Aesthetic Otoplasty

AESTHETIC
OTOPLASTY
By :Dr Mamush. A (MD, PRS resident)
Moderator :Dr Meki. K (MD, Ass’t prof. of plastic
and reconstructive surgery)
SPHMMC, DEPARTMENT OF SURGERY. DIVISION OF
PLASTIC, RECONSTRUCTIVE AND HAND SURGERY
Outline of presentation
• Objective
• Introduction
• History of Otoplasty
• Anatomy
• Patient evaluation
• Otoplasty techniques for different deformities
• Outcome and complications
• Conclusion
• Reference
Mamush A. (MD, plastic and reconstructive
08/09/2023 2
surgery resident)
Objective
• To discuss aesthetic otoplasty technique for
different auricular deformity and apply to
clinical activities
• To know otoplasty complication and its
management

08/09/2023 3
surgery resident)
Introduction
• “Otoplasty” refers to surgical changes in the
shape or position of the ear.
• The most common indication is prominent,
but normally shaped, ears
• rewarding procedure
• technical maneuvers required simplest
• complexity of the otoplasty procedure.

08/09/2023 4
surgery resident)
Cont’D
• achieving the optimal result begins with a three-
dimensional analysis of the deformity
• two general otoplasty technique
1. suture-based techniques, epitomized by the
Mustarde procedure
2. cartilage-altering techniques, most involving
incisions through the auricular cartilage
3. Two aditional methods:- nonoperative methods
and incisionless techniques.
08/09/2023 5
surgery resident)
Historical perspective
• 19th century, different technique to restore the
normal relationship of the auricle to the scalp
and underlying mastoid bone.
• first written description of otoplasty is attributed
to Ely.
• prominent ear by excising piece of auricle
consisting of anterior auricular skin, cartilage,
and posterior auricular skin
• Similar techniques followed
08/09/2023 6
surgery resident)
Cont’D
• Luckett(1910) classic lopear deformity to the absence of
the antihelical fold
• Luckett’s technique, a crescent-shaped excision of skin and
cartilage was performed at the site of the intended
antihelix
• Becker’s technique:- anterior and posterior incisions
around the intended antihelix.
• new antihelix with fixation sutures and posterior abrasion.
• Modern techniques stress the importance of avoiding the
surgical appearance

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surgery resident)
Anatomy and Embryology
• The external ear is a cartilaginous structure
except for the lobule
• flexible elastic cartilage is covered with skin,
which is closely adherent anteriorly and more
loosely attached posteriorly.
• Normal auricle protrudes 20 to 30 degrees
from the skull

08/09/2023 8
surgery resident)
08/09/2023 9
surgery resident)
Cont’D
• lateral edge of the helix to the mastoid skin, 2
to 2.5 cm .
• superior view point, conchomastoid angle of
90⁰ and a conchoscaphalic angle of 90⁰
• The average length and width of the male
auricle are 63.5mm and 35.5mm, respectively.
• female are 59 mm and 32.5 mm

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surgery resident)
Neurovascular supply

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surgery resident)
Embryology
• hillocks of His refers , six
visible protruberances in
the 39-day embryo.
• tragus arise first branchial
arch and the remainder
second branchial arch
• The majority of auricular
deformities are inherited in
an autosomal dominant
pattern

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surgery resident)
Epidemiology and cause
• 50% of newborns have • Not known
an auricular deformity • Vaginal delivery and
• persists in 33% by 1 increased birth weight
month old • result of absent or
• 84% of deformities misplaced muscles
continue to improve around the ear.
over the first year of life • Some newborn children
have extremely soft,
pliable ears

