11 The Surgical Technique of Otoplasty

Murat Songu

The prominent ear is the most common congenital

deformity of the auricle, occurring in approximately 5%
of the Caucasian population and is inherited as an auto-
somal dominant trait (Figs 1A and B).1 Although the physi-
ological consequences are insignificant, the psychological
and aesthetic consequences on the patient can be consid-
erable. The most common defects that prompt surgical
consultation are a poorly developed or absent antihelical
fold, an abnormally large concha and a prominent lobule.1
Otoplasty is a century-old procedure that has under-
gone many modifications over the years. Over 200 differ-
ent procedures have been described in the literature that
excise, bend, suture, scratch, or reposition the auricular
cartilage. This plenty of surgical techniques show that no
simple “best” technique exists.

Indications for the Surgery

Appropriate surgical planning relies on a thorough under-
standing of the normal and prominent ear. The major
visible and palpable landmarks of the ear are composed of
five critical elements, concha, helix, antihelix, tragus and
lobule, and parts of lesser importance, including the anti-
tragus, intertragic notch and Darwin’s tubercle (Fig. 2).2
The anatomical divisions of the ear are based in
embryology, with its origins based from the first mandib-
ular and second hyoid branchial arches. The hyoid arch
is the predominant contributor leading to the formation
of the helix, scapha, antihelix, concha, antitragus and
lobule, whereas the mandibular arch only contributes to
the tragus and helical crus. The ultimate shape is essen-
tially determined by 20 weeks gestation and 85% of growth
occurs by age of 3 years.3
Kalcioglu et al. compared the growth ratios of the auri-
cle in 1,552 volunteers from birth until age of 18 years.4
The development of the auricle regarding the transverse
growth and the growth of the conchal depth was fully
completed by the age of six years, independent of gender.
Only the growth in auricular length continued until the
age of 11 years. Even so, the length of the auricle increases
during the natural aging process because of the natu- Fig. 1: A) Preoperative B) Postoperative photographs of two
ral skin and soft tissue elasticity. Ito et al. evaluated 1958 brothers with protruding ears.
2 Section 1: Ear
Fig. 2: The major landmarks of the external ear.
Fig. 3: Prominent ears showing increased helix-mastoid angle,
antihelical hypoplasia, cavum hyperplasia and protruding
lobule.
volunteers aged 5 to 85 years regarding their growth in
auricular length and revealed that the increased replace-
ment of elastic auricular cartilage fibers by collagen-like
fibers is responsible for the growth in auricular length at
an advanced age.5 Despite these results, otoplasty in pedi-
atric patients has no significant influence on later auricu-
lar growth.6
The vascular supply to the auricle is provided by
branches from the external carotid artery. The superficial
temporal artery supplies much of the anterior portion,
including the lobule, whereas the posterior supply is
Table 1: Proportions of the esthetic ear.
The long axis of the ear inclines posteriorly at approximately
a 20° angle from the vertical.
The ear axis does not normally parallel the bridge of the
nose the angle differential is approximately 15°.
The ear is positioned at approximately one ear length 5.5-7
cm posterior to the lateral orbital rim between horizontal
planes that intersect the eyebrow and columella.
The width is approximately 50-60% of the length width, 3-4.5
cm, length, 5.5-7 cm.
The anterolateral aspect of the helix protrudes at a 21 to 30º
angle from the scalp.
The anterolateral aspect of the helix measures approximately
1.5 to 2 cm from the scalp although there is a large amount
of racial and gender variation.
The lobule and antihelical fold lie in a parallel plane at an
acute angle to the mastoid process.
The helix should project 2 to 5 mm more laterally than the
antihelix on frontal view.
derived from the posterior auricular artery. The venous
drainage replicates the arterial supply in reverse. The
parotid lymph nodes and posterior auricular nodes with
further contribution from level 2 and level 5 cervical beds
serve lymphatic drainage. The innervation to the external
ear consists of the anterior and posterior branches of the
great auricular nerve, which innervates the first branchial
arch structures tragus and helical crus, and the auriculo-
temporal nerve, which innervates the second branchial
arch structures helix, scapha, antihelix, concha, antitra-
gus, external acoustic meatus and lobule. The external
auditory meatus also receives innervation from branches
of the vagus and glossopharyngeal nerves.
The most common indication for performing otoplasty
is the prominent ear (Fig. 3). Other indications for
otoplasty include trauma, cupped ear deformity or to
correct a previous poor result. Anatomic norms for human
ears have been established, thus it is possible to more
objectively quantify patients who have irregular, promi-
nent ears. Janis and Rohrich summarized the proportions
that are common in the normal, esthetic ear Table 1. 7-13
While the measurements and proportions of a “normal”
ear have been well documented, the position of anatomi-
cal landmarks, and relation to one another at the end of
the otoplasty procedure, are far more important. The ears
must look proportional to the facial features and have a
natural appearance. Prominent ear occurs as a result of
one or more anatomic variants. Most often there is a lack
of an adequate antihelix; the ear is less furled back on
itself and thus protrudes from the skull. Another common
anatomic finding in patients with prominent ears is a rela-
tive excess of conchal bowl cartilage. A third component
can be an ear lobule that is excessive in size or positioned
 The Surgical Technique of Otoplasty
Table 2: McDowell’s basic goals of otoplasty.
All upper third ear protrusion must be corrected.
The helix of both ears should be seen beyond the antihelix
from the front view.
The helix should have a smooth and regular line throughout.
The postauricular sulcus should not be markedly decreased
or distorted.
The helix to mastoid distance should fall in the normal range
of 10 mm to 12 mm in the upper third, 16 mm to 18 mm in
the middle third, and 20 mm to 22 mm in the lower third.
The position of the lateral ear border to the head should
match within 3 mm at any point between the two ears.
laterally. The basic goals of otoplasty were summarized by
McDowell in 1968 and are listed in Table 2.7
LaTrenta suggested that three common anatomical
goals always must always be kept in mind: production of
a smooth, rounded and well-defined antihelical fold; a
conchoscaphal angle of 90;14 and conchal reduction or
reduction of the conchomastoidal angle.
Specific Preoperative Evaluation
Low self-esteem, general lack of self confidence and social
isolation are amongst the reasons why parents of affected
children or affected adults decide for otoplasty. In a study
by Sheerin et al. children with prominent ears were evalu-
ated by a psychiatrist before undergoing surgical correc-
tion.15 An increased tendency towards depression, lower
achievements in school, lower self-esteem, and socio-
communicative problems in school and at home were
observed. Schwentner et al. interviewed patients before
and after otoplasty regarding their pre and postoperative
emotional state, using a standardized questionnaire.16
The results showed an improved attitude towards life,
increased courage to face life, and better self-confidence
among the patients, with no difference between male and
female subjects. Horlock et al. stated that 74% of adults
and 91% of children reported an improvement in self-
confidence resulting in improved quality of life.17
The appropriate time for the correction of prominent
ears should depend on a rational approach based on auric-
ular growth and age of school matriculation. Although the
concern for ridicule and its effect on social development
has been clearly illustrated, many children are not referred
for otoplasty until teasing becomes an issue.17,18 Otoplasty
procedure in children is recommended to be performed
prior to the start of schooling.19 The hope is to correct the
malformation before the time of socialization in order to
minimize ridicule by peers. However, substantial psycho-
logical pressure exposed to children with protruding ears
among the peers at the preschool period or in kindergar-
ten is usually underestimated. Changing socioeconomic
3
trends have increased the proportion of families in which
both parents work outside of the home. As a result, chil-
dren have been increasingly exposed to peers through day
care centers well before age four or five years. This intense
early exposure to peers and caretakers outside of the
family may significantly affect development of self-esteem.
We observed that these children can provide information
about their psychological strain or possible problems
with other children associated with their protruding ears.
Furthermore, these children can also express concern
about the abnormal appearance of their ears before age
five.20
Like many procedures involving the child’s face, there
is a concern about how the operative site will respond
to pressures of normal growth. Until recently, very few
surgeons felt comfortable operating on the ear of a young
child due to concerns about longevity and altered growth.
Adamson et al. studied the growth patterns of the external
ear of 2,300 ears and showed that the ear reaches 85% of
its adult size by 3 years of age.3 On the other hand, Farkas
differed some in his measurements stating that the ears
reach 85% of full size by age 6, 90% by age 9, and 95% by age
14.21 Balogh and Millesi were the only authors to objec-
tively study growth alterations following otoplasty and
concluded that growth of the ear is not arrested follow-
ing otoplasty.6 Recently, Gosain and colleagues reported
that otoplasty can be safely performed under age 4 and as
young as 9 months without significant effect on ear growth
