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Closed anterior scoring for prominent-ear correction revisited
British Journal of Plastic Surgery (2001), 54, 581-587 9 2001 The British Association of Plastic Surgeons doi: 10.1054/bjps.2001.3677
BRITISH
JOURNAL
OF
[~I
PLASTIC
SURGERY
Closed anterior scoring for prominent-ear correction revisited S. S. Thomas and E Fatah
West Midlands Regional Plastic Surgery Unit, Wordsley Hospital, Stourbridge, UK SUMMARY.
The closed-anterior-scoring technique has been used over the past 3 years to correct 56 prominent ears in 32 patients at the West Midlands Regional Plastic Surgery Unit at Wordsley Hospital. A review was carried out to assess the result of this surgical procedure. We briefly discuss the historical development of other surgical techniques for prominent-ear correction, and describe in detail the operative technique for this procedure, which includes closed scoring and suturing of the cartilage. We used this technique to treat 24 patients with bilateral prominent ears and eight patients with unilateral prominent ears. The series comprised 20 females and 12 males, 26 children and six adults. The age range was from 4 to 24 years old. There were two complications (an upper-pole recurrence and protrusion of a buried prolene suture). Patients were followed up for between 6 months and 3 years (mean: 1.5 years). This procedure is quick and technically easy to learn, with no anterior scars or posterior cartilage overlap. Minimal dissection is involved, leading to a low rate of complications. The learning curve is rapid; this paper represents the experience of a specialist trainee (SST) after he was taught the technique by the senior author. 9 2001 The British Association of Plastic Surgeons
Keywords:prominent-ear correction, closed anterior scoring, pinnaplasty. Many different techniques for the correction of prominent ears have been described. In the UK the majority of plastic surgeons prefer the open anterior 'Chongchet' technique, l The closed-anterior-scoring technique is not commonly used and was first described by StenstrOm. 2 At the West Midlands Regional Plastic Surgery Unit both approaches are used; we present the results of a modification of the closed-anterior-scoring technique over the past 3 years. Though this technique has not been very popular in the UK, we have found it to be easy to learn and perform, in preference to the Chongchet technique.
Surgicaltechnique The face and ears are prepared with an aqueous antiseptic solution and draped, as in any prominent-ear correction. No head ring is used as it is more comfortable and easier to turn the head from side to side. For patients requiring general anaesthesia, 0.25% bupivacaine with 1:200000 adrenaline is used; 1% lignocaine with 1:200000 adrenaline is added to this solution in a 1:1 ratio for local anaesthesia. EMLA cream can be applied to the ears i h before the local anaesthetic is infiltrated. The site of the new antihelical fold is drawn anteriorly and a narrow ellipse of skin is marked posteriorly and excised, leaving the subcutaneous tissue and cutaneous nerves intact. The tail of the helical cartilage is identified and separated from the main body of the ear cartilage and antihelix by blunt-tipped-scissors dissection (Fig. 1), and access is gained to the anterior surface. Continuing the same manoeuvre of the scissors, the skin overlying the antihelical fold is separated from the underlying cartilage, from below upwards, to the upper pole (Fig. 2). For scoring, either a commercially available or a locally
\
Figure 1--The tail of the helical cartilage ts separatedfrom the body of the ear cartilage. made scorer can then be used (Fig. 3). The scorer is introduced through the same incision, to score the proposed new antihelical fold from above downwards in a 'fan'shaped manner until the cartilage can be folded back at the new antihelical fold, without tension, on digital 581
582 pressure (Fig. 4). If necessary, transverse or oblique scoring can also be performed, depending on the resilience of the cartilage. However, craniocaudal scoring is usually adequate.
British Journal of Plastic Surgery Between two and four clear 4/0 non-absorbable 'horizontal-mattress-style' sutures are used to maintain the position of the new antihelical fold (Fig. 5). These sutures must not be tied under excessive tension as this can cause overcorrection. Care is taken to bury the knots in small subcutaneous pockets so that they do not protrude from the suture line (Fig. 6). The skin is closed with an intradermal non-absorbable pull-out prolene suture tied over Jelonet and gauze (Fig. 7). A light bandage can be applied for 5-7 days for the patient's comfort. The operation is normally carried out as a day-case procedure.