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surgery resident)
Diagnosis
• Made by P/E
• separated into malformations (absence of part of the
ear) or deformations (fully developed ear but
misshapen)
• management of ear anomalies by dividing them into
three categories:
• Excess components—treated by excision
• Deficient parts—managed by addition of tissues
• Adequate structures that are malformed—treated by
rearrangement of tissues
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surgery resident)
Preoperative Evaluation
• Requires precise preoperative evaluation and
analysis
• Each ear must be evaluated separately
• evaluated as to its size, its relationship to the
scalp, and the interrelationship
• Typical measurements recorded during the
preoperative examination include :-
• Preoperative photographs
08/09/2023 15
surgery resident)
Cont’D
1. The mastoid–helical
distance as measured at
the superior aspect of
the helix
the level of the external
auditory canal
the level of the lobule
08/09/2023 16
surgery resident)
Cont’D
Overall size and shape
• Evaluate to determine
• Excessively large ears, Stahl’s ears, cryptotia,
underdeveloped shell-like helical rims,
postoperative deformities…….

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surgery resident)
Cont’D
Upper third
• evaluated to determine if it is prominent, if the
antihelix/superior crus of the triangular
fossa is well formed and if the helical rim is well
defined
Middle third
• concha is overly deep or protruding
• relationship between the antihelix and the helix

08/09/2023 18
surgery resident)
Cont’D
Lower third
• lobule is evaluated to determine if it is
prominent
Asymmetry
• preferable to operate on both ears rather than
attempt to set back only the prominent ear to
match

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surgery resident)
Patient selection
• primary indication for otoplasty is to improve the
patient’s self-esteem
• parents and grandparents may
be involved in surgical decision making
• Otoplasty is recommended as early as age 4
years.
• infancy, 3 to 4 years old, and late childhood or
adolescence. Timing of intervention
• General anesthesia or deep sedation
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surgery resident)
Treatment/surgical technique
• anatomic considerations are minimal .
• those of preservation: sulcus, natural softness of
the auricular contours, and normal landmarks
• any combination of incisions acceptable without
the risk of necrosis
• no motor nerves and injury to great auricular
nerve.
• external auditory canal (conchal setback narrows
the meatus)- compromised
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surgery resident)
I. Standard otoplasty for prominent ears of
normal size
Incision
• retroauricular sulcus:- extended up on to the back of the ear
to provide adequate exposure to place Mustarde sutures
between the triangular fossa and scapha.
Dissection
• No skin is excised, except a small triangle from the medial
surface of the lobule
• cartilage is exposed on the posterior (medial) surface of the
ear and soft tissue is excised from deep to the concha
• In the region of the earlobe, deep dissection is performed
under the concha in preparation for lobule repositioning
08/09/2023 22
surgery resident)
Cont’D
• Correction
• Mustarde concha-scapha
and triangular fossa-
scapha sutures are placed
using 4-0 clear nylon
suture
• The number of sutures
depends on the how far
into the middle third of
the ear the antihelical
deficiency extends
08/09/2023 23
surgery resident)
Cont'D
• Mustarde sutures are not parallel to each
other but, instead, are arranged like spokes on
a wheel, all pointing toward the top of the
tragus (center of the wheel)
• Care is taken to create a superior crus that
curves anteriorly such that it terminates
almost parallel to the inferior crus

08/09/2023 24
surgery resident)
Conchal Setback
• A small crescent of cartilage (≤3 mm at its
widest point) is excised from the posterior wall
of the concha.
• The defect in the concha is closed primarily
• conchal resection be placed precisely
• Lack of attention to the placement of the
conchal resection is a common cause of
complications.
08/09/2023 25
surgery resident)
Cont’D
• A conchal setback suture (Furnas suture) is
then placed between the reduced concha and
the mastoid fascia
• combination of a small conchal resection and
a small conchal setback avoids the distortion.
• The earlobe is repositioned by closing the
triangular defect on the medial surface of the
lobule

08/09/2023 26
surgery resident)
Cont'D

08/09/2023 27
surgery resident)
Cont’D
• endpoint of earlobe repositioning should be
slight over-correction because the skin will
stretch over time
• never compromising the appearance of
the lobe or the ability for the patient to
wear earrings.
• Sutures are placed close to the skin defect
while catching a bite of the concha deep
in the closure
08/09/2023 28
surgery resident)
Endpoint
• Otoplasty surgery is all about the endpoint
• How do you know how tight to make the
Mustarde sutures? That is, how do you know
how sharp to make the antihelix?
• How do you know how tight to tie the Furnas
conchal-mastoid suture? Or the earlobe
correction sutures? The answers to these
questions lie in the knowledge of a normal ear.