in a cohort of 12 patients with prominent ears.22,23 Due to
our experience, in unilateral “Jumbo” ears, we observed
that the protruding ear is usually bigger than the unaf-
fected ear in all dimensions. Growth alteration should be a
desired consequence among these patients and this desire
is another rationale for the early surgical intervention.
Nevertheless, we did not observe any visible disturbance
or growth restriction in our patients, even in the unilateral
operated group (Figs 4A and B).
An important advantage of performing otoplasty at
these younger ages is the increased malleability of the
auricular cartilage, decreasing the need to use cartilage-
cutting techniques. At this age, the auricular cartilage is
characteristically pliable; however, elasticity decreases
with advancing age, often demanding more aggressive
treatment. The softer the auricular cartilage, the easier it is
to shape the cartilage or auricle into the appropriate form
and pin it back, using gentle surgical techniques. We have
previously published the surgical technique we prefer
for management of the prominent ears in children.24 The
Négrevergne otoplasty technique was popularized in
the Institut Georges Portmann in France. The technique
includes partial-thickness posterior scoring of the auricu-
lar cartilage using monopolar cutting diathermy. Because
the ear cartilage is weak under age five, cartilage scoring
can be conservative, sufficient to release the cartilage
spring only.
4 Section 1: Ear
Fig. 4: A) Preoperative B) Postoperative photographs of
the patient who underwent left unilateral otoplasty and
adenoidectomy are shown to demonstrate the normal growth of
the ear that had been operated on relative to the unaffected ear.
The main disadvantage of the surgery before age five
is postoperative difficulties dealing with the dressing. The
procedure is best performed when the auricle has reached
maturation and the child is old enough to cooperate with
the postoperative care. It must be kept in mind that correc-
tion before age five may complicate the postoperative
course when the child, even if not intentionally pulls apart
the bandage and potentially disrupts the repair. Our prac-
tice has shown that, all of the study patients were followed
by multiple extra visits for redressings, and as their fingers
were constantly inside the bandage this resulted in
more swelling and certainly greater risk of postoperative
complications. Nevertheless, at the end of the follow-up
period, no serious complications occurred and the patient
showed full recovery in our series (Figs 5A and B).20
Following a detailed medical history, a meticulous
evaluation of the anatomy is performed. Another aspect
with significant impact on procedure planning is the anal-
ysis of the cartilage consistency and, in particular, the stiff-
ness and thickness of the cartilage. The consistency of the
cartilage is typically evaluated by palpitation and cautious,
controlled bending. It is important in surgical planning to
remember that the cartilage becomes more calcified and
brittle with age. Different combinations of abnormali-
ties on either ear are frequently observed. Furthermore,
additional abnormalities, such as auricular appendages,
Darwin tubercle etc., can also be excluded in many cases
simply by an inspection-based diagnosis. Awareness of
the potentially different contributions of deformities on
either side is crucial, if symmetry is to be attained.
Standard preoperative photographs and consent form
for the procedure are taken. The purpose of the photo-
graphic documentation is to document the preoperative
situation. A basic series should include full facial frontals
and laterals of both ears. Frontal close-ups, obliques and
posterior images of each ear are also helpful (Figs 6A to F).
Taking postoperative photos at intervals of 6 and 12
months helps to monitor postoperative success and is
also recommended for medicolegal reasons (Figs 7A and
B).25,26 Prophylactic antibiotics are recommended for the
majority of aesthetic and reconstructive procedures on the
ear. The risk of chondritis is a sufficient indication to use
an intraoperative dose of a broad spectrum antibiotic, and
to prescribe a few postoperative days dosage of the similar
agent.
Just as important as the anatomic irregularities of the
auricle are the expectations of the patient and family. It is
important to discuss the potential outcomes and compli-
cations, and to ensure the patient has realistic expecta-
tions. The patients or the parents of the child are informed
about the potential risks and unwanted complications,
including hematoma and infections of skin or cartilage,
and also regarding the possibility of an unsatisfactory
 The Surgical Technique of Otoplasty
Fig. 5: A) Preoperative B) Postoperative photographs of the
patient who underwent bilateral otoplasty and adenoidectomy
in combination with tonsillectomy. The ears remain relatively
symmetric postoperatively.
cosmetic result. The importance of diligent postopera-
tive care to avoid complications must be also established
before surgery. When counseling younger patients and
their families, the ability of the younger otoplasty patient
5
to appropriately participate in postoperative care and
protection of the dressings should be addressed.
Anesthetic Considerations
In an effort to reduce the potential surgical morbidity
related to general anesthesia, current trends in aesthetic
surgery have moved toward local anesthesia combined
with sedation, as opposed to general anesthesia.27
Remifentanil has gained specific popularity due to its
rapid effect and high patient tolerance for such indica-
tions.28 In children, general anesthesia has broadly been
accepted a reasonable choice; however, at least one group
is looking at the possibility of using local anesthesia with
conscious sedation in children.29 Regardless of whether
general anesthesia or monitored sedation is used, the
use of local anesthesia results in decreased postoperative
narcotic use and decreased pain scores.30 Local anesthe-
sia can be delivered in a number of ways. A peripheral
nerve block can provide broad range analgesia with one
injection, as opposed to local infiltration, which must be
precisely placed to have the appropriate effects. Local
infiltration, however, has the added benefit of hemostasis
when low-dose epinephrine is included. There are multi-
ple choices of substances available as local anesthetics,
including prilocaine, lidocaine, mepivacaine, bupivic-
aine and ropivicaine. Koeppe et al. found that prilocaine
and lidocaine were most commonly used while ropivic-
aine had the lowest side-effect profile.31 Another study on
ropivacaine found it to have comparable efficacy to bupi-
vacaine specifically in otoplasty, but with a more desirable
risk profile.32
Surgical Steps
In considering the proper surgical technique, there is
a room for surgeon preference and vision. The surgeon
should develop a complete surgical plan that is a conglom-
erate of the individual techniques necessary to correct
each observed anatomic irregularity. Surgical techniques
for the correction of the prominent ear can be grouped
into maneuvers used to create the antihelical fold, to
correct the conchal defect and to affect lobule positioning.
1. Perioperative Routine
There are as many variations in perioperative routine as
there are in surgical technique for otoplasty. The hair is
covered with a standard head bandage along the hairline.
A small sterile cotton ball is placed in the external audi-
tory canal to prevent blood from accumulating on the
tympanic membrane (Fig. 8).
The cleansing of the external ear is performed with
povidone-iodine solution. Surgical draping with Tegaderm
3M Health Care, St Paul, MN or other clear sticky drape
6 Section 1: Ear
A B
D E
Figs 6 A-F: Photographic documentation.
keeps the hair out of the surgical field. Drapes are placed
so that both ears are simultaneously on view providing
intraoperative comparison to obtain optimal symmetry
(Fig. 9).
2. Skin Incision
As symmetry is the key, it is recommended to begin with
the more severely affected side. Before local infiltration and
associated tissue distortion, the area of redundant postau-
ricular skin to be excised is estimated by gentle manipu-
lation of the ear and traction in the desired position. The
postauricular skin excision is then marked based on the
estimation. Although most investigators have advocated
an excision of skin, some have described a simple inci-
sion.25,33 The desired ear contours are simulated by exert-
ing gentle digital pressure on the helix and newly formed
antihelical fold is marked on the skin (Fig. 10). The poste-
rior auricular skin and mastoid soft tissues are infiltrated
subcutaneously with 1% Lidocaine HCl and 1:100,000
epinephrine solution. Local anesthesia enhances hemos-
tasis and demarcates the plain of dissection.
C
F
The estimated skin excision on the posterior surface
of the ear can be done safely with the narrowest width at
the middle third to avoid ‘‘telephone ear’’ deformity. This
occurs when the middle portion is reduced to a relatively
greater degree than the superior helix and lobule. This
overcorrection in the middle breaks the straight line of the
caudal helix and leaves a relatively over-projected supe-
rior helix and lobule, giving the ear a convexity similar to
the shape of a traditional telephone (Fig. 11). The reverse
phenomenon can also occur, if relatively less mid-portion
correction is performed. This is termed a reverse tele-
phone deformity.
If a lobule prominence accompanies, the skin excision
is finished with a diamond-shaped inferior end to correct
the lower pole prominence. The maximal width of the
diamond-shaped excision is designed to rest at the point
of maximal lobule prominence (Fig. 12). Others describe
creating a medial-based skin flap that is re-draped over
the posterior auricle at the end of the case and excising the
distal portion of the skin flap as needed to precisely fill the
defect without tension or excess.17 The main advantage of
 The Surgical Technique of Otoplasty 7

