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The ‘WiFi’ otoplasty : Combined concentric posterior microchondrectomies and sutures for correction of prominent ears
Journal of Plastic, Reconstructive & Aesthetic Surgery (2018) 71, 900–905
The ‘WiFi’ otoplasty : Combined concentric posterior microchondrectomies and sutures for correction of prominent ears Benoit I.M.M. Hendrickx a,b, Moustapha Hamdi a, Assaf Zeltzer a, Andrew Greensmith b,* a b
Department of Plastic Surgery, University Hospital of Brussels (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium Melbourne Institute of Plastic Surgery, 253, Wattletree Road, Malvern, Victoria 3144, Australia
Authored by a member of EURAPS
Received 24 April 2017; accepted 21 January 2018
KEYWORDS Ear correction; Bat ear deformity; Cartilage shaping; Mustarde; Otoplasty; Prominent ears; Protruding ear
Summary Background: Prominent ears are by far the most common congenital ear deformity. Many techniques have been described using one or a combination of 3 basic methods: cartilage cutting, cartilage weakening and pure cartilage shaping techniques. The ideal otoplasty technique should yield a natural correction of the deformity, with low recurrence rates and with little risk of complications. Methods: A new cartilage shaping technique using closing wedge concentric microchondrectomies through an entirely posterior approach is presented. Between 2006 and 2017, 200 bilateral otoplasties using this ‘WiFi’ pattern technique were performed. This technique combined with Mustarde sutures is based on the excision of concentric partial thickness cartilage wedges designed in the pattern of the WiFi symbol. Results: There were no major complications such as anterior skin necrosis and no returns to theatre for infections or haematomas. 3 patients (1.5%) had complete recurrence of the deformity and 10 patients (5%) had to undergo a minor revision for recurrence at the upper pole. 5 patients have had exposure of the end of the permanent upper pole scapho-temporal suture more than 3 months after surgery requiring simple outpatient suture trimming/removal without any recurrence of results. Palpable or bridging sutures were present upon clinical examination in 10 patients (5%) but did not require revision surgery. Conclusions: Here, we describe a fast, safe and reliable technique for otoplasty with no need for extensive dissection, which is applicable to the full range of deformity. Crown Copyright © 2018 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved.
* Corresponding author. Melbourne Institute of Plastic Surgery, 253, Wattletree Road, Malvern, Victoria 3144, Australia. E-mail address: [email protected] (A. Greensmith). https://doi.org/10.1016/j.bjps.2018.01.030 1748-6815/Crown Copyright © 2018 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved.
‘WiFi’ otoplasty for correction of prominent ears
Introduction Prominent ears are the most common congenital deformity of the ear, affecting almost 5% of the population.1 The deformity results from two basic congenital deficiencies of the ear: an overdeveloped conchal bowl and/or an underdeveloped antihelical fold, resulting in the three commonly listed signs of prominent ears: conchal height excess, absence/ weakness of antihelical fold and a conchoscaphal angle greater than 90°.2 Frequently more than one of these deformities are present and any surgical technique used for correction of prominent ears should therefore be versatile enough to correct each aspect. The goals of the procedure have been described by McDowell in 19683 as 1) correction of the protruding upper third of the ear, 2) visible helix beyond the antihelical fold in frontal view, 3) a smooth and regular helical line, 4) no distortion of the postauricular sulcus, 5) no overcorrection and 6) symmetrical results with no more than 3 mm difference between both ears. Until now, hundreds of techniques have been described for correction of prominent ears. These vary from cartilagesparing techniques with only sutures, to scoring cartilage or cartilage cutting and excision techniques, and combinations of these. The ideal otoplasty technique should yield a natural result according to McDowell’s goals, with low recurrence rates and involve as little risk of anterior skin necrosis as possible. Here we present a new technique that uses a novel method of cartilage shaping supplemented with traditional mattress and conchamastoid sutures.
Patients and methods Patients Between 2006 and 2017, 200 patients underwent bilateral otoplasty by either the senior author (AG) at the Melbourne Institute of Plastic Surgery, Melbourne, Australia or by the junior author (BH) at the University hospital Brussels, Belgium. The average age of patients at the time of surgery was 11.8 years (range 5–36 years), the male to female ratio was 117/ 83. All patients were followed-up at 1 week, 6 weeks and 6 months postoperatively and then discharged unless otherwise indicated. The mean follow-up term was 6.45 months (range 1.5–24 months). Since only patients with bilateral prominent ears were included, all other congenital ear deformities such as cup ears or constricted ears were excluded. All operations were performed under general anaesthesia.
