The Treatment of Prominent Ears by Buried Mattress
Sutures: A Ten-Year Survey
J. C. MUSTARDE, F.R.C.S. / Ayrshire, Scotland
During the 10 years in which I have been
correcting prominent ears and producing an
anthelix fold by the simple expedient of using
permanently buried silk (or similar material)
mattress sutures (fig. 1),1 I have personally
operated on 264 ears and my various assist-
ants have dealt with a further 127.
While it is difficult with this type of oper-
ation to be completely objective as to what
constitutes a good result, of the 391 correc-
tions, the vast majority were judged satis-
factory from the point of view of both the
parents and myself. However, there were a
small number of cases in which the result was
not satisfactory and in which an additional
procedure—such as the insertion of a further
suture or sutures, or removal of an existing
one, had to be carried out. In my own series
there were nine such cases, and in the hands
of my assistants there were eight. It is the
purpose of this paper to try to analyze these
faults, and to suggest both the cause of the
trouble and the appropriate remedy.
Before doing so, however, let me briefly
summarize the technique for the benefit of
those unfamiliar with it.?
In a prominent ear which has little, if any,
anthelix fold (and these are the easiest ones
to deal with), a fold is produced with the
fingers and the summit is indicated in ink.
The position of three, or in large ears four,
mattress sutures is marked on either side of
the summit line about 1 cm. away from it;
these marks are tattooed into the cartilage,
with a hollow, ink filled needle. A strip of
skin 1 cm. in width is excised from the
posterior surface of the ear midway between
the suture marks, and all of the subcutaneous
tissue is stripped away from the perichon-
drium on the back of the ear as far as the
helix margin peripherally, and in a central
direction to the postauricular sulcus. The 3-0
white silk mattress sutures are inserted
through both layers of perichondrium (fig.
2), and the intervening cartilage is tightened
382
sufficiently to produce the desired fold. The
skin is closed with a continuous pull-out
suture to avoid pulling the ear forward at the
first dressing. The contours of the ear are
carefully packed with damp cotton-wool and
a crepe-cotton bandage is applied for 2
weeks. After this, the bandage or a football
scrum cap need only be put on at night for
1 month longer (fig. 3.4 to C). Ears retropo-
sitioned in this way should remain so indefi-
nitely (fig. 3D). This is a very simple tech-
nique which takes little time to perform, is
susceptible to fine adjustment at the time of
operation and has the great merit of in no
way damaging the cartilage; thus it does not
interfere with the carrying out of some other
technique if the surgeon is not happy with
the result.
Faulty results may occasionally arise, par-
ticularly in the hands of someone not quite
familiar with the technique. These may be
considered under five headings, as follow:
1. Kinks in the anthelix. These may arise
at the time of operation or be delayed till 1
or 2 weeks later. They are caused by the
sutures being spaced too far from each other,
or being too wide in themselves because they
are too few in number. I usually find three
sutures adequate in most ears but will use
four if need be. This should-be the maximum
number required unless one resorts to end-on
mattress sutures as advocated by Davenport
and Bernard,* who insert seven or eight.
Careful packing of the contours should
eliminate any immediate tendency to kink
and is a most important part of the tech-
nique.
2. Sutures cutting out. Again, this may
happen during the operation, or may take
place some time later. As an early fault
there may be three main causes: (a) If the
sutures are placed too close to the summit
of the fold, a greater strain is needed to pull
the cartilage into the requisite fold, and the
sutures may slice through the cartilage as
Vol. 39, No. 4 / TREATMENT OF PROMINENT EARS 383

they are tightened, or may readily tend to

do so postoperatively if any additional strain
is put on them accidentally. (b) The sutures,
although correctly placed at a wide distance
from the summit of the fold, may be pulled
too tight before knotting. This produces an
excessive degree of folding with narrowing
of the ears and a greater risk of cutting
through if any strain is put on them. (c) The
“bite” of the suture may not be deep enough.
It is essential that the suture should encom-
pass not only the cartilage but also the peri- Fic. 1. Schematic representation of side-to-side
mattress suture inserted through aural cartilage
chondrium on the anterior surface, especially and both layers of perichondrium. A, before tighten-
near the helix rim where the cartilage may be ing suture; B, after suture has been tightened enough
thin and soft. to produce the required degree of folding.
Late cutting out of the sutures may be
caused, in addition to the factors noted
above, by failure to keep the ears packed
and bandaged for a long enough period after
operation or failure to use some protection
over the ears during sleep for 1 month
longer, by which time the silk sutures will
have been more permanently augmented by
fibrous tissue bridging across the hollow of
the fold. The treatment is to reinsert a fresh
suture or sutures.
3. Formation of sinuses. I have not per-
sonally had a single case of a sinus develop-
ing from one of the sutures, but my assistants
have had four, and I think that one of the
reasons for these has been a failure to extend
the process of exposing the surface of the
posterior perichondrium right out to the
helix margin and back to the scalp. This
wide dissection ensures that the skin wound,
when it is closed, will not lie in the proximity
of the mattress sutures, and the excision of
the strip of skin further assists in this, as it
makes the skin tend to bridge across the
hollow of the anthelix fold. Suture ends left \ 705)
too long may also tend to produce a sinus.
When a sinus does arise, however, one
should simply apply a small dressing and Fic. 2. Schematic view of postauricular region
leave the suture in place for 6 months from showing position of silk mattress sutures.
the time of operation. The suture is then re-
moved. In three of the cases the ears re- again become prominent, although the ant-
mained in good position, but in the fourth, helix fold may still be present.
where the top suture was involved, a further When mainly the upper part of the ear is
stitch was reinserted later. affected, this is due to failure to put the upper
4, Recurrence of prominence. In a small suture sufficiently high and forward so that
number of cases, despite a satisfactory im- it will control the area between the crura.
mediate correction, the ears have gradually At the time of operation, the need for this
384 PLASTIC & RECONSTRUCTIVE SURGERY, April 1967

