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Comparison of two incisionless otoplasty techniques for prominent ears in children
International Journal of Pediatric Otorhinolaryngology 79 (2015) 504–510
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International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Comparison of two incisionless otoplasty techniques for prominent ears in children Suheyl Haytoglu a, Tahir Gokhan Haytoglu b, Nuray Bayar Muluk c,*, Gokhan Kuran a, Osman Kursat Arikan a a b c
Adana Numune Training and Research Hospital, ENT Clinics, Adana, Turkey Istanbul Training and Research Hospital, Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul, Turkey Kırıkkale University, Faculty of Medicine, ENT Department, Kırıkkale, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 November 2014 Received in revised form 10 January 2015 Accepted 13 January 2015 Available online 20 January 2015
Objectives: In the present study, we applied two incisionless suture techniques for otoplasty: Haytoglu et al.’s modification of incisionless otoplasty technique and Fritsch’s incisionless otoplasty technique for correction of prominent ears. Methods: In this prospective study, 60 patients with prominent ears were included in the study. In Group 1, 55 ears of 30 patients (25 bilateral and 5 unilateral) were operated with Haytoglu et al.’s modification of incisionless otoplasty technique. In Group 2, 57 ears of 30 patients (27 bilateral and 3 unilateral) were operated with Fritsch’s incisionless otoplasty technique. For comparison of two methods, auriculocephalic distances were measured at three levels which were level 1 (the most superior point of the auricle), level 2 (the midpoint of the auricle) and level 3 (level of the lobule) pre-operatively (preop); and measurements were repeated at the end of the surgery (PO0-day), 1st month (PO1-Mo) and 6th month (PO6-Mo) after the surgery, in both groups. Patient satisfaction was evaluated using a visual analog scale (VAS). Moreover, Global Aesthetic Improvement Scale (GAIS) was rated by an independent, nonparticipating plastic surgeon at 6 months after the surgery. Results: Operation time was 15.9 5.6 min in Group 1 (Haytoglu et al.’s) and 19 4.7 min in Group 2 (Fritsch). Hematoma, infection, bleeding, keloid scar formation, sharp edges or irregularities of the cartilage were not observed in any group. Suture extrusion was detected in 14.03% of Group 1 and 16.1% of Group 2. No statistically significant difference was observed between auriculocephalic distances at levels 1–3 of groups at preop, PO0-day, PO1-Mo and PO6-Mo separately. Similarly, difference in auriculocephalic distances (preop values-PO6-Mo values) was not detected as statistically significant in Groups 1 and 2 at three levels. In both techniques, No statistically significant difference was observed in patient satisfaction at 6th months after the operation which was measured using Visual Analogue Scale (VAS) on 0 to 100 scales. According to GAIS, the patients were rated as 92.9% ‘‘improved’’ and 7.1% ‘‘no change’’ in Group 1; as 94.6% ‘‘improved’’ and 5.4% ‘‘no change’’ in Group 2. Conclusions: Due to the similar results, Haytoglu et al.’s and Fritsch’s incisionless otoplasty techniques are good options in the treatment of prominent ears, especially in pediatric patients with isolated inadequate development of antihelical ridge, and with soft auricular cartilage. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Incisionless otoplasty Prominent ears Visual analogue scale (VAS) Global aesthetic improvement scale (GAIS) Auriculocephalic distance
1. Introduction Prominent ears are the most common congenital deformity in the head and neck region. Incidence for Caucasians are described
* Corresponding author. Tel.: +90 312 4964073/+90 532 7182441; fax: +90 312 4964073. E-mail addresses: [email protected], [email protected] (N. Bayar Muluk). http://dx.doi.org/10.1016/j.ijporl.2015.01.014 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
about 5% and for microtia, it is 0.01% [1]. Otoplasty is now considered as a procedure with both aesthetic and functional purposes because it can lead a psychological trauma, especially in children being ridiculed by their peers [2]. By the age of 5, the development of the auricle nearly completed, it is an appropriate time to correct the prominent ear before the child start school [3,4]. Otoplasty is one of the most frequent aesthetic surgical procedures in children and adolescents. Several techniques can give satisfactory results, but few address all the components of the prominent ear deformity [5].
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The first case for correction of congenital prominent ear had been published in 1881 [6]. The concept of restoration of the antihelical fold for prominent ear deformity was the first introduced by Luckett [7] who resorted to a cartilage breaching technique consisting of cresentic medial skin and cartilage excision along the entire vertical length and the antihelical fold. Parallel antihelical incision held together with permanent sutures was first described in 1952 in an attempt for softening the external ear contour and producing conical antihelical tube. This technique was later refined by Converse et al. [8] and further elaborated by others [9,10]. A well-known suture technique with open approach was described by Mustarde to create the anti-helical fold [11]. The open approach techniques have a potential of leading to complications such as keloid formation, bleeding, a visible scar and infection because of the skin incision [12]. To prevent these complications and to reduce the need of ear dressings incisionless otoplasty techniques were developed. Fritsch described an incisionless technique by placing the Mustarde sutures to create the missing antihelical curve with permanent subcutaneous sutures [13]. In recent years, incisionless suture techniques have been more common for correction of prominent ears. In the present study, we applied two incisionless suture techniques for otoplasty: Haytoglu et al.’s modification of incisionless otoplasty technique [14] and Fritsch’s incisionless otoplasty technique [13]. For comparison of two methods, auriculocephalic distances were measured; and also VAS results were asked for patient satisfaction. Moreover, global aesthetic improvement scale (GAIS) was rated by an independent, non-participating plastic surgeon. 2. Materials and methods This prospective study was conducted in Adana Numune Training and Research Hospital between November 2011 to February 2014 according to the principles of the Helsinki Declaration [15]. Ethics Committee approval of Adana Numune Training and Research Hospital was also taken. Patients were included in the study after signing informed consent by their parents. 2.1. Subjects In total, 60 patients (26 female and 34 male) with prominent ears were included in the study. As incisionless otoplasty is effective in ears with soft cartilages, the patients under 18 years old were participated in this study. Sixteen male and 14 female patients were included in Group 1, and 18 male and 12 female patients were included in Group 2. Patients with psychiatric diseases, mental retardation, a previous otoplasty history, and craniofacial anomalies were excluded. The patients were randomly divided into two groups. In Group 1, 55 ears of 30 patients (25 bilateral and 5 unilateral) were operated with Haytoglu et al.’s modification of incisionless otoplasty technique [14]. In Group 2, 57 ears of 30 patients (27 bilateral and 3 unilateral) were operated with Fritsch’s incisionless otoplasty technique [13]. Surgical procedures were performed by the first author (S.H.). In both groups, recurrence was observed in 3 ears; and corrected again using first applied techniques.