Operative technique First, the location of the desired antihelical fold extending into the superior crus is marked as a single line marking the peak of the fold and the borders of the fold with two dotted lines (Figure 1A). To assess the need for conchal bowl excision, we developed a meatal occlusion test. The effect of the conchamastoid sutures on the diameter of the external acoustic meatus is mimicked by manually pushing the concha backwards against the mastoid. If more than one third of the meatus is occluded by this manoeuvre, a conchal bowl reduction should be considered in place of conchamastoid
901 sutures to avoid meatal occlusion. The conchal bowl, antihelical fold, posterior surface and the mastoid region are infiltrated with 10 ml of ropivacaine 0.75% with adrenaline 1:200000 per side (in paediatric cases this dose is adjusted accordingly). A gentle hourglass shaped postauricular skin incision is designed to leave the scar in the postauricular sulcus. This skin can either be resected or de-epithelialized to serve as a posteriorly based flap to cover the knots of the sutures as previously described,4 or simply be excised. The postauricular skin is then lifted off the perichondrium in the subcutaneous plane with tenotomy scissors and diathermy, almost to the level of the helical rim. Posteriorly, 3 different pockets to expose mastoid or temporal fascia are dissected with tenotomy scissors spreading longitudinally to avoid damage to the posterior branch of the great auricular nerve: 2 towards the mastoid fascia superior and inferior to the auricularis posterior muscle and 1 more superiorly towards the temporal fascia (Figure 1B). Medially and laterally at three different locations along the marked desired antihelical fold, a 16-gauge straight Keith needle dipped in surgical ink is pierced through the anterior skin, to transpose the location and borders of the curvature of the desired antihelical fold to the exposed posterior cartilage of the ear. Within the boundary of these markings, 2–3 concentric grooves are made on the posterior surface of the ear in a pattern that resembles a ‘WiFi’ symbol (Figure 1C). These grooves are made with the tip of a 15-blade gouging perpendicular to the cutting edge of the blade and pushing side to side in gouging motion with light pressure, so that a small wedge is scooped out of the posterior cartilage surface as opposed to previously described techniques of posterior scoring. Care should be taken not to cut the entire thickness of cartilage as this will result in a visible sharp edge on the anterior surface of the ear and may excessively weaken the cartilage; the surgeon’s non-dominant index finger is therefore placed in the concha to better evaluate the depth of the wedge excisions. Cartilage is not excised in between the linear chondrectomies. When the wedge excision approaches the anterior perichondrium, the cartilage colour changes to a slightly darker colour (from white to grey) indicating the gouge is almost full thickness through cartilage at which point the carving is ceased. These 2–3 grooves/wedges in a concentric pattern are best described as closing wedge concentric microchondrectomies narrow at their greatest depth and widest at their most superficial aspect. It is imperative to avoid penetrating full thickness through cartilage at any point and the colour change to grey/white from white is an easy end point indicator even for a surgeon learning this method. Perichondrium is not removed on the posterior surface in order to preserve blood supply over this area and to lead to more efficient scarification to take over from the function of the sutures used to fold back the antihelix. Next, two to three Mustarde-type mattress 3/0 Ethibond or 3/0 Prolene (either is sufficient but must be on a taper needle to avoid the suture cutting through cartilage) are placed (Figure 1D) to fold back the antihelix. Subsequently, two conchamastoid sutures are placed superior and inferior to the auricularis posterior muscle (Figure 1E). Two sutures are preferable to avoid changing the axis of the ear if a single suture is used. Since the wedge microchondrectomies are not full thickness, cartilage weakening is reduced or
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Figure 1 By folding back the ear, the location of the desired new antihelical fold is determined and marked (A). 3 separate pockets are dissected in the postauricular sulcus, 2 towards the mastoid fascia superior and inferior to the auricularis posterior muscle and 1 more superiorly towards the temporal fascia (B). Concentric partial thickness wedge microchondrectomies are performed holding a 15-blade perpendicular to the cutting edge (C). Classic concha-scapha Mustarde-type sutures are placed to recreate the antihelical fold. The partial thickness microchondrectomies allow the cartilage to fold onto itself while maintaining a smooth anterior contour without irregularities (D). Conchamastoid sutures (E) and a superior scapho-temporal suture (F) finalize the setback procedure.