Fig. 7: A) Preoperative B) Postoperative photographs of the patient who underwent bilateral otoplasty. The ears are symmetric
postoperatively and rising self-confidence is apparent even in the photograph.

Fig. 8: Small sterile cotton ball placed in the external Fig. 9: Surgical draping with clear sticky drape.
auditory canal.

this approach is tension-free closures, which may reduce
the incidence of hypertrophic scars.
The previously marked postauricular skin is widely
undermined exposing the perichondrium. Hemostasis
is meticulously maintained and dissection is developed
peripherally to the free edge of the helix and posteriorly to
the level of the mastoid bone. The bulky postauricular soft
tissue, auricularis posterior muscle fibers and fibrofatty
tissues cleanly excised off the perichondrium and mastoid
fascia with preservation of the periosteum (Figs 13 and
14).
Creation of a deep, mastoid pocket accommodates
the repositioned conchal cup, facilitates posterior rota-
tion of the concha, removes the postauricular tissues that
may act as a lever producing excessive prominence and
enhances the setback by effectively reducing conchal
height. Utilization of the mastoid pocket also serves to
reduce distortion of the external auditory meatus.
8 Section 1: Ear

Fig. 10: Ear contours are simulated by exerting gentle digital Fig. 12: The estimated skin excision with a diamond-shaped
pressure on the helix. Newly formed antihelical fold and inferior end.
planned mattress sutures are marked on the skin.

Fig. 13:The subcutaneous tissue over the mastoid surface of

the cartilage is dissected.

Fig. 11: “Telephone ear’’ deformity evident on the sixth

month control.

3. Creation of the Antihelical Fold

Many cases of prominent ears require reshaping of the
antihelix. As mentioned earlier, a practical way to deter-
mine how much reshaping is needed is to bend the antihe-
lix with digital pressure and then mark how the new anti-
helix should look (Fig. 10).
Cartilage incision techniques: The first aesthetic otoplast- Fig. 14: The bulky postauricular soft tissue, auricularis
ies described by Ely in 1881 and Luckett in 1910 were posterior muscle fibers and fibrofatty tissues excised.
examples of cartilage incision techniques.34 These tech-
niques include cartilaginous incisions or wedge excisions involved excising a crescentic segment of cartilage poste-
addressing either the antihelix or the cavum concha. 35-39 riorly and reapproximating the remaining edges to each
Luckett’s original procedure to create a new antihelical fold other. When the edges of this cartilage bridge are folded
 The Surgical Technique of Otoplasty 9