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Fig. 1. Scoring the cartilage.
To weaken the cartilage, a 21-ga needle was used by creating a new curve to its tip (Fig. 1). 1. For Group 1, Haytoglu et al.’s modification of incisionless otoplasty technique [14] was performed (Figs. 2–4). After scoring the cartilage, the next step was placing the sutures. First, the needle enters the skin at a 908 angle from the posterior surface of the auricle to hide the suture knot behind the ear at the end of the operation. The suture penetrates the full thickness of the cartilage and exits from the skin in front of the auricle. The points where the sutures penetrate the cartilage are symmetrically above and below the desired new anti-helical curve. Also, the median point of the two needle holes is intended to be the peak point of the new anti-helical curve. Second, the needle reenters from the exact exit hole and it rises upwards, in front of the cartilage subperichondrially, and exits symmetrically from above the hole to the new anti-helical curve. Third, the needle reenters from the exact exit hole to penetrate the full thickness of the cartilage towards the posterior surface of the auricle to exit the skin. Fourth, the needle reenters the skin, at the posterior of the cartilage subperichondrially, leading downward, to the original first entry hole to exit. At this point, the suture is knotted and tightened. The number of sutures placed was mostly 2. The third suture was rarely required. 2. For Group 2, Fritsch’s incisionless otoplasty technique [13] were performed (Fig. 5). The next step after scoring the cartilage was to create the suture loops with two short and two long limbs. For this purpose, the needle enters and exits the skin from the
2.2. Surgical procedures Under general anesthesia, the auriculocephalic distances were measured and recorded at three levels. The measurements were made along a hypothetical plane drawn from the lateral helical margin to the scalp. The measurements were made from level 1 (the most superior point of the auricle), level 2 (midpoint of the auricle) and level 3 (the level of the lobule). After determining the location of the sutures, the next step was scoring the cartilage.
Fig. 2. The suture positions of Haytoglu et al.’s modification of incisionless otoplasty technique [14]. Dotted lines are in front of the cartilage, solid lines are in the rear of the cartilage.
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Fig. 3. (a) The determination of the suture locations, (b) the tip of the 21-ga needle was reshaped, (c) 21-Gauge needle created a new curve to its tip was used for scoring the cartilage both longitudinally and horizontally, (d) to hide the knots, the suture settling was first started in the rear of the auricle. The needle enters the skin with a 908 angle and penetrates full thickness cartilage to exit from the skin in front of the auricle.
posterior surface of the auricle to create the first short limb. The needle penetrates the full-thickness cartilage, but stays below the anterior skin. The needle re-enters from its exit hole, and rises upward to the point where the second short limb will take place. The needle then re-enters from its second exit hole to create the second short limb. For the second long limb, the needle enters from its third exit hole through the original entry point of the suture loop. At this point, the suture is knotted and tightened. In most of the ears, two suture loops were enough to create the intended antihelical curve, but the third suture was rarely required. 3. Follow-up: After these sutures, the measurements are taken again at levels 1, 2, and 3. Patients do not need an ear dressing after the operation. If the patient is young enough that is hard to prevent him/her from touching the operated ear, an ear dressing can be placed for just the first day after the surgery. Patients are followed for a minimum of 6 months, visiting the clinic at the first and sixth months after the surgery to repeat the measurements. 2.3. Method 1. To evaluate prominent ear deformity: Auriculocephalic distances were measured at three levels pre-operatively (preop), at the end of the operation (PO0-day), 1st month (PO1-Mo)and 6th month (PO6-Mo) after the surgery, in both groups. These levels were level 1 (the most superior point of the auricle), level 2 (the midpoint of the auricle) and level 3 (the level of the lobule). 2. Visual analogue scale (VAS): Before surgery and 6 months after the operation, patient satisfaction was measured using a VAS on 0 to 100 scales. For the children below than 12 year-old, the scoring was performed by their parents. 3. Global aesthetic improvement scale (GAIS): The patients were evaluated by an independent, non-participating plastic surgeon. For this purpose, the patients’ medical photos taken before the
operation were compared with the patients at 6 months after the surgery. The patients were rated as ‘‘improved’’, ‘‘no change’’ or ‘‘worse’’. 2.4. Statistical analysis All study data were evaluated using the ‘‘statistical packages for social science’’ (SPSS) 16.0 software. Chi-Square Test, Mann Whitney U test and Wilcoxon Signed Ranks Test were used for analysis. A value of p < 0.05 was considered statistically significant. 3. Results Operation time was 15.9 5.6 min in Group 1 and 19 4.7 min in Group 2. Hematoma, infection, bleeding, keloid scar formation, sharp edges or irregularities of the cartilage were not observed in any patient in any group. In Group 1, 114 sutures were applied, in Group 2, 118 sutures were applied. VAS results and auriculocephalic distances in levels 1–3 of Groups 1 and 2 were shown in Table 1, Figs. 6 and 7. No statistically significant difference was observed between VAS results of groups at preop and PO6Mo separately (p > 0.05). No statistically significant difference was observed between auriculocephalic distances at levels 1–3 of groups in preop, PO0-day, PO1-Mo and PO6-Mo separately (p > 0.05). In each of Groups 1 and 2; pairwise comparisons for auriculocephalic distances at levels 1–3 were shown on Table 2. In both groups, at each of the levels 1–3, postoperative auriculocephalic distances were significantly lower than preoperative periods (p < 0.05). Differences of auriculocephalic distances between preoperative and 6 months after surgery were shown in Table 3. In Group 1, difference in auriculocephalic distances (preop values-PO6-Mo values) of levels 1–3 were 12.0, 14.0 and 14.0 mm (median), respectively. In group 2, difference in auriculocephalic distances (preop values-PO6-Mo values) of levels 1–3 were 13.0, 13.0 and
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Fig. 4. (a) The needle enters from its exit hole, and it rises up to its second exit hole, (b) the needle reenters from the second exit hole with a 908 angle and penetrates the full thickness cartilage towards the posterior surface of the auricle, (c) the needle reenters from the exit hole in the posterior of the auricle, and it leads downward to its first original entry hole, (d) the sutures are knotted and tightened, and the knots are buried under the skin in the posterior of the auricle.
13.0 mm (median), respectively. There was no significant difference between Groups 1 and 2 at levels 1–3 (p > 0.05). The GAIS was performed by an independent non-participating plastic surgeon who rated the patients as 92.9% ‘‘improved’’ and 7.1% ‘‘no change’’ in Group 1; as 94.6% ‘‘improved’’ and 5.4% ‘‘no change’’ in Group 2. No subject was rated as ‘worse’ in both groups. No statistically significant difference was observed between GAIS values of the groups 1 and 2 by Chi-square test (Fisher’s exact test) (p > 0.05).