avoided, but these wedges will simply close as the Mustarde sutures are gently tightened. Care should be taken not to place these sutures too anteriorly, as this will shift the conchal bowl anteriorly and could possibly result in obliteration of the external acoustic meatus. We orientate the pass of these sutures vertically, to avoid blood vessels and nerves in that region. By slightly changing the position of these sutures, any desired change in rotation of the ear can be achieved. In patients with a deep conchal bowl and obliteration of the external acoustic meatus upon manual setback, a wedge resection of the conchal bowl is performed at this stage. To complete the recreation of the antihelical fold, two or three 4/0 clear nylon Mustarde sutures are placed according to the blue markings of the desired antihelical fold (a taper needle here would be desirable but is not yet commercially avail-
able on a clear permanent monofilament suture although we are currently developing this with a suture provider in Japan). To correct the superior pole of the ear, a single 4/0 clear nylon suture is placed from the anterosuperior scapha to the temporoparietal fascia in the third and superior-most posterior pocket (Figure 1F). This is called the “scaphotemporal” suture. After each bite through the scaphal or conchal cartilage, the anterior skin should be checked for possible dimpling or penetration. If the hourglass incision is kept as a de-epithelialized posteriorly based flap, it can be used to cover the knots and so to decrease palpability or protrusion of the sutures. It must be emphasized that the authors do not recommend any overcorrection since the technique is powerful and “what you see is what you get”. On rare occasions when a lobule is prominent, a standard fishtail
‘WiFi’ otoplasty for correction of prominent ears adjustment to the inferior skin incision is made and applied accordingly. The skin is closed with a running 4/0 Vicryl Rapide suture and a paraffin gauze with a Betadine gel soaked wool dressing is applied underneath a head bandage that is soft enough not to create any perfusion problems to the anterior skin of the ear. No packing is used in the conchal bowl to avoid nausea and in any case the anterior skin has not been undermined so packing is unnecessary. The entire surgical procedure takes no longer than 1 hour for both sides. The patients are instructed to keep their head elevated and to avoid external pressure on the ear. All patients are discharged the same day and returned 1 week later to remove the dressing. After this time, the ears are left open but patients are instructed to use a light head bandage (tubigrip, a girl’s headband or a beanie cap in boys) for 6 weeks at night while sleeping to avoid traumatizing the ears in the healing phase.
Results In total, 400 ears were operated on (200 bilateral otoplasties). There were no major complications and no returns to theatre for infections or haematomas. 10 patients (5%) had to undergo a minor revision with replacement of the superiormost suture (scapho-temporal suture) due to localized recurrence of the upper pole deformity. 3 patients (1.5%) had complete recurrence (2 unilaterally, 1 bilaterally). In 7 (3.5%) patients the sutures caused late problems more than 3 months post-surgery: in 4 patients (2%) one of the Ethibond conchamastoid sutures was palpable and in 3 patients (1.5%) the superior nylon stitch was visibly bridging. In all 7 cases, the problematic suture was removed, with no subsequent recurrence.
Discussion Generally, otoplasty techniques can be divided into 3 main categories: cartilage cutting, cartilage weakening and cartilage sparing/pure shaping. The principle of cutting the cartilage to recreate the antihelical fold was first introduced by Luckett.5 The initial cartilage cutting techniques however often resulted in sharp edges and therefore more recent modifications have focused on putting the incision away from the antihelical fold and use scoring techniques to soften the contour of the newly formed antihelical fold. Irregularities, sharp edges and overcorrection are however still quite common1 and these iatrogenic complications are often hard to correct in revision surgery. On the other hand, techniques keeping the cartilage completely intact (cartilage sparing/pure shaping techniques) rely entirely on sutures to plicate the cartilage to reposition the conchal bowl closer to the mastoid and to better define the antihelical fold. The thicker the cartilage, the more likely it will recoil into its original position, especially in cartilage over 3 mm thick, which is not uncommon in the adult ear.6 Therefore, many techniques have been developed to break the strength of the cartilage, according to the principles of Gibson and Davis, and later refined by Stenström. These rely on the principle that cartilage tends to warp away from its injured surface and thus
