrect antihelical scor-
ing. Correction requires reoperation and re-
placement of the Mustardé sutures.
Reverse Telephone-Ear Deformity with Narrowing of
the External Auditory Canal
The reverse telephone-ear deformity occurs
when the conchal bowl setback is done too
aggressively and the conchal bowl actually rolls
in the sagittal plane, pushing the tragus later-
ally and narrowing the outer eighth of the
external auditory canal. Correction requires
surgical replacement of the setback sutures.
Postauricular Suture Line Problems
Although the postauricular suture line may
be managed in many ways, conchal setback
sutures may occasionally be visible as a result of
“bow stringing” of the sutures under the thin
skin cover. Correction requires repositioning
of the conchomastoid sutures.
Surgical Complications
The usual complications attendant to any
operation may occur in otoplasty. Most of the
problems are heralded by the onset of pain.
Notification of severe pain is always an indica-
tion to see the patient and redress the ears to
identify any problems.
Bleeding and Hematoma
Bleeding and hematomas are secondary to
incomplete hemostasis at the time of surgery.
When they do occur, the collection of blood
should be evacuated as soon as possible to
prevent embarrassment of the blood supply to
the skin and subsequent necrosis.
Infection and Chondritis
The blood supply to the ear is luxuriant and
infections after surgery are rare. However,
when the perichondrium is disrupted, as it is in
the abrasion technique, contamination could
possibly occur. However, this complication is
so uncommon that prophylactic antibiotics are
usually not indicated.
Skin Necrosis and Loss
The luxuriant blood supply likewise protects
the skin cover of the ear, maintaining its vitality
through the subdermal circulation. The skin
can be widely undermined to provide the nec-
essary access to underlying structures.
Vol. 115, No. 1 / OTOPLASTY SEQUENCING 15e

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,
however, can obstruct the venous circulation in
the subdermal plexus, with resulting loss of
skin in the involved area. This complication
can be avoided with appropriate dressings.
Abnormal Scar Formation
In approximately 2 percent of patients,
scar tissue hypertrophy of the postauricular
suture line occurs. Hypertrophic scars are
clinically diagnosed by the triad of (1) scar
enlargement in the confines of the original
wound (does not invade normal tissue), (2)
scar tenderness, and (3) no racial predilec-
tion. Management with serial intralesional
steroid injections will usually control the
overgrowth of scar tissue.
Keloid formation can occur in African Ameri-
cans. The clinical diagnosis of keloid scarring is
made by the clinical triad of (1) scar enlarge-
ment extending outside the operative site (invad-
ing otherwise normal tissue), (2) no scar tender-
ness, and (3) predilection for people of Negroid
descent. Management is more difficult and often
consists of intralesional excision and steroid in-
jections followed by cutaneous irradiation in der-
16e
mal doses. Recurrence of keloid scars, even after
treatment, is not uncommon.
Suture Line Granulomas
Occasionally, a buried suture will accrete a
granulomatous formation around it. If the of-
fending suture is close enough to the skin,
extrusion occurs and removal of the suture is
sufficient. The typical late occurrence of suture
line granulomas allows local treatment by re-
moval and topical wound care without change
in the surgical contours.
Hyperesthesias and Dysthesias
Disturbances of fine sensation are not uncom-
mon after incisions in the postauricular groove.
The nerve disturbance is caused by the incisions,
abrasions, and undermining, but not by direct
sectioning, of a named nerve branch. Although
gradual spontaneous return of acceptable sensa-
tion is the normal course of events, the occa-
sional patient will need supportive care over the
postoperative period.
CONCLUSIONS
Sequencing the steps in the preoperative as-
sessment, preoperative planning, patient man-
agement, operative technique, and postoperative
care produces reproducible results (Fig. 12) for
the attentive surgeon. Careful attention to the
details of the operation of otoplasty will avoid
many postoperative problems.
James G. Hoehn, M.D.
4 Executive Park
Albany, N.Y. 12208
jhoehn1@nycap.rr.com
PLASTIC AND RECONSTRUCTIVE SURGERY, January 2005
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