Fig. 5. The suture positions of Fritsch’s incisionless otoplasty technique [13]. Dotted lines are in front of the cartilage, solid lines are in the rear of the cartilage.
Suture extrusion was detected in 14.03% of Group 1 and 16.1% of Group 2. There was no significant difference between suture extrusion values of Groups 1 and 2 by Chi-square test (X2 = 0.06, p = 0.798). 4. Discussion Prominent ear is characterized by an increase in the cephaloauricular angle, which occurs because of an immature antihelical fold; an excessive conchal cartilage; or abnormal attachment of the auricle to the side of the head, alone or in combination. Otoplasty techniques can be divided into two groups: the cartilage-incision and the suture-placement procedures [16]. These techniques focus on creating a new antihelical fold, reducing the scaphomastoid angle and trimming the concha [16]. In the 1960s, Mustarde` announced a procedure with remodeling of the auricular cartilage by using mattress sutures. However, this procedure had a 7% relapse rate if the cartilage was too weak, especially if the tissue was thick. This method also includes no change in the conchal cartilage, so the scaphomastoid angle remained un-changed [17]. Another method for correcting the antihelical fold was described with a cartilage cutting and suturing. Several fullthickness cuts through the cartilage are carried out in the scaphoid fossa. The problems associated with this method the sharp cartilaginous ridges that can be seen through the thin anterior skin [18–20]. When methods of Stenstro¨m and Mustarde` are combined, slowly absorbed sutures can be used because the function of the sutures ends in a few weeks with the development
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Table 1 VAS results and auriculocephalic distances in levels 1–3 of groups. Group 1
Age VAS
Suture levels Level 1
Level 2
Level 3
*
Group 2
p*
z
Mean
Median
Minimum
Maximum
Mean
Median
Minimum
Maximum
Pre-op PO6mo
7.8 23.7 91.3
6.5 25.0 92.5
5.0 10.0 70.0
16.0 40.0 100.0
8.7 25.3 91.7
7.0 25.0 95.0
5.0 10.0 65.0
16.0 40.0 100.0
1.4 0.65 0.58
0.145 0.511 0.556
Pre-op PO0-day PO1-mo PO6mo Pre-op PO0-day PO1-mo PO6mo Pre-op PO0-day PO1-mo PO6mo
25.8 11.5 12.4 13.5 31.7 16.2 17.1 18.4 37.4 21.4 22.4 23.6
26.0 11.0 12.0 13.0 32.0 16.0 17.0 18.0 38.0 21.0 22.0 23.5
22.0 10.0 10.0 11.0 28.0 15.0 15.0 15.0 32.0 20.0 20.0 21.0
35.0 15.0 18.0 23.0 40.0 20.0 23.0 29.0 44.0 28.0 29.0 32.0
26.0 11.1 12.2 13.6 31.6 16.1 17.2 18.8 37.0 21.4 22.5 24.0
26.0 11.0 12.0 13.0 32.0 16.0 17.0 18.0 37.0 21.0 22.0 24.0
22.0 10.0 11.0 11.0 28.0 15.0 15.0 15.0 32.0 20.0 20.0 21.0
28.0 12.0 19.0 25.0 35.0 17.0 23.0 29.0 41.0 23.0 29.0 35.0
1.3 1.5 0.56 0.29 0.12 0.48 0.61 1.18 0.66 1.02 1.02 1.12
0.183 0.122 0.583 0.765 0.908 0.625 0.542 0.235 0.507 0.306 0.307 0.261
p value shows the results of the Mann–Whitney U test.
Fig. 6. Auriculocephalic distance at levels 1–3 of Group 1.
Fig. 7. Auriculocephalic distance at levels 1–3 of Group 2.
of fibrosis [21,22]. In the light of these studies, the incisionless otoplasty techniques were developed to settle the sutures with no need of incision to prevent the complications cause by the skin incision.
In the present study, we compared the results of two incisionless otoplasty techniques, namely Haytoglu et al.’s modification of incisionless otoplasty technique [14] and Fritsch’s incisionless otoplasty technique [13]. For comparison of two
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Table 2 The results of pairwise comparisons in each of the Group 1 and 2. Group 1
Group 2
z 0-day
p
*
p*
z
Level 1
Preop–PO Preop–PO1-mo Preop–PO6-mo PO0-day–PO1-mo PO0-day–PO6-mo PO1-mo–PO6-mo
6.6 6.5 6.5 5.1 6.2 6.3
0.0001 0.0001 0.0001 0.0001 0.0001 0.0001
6.6 6.5 6.5 5.2 6.2 6.4
0.0001 0.0001 0.0001 0.0001 0.0001 0.0001
Level 2
Preop–PO0-day Preop–PO1-mo Preop–PO6-mo PO0-day–PO1-mo PO0-day–PO6-mo PO1-mo–PO6-mo
6.55 6.53 6.52 5.15 6.25 6.36
0.0001 0.0001 0.0001 0.0001 0.0001 0.0001
6.59 6.53 6.53 5.59 6.4 6.51
0.0001 0.0001 0.0001 0.0001 0.0001 0.0001
Level 3
Preop–PO0-day Preop–PO1-mo Preop–PO6-mo PO0-day–PO1-mo PO0-day–PO6-mo PO1-mo–PO6-mo
6.52 6.52 6.52 5.28 6.14 5.86
0.0001 0.0001 0.0001 0.0001 0.0001 0.0001
6.54 6.53 6.53 5.37 6.1 6.04
0.0001 0.0001 0.0001 0.0001 0.0001 0.0001
*
p value shows the results of Wilcoxon signed ranks test.