Results
Figure 2---The antitragal area is separated to enter the anterior surface of the cartilage.
Over the past 3 years a total of 56 prominent ears were corrected in 32 patients using this technique. There were 24 patients with bilateral prominent ears and eight patients with unilateral prominent ears; the series comprised 20 females and 12 males, 26 children and six adults. The age range was from 4 to 24 years, with an average age of 8 years. Patients were followed up for a minimum of 6 months and a maximum of 3 years (mean: 1.5 years). There were two complications. One patient experienced extrusion of a buried suture, which settled spontaneously, and there was o n e upper-pole recurrence. This patient was treated during the earlier part of the learning curve, when the need for adequate upper-pole scoring was overlooked. There were no infections or haematomas. A follow-up questionnaire was sent to all the patients, or their parents, to assess ear scars, symmetry and overall sarisfaction. Responses were received from 21 out of the 32 patients (65.6%). All respondents categorised their results as good or excellent, except for one patient who judged the
/ \, / ,f
/
~5
Figure 3---Either (A) a commercially or (B) a locally made cartilage scorer can be used.
..........
Closed anterior scoring for prominent-ear correction revisited
583
Figure 4---(A-D) The cartilage scorer is introduced posteriorly through the same incision as the scissors to score the anterior surface of the ear cartilage craniocaudally.
result to be 'fair' in terms of overall satisfaction, because of repeat surgery for upper-pole recurrence (Table 1). Though the majority of patients were satisfied, in some o f the earlier cases there was a less than satisfactory curvature of the antihelical fold on critical evaluation. With
adequate upper-pole scoring and intraoperative adjustment of the posterior cartilage sutures this was overcome in subsequent cases. The results of some clinical cases are seen in Figures 8-11.
584
British Journal of Plastic Surgery
Figure 6 - - T h e skin and s u b c u t a n e o u s margins are undermined at the site o f the sutures to prevent t h e m f r o m extruding. The dotted area represents the skin ellipse excision leaving the cutaneous nerves intact. The diagonal lines indicate the u n d e r m i n e d subcutaneous pockets where the non-absorbable sutures are buried. F i g u r e 5 - - N o n - a b s o r b a b l e horizontal mattress-style sutures are used to hold the new antihelical fold.
Table 1 Responses to the patient questionnaire (replies received from 21 out of the 32 patients) Unacceptable Poor Fair Good Excellent Total ear scars ear s y m m e t r y satisfaction with operation
F i g u r e 7 - - T h e skin is closed using a pull-out prolene suture tied over Jelonet a n d gauze.
Discussion
The medical literature records nearly 200 different techniques for the correction of prominent ears. Though it is sometimes considered a junior-trainee operation, the
-
-
1
I1 13 5
10 8 15
21 21 21
deformity needs careful understanding in order to choose the correct procedure. Surgery for prominent ears was first performed in 1881 by Edward Ely, 3 who excised skin and cartilage from one side, treating the other side 6 weeks later. William Keen used this procedure on both ears simultaneously.4 In 1910 Luckett highlighted the importance of correcting a poorly developed antihelical fold. 5 Morestin's suggestion in 1903 of using horizontal mattress sutures to fold the cartilage back was popularised by Mustard6 in the 1960s. 6'7 The disadvantages of this technique, however, are the tendency of the cartilage to spring back, and the possibility of infection and extrusion of silk stitches. At around the same time, Chongchet initiated open anterior cartilage scoring] which is probably the most popular technique used and taught in plastic surgery units in the UK. In a retrospective review of 101 patients treated using the Chongchet technique and 45 patients treated using the Mustardfi technique, Tan found a 9.9% and a 24% re-operation rate, respectively,s This was attributed to the use of white silk sutures, which also caused stitch abscesses and protrusion of sutures. StenstrOm advocated blind anterior scoring with a rasp made from the split ends of an Adson-Brown forceps.2
Closed anterior scoring for prominent-ear correction revisited
585
:Iv
_
! Figure 8--This 16-year-old patient underwent bilateral prominent-ear correction. (A-C) Preoperative views and (D-F) postoperative results at day 14. Note the minimal bruising seen on (E) the right and (F) the left lateral views.