903 scoring on the anterior side of the antihelical fold would therefore result in better plication of the cartilage and less recurrence.7 Although some authors report very satisfactory results,8 it may often result in irregularities in the antihelical rim.9,10 In a review of 562 cases, Calder et al report 1.4% anterior skin necrosis and 8% residual deformity or recurrence. To avoid anterior skin necrosis, the dissection can be limited to the posterior side of the ear. According to the Gibson principle, scoring on the posterior side of the antihelical fold would however lead to further flattening of the fold with increased chance on recurrence. To overcome this, some authors prefer cartilage weakening and use extensive scratching and rasping of a broad area of the posterior cartilage surface to as little as 25% of its original thickness before placing sutures.11 A number of posterior only approaches have been described by Keen and Schetrumph in 1890 and 1975 respectively.12,13 While in these papers the V shaped cut may appear similar to our description, on further study it is clear that both these methods aim specifically to weaken the cartilage with full thickness V shaped vertical single or multiple vertical parallel cuts sparing only the anterior perichondrium. Our method in contrast does not cut completely through cartilage and so allows folding softly without weakening and in addition follows a carefully designed concentric curve to follow the anatomical fold of the desired antihelical making it bespoke and anatomically correct. Other authors have suggested scoring techniques using burrs or abraders to weaken the cartilage at the posterior surface.14–16 In our technique however, the controlled fine gouging of 2–3 partial thickness microchondrectomies produces linear concentric cartilage wedges in a “WiFi” symbol pattern (Figure 1C) on the posterior cartilage surface. This is distinct from posterior scoring methods and allows for negligible or minimal cartilage weakening (as the cartilage between the linear grooves is intact) and soft and gradual folding of the antihelical fold without sharp anterior folds or anterior irregularities, since the anterior side remains undissected. The removal of these three linear triangular wedges in the posterior cartilage produces a closing wedge effect that helps to recreate a soft antihelical fold and to simultaneously lower conchal height, whereas simple scoring/ weakening of the posterior cartilage would have an opposite effect. Since the anterior surface of the cartilage remains intact, contour irregularities can be avoided with a natural looking antihelical fold. Hence, it allows for much better cartilage folding than posterior scoring techniques, with better rounding and more natural alignment of the posterior cartilage surface. This technique has proven to be very effective even in older patients with thicker cartilage, as demonstrated by the average age of the patient population. The thickness of the cartilage is irrelevant as the wedge-shaped gouge is proportionally the same depth in thicker (older patients) or thinner (younger patients) cartilages. Since no anterior dissection is performed, anterior skin necrosis is never a concern; in our series, no anterior skin necrosis or irregularities were recorded (Figures 2 and 3). Another important addition in our method is the novel use of a “scapho-temporal” suture to control the upper pole in prominent ears. This suture is in the opinion of the senior author an important tool to control the upper pole without the need for a third Mustarde suture superiorly which can
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Figure 2 Preoperative and 1 year postoperative results of a 7-year-old girl. Note the symmetrical correction and the natural shape and appearance of the antihelical fold.
Figure 3
Preoperative and 1 year postoperative results of a 17-year-old girl.
create an excessively vertical axis to the antihelical fold when the ear is viewed in profile and extends the antihelical fold too superiorly and close to the helical rim. By placing the scapho-temporal suture it also allows the antihelical fold to curve anteriorly and broaden along its superior third which creates a more natural and anatomical fold. This is
desirable in most prominent ears and secondarily corrects any excess upper pole lidding as needed in some prominent ear corrections. This suture is distinct in its execution and purpose from the “mastoid hitch” (and in our opinion incorrectly named as their method hitches to the temporoparietal fascia rather than the mastoid fascia) of Horlock, et al4
‘WiFi’ otoplasty for correction of prominent ears which specifically attempts to correct severe upper pole lidding in constricted ears. All varieties of prominent ears can be corrected with this “WiFi” technique. If a meatal occlusion test indicates any significant obliteration of the external auditory canal, a conchal wedge excision is warranted. Rotational asymmetry of the axis of the ear can be corrected with considered placement of the conchamastoid sutures at either side of the auricular posterior muscle. In dissecting the pockets for the conchamastoid sutures, care should be taken to preserve the posterior auricularis muscle and posterior auricular nerve. Not only will this contribute to sensation and perfusion of the ear, the function of the muscle—even though minimal in most patients—is to pull the ear towards the head17 which works in favour in the context of a setback otoplasty. Emphasis should be placed on the use of permanent Mustarde sutures and conchamastoid sutures. On the long term, this method is not relying on suture hold, but we feel that in the first 3 months the hold of permanent sutures is needed to prevent recurrence; after this time scar tissue will maintain the result. Therefore, any exposure of permanent suture material requiring removal after this time should not be a concern. The use of temporary suture material would lead to a higher early recurrence rate in our opinion and to avoid palpability of the permanent sutures, some surgeons may prefer to use the posteriorly based mastoid flap to cover the knots. In addition, care is taken to bury conchamastoid and scaphotemporal suture knots deeply near the mastoid and temporal fascia respectively or to cover them with a posteriorly based de-epithelialized skin flap.