methods, auriculocephalic distances were measured; and also VAS results were asked for patient satisfaction. Moreover, global aesthetic improvement scale (GAIS) was rated by an independent, non-participating plastic surgeon. The major difference of the two types of incisionless otoplasty subjected to this study is the sutures placed as a loop in Fritsch’s incisionless otoplasty technique. This suture loop has two short limbs buried under the skin in front of the auricle, and two long limbs buried under the skin in the rear of the auricle. In Haytoglu et al.’s modification of incisionless otoplasty technique [14], the sutures have just two long limbs, buried under the skin one of the long limbs in front of the auricle and one in the rear of the auricle. And the first step of the operations is scoring the cartilage. The Fritsch’s incisionless otoplasty technique includes scoring the cartilage longitudinally, Haytoglu et al.’s modification of incisionless otoplasty technique includes scoring the cartilage both longitudinally and horizontally. Operation time was 15.9 5.6 min in Group 1 (Haytoglu et al.’s) and 19 4.7 min in Group 2 (Fritsch). Although both techniques are not time-consuming, the reason of the shorter time in Group 1 may be the shorter pathway of the sutures and the easier settling. In Group 1, 114 sutures were applied, in Group 2, 118 sutures were applied. In the literature, the suture extrusion rate is between 0% and 22.2% [12,23]. Suture extrusion was detected in 14.03% of Group 1 and 16.1% of Group 2. This may be related to the higher angulations and longer pathway of sutures in Group 2. Two sutures were settled in most of the patients subjected to this study, the third suture was used when there is a need to shape the new anti-helical fold. The reason of two sutures used for most of the patients may be the groups include just the pediatric patients, and their auricular cartilages are softer when compared by the adults. To prevent suture extrusion, the needle must reenter from the exact exit hole with a 908 angle, and the knots must be precisely buried under the skin. We
used a hook to hide the knots under the skin, which is more suitable to bury in the rear of the auricle. To weaken the cartilage, scoring performed for all patients in both groups. Rauing described a sutureless technique, a diamond rasp was used to weaken the cartilage, and he used a compressive ear dressing for 7 days, and after removing the dressing, a fixation with an adhesive strip was used for 6 weeks to protect the desired new antihelical shape of the cartilage [24]. We performed scoring using a 21-gauge needle with reshaping its tip, to weaken the auricular cartilage to reshape the antihelix easier and to prevent the need for suture tightness to fix the new antihelix. White braided polyester sutures were used, to prevent the visibility of the sutures especially in patients with light-skinned. In both techniques, there was no significant difference in patient satisfaction at 6th months after the operation which was measured using a VAS on 0 to 100 scales. GAIS values were improved (92.9%) and no-change (7.1%) in Group 1; and improved (94.6%) and no-change (5.4%) in Group 2. There was no significant difference between GAIS values of the groups 1 and 2. In previous publications the satisfaction rates were higher in patients than in surgeons, but in our study the satisfaction rates are very close together in both groups [25,26]. In both groups, a slight rise was observed in the auriculocephalic distances. No statistically significant difference was observed between auriculocephalic distances at levels 1–3 of groups in preop, PO0-day, PO1-Mo and PO6-Mo separately. Similarly, difference in auriculocephalic distances (preop values-PO6-Mo values) was not detected as significant in groups 1 and 2 at three levels. The complication rates are between 0% and 47.3% for otoplasty in the literature [12]. No hematoma or infection was observed in any group. Bleeding, keloid scar formation, sharp edges or irregularities of the cartilage are not expected complications in incisionless otoplasty and were not observed in any patient in any group.
Table 3 Difference of auriculocephalic distances between preoperative and post-operative 6-month periods of groups. Group 1
Difference between Pre-op and PO6-mo
*
Level 1 Level 2 Level 3
p value shows the results of Mann–Whitney U test.
Group 2
p*
z
Mean
Median
Minimum
Maximum
Mean
Median
Minimum
Maximum
12.25 13.34 13.77
12.00 14.00 14.00
4.00 3.00 4.00
19.00 19.00 20.00
12.34 12.79 13.04
13.00 13.00 13.00
2.00 3.00 3.00
16.00 18.00 19.00
0.952 1.034 1.419
0.341 0.301 0.156
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In the literature, the recurrence rate is between 0% and 12% [12,23]. In both groups, recurrence was observed in 3 ears (group 1 5.4% and group 2 5.2%); and corrected again using first applied technique. These patients were followed up for 6 months after surgery, and no recurrence was observed. Both, Haytoglu et al.’s and Fritsch techniques are incisionless otoplasty techniques. According to our results, comparison of these techniques showed that patient satisfaction was also good in both. Operation time was a little shorter in Haytoglu’s technique. The suture extrusion rates were lower in Haytoglu’s technique. Auriculocephalic distances decreased postoperatively in both groups, but this slight rise did not cause any recurrence or patient dissatisfaction. GAIS and VAS values improved in both techniques. 5. Conclusion In the light of our study, Haytoglu et al.’s modification of incisionless otoplasty technique has the comparable rates of efficacy, complications, recurrence and patient satisfaction as Fritsch otoplasty technique. Due to the similar results such as low complication rates, low recurrence risks, high patient satisfaction, no need of prolonged ear dressing after surgery, no need of long operation periods, Haytoglu et al.’s and Fritsch’s incisionless otoplasty techniques are good options in the treatment of prominent ears, especially in pediatric patients with isolated inadequate development of antihelical ridge, and with soft auricular cartilage. Conflict of interest The authors declare that there is no conflict of interest. References [1] D.C. Baker, J.M. Converse, Correction of protruding ears: a 20-year retrospective, Aesthetic Plast. Surg. 3 (1) (1979) 29–39. [2] F.C. Macgregor, Ear deformities: social and psychological implications, Clin. Plast. Surg. 5 (1978) 347–350.