back, it forms a tube, which is subsequently sutured to

form a smooth, rounded, more natural-appearing antihe-
lix. With any cartilage-cutting technique, there is the risk
of creating visible contour irregularities and sharp edges,
overcorrection and the appearance of an operated-on ear.
Cartilage-sparing techniques: Cartilage-sparing tech-
niques are emerged in an attempt to prevent potential
contour irregularities that may develop with aggressive
cartilage-cutting techniques. Mainly, suturing rather than
cutting, is used to create the desired auricular contours,
thereby preserving cartilaginous support and minimizing
contour irregularities. In 1963, Mustarde first described
the use of multiple horizontal mattress sutures placed in
the posterior cartilage that incorporate the full thickness
of the cartilage and anterior perichondrium but not the
anterior skin to form the antihelical fold (Figs 15A and
B).40 The sutures are then tightened to the extent required
to appropriately reduce the defect and create an antihe-
lix (Fig. 15C). To create the superior crus, the same type of
stitch is secured onto the fossa triangularis.
Mustarde has conducted two reviews of his own proce-
dure. Of 264 ears operated over a 10-year period, 17 cases
were judged as unsatisfactory with problems, such as
kinking within the antihelix, sutures cutting out and recur-
rence of prominence.41 A subsequent study of 600 ears
operated over a 20-year period revealed a 0% incidence of
stitch rejection, a 0.01% incidence of sinus tract formation
and a 0.02% incidence of reoperation.42 Spira and Hardy
studied their experience with the Mustarde technique and
determined that there were a large number of relatively
minor complications and a high rate of partial recurrence
of the original deformity.43
Criticisms of the cartilage-sparing technique have
focused on the relatively high rate of up to 25% loss of
correction or the possibility of stitch extrusion up to 15%
43. Permanent sutures, more frequently initiate develop-
ment of indolent infections or foreign-body granulomas.
In these instances, removal of the offending suture is cura-
tive. Kaye and Tramier advocate an anterior approach to
place the plication sutures in an effort to eliminating the
need for extensive flap dissection and minimizing postop-
erative discomfort and risk of infection and hematoma.44,45
Horlock et al. proposed a method for eliminating problems
with extrusion by raising a postauricular fascial flap.46 In
this technique, rather than dissecting a single subperi-
chondrial plane, a separate plane is dissected subder-
mally first and followed by the cartilage exposure to leave
a mastoid-based fascial flap that can be repositioned over
the sutures and provide a layer of protection to prevent
extrusion. This maneuver did not significantly change the
incidence of loss of correction when compared with other
studies but did eliminate stitch extrusion.
Adamson et al. retrospectively reviewed their experi- Fig. 15: A) Mustarde suture. Side and posterior views of a
ence with conchal setback and antihelical suture place- constructed antihelix. B) Dental needles marking the planned
mattress sutures. C) Precise tension placed on mattress sutures
ment in 119 ears.47 They found that the superior pole
are shown.
10 Section 1: Ear
became lateralized to approximately 40% of the original
correction, which led to revision in 6.5% of the ears. They
recommended adding fossa triangularis–temporalis fascia
sutures to correct this superior pole lateralization. Loss of
superior pole correction was also reported by Messner
and Crysdale in patients who underwent cartilage-spar-
ing otoplasty, including placement of fossa triangularis–
temporalis fascia sutures.48 The corrected ears returned to
their preoperative position in one third of their cases and
one third of their cases had a final position between their
preoperative and postoperative positions. Despite this
loss of correction, 85% of patients were satisfied with their
results.
Cartilage weakening techniques: Cartilage-weakening
techniques are often used in an attempt to reduce the
complications created by cartilage-cutting and cartilage-
sparing techniques. Although scoring of either the poste-
rior or anterior auricular surfaces are injurious to cartilage,
no full-thickness cartilaginous incisions are performed.
Many different tools have been used, including scal-
pel, rasp, hypodermic needle, diamond burr drill and
dermabrasion tool. Tan et al. advocated the widely avail-
able Adson-Brown forceps as their scoring instrument of
choice while Di Mascio et al. reported a cartilage incising
procedure that uses a dermabrader drill to score the ante-
rior surface of the cartilage.49,50 Azuara reported his expe-
rience using a no. 15 blade in his technique, where the
cartilage incisions allow a tension-free rolling of the carti-
lage posteriorly.51 Scoring techniques are mainly based on
the observations that cartilage tends to warp away from an
injured surface.52 Fry later confirmed this observation and
attributed it to “interlocked stresses” that were released
by a perichondrial incision.53 Stenstrom and Chongchet
applied this theory to otoplasty.54,55 Stenstrom’s initial
technique consisted of anterior scaphal scoring to produce
an antihelical fold.56 Qureshi observed the combination
of the two cartilage-weakening methods and stated that
scoring by scalpel blade on one side of the cartilage and
bipolar diathermy on the other, produces greater warp-
ing towards the direction of the bipolared side.57 Heftner
surveyed patient satisfaction with use of the Stenstrom
technique and found that 89% were either very satisfied
or just satisfied.58 He also noted that 14% of patients had
a sharp contour. Calder reviewed 562 Stenstrom otoplast-
ies and found a 16.6% overall complication rate with an
8% incidence of residual deformity.59 Many methods of
posterior surface weakening were also described in the
literature.24 These maneuvers include abrasion, scoring,
partial-thickness incisions and longitudinal wedge exci-
sion.60-65 The deficiencies of these maneuvers are the need
for special instrumentation and unreliability in producing
consistent results. Nearly all of them are combined with
a cartilage-sparing technique by using additional suture
fixatCombined techniques: Understanding the principles
behind the various techniques may lead the surgeons
to form surgical strategies based on personal surgical
philosophies. Nolst Trenite used a scalpel to make multi-
ple partial-thickness cartilage incisions posteriorly, but
stresses the importance of not incising the anterior surface
perichondrium.66 In this approach, mattress sutures are
added to set the final position. He reported two cases
with noticeable sharp and two cases with ‘‘telephone-ear’’
deformities from poor suture placement in his series of
65 ears. Bulstrode et al. reported their experience using
a precisely bent hypodermic needle to perform percuta-
neous cartilage scoring followed by posterior mattress
suturing.67 Fritsch also described an approach that used a
21-gauge needle to score the cartilage anteriorly through
a puncture site and Mustarde-type mattress sutures are
placed percutaneously with the goal of the suture passing
sub-perichondrially, with a common entrance and exit
site.68 Yugueros et al. also reported a combined approach
with anterior scoring through a small anterior incision,
Mustarde-type mattress sutures and conchal-mastoid
sutures.69
One major difficulty in trying to objectively evaluate
these techniques is the small number of literature of head-
to-head comparisons of the surgical philosophies. One
European group compared a cartilage-cutting method
of incising and folding the cartilage to reconstruct an
antihelix with a modified mattress suture technique that