Conclusion The myriad of techniques of setback otoplasty described in the literature probably indicates that there is no superior method. Moreover, some of the techniques are quite complicated to perform for the beginning surgeon. Here, we describe a simple and efficient technique for otoplasty that is as powerful and versatile as possible without sacrificing safety. It is a reliable technique, with no need for extensive dissection and is applicable to various degrees of deformity in all age groups. Importantly the technique is unique in allowing antihelical fold formation (guided and initially maintained by sutures) without sacrificing significant cartilage strength making it unique amongst reported methods. While our method or aspects of it do not need to be applied to every case of prominent ears we offer it as a unique method that is applicable to all types of prominent ears with a low
905 complication rate consisting entirely of rare upper pole recurrence or minor suture exposure issues.
Conflict of interest and funding The authors declare that there is no conflict of interest or funding involved with this work.
References 1. Kelley P, Hollier L, Stal S. Otoplasty: evaluation, technique, and review. J Craniofac Surg 2003;14:643–53. 2. Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg 2005;115:60e–72e. 3. McDowell AJ. Goals in otoplasty for protruding ears. Plast Reconstr Surg 1968;41:17–27. 4. Horlock N, Misra A, Gault D. The postauricular flap as an adjunct to Mustarde and Furnas type otoplasty. Plast Reconstr Surg 2001;108:1487–90. 5. Rogers BO. The classic reprint. A new operation for prominent ears based on the anatomy of the deformity by William H. Luckett, M.D. (reprinted from Surg. Gynec. & Obst., 10: 635–7, 1910). Plast Reconstr Surg 1969;43:83–6. 6. Minderjahn A, Huttl WR, Hildmann H. Mustarde’s otoplasty – evaluation of correlation between clinical and statistical findings. J Maxillofac Surg 1980;8:241–50. 7. de la Fuente A, Sordo G. Minimally invasive otoplasty: technical details and long-term results. AestheticPlast Surg 2012;36:77– 82. 8. Thomas SS, Fatah F. Closed anterior scoring for prominent-ear correction revisited. Br J Plast Surg 2001;4:581–7. 9. Nielsen F, Kristensen S, Crawford M. Prominent ears: a follow-up study. J Laryngol Otol 1985;99:221–4. 10. Mandal A, Bahia H, Ahmad T, Stewart KJ. Comparison of cartilage scoring and cartilage sparing otoplasty – a study of 203 cases. J Plast Reconstr Aesthet Surg 2006;59:1170–6. 11. Sevin K, Sevin A. Otoplasty with Mustarde suture, cartilage rasping, and scratching. Aesthetic Plast Surg 2006;30:437–41. 12. Keen W. New method of operating for relief of deformity of prominent ears. Ann Surg 1890;11(1):49–51. 13. Schetrumpf J. A method for prominent ear correction. Br J Plast Surg 1975;28(4):292–5. 14. Madhharov M. A new method of auriculoplasty for protruding ears. Br J Plast Surg 1989;42:285–90. 15. Graham K, Gault D. Endoscopic assisted otoplasty: a preliminary report. Br J Plast Surg 1997;50:47–57. 16. Gumus N, Yilmaz S. Otoplasty with an unusual cartilage scoring approach. J Plast Surg Hand Surg 2016;50:19–24. 17. Scuderi N, Tenna S, Bitonti A, Vonella M. Repositioning of posterior auricular muscle combined with conventional otoplasty: a personal technique. J Plast Reconstr Aesthet Surg 2007;60: 201–4.
The ‘WiFi’ otoplasty : Combined concentric posterior microchondrectomies and sutures for correction of prominent ears Benoit I.M.M. Hendrickx a,b, Moustapha Hamdi a, Assaf Zeltzer a, Andrew Greensmith b,* a b
Department of Plastic Surgery, University Hospital of Brussels (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium Melbourne Institute of Plastic Surgery, 253, Wattletree Road, Malvern, Victoria 3144, Australia
Authored by a member of EURAPS
Received 24 April 2017; accepted 21 January 2018
KEYWORDS Ear correction; Bat ear deformity; Cartilage shaping; Mustarde; Otoplasty; Prominent ears; Protruding ear
Summary Background: Prominent ears are by far the most common congenital ear deformity. Many techniques have been described using one or a combination of 3 basic methods: cartilage cutting, cartilage weakening and pure cartilage shaping techniques. The ideal otoplasty technique should yield a natural correction of the deformity, with low recurrence rates and with little risk of complications. Methods: A new cartilage shaping technique using closing wedge concentric microchondrectomies through an entirely posterior approach is presented. Between 2006 and 2017, 200 bilateral otoplasties using this ‘WiFi’ pattern technique were performed. This technique combined with Mustarde sutures is based on the excision of concentric partial thickness cartilage wedges designed in the pattern of the WiFi symbol. Results: There were no major complications such as anterior skin necrosis and no returns to theatre for infections or haematomas. 3 patients (1.5%) had complete recurrence of the deformity and 10 patients (5%) had to undergo a minor revision for recurrence at the upper pole. 5 patients have had exposure of the end of the permanent upper pole scapho-temporal suture more than 3 months after surgery requiring simple outpatient suture trimming/removal without any recurrence of results. Palpable or bridging sutures were present upon clinical examination in 10 patients (5%) but did not require revision surgery. Conclusions: Here, we describe a fast, safe and reliable technique for otoplasty with no need for extensive dissection, which is applicable to the full range of deformity. Crown Copyright © 2018 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved.