[3] B. Balogh, H. Millesi, Are growth alterations a consequence of surgery for prominent ears? Plast. Reconstr. Surg. 89 (1992) 623–630. [4] A.J. Maniglia, J.V. Maniglia, Congenital lop ear deformity, Otolaryngol. Clin. North Am. 14 (1981) 83–93. [5] F.D. Burstein, Cartilage-sparing complete otoplasty technique: a 10-year experience in 100 patients, J. Craniofac. Surg. 14 (4) (2003) 521–525. [6] E.T. Ely, An operation for prominence of the auricle, Arch. Otolaryngol. 10 (1881) 97. [7] W.H. Luckett, A new operation for prominent ears based on the anatomy of the deformity, Surg. Gynecol. Obstet. 10 (1910) 635–637. [8] J. Converse, A. Nigro, F. Wilson, N. Johnson, A technique for surgical correction of lop ear, Plast. Reconstr. Surg. 15 (1955) 411–418. [9] J.M. Converse, D. Wood-Smith, Technical details in the surgical correction of the lop ear deformity, Plast. Reconstr. Surg. 31 (1963) 118–128. [10] D. Wood-Smith, J.M. Converse, The lop ear deformity, Surg. Clin. North Am. 51 (1971) 417–427. [11] J.C. Mustarde´, The treatment of prominent ears by buried mattress sutures: a tenyear survey, Plast. Reconstr. Surg. 39 (1967) 382–386. [12] G.C. Limandjaja, C.C. Breugem, A.B. Mink van der Molen, M. Kon, Complications of otoplasty: a literature review, J. Plast. Reconstr. Aesthetic Surg. 62 (2009) 19–27. [13] M.H. Fritsch, Incisionless otoplasty, Otolaryngol. Clin. North Am. 42 (6) (2009) 1199–1208. [14] S. Haytoglu, T.G. Haytoglu, I. Yildirim, O.K. Arikan, A modification of incisionless otoplasty for correcting the prominent ear deformity, Eur. Arch. Otrhinolaryngol. (Oct 14) (2014), http://dx.doi.org/10.1007/s00405-014-3329-3 (Epub ahead of print). [15] 52nd WMA General Assembly, World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects, JAMA 284 (2000) 3043–3049. [16] N. Sivrioglu, S. Irkoren, B. Aksoy, E. Copcu, Chong-Chet anterior scoring technique for the correction of prominent ears: results in 30 patients, Mod. Plast. Surg. 2 (2012) 39–42. [17] J.C. Mustarde, The correction of prominent ears using simple mattress sutures, Br. J. Plast. Surg. 16 (1963) 170–178. [18] F. Peker, B. Celikoz, Otoplasty: anterior scoring and posterior rolling techniques in adults, Aesthetic Plast. Surg. 26 (4) (2002) 267–273. [19] S.J. Stenstrom, A natural technique for correction of congenitally prominent ears, Plast. Reconstr. Surg. 32 (1963) 509–518. [20] P.A. Adamson, Complications of otoplasty, Ear Nose Throat J. 64 (12) (1985) 668–674. [21] J.C. Mustarde, Correction of prominent ears using buried mattress sutures, Clin. Plast. Surg. 5 (3) (1978) 459–464. [22] S.J. Stenstro¨m, A simple operation for prominent ears, Acta Otolaryngol. 224 (1966) 393. [23] H. Weerda, R. Siegert, Complications in otoplastic surgery and their treatment, Facial Plast. Surg. 10 (1994) 287–297. [24] H. Raunig, Antihelix plasty without modeling sutures, Arch. Facial Plast. Surg. 7 (2005) 334–341. [25] S.D. Richards, A. Jebreel, R. Capper, Otoplasty: a review of the surgical technique, Clin. Otolaryngol. 30 (2005) 2–8. [26] N.E. Nachlas, Otoplasty, in: ID Papel (Ed.), Facial Plastic & Reconstructive Surgery, second ed., Thieme, New York, NY, 2002, pp. 309–321.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Comparison of two incisionless otoplasty techniques for prominent ears in children Suheyl Haytoglu a, Tahir Gokhan Haytoglu b, Nuray Bayar Muluk c,*, Gokhan Kuran a, Osman Kursat Arikan a a b c
Adana Numune Training and Research Hospital, ENT Clinics, Adana, Turkey Istanbul Training and Research Hospital, Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul, Turkey Kırıkkale University, Faculty of Medicine, ENT Department, Kırıkkale, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 November 2014 Received in revised form 10 January 2015 Accepted 13 January 2015 Available online 20 January 2015
Objectives: In the present study, we applied two incisionless suture techniques for otoplasty: Haytoglu et al.’s modification of incisionless otoplasty technique and Fritsch’s incisionless otoplasty technique for correction of prominent ears. Methods: In this prospective study, 60 patients with prominent ears were included in the study. In Group 1, 55 ears of 30 patients (25 bilateral and 5 unilateral) were operated with Haytoglu et al.’s modification of incisionless otoplasty technique. In Group 2, 57 ears of 30 patients (27 bilateral and 3 unilateral) were operated with Fritsch’s incisionless otoplasty technique. For comparison of two methods, auriculocephalic distances were measured at three levels which were level 1 (the most superior point of the auricle), level 2 (the midpoint of the auricle) and level 3 (level of the lobule) pre-operatively (preop); and measurements were repeated at the end of the surgery (PO0-day), 1st month (PO1-Mo) and 6th month (PO6-Mo) after the surgery, in both groups. Patient satisfaction was evaluated using a visual analog scale (VAS). Moreover, Global Aesthetic Improvement Scale (GAIS) was rated by an independent, nonparticipating plastic surgeon at 6 months after the surgery. Results: Operation time was 15.9 5.6 min in Group 1 (Haytoglu et al.’s) and 19 4.7 min in Group 2 (Fritsch). Hematoma, infection, bleeding, keloid scar formation, sharp edges or irregularities of the cartilage were not observed in any group. Suture extrusion was detected in 14.03% of Group 1 and 16.1% of Group 2. No statistically significant difference was observed between auriculocephalic distances at levels 1–3 of groups at preop, PO0-day, PO1-Mo and PO6-Mo separately. Similarly, difference in auriculocephalic distances (preop values-PO6-Mo values) was not detected as statistically significant in Groups 1 and 2 at three levels. In both techniques, No statistically significant difference was observed in patient satisfaction at 6th months after the operation which was measured using Visual Analogue Scale (VAS) on 0 to 100 scales. According to GAIS, the patients were rated as 92.9% ‘‘improved’’ and 7.1% ‘‘no change’’ in Group 1; as 94.6% ‘‘improved’’ and 5.4% ‘‘no change’’ in Group 2. Conclusions: Due to the similar results, Haytoglu et al.’s and Fritsch’s incisionless otoplasty techniques are good options in the treatment of prominent ears, especially in pediatric patients with isolated inadequate development of antihelical ridge, and with soft auricular cartilage. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Incisionless otoplasty Prominent ears Visual analogue scale (VAS) Global aesthetic improvement scale (GAIS) Auriculocephalic distance
1. Introduction Prominent ears are the most common congenital deformity in the head and neck region. Incidence for Caucasians are described
* Corresponding author. Tel.: +90 312 4964073/+90 532 7182441; fax: +90 312 4964073. E-mail addresses: [email protected], [email protected] (N. Bayar Muluk). http://dx.doi.org/10.1016/j.ijporl.2015.01.014 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
about 5% and for microtia, it is 0.01% [1]. Otoplasty is now considered as a procedure with both aesthetic and functional purposes because it can lead a psychological trauma, especially in children being ridiculed by their peers [2]. By the age of 5, the development of the auricle nearly completed, it is an appropriate time to correct the prominent ear before the child start school [3,4]. Otoplasty is one of the most frequent aesthetic surgical procedures in children and adolescents. Several techniques can give satisfactory results, but few address all the components of the prominent ear deformity [5].