B
e
.....
D
Figure 9--This 8-year-old patient was treated using the closed-anterior-scoringprocedure. (A) Preoperative and (B) postoperative frontal views at 3 months. (C) The right and (D) the left lateral views.
His original technique involved making a cut in the cartilage to weaken the inferior spring, and the skin sutures were placed to take the tension of the corrected ear. He attributed his recurrences to inadequate skin excision. Our modification relies on anterior scoring to allow the cartilage to fold
back at the new antihelical fold, which is maintained by the mattress sutures while healing progresses. The skin is approximated without tension. Many procedures have been developed in an attempt to minimise scars but they involve using needles and incisions
586
British Journal of Plastic Surgery
Figure 10~This 6-year-old girl underwent a unilateral left prominent-ear correction. (A) Preoperative and (B) postoperative frontal views. (C) The corrected left ear matches well with (D) the uncorrected right ear.
~
i 84
A
Figure U--(A-C) Preoperative and (D-F) postoperativeviews at 18 months. Note that there is no recurrence.
on the anterior surface. Using hypodermic needles 9,10 after manually bending the tip does not give the surgeon a 'feel' for where exactly the needle lies in relation to the cartilage thickness. Hence, it is very easy to go through
the whole thickness o f the cartilage and fracture it. Incisions on the anterior surface 11,12 increase the risk o f hypertrophic scarfing and keloid formation on the visible part o f the ear. Even endoscopic pinnaplasty 13 has been
Closed anterior scoring for prominent-ear correction revisited
tried but has been found to be technically difficult and time consuming. The advantage of the closed-anterior-scoring procedure is that it is versatile and applicable to both children and adults. Though it is technically easier to perform in children, with more pliable cartilage, it can be performed in adults, with more resilient cartilage. A deep concha can be adjusted by repositioning the antihelical fold. The result seen on the operating table is the final postoperative result, as the cartilage does not spring back. If the correction is deficient in any way, such as a protruding ear lobule, then this can very easily be corrected during the initial procedure. The option of reverting to an open procedure is always there if one encounters a very resilient cartilage that is refractory to closed scoring. In our series, however, the need for this never arose. Our procedure is also technically easy and less time consuming than the open Chongchet technique. The average time taken for a bilateral procedure is 45 min. There are no anterior scars or posterior cartilage overlaps. There is minimal dissection, leaving the subcutaneous tissue and cutaneous nerves intact, thus reducing the chance of haematoma formation. The bandage is more for comfort than for maintaining position, hence no pressure is applied, reducing the incidence of pressure necrosis. The disadvantages of our procedure are the use of buried non-absorbable sutures, but in the latter cases polydioxanone t4 has been used with similar results. It may not always be possible to obtain a satisfactory curve of the upper pole with multiple craniocaudal scoring manoeuvres, but this can be achieved by changing the site and the number of cartilage stitches. Surface irregularity can be avoided with gentle and careful scoring. For trainee surgeons, the closed-anterior-scoring technique is less likely to produce unacceptable results in the early stages because it has a rapid learning curve. It gives a more natural appearance with fewer complications and should always be kept in mind when assessing a patient with prominent ears.
Acknowledgements We thank the Photography Department, and Mr J. H. Goldin FRCS, retired Consultant Plastic Surgeon at Wordsley Hospital, for allowing his patients to be included in this study.