* Corresponding author. Melbourne Institute of Plastic Surgery, 253, Wattletree Road, Malvern, Victoria 3144, Australia. E-mail address: [email protected] (A. Greensmith). https://doi.org/10.1016/j.bjps.2018.01.030 1748-6815/Crown Copyright © 2018 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved.
‘WiFi’ otoplasty for correction of prominent ears
Introduction Prominent ears are the most common congenital deformity of the ear, affecting almost 5% of the population.1 The deformity results from two basic congenital deficiencies of the ear: an overdeveloped conchal bowl and/or an underdeveloped antihelical fold, resulting in the three commonly listed signs of prominent ears: conchal height excess, absence/ weakness of antihelical fold and a conchoscaphal angle greater than 90°.2 Frequently more than one of these deformities are present and any surgical technique used for correction of prominent ears should therefore be versatile enough to correct each aspect. The goals of the procedure have been described by McDowell in 19683 as 1) correction of the protruding upper third of the ear, 2) visible helix beyond the antihelical fold in frontal view, 3) a smooth and regular helical line, 4) no distortion of the postauricular sulcus, 5) no overcorrection and 6) symmetrical results with no more than 3 mm difference between both ears. Until now, hundreds of techniques have been described for correction of prominent ears. These vary from cartilagesparing techniques with only sutures, to scoring cartilage or cartilage cutting and excision techniques, and combinations of these. The ideal otoplasty technique should yield a natural result according to McDowell’s goals, with low recurrence rates and involve as little risk of anterior skin necrosis as possible. Here we present a new technique that uses a novel method of cartilage shaping supplemented with traditional mattress and conchamastoid sutures.
Patients and methods Patients Between 2006 and 2017, 200 patients underwent bilateral otoplasty by either the senior author (AG) at the Melbourne Institute of Plastic Surgery, Melbourne, Australia or by the junior author (BH) at the University hospital Brussels, Belgium. The average age of patients at the time of surgery was 11.8 years (range 5–36 years), the male to female ratio was 117/ 83. All patients were followed-up at 1 week, 6 weeks and 6 months postoperatively and then discharged unless otherwise indicated. The mean follow-up term was 6.45 months (range 1.5–24 months). Since only patients with bilateral prominent ears were included, all other congenital ear deformities such as cup ears or constricted ears were excluded. All operations were performed under general anaesthesia.
Operative technique First, the location of the desired antihelical fold extending into the superior crus is marked as a single line marking the peak of the fold and the borders of the fold with two dotted lines (Figure 1A). To assess the need for conchal bowl excision, we developed a meatal occlusion test. The effect of the conchamastoid sutures on the diameter of the external acoustic meatus is mimicked by manually pushing the concha backwards against the mastoid. If more than one third of the meatus is occluded by this manoeuvre, a conchal bowl reduction should be considered in place of conchamastoid
901 sutures to avoid meatal occlusion. The conchal bowl, antihelical fold, posterior surface and the mastoid region are infiltrated with 10 ml of ropivacaine 0.75% with adrenaline 1:200000 per side (in paediatric cases this dose is adjusted accordingly). A gentle hourglass shaped postauricular skin incision is designed to leave the scar in the postauricular sulcus. This skin can either be resected or de-epithelialized to serve as a posteriorly based flap to cover the knots of the sutures as previously described,4 or simply be excised. The postauricular skin is then lifted off the perichondrium in the subcutaneous plane with tenotomy scissors and diathermy, almost to the level of the helical rim. Posteriorly, 3 different pockets to expose mastoid or temporal fascia are dissected with tenotomy scissors spreading longitudinally to avoid damage to the posterior branch of the great auricular nerve: 2 towards the mastoid fascia superior and inferior to the auricularis posterior muscle and 1 more superiorly towards the temporal fascia (Figure 1B). Medially and laterally at three different locations along the marked desired antihelical fold, a 16-gauge straight Keith needle dipped in surgical ink is pierced through the anterior skin, to transpose the location and borders of the curvature of the desired antihelical fold to the exposed posterior cartilage of the ear. Within the boundary of these markings, 2–3 concentric grooves are made on the posterior surface of the ear in a pattern that resembles a ‘WiFi’ symbol (Figure 1C). These grooves are made with the tip of a 15-blade gouging perpendicular to the cutting edge of the blade and pushing side to side in gouging motion with light pressure, so that a small wedge is scooped out of the posterior cartilage surface as opposed to previously described techniques of posterior scoring. Care should be taken not to cut the entire thickness of cartilage as this will result in a visible sharp edge on the