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The first case for correction of congenital prominent ear had been published in 1881 [6]. The concept of restoration of the antihelical fold for prominent ear deformity was the first introduced by Luckett [7] who resorted to a cartilage breaching technique consisting of cresentic medial skin and cartilage excision along the entire vertical length and the antihelical fold. Parallel antihelical incision held together with permanent sutures was first described in 1952 in an attempt for softening the external ear contour and producing conical antihelical tube. This technique was later refined by Converse et al. [8] and further elaborated by others [9,10]. A well-known suture technique with open approach was described by Mustarde to create the anti-helical fold [11]. The open approach techniques have a potential of leading to complications such as keloid formation, bleeding, a visible scar and infection because of the skin incision [12]. To prevent these complications and to reduce the need of ear dressings incisionless otoplasty techniques were developed. Fritsch described an incisionless technique by placing the Mustarde sutures to create the missing antihelical curve with permanent subcutaneous sutures [13]. In recent years, incisionless suture techniques have been more common for correction of prominent ears. In the present study, we applied two incisionless suture techniques for otoplasty: Haytoglu et al.’s modification of incisionless otoplasty technique [14] and Fritsch’s incisionless otoplasty technique [13]. For comparison of two methods, auriculocephalic distances were measured; and also VAS results were asked for patient satisfaction. Moreover, global aesthetic improvement scale (GAIS) was rated by an independent, non-participating plastic surgeon. 2. Materials and methods This prospective study was conducted in Adana Numune Training and Research Hospital between November 2011 to February 2014 according to the principles of the Helsinki Declaration [15]. Ethics Committee approval of Adana Numune Training and Research Hospital was also taken. Patients were included in the study after signing informed consent by their parents. 2.1. Subjects In total, 60 patients (26 female and 34 male) with prominent ears were included in the study. As incisionless otoplasty is effective in ears with soft cartilages, the patients under 18 years old were participated in this study. Sixteen male and 14 female patients were included in Group 1, and 18 male and 12 female patients were included in Group 2. Patients with psychiatric diseases, mental retardation, a previous otoplasty history, and craniofacial anomalies were excluded. The patients were randomly divided into two groups. In Group 1, 55 ears of 30 patients (25 bilateral and 5 unilateral) were operated with Haytoglu et al.’s modification of incisionless otoplasty technique [14]. In Group 2, 57 ears of 30 patients (27 bilateral and 3 unilateral) were operated with Fritsch’s incisionless otoplasty technique [13]. Surgical procedures were performed by the first author (S.H.). In both groups, recurrence was observed in 3 ears; and corrected again using first applied techniques.
505
Fig. 1. Scoring the cartilage.
To weaken the cartilage, a 21-ga needle was used by creating a new curve to its tip (Fig. 1). 1. For Group 1, Haytoglu et al.’s modification of incisionless otoplasty technique [14] was performed (Figs. 2–4). After scoring the cartilage, the next step was placing the sutures. First, the needle enters the skin at a 908 angle from the posterior surface of the auricle to hide the suture knot behind the ear at the end of the operation. The suture penetrates the full thickness of the cartilage and exits from the skin in front of the auricle. The points where the sutures penetrate the cartilage are symmetrically above and below the desired new anti-helical curve. Also, the median point of the two needle holes is intended to be the peak point of the new anti-helical curve. Second, the needle reenters from the exact exit hole and it rises upwards, in front of the cartilage subperichondrially, and exits symmetrically from above the hole to the new anti-helical curve. Third, the needle reenters from the exact exit hole to penetrate the full thickness of the cartilage towards the posterior surface of the auricle to exit the skin. Fourth, the needle reenters the skin, at the posterior of the cartilage subperichondrially, leading downward, to the original first entry hole to exit. At this point, the suture is knotted and tightened. The number of sutures placed was mostly 2. The third suture was rarely required. 2. For Group 2, Fritsch’s incisionless otoplasty technique [13] were performed (Fig. 5). The next step after scoring the cartilage was to create the suture loops with two short and two long limbs. For this purpose, the needle enters and exits the skin from the
2.2. Surgical procedures Under general anesthesia, the auriculocephalic distances were measured and recorded at three levels. The measurements were made along a hypothetical plane drawn from the lateral helical margin to the scalp. The measurements were made from level 1 (the most superior point of the auricle), level 2 (midpoint of the auricle) and level 3 (the level of the lobule). After determining the location of the sutures, the next step was scoring the cartilage.
Fig. 2. The suture positions of Haytoglu et al.’s modification of incisionless otoplasty technique [14]. Dotted lines are in front of the cartilage, solid lines are in the rear of the cartilage.
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Fig. 3. (a) The determination of the suture locations, (b) the tip of the 21-ga needle was reshaped, (c) 21-Gauge needle created a new curve to its tip was used for scoring the cartilage both longitudinally and horizontally, (d) to hide the knots, the suture settling was first started in the rear of the auricle. The needle enters the skin with a 908 angle and penetrates full thickness cartilage to exit from the skin in front of the auricle.
posterior surface of the auricle to create the first short limb. The needle penetrates the full-thickness cartilage, but stays below the anterior skin. The needle re-enters from its exit hole, and rises upward to the point where the second short limb will take place. The needle then re-enters from its second exit hole to create the second short limb. For the second long limb, the needle enters from its third exit hole through the original entry point of the suture loop. At this point, the suture is knotted and tightened. In most of the ears, two suture loops were enough to create the intended antihelical curve, but the third suture was rarely required. 3. Follow-up: After these sutures, the measurements are taken again at levels 1, 2, and 3. Patients do not need an ear dressing after the operation. If the patient is young enough that is hard to prevent him/her from touching the operated ear, an ear dressing can be placed for just the first day after the surgery. Patients are followed for a minimum of 6 months, visiting the clinic at the first and sixth months after the surgery to repeat the measurements. 2.3. Method 1. To evaluate prominent ear deformity: Auriculocephalic distances were measured at three levels pre-operatively (preop), at the end of the operation (PO0-day), 1st month (PO1-Mo)and 6th month (PO6-Mo) after the surgery, in both groups. These levels were level 1 (the most superior point of the auricle), level 2 (the midpoint of the auricle) and level 3 (the level of the lobule). 2. Visual analogue scale (VAS): Before surgery and 6 months after the operation, patient satisfaction was measured using a VAS on 0 to 100 scales. For the children below than 12 year-old, the scoring was performed by their parents. 3. Global aesthetic improvement scale (GAIS): The patients were evaluated by an independent, non-participating plastic surgeon. For this purpose, the patients’ medical photos taken before the
operation were compared with the patients at 6 months after the surgery. The patients were rated as ‘‘improved’’, ‘‘no change’’ or ‘‘worse’’. 2.4. Statistical analysis All study data were evaluated using the ‘‘statistical packages for social science’’ (SPSS) 16.0 software. Chi-Square Test, Mann Whitney U test and Wilcoxon Signed Ranks Test were used for analysis. A value of p < 0.05 was considered statistically significant. 3. Results Operation time was 15.9 5.6 min in Group 1 and 19 4.7 min in Group 2. Hematoma, infection, bleeding, keloid scar formation, sharp edges or irregularities of the cartilage were not observed in any patient in any group. In Group 1, 114 sutures were applied, in Group 2, 118 sutures were applied. VAS results and auriculocephalic distances in levels 1–3 of Groups 1 and 2 were shown in Table 1, Figs. 6 and 7. No statistically significant difference was observed between VAS results of groups at preop and PO6Mo separately (p > 0.05). No statistically significant difference was observed between auriculocephalic distances at levels 1–3 of groups in preop, PO0-day, PO1-Mo and PO6-Mo separately (p > 0.05). In each of Groups 1 and 2; pairwise comparisons for auriculocephalic distances at levels 1–3 were shown on Table 2. In both groups, at each of the levels 1–3, postoperative auriculocephalic distances were significantly lower than preoperative periods (p < 0.05). Differences of auriculocephalic distances between preoperative and 6 months after surgery were shown in Table 3. In Group 1, difference in auriculocephalic distances (preop values-PO6-Mo values) of levels 1–3 were 12.0, 14.0 and 14.0 mm (median), respectively. In group 2, difference in auriculocephalic distances (preop values-PO6-Mo values) of levels 1–3 were 13.0, 13.0 and
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Fig. 4. (a) The needle enters from its exit hole, and it rises up to its second exit hole, (b) the needle reenters from the second exit hole with a 908 angle and penetrates the full thickness cartilage towards the posterior surface of the auricle, (c) the needle reenters from the exit hole in the posterior of the auricle, and it leads downward to its first original entry hole, (d) the sutures are knotted and tightened, and the knots are buried under the skin in the posterior of the auricle.