08/09/2023 29
surgery resident)
Crucial points
1. Front view , the helical rim should be visible, poking
out from behind the antihelix.
2. Side view, the contours of the ear should be round
and soft, never sharp
3. From behind (most helpful to the surgeon who is sitting
behind), the contour of the helical rim should be a straight
line, not a “C”, or a “hockey stick”, or any other shape
• If the helical contour is a straight line, almost ensures
correction.

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surgery resident)
Cont’D
• Closure
• skin is approximated
using 5-0 plain gut
sutures without
excision skin

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surgery resident)
II. Otoplasty for large ears or ears with
inadequate helical rim definition
Incision
• Made on the lateral (visible) surface of the ear, just
inside the helical rim
• incision in the retroauricular sulcus may also be
required
Dissection
• extended through the cartilage.
• The posterior surface of the cartilage is dissected

08/09/2023 32
surgery resident)
Cont’D
 Correction
• trimmed to the desired size
and shape.
• excise more cartilage than
skin
• helical rim require shortening
at the end of the procedure.
• Conchal resection/setback
and earlobe repositioning are
performed through a separate
incision
 Closure
08/09/2023 33
surgery resident)
III. Otoplasty for constricted ears
• variable and no single technique is applicable
to all
• Tanzer divided constricted ear deformities into
three types:
• type I – involving only the helix;
• type II – involving the helix and scapha
• type III –extreme cupping of the ear.

08/09/2023 34
surgery resident)
Cont’D
• most difficult deformities to correct.
• The simplest appearing is the “lop ear”, upper pole of the ear
is turned over.
• There is always deficiency of tissue in this region.
• more significant deformities, necessary to expand the
overhanging cartilage with radial cuts and reinforce with a
conchal graft
• ear cannot lie flat because short helical rim draws the auricle
into a cup
• Any attempt to set back a constricted ear must be
accompanied by elongation of the helix
08/09/2023 35
surgery resident)
Treatment
• Nonsurgical ear molding
• Newborns with constricted/lop/cup ear
deformities may respond.
• Ear molding uses a combination of a
commercially available ear molding systems and
orthodontic molding materials to reshape the ear
• started early enough (ideally in the first few
weeks of life), surgery can often be avoided.

08/09/2023 36
surgery resident)
Cont’D

08/09/2023 37
surgery resident)
Cont’D
• most common technique for elongating the helix is by a
variation of the incision described above for large ears.
• The incision is made inside the helical rim and extended
anteriorly around the crus of the helix
• crus of the helix is then mobilized, recruited into the
helical rim.
• The donor site in the concha is closed primarily
• Any excess or unusable crus of the helix is discarded.
• more severely constricted ears (Tanzer type III), discard
the cartilage and construct a framework
08/09/2023 38
surgery resident)
IV. Otoplasty for cryptotia
• rare condition where the upper potion of the ear is buried
• ear can literally be pulled out of the scalp to examine it.
• The correction is performed by pulling the ear out
of its bed in the scalp
• incising around it in order to release it fully
• resurfacing the defect behind with a skin graft or a local flap
• cartilage is normal and only requires the soft tissue
rearrangement
• cartilage is misshapen, requires cartilage grafting to
augment the deficient native cartilage framework

08/09/2023 39
surgery resident)
Cont’D
 Goals of cryptotia surgery are:
• Restore the natural groove between the upper
ear and the side of the head:- auriculocephalic
sulcus
• Replace insufficient skin with local skin flaps or
grafts
• Release tethered ear muscles
• Reinforce collapsed cartilage
08/09/2023 40
surgery resident)
Modified Onizuka's method flap design