anterior surface of the ear and may excessively weaken the cartilage; the surgeon’s non-dominant index finger is therefore placed in the concha to better evaluate the depth of the wedge excisions. Cartilage is not excised in between the linear chondrectomies. When the wedge excision approaches the anterior perichondrium, the cartilage colour changes to a slightly darker colour (from white to grey) indicating the gouge is almost full thickness through cartilage at which point the carving is ceased. These 2–3 grooves/wedges in a concentric pattern are best described as closing wedge concentric microchondrectomies narrow at their greatest depth and widest at their most superficial aspect. It is imperative to avoid penetrating full thickness through cartilage at any point and the colour change to grey/white from white is an easy end point indicator even for a surgeon learning this method. Perichondrium is not removed on the posterior surface in order to preserve blood supply over this area and to lead to more efficient scarification to take over from the function of the sutures used to fold back the antihelix. Next, two to three Mustarde-type mattress 3/0 Ethibond or 3/0 Prolene (either is sufficient but must be on a taper needle to avoid the suture cutting through cartilage) are placed (Figure 1D) to fold back the antihelix. Subsequently, two conchamastoid sutures are placed superior and inferior to the auricularis posterior muscle (Figure 1E). Two sutures are preferable to avoid changing the axis of the ear if a single suture is used. Since the wedge microchondrectomies are not full thickness, cartilage weakening is reduced or
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Figure 1 By folding back the ear, the location of the desired new antihelical fold is determined and marked (A). 3 separate pockets are dissected in the postauricular sulcus, 2 towards the mastoid fascia superior and inferior to the auricularis posterior muscle and 1 more superiorly towards the temporal fascia (B). Concentric partial thickness wedge microchondrectomies are performed holding a 15-blade perpendicular to the cutting edge (C). Classic concha-scapha Mustarde-type sutures are placed to recreate the antihelical fold. The partial thickness microchondrectomies allow the cartilage to fold onto itself while maintaining a smooth anterior contour without irregularities (D). Conchamastoid sutures (E) and a superior scapho-temporal suture (F) finalize the setback procedure.
avoided, but these wedges will simply close as the Mustarde sutures are gently tightened. Care should be taken not to place these sutures too anteriorly, as this will shift the conchal bowl anteriorly and could possibly result in obliteration of the external acoustic meatus. We orientate the pass of these sutures vertically, to avoid blood vessels and nerves in that region. By slightly changing the position of these sutures, any desired change in rotation of the ear can be achieved. In patients with a deep conchal bowl and obliteration of the external acoustic meatus upon manual setback, a wedge resection of the conchal bowl is performed at this stage. To complete the recreation of the antihelical fold, two or three 4/0 clear nylon Mustarde sutures are placed according to the blue markings of the desired antihelical fold (a taper needle here would be desirable but is not yet commercially avail-
able on a clear permanent monofilament suture although we are currently developing this with a suture provider in Japan). To correct the superior pole of the ear, a single 4/0 clear nylon suture is placed from the anterosuperior scapha to the temporoparietal fascia in the third and superior-most posterior pocket (Figure 1F). This is called the “scaphotemporal” suture. After each bite through the scaphal or conchal cartilage, the anterior skin should be checked for possible dimpling or penetration. If the hourglass incision is kept as a de-epithelialized posteriorly based flap, it can be used to cover the knots and so to decrease palpability or protrusion of the sutures. It must be emphasized that the authors do not recommend any overcorrection since the technique is powerful and “what you see is what you get”. On rare occasions when a lobule is prominent, a standard fishtail
‘WiFi’ otoplasty for correction of prominent ears adjustment to the inferior skin incision is made and applied accordingly. The skin is closed with a running 4/0 Vicryl Rapide suture and a paraffin gauze with a Betadine gel soaked wool dressing is applied underneath a head bandage that is soft enough not to create any perfusion problems to the anterior skin of the ear. No packing is used in the conchal bowl to avoid nausea and in any case the anterior skin has not been undermined so packing is unnecessary. The entire surgical procedure takes no longer than 1 hour for both sides. The patients are instructed to keep their head elevated and to avoid external pressure on the ear. All patients are discharged the same day and returned 1 week later to remove the dressing. After this time, the ears are left open but patients are instructed to use a light head bandage (tubigrip, a girl’s headband or a beanie cap in boys) for 6 weeks at night while sleeping to avoid traumatizing the ears in the healing phase.