included anterior scoring.70 Twenty eight patients were
selected and compared by the length and breadth of the
ear; the superior, medial and inferior cephaloauricular
distances and the conchoscaphal angle, as well as by using
the Strasser evaluation system for appearance.71 They
observed a statistically significant greater amount of asym-
metry and decreased patient satisfaction when cartilage is
incised. Panettiere et al. reported a study that compared a
cartilage-incising technique versus a cartilage-weakening
and mattress suture technique.72 Comparison was made
by a blinded, independent surgeon’s review of follow-up
photos. Ninety-two percent of the ears in the cartilage-
incising technique group had noticeably sharp edges,
whereas none of the weakened and sutured ears displayed
this irregularity in follow-up. Both methods were without
recurrence in a 12-month follow-up.
Tan et al. compared Mustardé’s posterior suturing
technique with Stenstrom’s anterior scoring technique and
found that although patient satisfaction with the aesthetic
results were the same between the two approaches, ears
treated by Mustarde’s method required more than twice as
many reoperations.73 In a comparative study, Hyckel et al.
compared Mustarde’s and Converse’s methods and found
no objective or subjective differences.74
4. Correction of the Conchal Bowl
Conchal deformity can be addressed by several methods,
including scoring and suturing and excisional techniques
and scoring. Conchal mastoid sutures can be used to
 The Surgical Technique of Otoplasty
Fig. 16: A) Furnas suture. B) Constructed conchal bowl on
the axial plane. C) Permanent suture is used to medialize the
conchal bowl B to the mastoid periosteum.
correct conchal prominence of the ear. This suture tech-
nique was originally described by Owens and Delgado.75
Their method was subsequently modified by Furnas,76
11
who used nonabsorbable mattress sutures placed in the
conchal cartilage and sutured it to the mastoid fascia
(Figs 16A). He stated that sutures placed too far forward
on the mastoid or too far back on the concha will cause
outward and forward rotation of the conchal cup, causing
reduction of the external auditory canal diameter (Figs
16B and C). A popular excisional technique to control
conchal bowl prominence involves separating the carti-
lage where the concha meets the tail of the helix and
removing an adequate portion along the conchal rim. The
cartilage must then be re-approximated. Proponents of
this technique claim that this cartilage incision hides well
in the natural convexity of the junction of the conchal bowl
and antihelical fold. Excision techniques can also be used
to reduce conchal hypertrophy. These techniques can be
grouped into those that excise cartilage alone and those
that excise both skin and cartilage. The cartilage-only
procedures are usually performed through a posterior
approach, whereas the skin and cartilage techniques are
usually performed through an anterior approach. Finally,
careful scoring may be used alone or in combination to
reduce conchal prominence.
5. Lobule and Helical Rim Positioning
The lobule can be an overlooked component of the promi-
nent ear and appear accentuated after the auricle is repo-
sitioned. The lobule should rest in a straight line with the
helical cartilage when viewed from the front. Beernink, in
a study of 159 ears, stated antihelical correction corrected
an associated protruding lobule in 28% of patients.63
Wood-Smith suggested a “fish tail-like” retrolobular
skin excision with a subsequent V-Y plasty.77 Posterior
lobule skin and fibrofatty tissue can be also excised in a
V-shape, heart shape and eccentric elliptical patterns with
suture approximation producing the desired setback.
Additionally, a Z-plasty can be fashioned at the most
inferior aspect of the postauricular incision, producing a
similar effect. Gosain advocated a single stitch approach
in which the loble is secured to the mastoid region.78 The
excess skin is then excised and the incision is closed. Spira
et al. treat the protruding lobule by wedge-excision and
a periosteum suture between the dermis and the scalp.79
Another method involves a curvilinear, fusiform excision
from the anterior to posterior lobe margin with a central V
excision to effect easy closure.1
One further consideration in the prominent ear, not
mentioned elsewhere, is the helical curl itself. Often this
can be flattened and floppy, further contributing to the
overly abnormal appearance. Few investigators have
focused on this particular aspect. One study does describe
a simple wedge excision along the helix alone without
extending into the scaphae.80 This shortens the outermost
edge of the helix, enhancing its curl inward. This is used
as an adjunct when the helix itself is noticeably flattened.
In majority of our cases, we prefer a diamond-shaped
posterior skin excision behind the lobule and suture the
12 Section 1: Ear
Fig. 17: Molded greasy gauze placed to fit the new folds and
contours of the reconstructed ear.
Fig. 18: Headband to prevent inadvertent nocturnal trauma.
opposing points of the diamond in the closure using a
running, locked, 4-0 long-term absorbable suture. It obvi-
ates the discomfort of suture removal, especially in chil-
dren (Fig. 12).
6. Dressing and Postoperative Care
The appropriate dressing for the ear is a critical aspect of
the procedure. At the completion of the procedure the
wounds are carefully cleansed and dressed with greasy
gauzes soaked in Bepanthen Plus® 50 mg Dekspantenol,
5 mg klorheksidin HCI. It is extremely important that the
greasy gauze be carefully molded to fit the new folds and
contours of the ear and to gently pad the postauricular
surface (Fig. 17).
Fig. 19: Seventeen-year-old boy before and six months after
surgery.
All patients are placed on a five-day regimen of anti-
biotics and acetaminophen as needed for pain. Aygit
reported a custom-made mold for 2 weeks postopera-
tive.81 Azuara used a moldable porous polyester splint in
a similar fashion for 72 hours with a compression dress-
ing fulltime for the first week postoperatively followed by 1
month of night time compression (Fig. 18).54.
In our practice, the dressing is removed on the first
postoperative day to inspect the ears. This facilitates early
identification of complications, such as hematoma forma-
tion or skin ischemia. A slightly lighter dressing is replaced
and is changed every other day for a further 7 days. After
removal of the dressings, patients are instructed to wear
a headband nightly for one month to prevent inadvert-
ent nocturnal trauma. Patients are discouraged from any
rough play or circumstances that might lead to accidental
trauma, as a history of external trauma has been associated
with about half of the cases of loss of correction requiring
revision surgery.47 Patients are then typically seen at 3 to
6 months postoperatively and 1 year postoperatively to
document results (Fig. 19).
New Techniques in the Surgery
The Négrevergne Otoplasty Technique
The Négrevergne otoplasty technique adopted in the
Institut Georges Portmann is a simple method of carti-
lage weakening mainly preferred in young children in our
practice.26 A surgical instrument, monopolar diathermy,
which is already present in the surgical field, is used. Since
the technique is suture-free, low-complication rates can
be obtained. Common complications, such as suture fail-
ures and extrusions, suture material induced foreign-body
granulomas and wound breakdown are never observed.
In this technique, the cartilage under the desired fold is
marked by inserting dental needles at two or three points
from anterior-to-posterior fashion. The inserted needles
mark the lines of cartilage weakening (Fig. 20).
 The Surgical Technique of Otoplasty 13