13.0 mm (median), respectively. There was no significant difference between Groups 1 and 2 at levels 1–3 (p > 0.05). The GAIS was performed by an independent non-participating plastic surgeon who rated the patients as 92.9% ‘‘improved’’ and 7.1% ‘‘no change’’ in Group 1; as 94.6% ‘‘improved’’ and 5.4% ‘‘no change’’ in Group 2. No subject was rated as ‘worse’ in both groups. No statistically significant difference was observed between GAIS values of the groups 1 and 2 by Chi-square test (Fisher’s exact test) (p > 0.05).
Fig. 5. The suture positions of Fritsch’s incisionless otoplasty technique [13]. Dotted lines are in front of the cartilage, solid lines are in the rear of the cartilage.
Suture extrusion was detected in 14.03% of Group 1 and 16.1% of Group 2. There was no significant difference between suture extrusion values of Groups 1 and 2 by Chi-square test (X2 = 0.06, p = 0.798). 4. Discussion Prominent ear is characterized by an increase in the cephaloauricular angle, which occurs because of an immature antihelical fold; an excessive conchal cartilage; or abnormal attachment of the auricle to the side of the head, alone or in combination. Otoplasty techniques can be divided into two groups: the cartilage-incision and the suture-placement procedures [16]. These techniques focus on creating a new antihelical fold, reducing the scaphomastoid angle and trimming the concha [16]. In the 1960s, Mustarde` announced a procedure with remodeling of the auricular cartilage by using mattress sutures. However, this procedure had a 7% relapse rate if the cartilage was too weak, especially if the tissue was thick. This method also includes no change in the conchal cartilage, so the scaphomastoid angle remained un-changed [17]. Another method for correcting the antihelical fold was described with a cartilage cutting and suturing. Several fullthickness cuts through the cartilage are carried out in the scaphoid fossa. The problems associated with this method the sharp cartilaginous ridges that can be seen through the thin anterior skin [18–20]. When methods of Stenstro¨m and Mustarde` are combined, slowly absorbed sutures can be used because the function of the sutures ends in a few weeks with the development
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Table 1 VAS results and auriculocephalic distances in levels 1–3 of groups. Group 1
Age VAS
Suture levels Level 1
Level 2
Level 3
*
Group 2
p*
z
Mean
Median
Minimum
Maximum
Mean
Median
Minimum
Maximum
Pre-op PO6mo
7.8 23.7 91.3
6.5 25.0 92.5
5.0 10.0 70.0
16.0 40.0 100.0
8.7 25.3 91.7
7.0 25.0 95.0
5.0 10.0 65.0
16.0 40.0 100.0
1.4 0.65 0.58
0.145 0.511 0.556
Pre-op PO0-day PO1-mo PO6mo Pre-op PO0-day PO1-mo PO6mo Pre-op PO0-day PO1-mo PO6mo
25.8 11.5 12.4 13.5 31.7 16.2 17.1 18.4 37.4 21.4 22.4 23.6
26.0 11.0 12.0 13.0 32.0 16.0 17.0 18.0 38.0 21.0 22.0 23.5
22.0 10.0 10.0 11.0 28.0 15.0 15.0 15.0 32.0 20.0 20.0 21.0
35.0 15.0 18.0 23.0 40.0 20.0 23.0 29.0 44.0 28.0 29.0 32.0
26.0 11.1 12.2 13.6 31.6 16.1 17.2 18.8 37.0 21.4 22.5 24.0
26.0 11.0 12.0 13.0 32.0 16.0 17.0 18.0 37.0 21.0 22.0 24.0
22.0 10.0 11.0 11.0 28.0 15.0 15.0 15.0 32.0 20.0 20.0 21.0
28.0 12.0 19.0 25.0 35.0 17.0 23.0 29.0 41.0 23.0 29.0 35.0
1.3 1.5 0.56 0.29 0.12 0.48 0.61 1.18 0.66 1.02 1.02 1.12
0.183 0.122 0.583 0.765 0.908 0.625 0.542 0.235 0.507 0.306 0.307 0.261
p value shows the results of the Mann–Whitney U test.
Fig. 6. Auriculocephalic distance at levels 1–3 of Group 1.
Fig. 7. Auriculocephalic distance at levels 1–3 of Group 2.
of fibrosis [21,22]. In the light of these studies, the incisionless otoplasty techniques were developed to settle the sutures with no need of incision to prevent the complications cause by the skin incision.