08/09/2023 41
surgery resident)
V. Otoplasty for Stahl’s ears
• consists of an abnormal crus extending superolaterally
• deformity is variable
• mildest cases, the extra crus is barely noticeable and
can be ignored
• More severe deformities include excess scapha in the
region of the abnormal crus
and termination of the abnormal crus in a point (“Mr
Spock” ears)

08/09/2023 42
surgery resident)
Cont’D
• most severe cases, there is also complete absence of the
normal superior crus
• Correction of the deformity mandates resection of the
abnormal crus
• incision inside the helical rim.
• skin is carefully dissected off the cartilage
• preserve the viability of the skin.
• abnormal crus is resected and placed as an onlay graft to
reconstruct

08/09/2023 43
surgery resident)
Cont’D
(A) The skin incision is
shown inside the helical rim.
(B) The abnormal crus is
excised.
(C) The cartilage defect is
reapproximated and the
excised cartilage is placed as
an onlay graft to reconstruct
the superior crus.
(D) The final result.

08/09/2023 44
surgery resident)
VI. Correction of aging, elongated ear lobes
• Earlobe reduction:- droopy, inelastic,

elongated earlobes
• can be performed concomitantly with a
facelift or as an isolated procedure
• number of techniques have been described.
• most common procedure, amputation of the
caudal border of the lobule

08/09/2023 45
surgery resident)
Cont’D
Incision
• The ideal contour is drawn.
• The excision is designed asymmetrically
• ends of the excision are located slightly medial to
the margin of the lobule.
• The idea is to excise more tissue from the medial
side of the ear lobe and to create a longer skin
flap.
 Closure
08/09/2023 46
surgery resident)
VII. Correction of earring-related
complications
• extremely common.
• most common in the lobule
• number of procedures have been described
for correction of elongated piercings
• simple excision and closure is most effective
• applies to both elongated earring holes and
those that have torn completely through the
lobule margin
08/09/2023 47
surgery resident)
Cont’D
• Z-plasty can be added in an effort to avoid a
notch
• everted closure using horizontal mattress
sutures
• The earlobes can be re-pierced in 6 weeks.
• Avoiding absorbable sutures

08/09/2023 48
surgery resident)
VIII. Correction of facelift deformities
around the ear
• facelift is just one type of otoplasty.
• Facelift deformities of the ear are frequently unfixable:
• AVOID THEM.
• categories:
1. Deformities of the lobule (pixie ear)
2. Deformities of the tragus
3. Deformities of the retroauricular sulcus
4. Unsightly hypertrophic or poorly placed periauricular
scars.

08/09/2023 49
surgery resident)
Earlobe deformities ( Pixie ear)
• result of excessive anterior and inferior
traction on the lobule due to inexpert
trimming of the facelift flap
• completely avoidable but difficult to correct.
• The facial skin should be trimmed so that the
ear can barely pulled out from under it

08/09/2023 50
surgery resident)
Tragal deformities
• consist of either anterior traction on the
tragus, amputation of some of the Tragal
cartilage or excess facial skin at the bottom of
the tragus that serves as an across the-room
surgical signature.
• There is little that can be done for the first two
conditions, since too much tissue has been
removed

08/09/2023 51
surgery resident)
Cont’D
• lack of definition of the caudal tragus,
however, can be corrected
• by removing a triangle of skin from the caudal
aspect of the tragus to recreate the natural,
right-angle contour
• Removal of a triangle of skin can correct the
problem and make it much less obvious that
the patient has had a facelift.