The monopolar diathermy in cutting mode is adjusted

to a setting sufficient to create a partial-thickness trough
through the cartilage. Three passes are made to form the
antihelical fold while maintaining sufficient flexibility to
prevent a sharp angle at the fold (Figs 21A and 22A). Next,
the conchal hypertrophy component is addressed. The
conchal-mastoid groove has been cleared of the fibro-
fatty tissue and the postauricularis muscle previously as
described. The ear is drawn backward into the desired
position and the site of contact between the conchal carti-
lage and mastoid fascia is checked. The marked conchal
limits are used to mark proposed conchal scoring inci-
sions, which are parallel the long axis of the ear. Two or
three incisions are made with a monopolar diathermy in
cutting mode (Figs 21B and 22B). This maneuver breaks Fig. 20: Dental needles marking the lines of cartilage weakening.
the spring of the conchal bowl and leads the fibrosis to the
mastoid fascia.

Complications
Elliott divided unsatisfactory results of otoplasty into early
complications and late sequelae.82 Early complications
include hematoma, infection, chondritis, pain, bleeding,
pruritus and necrosis. Late sequelae include unsightly
scarring, patient dissatisfaction, suture problems and
dysesthesias.
Early complications: Hematoma is one of the most
dreaded immediate postoperative complications. It is
heralded by the acute onset of severe, persistent and often
unilateral pain. If encountered, the head dressing should
be removed and sutures released to drain the hematoma.
If there is evidence of ongoing bleeding, reoperation and
exploration are mandatory. Infection is another poten- Fig. 21: Axial view demonstrate the sequential effects of surgical
tially devastating complication of otoplasty, especially maneuvers on ear protrusion. A) Partial-thickness scoring of
because it can lead to the development of chondritis and scapha to create antihelical fold. B) Partial-thickness scoring of
residual deformity. Infection can be caused by a break in concha to break the spring of the cartilage.
proper sterile surgical technique or dehiscence secondary
to excessive tension during closure or it can be an unto-
ward sequela of prior hematoma evacuation (Fig. 23). If
redness, swelling and drainage are encountered, treat-
ment with intravenous antibiotics is recommended, as is
the use of topical mafenide acetate cream. The usual path-
ogens are Staphylococcus, Streptococcus and sometimes
Pseudomonas. Chondritis is a surgical emergency. If left
untreated, it can result in deformity. Therefore, prompt
debridement of devitalized tissue is necessary.
Late sequelae: Residual deformity is, by far, the most
common unsatisfactory result of otoplasty. It usually is
apparent by 6 months postoperatively and is manifested by
one or more of the following: a sharply ridged antihelical
fold; lack of normal curvature of the superior crus; irreg-
ular contouring; a malpositioned or poorly constructed Fig. 22: A) Frontal view shows partial-thickness scoring of
antihelical fold; an excessively large scapha; and a narrow scapha to create antihelical fold. B) Partial-thickness scoring
ear.83 Most of the time, the residual deformity is a result of concha to break the spring of the cartilage.
14 Section 1: Ear

Fig. 23: A) Redness and swelling observed on the second postoperative day. B) Regressed with antibiotics treatment.

A B C
Fig. 24: A) Tanzer type 2B cup ear deformity. B) Persistent superior pole prominence in the postoperative period. C) The ears
are symmetric 6 months after the revision surgery.