In the present study, we compared the results of two incisionless otoplasty techniques, namely Haytoglu et al.’s modification of incisionless otoplasty technique [14] and Fritsch’s incisionless otoplasty technique [13]. For comparison of two
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Table 2 The results of pairwise comparisons in each of the Group 1 and 2. Group 1
Group 2
z 0-day
p
*
p*
z
Level 1
Preop–PO Preop–PO1-mo Preop–PO6-mo PO0-day–PO1-mo PO0-day–PO6-mo PO1-mo–PO6-mo
6.6 6.5 6.5 5.1 6.2 6.3
0.0001 0.0001 0.0001 0.0001 0.0001 0.0001
6.6 6.5 6.5 5.2 6.2 6.4
0.0001 0.0001 0.0001 0.0001 0.0001 0.0001
Level 2
Preop–PO0-day Preop–PO1-mo Preop–PO6-mo PO0-day–PO1-mo PO0-day–PO6-mo PO1-mo–PO6-mo
6.55 6.53 6.52 5.15 6.25 6.36
0.0001 0.0001 0.0001 0.0001 0.0001 0.0001
6.59 6.53 6.53 5.59 6.4 6.51
0.0001 0.0001 0.0001 0.0001 0.0001 0.0001
Level 3
Preop–PO0-day Preop–PO1-mo Preop–PO6-mo PO0-day–PO1-mo PO0-day–PO6-mo PO1-mo–PO6-mo
6.52 6.52 6.52 5.28 6.14 5.86
0.0001 0.0001 0.0001 0.0001 0.0001 0.0001
6.54 6.53 6.53 5.37 6.1 6.04
0.0001 0.0001 0.0001 0.0001 0.0001 0.0001
*
p value shows the results of Wilcoxon signed ranks test.
methods, auriculocephalic distances were measured; and also VAS results were asked for patient satisfaction. Moreover, global aesthetic improvement scale (GAIS) was rated by an independent, non-participating plastic surgeon. The major difference of the two types of incisionless otoplasty subjected to this study is the sutures placed as a loop in Fritsch’s incisionless otoplasty technique. This suture loop has two short limbs buried under the skin in front of the auricle, and two long limbs buried under the skin in the rear of the auricle. In Haytoglu et al.’s modification of incisionless otoplasty technique [14], the sutures have just two long limbs, buried under the skin one of the long limbs in front of the auricle and one in the rear of the auricle. And the first step of the operations is scoring the cartilage. The Fritsch’s incisionless otoplasty technique includes scoring the cartilage longitudinally, Haytoglu et al.’s modification of incisionless otoplasty technique includes scoring the cartilage both longitudinally and horizontally. Operation time was 15.9 5.6 min in Group 1 (Haytoglu et al.’s) and 19 4.7 min in Group 2 (Fritsch). Although both techniques are not time-consuming, the reason of the shorter time in Group 1 may be the shorter pathway of the sutures and the easier settling. In Group 1, 114 sutures were applied, in Group 2, 118 sutures were applied. In the literature, the suture extrusion rate is between 0% and 22.2% [12,23]. Suture extrusion was detected in 14.03% of Group 1 and 16.1% of Group 2. This may be related to the higher angulations and longer pathway of sutures in Group 2. Two sutures were settled in most of the patients subjected to this study, the third suture was used when there is a need to shape the new anti-helical fold. The reason of two sutures used for most of the patients may be the groups include just the pediatric patients, and their auricular cartilages are softer when compared by the adults. To prevent suture extrusion, the needle must reenter from the exact exit hole with a 908 angle, and the knots must be precisely buried under the skin. We
used a hook to hide the knots under the skin, which is more suitable to bury in the rear of the auricle. To weaken the cartilage, scoring performed for all patients in both groups. Rauing described a sutureless technique, a diamond rasp was used to weaken the cartilage, and he used a compressive ear dressing for 7 days, and after removing the dressing, a fixation with an adhesive strip was used for 6 weeks to protect the desired new antihelical shape of the cartilage [24]. We performed scoring using a 21-gauge needle with reshaping its tip, to weaken the auricular cartilage to reshape the antihelix easier and to prevent the need for suture tightness to fix the new antihelix. White braided polyester sutures were used, to prevent the visibility of the sutures especially in patients with light-skinned. In both techniques, there was no significant difference in patient satisfaction at 6th months after the operation which was measured using a VAS on 0 to 100 scales. GAIS values were improved (92.9%) and no-change (7.1%) in Group 1; and improved (94.6%) and no-change (5.4%) in Group 2. There was no significant difference between GAIS values of the groups 1 and 2. In previous publications the satisfaction rates were higher in patients than in surgeons, but in our study the satisfaction rates are very close together in both groups [25,26]. In both groups, a slight rise was observed in the auriculocephalic distances. No statistically significant difference was observed between auriculocephalic distances at levels 1–3 of groups in preop, PO0-day, PO1-Mo and PO6-Mo separately. Similarly, difference in auriculocephalic distances (preop values-PO6-Mo values) was not detected as significant in groups 1 and 2 at three levels. The complication rates are between 0% and 47.3% for otoplasty in the literature [12]. No hematoma or infection was observed in any group. Bleeding, keloid scar formation, sharp edges or irregularities of the cartilage are not expected complications in incisionless otoplasty and were not observed in any patient in any group.
Table 3 Difference of auriculocephalic distances between preoperative and post-operative 6-month periods of groups. Group 1
Difference between Pre-op and PO6-mo
*
Level 1 Level 2 Level 3
p value shows the results of Mann–Whitney U test.
Group 2
p*
z
Mean
Median
Minimum
Maximum
Mean
Median
Minimum
Maximum
12.25 13.34 13.77
12.00 14.00 14.00
4.00 3.00 4.00
19.00 19.00 20.00
12.34 12.79 13.04
13.00 13.00 13.00
2.00 3.00 3.00
16.00 18.00 19.00
0.952 1.034 1.419
0.341 0.301 0.156
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In the literature, the recurrence rate is between 0% and 12% [12,23]. In both groups, recurrence was observed in 3 ears (group 1 5.4% and group 2 5.2%); and corrected again using first applied technique. These patients were followed up for 6 months after surgery, and no recurrence was observed. Both, Haytoglu et al.’s and Fritsch techniques are incisionless otoplasty techniques. According to our results, comparison of these techniques showed that patient satisfaction was also good in both. Operation time was a little shorter in Haytoglu’s technique. The suture extrusion rates were lower in Haytoglu’s technique. Auriculocephalic distances decreased postoperatively in both groups, but this slight rise did not cause any recurrence or patient dissatisfaction. GAIS and VAS values improved in both techniques. 5. Conclusion In the light of our study, Haytoglu et al.’s modification of incisionless otoplasty technique has the comparable rates of efficacy, complications, recurrence and patient satisfaction as Fritsch otoplasty technique. Due to the similar results such as low complication rates, low recurrence risks, high patient satisfaction, no need of prolonged ear dressing after surgery, no need of long operation periods, Haytoglu et al.’s and Fritsch’s incisionless otoplasty techniques are good options in the treatment of prominent ears, especially in pediatric patients with isolated inadequate development of antihelical ridge, and with soft auricular cartilage. Conflict of interest The authors declare that there is no conflict of interest. References [1] D.C. Baker, J.M. Converse, Correction of protruding ears: a 20-year retrospective, Aesthetic Plast. Surg. 3 (1) (1979) 29–39. [2] F.C. Macgregor, Ear deformities: social and psychological implications, Clin. Plast. Surg. 5 (1978) 347–350.
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