587
References 1. Chongchet V. A method of antihelix reconstruction. Br J Plast Surg 1963; 16: 268-72. 2. Stenstrrm SJ. A 'natural' technique for correction of congenitally prominent ears. Plast Reconstr Surg 1963; 32: 509-18. 3. Ely ET. An operation for prominence of the auricles (with two wood-cuts). Arch Otol 1881; 10: 97-8. 4. Keen WW. New method of operating for relief of deformity from prominent ears. Arch Otol 1889; 10: 49-51. 5. Luckett WH. A new operation for prominent ears based on the anatomy of the deformity. Surg Gynecol Obstet 1910; 10: 635-7. 6. Mustard6 JC. The correction of prominent ears using simple mattress sutures. Br J Plast Surg 1963; 16: 170-6. 7. Mustard6 JC. The treatment of prominent ears by buried mattress sutures: a ten-year survey. Plast Reconstr Surg 1967; 39: 382~. 8. Tan KH. Long-term survey of prominent ear surgery: a comparison of two methods. Br J Plast Surg 1986; 39: 270-3. 9. Mahler D. The correction of the prominent ear. Aesthetic Plast Surg 1986; 10: 29-33. 10. Peled IJ. Knifeless otoplasty: how simple can it be? Aesthetic Plast Surg 1995; 19: 253-5. 11. Ely JE Small incision otoplasty for prominent ears. Aesthetic Plast Surg 1988; 12: 63-9. 12. Kaye BL. A simplified method for correcting the prominent ear. Plast Reconstr Surg 1967; 40: 44-8. 13. Graham KE, Ganlt DT. Endoscopic assisted otoplasty: a preliminary report. Br J Hast Surg 1997; 50: 47-57. 14. Salgarelli A, Magnato R, Carminati R, Nocini PF. A combined technique for correction of the prominent ear. J Oral Maxillofac Surg 1997; 55: 1235--41.
The Authors Sunil S, Thomas MS, FRCSI, Specialist Registrar in Plastic Surgery Fazel Fatah FRCS, Consultant Plastic Surgeon West Midlands Regional Plastic Surgery Unit, Wordsley Hospital, Stourbridge, West Midlands DY8 5QX, UK. Presently at the West Midlands Regional Burns & Plastic Surgery Unit, University Hospital NHS Trust, Raddlebarn Road, Selly Oak, Birmingham B29 6JD, UK. Correspondence to Mr Sunil S. Thomas. Paper received 18 January 2000. Accepted 27 April 2001, after revision.
BRITISH
JOURNAL
OF
[~I
PLASTIC
SURGERY
Closed anterior scoring for prominent-ear correction revisited S. S. Thomas and E Fatah
West Midlands Regional Plastic Surgery Unit, Wordsley Hospital, Stourbridge, UK SUMMARY.
The closed-anterior-scoring technique has been used over the past 3 years to correct 56 prominent ears in 32 patients at the West Midlands Regional Plastic Surgery Unit at Wordsley Hospital. A review was carried out to assess the result of this surgical procedure. We briefly discuss the historical development of other surgical techniques for prominent-ear correction, and describe in detail the operative technique for this procedure, which includes closed scoring and suturing of the cartilage. We used this technique to treat 24 patients with bilateral prominent ears and eight patients with unilateral prominent ears. The series comprised 20 females and 12 males, 26 children and six adults. The age range was from 4 to 24 years old. There were two complications (an upper-pole recurrence and protrusion of a buried prolene suture). Patients were followed up for between 6 months and 3 years (mean: 1.5 years). This procedure is quick and technically easy to learn, with no anterior scars or posterior cartilage overlap. Minimal dissection is involved, leading to a low rate of complications. The learning curve is rapid; this paper represents the experience of a specialist trainee (SST) after he was taught the technique by the senior author. 9 2001 The British Association of Plastic Surgeons
Keywords:prominent-ear correction, closed anterior scoring, pinnaplasty. Many different techniques for the correction of prominent ears have been described. In the UK the majority of plastic surgeons prefer the open anterior 'Chongchet' technique, l The closed-anterior-scoring technique is not commonly used and was first described by StenstrOm. 2 At the West Midlands Regional Plastic Surgery Unit both approaches are used; we present the results of a modification of the closed-anterior-scoring technique over the past 3 years. Though this technique has not been very popular in the UK, we have found it to be easy to learn and perform, in preference to the Chongchet technique.