of poor surgical planning and execution rather than an
inherent technical problem (Figs 24A, B and C).
Persistent superior pole prominence was also noted by
Georgiade et al.84 They recommended additional superior
helix scoring or higher posterior vertical mattress suture
placement to resolve this problem. Webster recommends
slight overcorrection of the superior pole to allow for post-
operative changes. The psychological and social outcomes
of prominent ear correction were evaluated by Bradbury
et al. who found improved wellbeing in 90% of the chil-
dren 12 months postoperatively.85
Other Treatment Options available for
the Same Condition
Nonsurgical correction of prominent ears usually has
poor results. There is evidence, however, that interven-
tion within the first few days of life may adequately treat
a prominent ear. Several investigators have applied
splinting to prominent ears that were identified at birth
with promising long-term results when applied within the
first 3 days of life.86,87 However, delay of treatment yielded
poor results. Tan attributes the loss of cartilage pliability
 The Surgical Technique of Otoplasty
after birth to decreasing levels for circulating maternal
estrogens, which are highest in the first 3 days after birth
and decrease to normal levels by 6 weeks of age.88,89
Matsuo et al. also reported no recurrence after 6 months
when the prominent ear was corrected with surgical tape
within 3 days of birth.90 However, results were poor when
the taping was started after this period. Matsuo et al. also
observed that the percentage of protruding ears increases
from 0.4% at birth to 5.5% at 1 year of age and concluded
that most protruding ears are acquired deformities. They
postulated that the mechanism is that when a baby is
placed in a supine position, the weight of the baby’s head
will fold the ear forward when the baby turns its head to
one side.91 This mechanism has not been definitively
proven; thus, behavioral modification techniques have
not been a mainstay of nonsurgical treatment. The Auri
method, popularized by Sorribes and Tos, uses a plastic
clip device at night with a clear adhesive tape in the day
to hold the auricle in a position that forces an antihelix.
Treatment times were daily for 1 to 10 months. There is a
substantial compliance related drop-out. Good correction
is reported as high as 34% with an additional 55% with fair
correction.87 The combination of this splinting technique
with the use of injectable cartilage molding compounds
may have promising applications in a broader range of age
groups and potentially shorter treatment times.
Few basic science studies also focused on otoplasty
procedure. Some recent research has been reported on
cartilage reshaping in animal models. Preliminary stud-
ies using hyluronidase and elastase injected into rabbit
ears show statistically significant cartilage remodeling
compared with saline alone when splinting is applied.92
Summary
Auricular deformities, specifically, prominent ears, are
relatively frequent. Although the physiological conse-
quences are negligible, the aesthetic and psychologi-
cal effects on the patient can be substantial. Accurate
preoperative diagnosis of the specific components of the
deformity, proper planning and excellent technical execu-
tion of the procedure are paramount to obtaining a good,
long-lasting and aesthetic result.
Acknowledgement
Medical photography consent forms are obtained from
the patients or parents.
References
1. Adamson PA, Strecker HD. Otoplasty techniques. Facial
Plast Surg. 1995;11(4):284-300.
2. Tolleth H. Artistic anatomy, dimensions, and proportions of
the external ear. Clin Plast Surg. 1978;5(3):337-45.
15
3. Adamson JE, Horton CE, Crawford HH. The growth pattern
of the external ear. Plast Reconstr Surg. 1965;36(4):466-70.
4. Kalcioglu MT, Miman MC, Toplu Y, et al. Anthropometric
growth study of normal human auricle. Int J Pediatr
Otorhinolaryngol. 2003;67(11):1169-77.
5. Ito I, Imada M, Ikeda M, et al. A morphological study
of age changes in adult human auricular cartilage with
special emphasis on elastic fibers. Laryngoscope. 2001;
111(5):881-6.
6. Balogh B, Millesi H. Are growth alterations a consequence
of surgery for prominent ears? Plast Reconstr Surg. 1992;
90(2):192-9.
7. McDowell AJ. Goals in otoplasty for protruding ears. Plast
Reconstr Surg. 1968;41(1):17-27.
8. Skiles MS, Randall P. The anesthetics of ear placement: An
experimental study. Plast Reconstr Surg. 1983;72(2):133-40.
9. Farkas LG. Anthropometry of normal and anomalous ears.
Clin Plast Surg. 1978;5(3):401-12.
10. Farkas LG. Anthropometry of the normal and defective ear.
Clin Plast Surg. 1990;17(2):213-21.
11. Tolleth H. A hierarchy of values in the design and construc-
tion of the ear. Clin Plast Surg. 1990;17(2):193-207.
12. Smith HW. Calibrated otoplasty. Laryngoscope. 1979;
89(4):657-65.
13. Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr
Surg. 2005;115(4):60e-72e.
14. LaTrenta GS. Otoplasty. In: Rees TD and LaTrenta
GS (Eds). Aesthetic Plastic Surgery, 2nd edition.
Philadelphia:Saunders; 1994;891-921.
15. Sheerin D, MacLeod M, Kusumakar V. Psychosocial adjust-
ment in children with port-wine stains and prominent ears.
J Am Acad Child Adolesc Psychiatry. 1995;34(12):1637-47.
16. Schwentner I, Schmutzhard J, Deibl M, et al. Health-related
quality of life outcome of adult patients after otoplasty. J
Craniofac Surg. 2006;17(4):629-35.
17. Horlock N, Vögelin E, Bradbury ET, et al. Psychosocial
outcome of patients after ear reconstruction: a retrospective
study of 62 patients. Ann Plast Surg. 2005;54(5):517-24.
18. Keery H, Boutelle K, van den Berg P, et al. The impact of
appearance-related teasing by family members. J Adolesc
Health. 2005;37(2):120-7.
19. Kelley P, Hollier L, Stal S. Otoplasty: evaluation, technique,
and review. J Craniofac Surg. 2003;14(5):643-53.
20. Songu M, Adibelli H. Otoplasty in children younger
than 5 years of age. Int J Pediatr Otorhinolaryngol. 2010;
74(3):292-6.
21. Farkas LG. Growth of normal and reconstructed auri-
cles. In: Tanzer RC, Edgerton MT (Eds). Symposium on
Reconstruction of the Auricle. St. Louis: Mosby; 1974;24-31.
22. Gosain AK, Recinos RF. Otoplasty in children less than four
years of age: surgical technique. J Craniofac Surg. 2002;
13(4):505-9.
23. Gosain AK, Kumar A, Huang G. Prominent ears in children
younger than 4 years of age: what is the appropriate timing
for otoplasty? Plast Reconstr Surg. 2004;114(5):1042-54.
24. Songu M, Négrevergne M, Portmann D. The Négrevergne
otoplasty technique. Ann Otol Rhinol Laryngol. 2010;
119(1):27-31.
25. Spira M. Otoplasty: what I do now--a 30-year perspective.
Plast Reconstr Surg. 1999;104(3):834-41.
16 Section 1: Ear
26. Becker W, Deutsch E, Knappen FJ, et al. [Panel discus-
sion: problems of the specialist’s duty to inform the patient
(author’s transl)] HNO. 1976;24(6):181-96.
27. Cregg N, Conway F, Casey W. Analgesia after otoplasty:
regional nerve blockade vs local anaesthetic infiltration of
the ear. Can J Anaesth. 1996;43(2):141-7.
28. Ferraro GA, Corcione A, Nicoletti G, et al. Blepharoplasty and
otoplasty: comparative sedation with remifentanil, propofol
and midazolam. Aesthetic Plast Surg. 2005;29(3):181-3.
29. Lancaster JL, Jones TM, Kay AR, et al. Paediatric day-
case otoplasty: local versus general anaesthetic. Surgeon.
2003;1(2):96-8.
30. Pavlin DJ, Chen C, Penaloza DA, et al. Pain as a factor
complicating recovery and discharge after ambulatory
surgery table of contents. Anesth Analg. 2002; 953:627-34.
31. Koeppe T, Constantinescu MA, Schneider J, et al. Current
trends in local anesthesia in cosmetic plastic surgery of the
head and neck: results of a German national survey and
observations on the use of ropivacaine. Plast Reconstr Surg.
2005;115(6):1723-30.
32. Romo T 3rd , Sclafani AP, Shapiro AL. Otoplasty using the
postauricular skin flap technique. Arch Otolaryngol Head
Neck Surg. 1994;120(10):1146-50.