08/09/2023 52
surgery resident)
Retroauricular deformities
• it is necessary to place the facelift incision up on the
back of the ear.
• excessive, there may be little skin remaining behind
the ear
• If the incision is placed in the sulcus or minimally on
the auricular cartilage, it will not migrate if the flaps
are trimmed judiciously.
• Once the deformity is created, there is no solution
except release of the ear and placement of a full
thickness skin graft.
08/09/2023 53
surgery resident)
Scars
• Unsightly scars can frequently be improved by excision.
• Hypertrophic scars are more problematic.
• due to tension”- improve
• due to the patients’ intrinsic scar forming, they will not
be.
• revision of scars.
• Kenalog injection is helpful
• recurrent hypertrophic scars or real keloids develop, scar
revision with postoperative radiation
• Late complication of otoplasty
08/09/2023 54
surgery resident)
Postoperative care
• Soft bulky dressing
• The purpose of the dressing is to protect the repair,
keep the skin of the ear moist, and to absorb drainage.
• No attempt is made to put pressure on the ear.
• A doughnut of gauze is placed around each ear
specifically to avoid pressure
• Dressing left in place for 3-5 days
• Wear loose headband at night time only for 4-6 weeks

08/09/2023 55
surgery resident)
Outcomes and complications
• Most patients who undergo otoplasty are
satisfied with the results, making the
procedure gratifying for the surgeon as well.
• Suture complication. Common;- protrusion,
inflammation and granuloma formation
• under-correction or recurrence. 2nd most
common complication

08/09/2023 56
surgery resident)
Early Complications
• Hematoma and Cartilage necrosis
• hematoma necessitates reopening the wound,
controlling the bleeding, irrigating with an
antibiotic solution, and reapplying the dressing
• infection:- perichondritis and suppurative
Chondritis (serious complication)
• Wound infection must be treated aggressively.
• Administration of systemic antibiotics, including
coverage for Pseudomonas aeruginosa
08/09/2023 57
surgery resident)
Late Complication
• suture extrusion:- result from incorrect suture
placement, from excess tension on the auricular
cartilage, or from infection.
• Treatment is the removal of the offending suture
• Early:- requires revision surgery to restore the
correction.
• Later extrusions may not require revision surgery
because the auricle may retain the corrected
shape
08/09/2023 58
surgery resident)
aesthetic complications
• inadequate correction of the protruding ear,
reprotrusion, and overcorrection
• telephone deformity
• reverse telephone deformity
• auricular buckling
• visible cartilage edges
• bowstringing of sutures
• Scars formation
08/09/2023 59
surgery resident)
Secondary procedures
• most common complaints
1. Over-correction:- can usually be improved by removing
sutures, undermining skin and occasionally placing a skin
graft
2. Visible cartilage irregularities or unnatural contours:-
extremely difficult to correct
 Visible cartilage irregularities are Removing the damaged
cartilage and placed expertly curved pieces of rib cartilage
3. Unpleasing shape of the ear (e.g., telephone ear,
protruding lobules)
4. Under-correction, usually of the upper pole of the ear.
08/09/2023 60
surgery resident)
Conclusion
• Emphasis in otoplasty is placed on precise
preoperative analysis and measurements,
selecting the most predictable and conservative
procedure for the particular deformity.
• Although no surgeon can be versatile in all
otoplasty techniques, a fundamental
knowledge of the principles of otoplasty will
permit correction of a wide variety of
deformities with any given approach.
08/09/2023 61
surgery resident)
Reference
1. Grabb & smith’s plastic surgery, 8th edition. 2014
2. Neligan & Warren (2013). Plastic Surgery 3rd edition, Volu
me 2, Aesthetic, Chapter 22, Otoplasty
3. Peter C. Neligan and Donald W. Buck II. Core Procedures in
Plastic Surgery. 2014
4. ARI S. HOSCHANDER, CHRISTOPHER J. SALGADO, WROOD
KASSIRA and SETH R. THALLER. Operative Procedures in
Plastic, Aesthetic and Reconstructive Surgery. 2016
5. David L. Brown, Gregory H. Borschel and Benjamin Levi.
MICHIGAN MANUAL OF PLASTIC SURGERY, 2nd edition.
2015
08/09/2023 62
surgery resident)
THANK YOU

08/09/2023 63
surgery resident)

Aesthetic Otoplasty

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AESTHETIC

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

• Earlobe reduction:- droopy, inelastic,

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

Mamush A. (MD, plastic and reconstructive

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