Surgicaltechnique The face and ears are prepared with an aqueous antiseptic solution and draped, as in any prominent-ear correction. No head ring is used as it is more comfortable and easier to turn the head from side to side. For patients requiring general anaesthesia, 0.25% bupivacaine with 1:200000 adrenaline is used; 1% lignocaine with 1:200000 adrenaline is added to this solution in a 1:1 ratio for local anaesthesia. EMLA cream can be applied to the ears i h before the local anaesthetic is infiltrated. The site of the new antihelical fold is drawn anteriorly and a narrow ellipse of skin is marked posteriorly and excised, leaving the subcutaneous tissue and cutaneous nerves intact. The tail of the helical cartilage is identified and separated from the main body of the ear cartilage and antihelix by blunt-tipped-scissors dissection (Fig. 1), and access is gained to the anterior surface. Continuing the same manoeuvre of the scissors, the skin overlying the antihelical fold is separated from the underlying cartilage, from below upwards, to the upper pole (Fig. 2). For scoring, either a commercially available or a locally
\
Figure 1--The tail of the helical cartilage ts separatedfrom the body of the ear cartilage. made scorer can then be used (Fig. 3). The scorer is introduced through the same incision, to score the proposed new antihelical fold from above downwards in a 'fan'shaped manner until the cartilage can be folded back at the new antihelical fold, without tension, on digital 581
582 pressure (Fig. 4). If necessary, transverse or oblique scoring can also be performed, depending on the resilience of the cartilage. However, craniocaudal scoring is usually adequate.
British Journal of Plastic Surgery Between two and four clear 4/0 non-absorbable 'horizontal-mattress-style' sutures are used to maintain the position of the new antihelical fold (Fig. 5). These sutures must not be tied under excessive tension as this can cause overcorrection. Care is taken to bury the knots in small subcutaneous pockets so that they do not protrude from the suture line (Fig. 6). The skin is closed with an intradermal non-absorbable pull-out prolene suture tied over Jelonet and gauze (Fig. 7). A light bandage can be applied for 5-7 days for the patient's comfort. The operation is normally carried out as a day-case procedure.
Results
Figure 2---The antitragal area is separated to enter the anterior surface of the cartilage.
Over the past 3 years a total of 56 prominent ears were corrected in 32 patients using this technique. There were 24 patients with bilateral prominent ears and eight patients with unilateral prominent ears; the series comprised 20 females and 12 males, 26 children and six adults. The age range was from 4 to 24 years, with an average age of 8 years. Patients were followed up for a minimum of 6 months and a maximum of 3 years (mean: 1.5 years). There were two complications. One patient experienced extrusion of a buried suture, which settled spontaneously, and there was o n e upper-pole recurrence. This patient was treated during the earlier part of the learning curve, when the need for adequate upper-pole scoring was overlooked. There were no infections or haematomas. A follow-up questionnaire was sent to all the patients, or their parents, to assess ear scars, symmetry and overall sarisfaction. Responses were received from 21 out of the 32 patients (65.6%). All respondents categorised their results as good or excellent, except for one patient who judged the
/ \, / ,f
/
~5
Figure 3---Either (A) a commercially or (B) a locally made cartilage scorer can be used.
..........
Closed anterior scoring for prominent-ear correction revisited
583
Figure 4---(A-D) The cartilage scorer is introduced posteriorly through the same incision as the scissors to score the anterior surface of the ear cartilage craniocaudally.
result to be 'fair' in terms of overall satisfaction, because of repeat surgery for upper-pole recurrence (Table 1). Though the majority of patients were satisfied, in some o f the earlier cases there was a less than satisfactory curvature of the antihelical fold on critical evaluation. With
adequate upper-pole scoring and intraoperative adjustment of the posterior cartilage sutures this was overcome in subsequent cases. The results of some clinical cases are seen in Figures 8-11.