33. Caouette-Laberge L, Guay N, Bortoluzzi P, et al. Otoplasty:
anterior scoring technique and results in 500 cases review.
Plast Reconstr Surg. 2000;105(2):504-15.
34. Ely ET. An operation for prominent auricles. Arch
Otolaryngol. 1881; 10:97 (reprinted in Plast Reconstr Surg.
1968;42:582).
35. Becker OJ. Correction of the protruding deformed ear. Br J
Plast Surg. 1952;5(3):187-96.
36. Converse JM, Nigro A, Wilson FA, et al. A technique for
surgical correction of lop ears. Plast Reconstr Surg. 1955;
15:411-8.
37. Converse JM, Wood-Smith D. Technical details in the surgi-
cal correction of lop ear deformity. Plast Reconstr Surg.
1963;31:118-28.
38. Farrior RT. A method of otoplasty. Arch Otolaryngol. 1959;
69:400-8.
39. Pitanguy Y, Rebello C. Ansiform ears-correction by ‘‘island’’
technique. Acta Chir Plast. 1962;4:267-77.
40. Mustardé JC. The correction of prominent ears using simple
mattress sutures. Br J Plast Surg. 1963;16:170-8.
41. Mustardé JC. The treatment of prominent ears by buried
mattress sutures: a ten-year survey. Plast Reconstr Surg.
1967;39(4):382-6.
42. Mustardé JC. Results of otoplasty by the author’s method.
In: Goldwyn RM (Ed.). Long-Term Results in Plastic and
Reconstructive Surgery. Boston: Little Brown; 1980;139-44.
43. Spira M, Hardy SB. Mustarde otoplasty: A critical second
look. In: Marchac D and Hueston JT (Eds). Transactions
of the Sixth International Conference of Plastic and
Reconstructive Surgery. Paris: Masson; 1975;297-9.
44. Kaye BL. A simplified method for correcting the prominent
ear. Plast Reconstr Surg. 1967;40(1):44-8.
45. Tramier H. Personal approach to treatment of prominent
ears. Plast Reconstr Surg. 1997;99(2):562-5.
46. Horlock N, Misra A, Gault DT. The postauricular fascial flap
as an adjunct to Mustardé and Furnas type otoplasty. Plast
Reconstr Surg. 2001;1086:1487-90; discussion 1491.
47. Adamson PA, McGraw BL, Tropper GJ. Otoplasty: Critical
review of clinical results. Laryngoscope. 1991;101(8):883-8.
48. Messner AH, Crysdale WS. Otoplasty. Clinical protocol and
long-term results. Arch Otolaryngol Head Neck Surg. 1996;
122(7):773-7.
49. Tan O, Atik B, Karaca C, et al. A new instrument as cartilage
scorer for otoplasty and septoplasty: Adson-Brown forceps.
Plast Reconstr Surg. 2005;115(2):671-2.
50. Di cio D, Castagnetti F, Baldassarre S. Otoplasty: anterior
abrasion of ear cartilage with dermabrader. Aesthetic Plast
Surg. 2003;27(6):466-71.
51. Azuara E. Aesthetic otoplasty with remodeling of the anti-
helix for the correction of the prominent ear: criteria and
personal technique. Arch Facial Plast Surg. 2000;2(1):57-61.
52. Gibson T, Davis W. The distortion of autogenous cartilage
grafts: Its causes and prevention. Br J Plast Surg. 1958;10:257.
53. Fry HJ. Interlocked stresses in human nasal septal cartilage.
Br J Plast Surg. 1966;19(3):276-8.
54. Stenstroem SJ. A “natural” technique for correction of
congenitally prominent ears. Plast Reconstr Surg. 1963;
32:509-18.
55. Chongchet V. A method of antihelix reconstruction. Br J
Plast Surg. 1963;16:268-72.
56. Stenstrom SJ, Heftner J. The Stenstrom otoplasty. Clin Plast
Surg. 1978;5(3):465-70.
57. Qureshi TR, Hurren JS, Gourlay T. The effectiveness of scor-
ing and bipolar diathermy on ear cartilage behavior: ex vivo
study. Ann Plast Surg. 2007;58(3):321-7.
58. Heftner J. Follow-up study on 167 Stenstrom otoplasties.
Clin Plast Surg. 1978;5:470.
59. Calder JC, Naasan A. Morbidity of otoplasty: a review of 562
consecutive cases. Br J Plast Surg. 1994;47(3):170-4.
60. Ohlsen L, Verdung S. Reconstructing the antihelix of
protruding ears by perichondroplasty: a modified tech-
nique. Plast Reconstr Surg. 1980;65:753-62.
61. Johnson PE. Otoplasty: shaping the antihelix. Aesthetic Plast
Surg. 1994;18(1):71-4.
62. Pilz S, Hintringer T, Bauer M. Otoplasty using a spherical
metal head dermabrader to form a retroauricular furrow:
five year results. Aesthetic Plast Surg. 1995;19:83-91.
63. Epstein JS, Kabaker SS, Swerdloff J. The ‘‘electric’’ otoplasty.
Arch Facial Plast Surg. 1999;1(3):204-7.
64. Wright WK. Otoplasty goals and principles. Arch
Otolaryngol. 1970;92:568-72.
65. Scrimshaw GC. Otoplasty by abrasion, sculpture, and fixa-
tion. Arch Otolaryngol. 1977;103(10):579-81.
66. Nolst Trenité GJ. Otoplasty: a modified anterior scoring
technique. Facial Plast Surg. 2004;20(4):277-85.
67. Bulstrode NW, Huang S, Martin DL. Otoplasty by percutane-
ous anterior scoring. Another twist to the story: a long-term
study of 114 patients. Br J Plast Surg. 2003; 56(2):145-9.
68. Fritsch MH. Incisionless otoplasty. Facial Plast Surg. 2004;
20(4):267-70.
69. Yugueros P, Friedland JA. Otoplasty: the experience of 100
consecutive patients. Plast Reconstr Surg. 2001;108(4):1045-
51 discussion 1052–3.
70. Kompatscher P, Schuler CH, Clemens S, et al. The cartilage-
sparing versus the cartilage-cutting technique: a retro-
spective quality control comparison of the Francesconi
and Converse otoplasties. Aesthetic Plast Surg. 2003;
27(6):446-53.
 The Surgical Technique of Otoplasty
71. Strasser EJ. An objective grading system for the evalua-
tion of cosmetic surgical results. Plast Reconstr Surg. 1999;
104(7):2282-5.
72. Panettiere P, Marchetti L, Accorsi D, et al. Otoplasty: a
comparison of techniques for antihelical defects treatment.
Aesthetic Plast Surg. 2003;27(6):462-5.
73. Tan KH. Long-term survey of prominent ear surgery:
A comparison of two methods. Br J Plast Surg. 1986;
39(2):270-3.
74. Hyckel P, Schumann D, Mansel B. Method of Converse for
correction of prominent ears: comparison of results. Acta
Chir Plast. 1990;32(3):164-71.
75. Owens N, Delgado DD. The management of outstanding
ears. South Med J. 1965; 58:32-3.
76. Furnas DW. Correction of prominent ears with multiple
sutures. Clin Plast Surg. 1978; 5(3):491-5.
77. Wood-Smith D. Otoplasty. In: T. Rees (Ed.). Aesthetic Plastic
Surgery. Philadelphia: Saunders; 1980;833.
78. Gosain AK, Recinos RF. A novel approach to correction of
the prominent lobule during otoplasty. Plast Reconstr Surg.
2003;112(2):575-83.
79. Spira M, McCrea R, Gerow FJ, et al. Correction of the prin-
cipal deformities causing protruding ears. Plast Reconstr
Surg. 1969;44(2):150-4.
80. Maurice PF, Eisbach KJ. Aesthetic otoplasty: wedge excision
of a flattened helix to create a helical curl. Arch Facial Plast
Surg. 2005;7(3):195-7.
81. Aygit AC. Molding the ears after anterior scoring and concha
repositioning: a combined approach for protruding ear
correction. Aesthetic Plast Surg. 2003;27(1):77-81.
17
82. Elliott RA. Complications in the treatment of prominent
ears. Clin Plast Surg. 1978;5(3):479-90.
83. Hackney FL. Otoplasty. Select Read Plast Surg. 2001; 9:20.
84. Georgiade GS, Riefkohl R, Georgiade NG. Prominent ears
and their correction: A forty-year experience. Aesthetic Plast
Surg. 19(5);19:439-43.
85. Bradbury ET, Hewison J, Timmons MJ. Psychological and
social outcome of prominent ear correction in children. Br J
Plast Surg. 1992;45(2):97-100.
86. Furnas DW. Otoplasty for prominent ears. Clin Plast Surg.
2002;292:273-88 viii.
87. Sorribes MM, Tos M. Nonsurgical treatment of prominent
ears with the Auri method. Arch Otolaryngol Head Neck
Surg. 2002;128(12):1369-76.
88. Tan ST, Abramson DL, MacDonald DM, et al. Molding ther-
apy for infants with deformational auricular anomalies. Ann
Plast Surg. 1997;38(3):263-8.
89. Tan ST, Shibu M, Gault DT. A splint for correction of congen-
ital ear deformities. Br J Plast Surg. 1994;47(8):575-8.
90. Matsuo K, Hirose T, Tomono T, et al. Nonsurgical correction
of congenital auricular deformities in the early neonate: a
preliminary report. Plast Reconstr Surg. 1984;73(1):38-51.
91. Matsuo K, Hayashi R, Kiyono M, et al. Nonsurgical correc-
tion of congenital auricular deformities. Clin Plast Surg.
1990;17(2):383-95.
92. Massengill PL, Goco PE, Norlund LL, et al. Enzymatic recon-
touring of auricular cartilage in a rabbit model. Arch Facial
Plast Surg. 2005; 7(2):104-10.