Fic. 3. Prominent ears where no anthelix fold is present. 4, preoperative view; B and
C, 2 months postoperatively; D, 10 years postoperatively, showing permanency of the cor-
rection. (This is the patient whose photographs originally appeared in the author’s article in
1963.?
Vol. 39, No. 4 / TREATMENT OF PROMINENT EARS 385

Fic. 4. Correction of prominent ears where a well marked anthelix fold is present. 4,
preoperatively; note forward and upward projection of the tip of the tail of the helix and
the lobule; B, postoperative view following rolling of the anthelix fold backwards, as de-
scribed in the author’s pevious article;? note failure to correction forward projection of the
lobule.

Fic. 5. Correction of forward projection of the tail of the helix and lobule, in cases
with well marked anthelix folds after all fibrous tissue in the hollow of the posterior surface
of the anthelix fold has been carefully excised. A, splitting of the tail of the helix from the
cartilage of the antitragus; B, tail of the helix completely freed from the antitragus, thereby
allowing the tail of the helix and lobule to slide downward and backward on the antitragus
cartilage. (Note wide dissection of skin from posterior surface of the auricular cartilage;
from edge of helix to the cephaloauricular angle.)
386 PLASTIC & RECONSTRUCTIVE SURGERY, April 1967

may not be very apparent, and one may even
be tempted to omit the upper suture
gether but it must be inserted.
Where the whole ear projects again, the
fault is usually due to the sutures being in-
serted too close to the summit of the fold,
with the production of a very narrow fold
in which not enough concha has been in-
cluded. Consequently, as the already ex-
cessive concha continues to grow, the ant-
helix fold is pushed forward. Operation at
too young an age may also be a factor, as it
may take several years for prominence to de-
velop fully. I think that 34 to 4 years is
young enough. The treatment of reprojecting
ears can be included in that of the final
category.
5. Horizontal projection of the antitragus
and lobule. Where an anthelix fold already
exists, but the concha is excessively deep
(fig. 4A) insertion of mattress sutures is not
in itself enough to produce the deformity, or,
more particularly, to get rid of the horizontal
projection of the lower part of the ear. In
these cases, the cartilage must be rolled
backward so that a new fold can be created
closer to the head. To accomplish this it is
necessary to exercise every vestige of con-
nective tissue in the hollow of the existing
fold, especially in its lower part. Even when
this has been thoroughly done, the
folded cartilage in the lowest part of the ant-
helix tends to retain its projecting appear-
ance, because, although the surface of the
two sides of the anthelix fold become divided
alto- from each other at this level, they are firmly
fixed to one another in the antitragohelix
fissure (fig. 5).
To overcome this, the tail of the helix
should be completely separated from the
cartilage of the antitragus so that they can
slide one on the other.
A further excision of a wedge of tissue
from behind the lobule will help to hold the
lower part of the ear in the correct position
until healing and fibrosis produce a perma-
nent result.
Acknowledgment. The author extends thanks
to E. & S. Livingstone, Ltd., for permission to use
figures 1 and 3.
J. C. Mustardé, F.R.C.S.
No. 3 Longbank Road
Ayr, Ayrshire, Scotland
REFERENCES
1. Mustardé, J. C.: Effective formation of antihelix
fold without incising the cartilage. In Trans-
actions of the International Society of Plastic
Surgeons, Second Congress, edited by A. B.
Wallace. The Williams & Wilkins Co., Balti-
more, 1960.
2. Mustardé, J. C.: The correction of prominent
ears using simple mattress sutures. Brit. J.
acutely Plast. Surg., 76: 170, 1963.
3. Davenport, G., and Bernard, F. D.: Experience
with the mattress suture technique in the cor-
rection of prominent ears. Plast. & Recon-
struct. Surg., 36: 91, 1965.

Prastic AND RECONSTRUCTIVE SURGERY Vol. 39, No. 4

Copyright © 1967 by The Williams & Wilkins Co. Printed in U.S.A,