584
British Journal of Plastic Surgery
Figure 6 - - T h e skin and s u b c u t a n e o u s margins are undermined at the site o f the sutures to prevent t h e m f r o m extruding. The dotted area represents the skin ellipse excision leaving the cutaneous nerves intact. The diagonal lines indicate the u n d e r m i n e d subcutaneous pockets where the non-absorbable sutures are buried. F i g u r e 5 - - N o n - a b s o r b a b l e horizontal mattress-style sutures are used to hold the new antihelical fold.
Table 1 Responses to the patient questionnaire (replies received from 21 out of the 32 patients) Unacceptable Poor Fair Good Excellent Total ear scars ear s y m m e t r y satisfaction with operation
F i g u r e 7 - - T h e skin is closed using a pull-out prolene suture tied over Jelonet a n d gauze.
Discussion
The medical literature records nearly 200 different techniques for the correction of prominent ears. Though it is sometimes considered a junior-trainee operation, the
-
-
1
I1 13 5
10 8 15
21 21 21
deformity needs careful understanding in order to choose the correct procedure. Surgery for prominent ears was first performed in 1881 by Edward Ely, 3 who excised skin and cartilage from one side, treating the other side 6 weeks later. William Keen used this procedure on both ears simultaneously.4 In 1910 Luckett highlighted the importance of correcting a poorly developed antihelical fold. 5 Morestin's suggestion in 1903 of using horizontal mattress sutures to fold the cartilage back was popularised by Mustard6 in the 1960s. 6'7 The disadvantages of this technique, however, are the tendency of the cartilage to spring back, and the possibility of infection and extrusion of silk stitches. At around the same time, Chongchet initiated open anterior cartilage scoring] which is probably the most popular technique used and taught in plastic surgery units in the UK. In a retrospective review of 101 patients treated using the Chongchet technique and 45 patients treated using the Mustardfi technique, Tan found a 9.9% and a 24% re-operation rate, respectively,s This was attributed to the use of white silk sutures, which also caused stitch abscesses and protrusion of sutures. StenstrOm advocated blind anterior scoring with a rasp made from the split ends of an Adson-Brown forceps.2
Closed anterior scoring for prominent-ear correction revisited
585
:Iv
_
! Figure 8--This 16-year-old patient underwent bilateral prominent-ear correction. (A-C) Preoperative views and (D-F) postoperative results at day 14. Note the minimal bruising seen on (E) the right and (F) the left lateral views.
B
e
.....
D
Figure 9--This 8-year-old patient was treated using the closed-anterior-scoringprocedure. (A) Preoperative and (B) postoperative frontal views at 3 months. (C) The right and (D) the left lateral views.
His original technique involved making a cut in the cartilage to weaken the inferior spring, and the skin sutures were placed to take the tension of the corrected ear. He attributed his recurrences to inadequate skin excision. Our modification relies on anterior scoring to allow the cartilage to fold
back at the new antihelical fold, which is maintained by the mattress sutures while healing progresses. The skin is approximated without tension. Many procedures have been developed in an attempt to minimise scars but they involve using needles and incisions
586
British Journal of Plastic Surgery
Figure 10~This 6-year-old girl underwent a unilateral left prominent-ear correction. (A) Preoperative and (B) postoperative frontal views. (C) The corrected left ear matches well with (D) the uncorrected right ear.
~
i 84
A
Figure U--(A-C) Preoperative and (D-F) postoperativeviews at 18 months. Note that there is no recurrence.
on the anterior surface. Using hypodermic needles 9,10 after manually bending the tip does not give the surgeon a 'feel' for where exactly the needle lies in relation to the cartilage thickness. Hence, it is very easy to go through
the whole thickness o f the cartilage and fracture it. Incisions on the anterior surface 11,12 increase the risk o f hypertrophic scarfing and keloid formation on the visible part o f the ear. Even endoscopic pinnaplasty 13 has been
Closed anterior scoring for prominent-ear correction revisited
tried but has been found to be technically difficult and time consuming. The advantage of the closed-anterior-scoring procedure is that it is versatile and applicable to both children and adults. Though it is technically easier to perform in children, with more pliable cartilage, it can be performed in adults, with more resilient cartilage. A deep concha can be adjusted by repositioning the antihelical fold. The result seen on the operating table is the final postoperative result, as the cartilage does not spring back. If the correction is deficient in any way, such as a protruding ear lobule, then this can very easily be corrected during the initial procedure. The option of reverting to an open procedure is always there if one encounters a very resilient cartilage that is refractory to closed scoring. In our series, however, the need for this never arose. Our procedure is also technically easy and less time consuming than the open Chongchet technique. The average time taken for a bilateral procedure is 45 min. There are no anterior scars or posterior cartilage overlaps. There is minimal dissection, leaving the subcutaneous tissue and cutaneous nerves intact, thus reducing the chance of haematoma formation. The bandage is more for comfort than for maintaining position, hence no pressure is applied, reducing the incidence of pressure necrosis. The disadvantages of our procedure are the use of buried non-absorbable sutures, but in the latter cases polydioxanone t4 has been used with similar results. It may not always be possible to obtain a satisfactory curve of the upper pole with multiple craniocaudal scoring manoeuvres, but this can be achieved by changing the site and the number of cartilage stitches. Surface irregularity can be avoided with gentle and careful scoring. For trainee surgeons, the closed-anterior-scoring technique is less likely to produce unacceptable results in the early stages because it has a rapid learning curve. It gives a more natural appearance with fewer complications and should always be kept in mind when assessing a patient with prominent ears.
Acknowledgements We thank the Photography Department, and Mr J. H. Goldin FRCS, retired Consultant Plastic Surgeon at Wordsley Hospital, for allowing his patients to be included in this study.
587
References 1. Chongchet V. A method of antihelix reconstruction. Br J Plast Surg 1963; 16: 268-72. 2. Stenstrrm SJ. A 'natural' technique for correction of congenitally prominent ears. Plast Reconstr Surg 1963; 32: 509-18. 3. Ely ET. An operation for prominence of the auricles (with two wood-cuts). Arch Otol 1881; 10: 97-8. 4. Keen WW. New method of operating for relief of deformity from prominent ears. Arch Otol 1889; 10: 49-51. 5. Luckett WH. A new operation for prominent ears based on the anatomy of the deformity. Surg Gynecol Obstet 1910; 10: 635-7. 6. Mustard6 JC. The correction of prominent ears using simple mattress sutures. Br J Plast Surg 1963; 16: 170-6. 7. Mustard6 JC. The treatment of prominent ears by buried mattress sutures: a ten-year survey. Plast Reconstr Surg 1967; 39: 382~. 8. Tan KH. Long-term survey of prominent ear surgery: a comparison of two methods. Br J Plast Surg 1986; 39: 270-3. 9. Mahler D. The correction of the prominent ear. Aesthetic Plast Surg 1986; 10: 29-33. 10. Peled IJ. Knifeless otoplasty: how simple can it be? Aesthetic Plast Surg 1995; 19: 253-5. 11. Ely JE Small incision otoplasty for prominent ears. Aesthetic Plast Surg 1988; 12: 63-9. 12. Kaye BL. A simplified method for correcting the prominent ear. Plast Reconstr Surg 1967; 40: 44-8. 13. Graham KE, Ganlt DT. Endoscopic assisted otoplasty: a preliminary report. Br J Hast Surg 1997; 50: 47-57. 14. Salgarelli A, Magnato R, Carminati R, Nocini PF. A combined technique for correction of the prominent ear. J Oral Maxillofac Surg 1997; 55: 1235--41.
The Authors Sunil S, Thomas MS, FRCSI, Specialist Registrar in Plastic Surgery Fazel Fatah FRCS, Consultant Plastic Surgeon West Midlands Regional Plastic Surgery Unit, Wordsley Hospital, Stourbridge, West Midlands DY8 5QX, UK. Presently at the West Midlands Regional Burns & Plastic Surgery Unit, University Hospital NHS Trust, Raddlebarn Road, Selly Oak, Birmingham B29 6JD, UK. Correspondence to Mr Sunil S. Thomas. Paper received 18 January 2000. Accepted 27 April 2001, after revision.