Results In total, 400 ears were operated on (200 bilateral otoplasties). There were no major complications and no returns to theatre for infections or haematomas. 10 patients (5%) had to undergo a minor revision with replacement of the superiormost suture (scapho-temporal suture) due to localized recurrence of the upper pole deformity. 3 patients (1.5%) had complete recurrence (2 unilaterally, 1 bilaterally). In 7 (3.5%) patients the sutures caused late problems more than 3 months post-surgery: in 4 patients (2%) one of the Ethibond conchamastoid sutures was palpable and in 3 patients (1.5%) the superior nylon stitch was visibly bridging. In all 7 cases, the problematic suture was removed, with no subsequent recurrence.
Discussion Generally, otoplasty techniques can be divided into 3 main categories: cartilage cutting, cartilage weakening and cartilage sparing/pure shaping. The principle of cutting the cartilage to recreate the antihelical fold was first introduced by Luckett.5 The initial cartilage cutting techniques however often resulted in sharp edges and therefore more recent modifications have focused on putting the incision away from the antihelical fold and use scoring techniques to soften the contour of the newly formed antihelical fold. Irregularities, sharp edges and overcorrection are however still quite common1 and these iatrogenic complications are often hard to correct in revision surgery. On the other hand, techniques keeping the cartilage completely intact (cartilage sparing/pure shaping techniques) rely entirely on sutures to plicate the cartilage to reposition the conchal bowl closer to the mastoid and to better define the antihelical fold. The thicker the cartilage, the more likely it will recoil into its original position, especially in cartilage over 3 mm thick, which is not uncommon in the adult ear.6 Therefore, many techniques have been developed to break the strength of the cartilage, according to the principles of Gibson and Davis, and later refined by Stenström. These rely on the principle that cartilage tends to warp away from its injured surface and thus
903 scoring on the anterior side of the antihelical fold would therefore result in better plication of the cartilage and less recurrence.7 Although some authors report very satisfactory results,8 it may often result in irregularities in the antihelical rim.9,10 In a review of 562 cases, Calder et al report 1.4% anterior skin necrosis and 8% residual deformity or recurrence. To avoid anterior skin necrosis, the dissection can be limited to the posterior side of the ear. According to the Gibson principle, scoring on the posterior side of the antihelical fold would however lead to further flattening of the fold with increased chance on recurrence. To overcome this, some authors prefer cartilage weakening and use extensive scratching and rasping of a broad area of the posterior cartilage surface to as little as 25% of its original thickness before placing sutures.11 A number of posterior only approaches have been described by Keen and Schetrumph in 1890 and 1975 respectively.12,13 While in these papers the V shaped cut may appear similar to our description, on further study it is clear that both these methods aim specifically to weaken the cartilage with full thickness V shaped vertical single or multiple vertical parallel cuts sparing only the anterior perichondrium. Our method in contrast does not cut completely through cartilage and so allows folding softly without weakening and in addition follows a carefully designed concentric curve to follow the anatomical fold of the desired antihelical making it bespoke and anatomically correct. Other authors have suggested scoring techniques using burrs or abraders to weaken the cartilage at the posterior surface.14–16 In our technique however, the controlled fine gouging of 2–3 partial thickness microchondrectomies produces linear concentric cartilage wedges in a “WiFi” symbol pattern (Figure 1C) on the posterior cartilage surface. This is distinct from posterior scoring methods and allows for negligible or minimal cartilage weakening (as the cartilage between the linear grooves is intact) and soft and gradual folding of the antihelical fold without sharp anterior folds or anterior irregularities, since the anterior side remains undissected. The removal of these three linear triangular wedges in the posterior cartilage produces a closing wedge effect that helps to recreate a soft antihelical fold and to simultaneously lower conchal height, whereas simple scoring/ weakening of the posterior cartilage would have an opposite effect. Since the anterior surface of the cartilage remains intact, contour irregularities can be avoided with a natural looking antihelical fold. Hence, it allows for much better cartilage folding than posterior scoring techniques, with better rounding and more natural alignment of the posterior cartilage surface. This technique has proven to be very effective even in older patients with thicker cartilage, as demonstrated by the average age of the patient population. The thickness of the cartilage is irrelevant as the wedge-shaped gouge is proportionally the same depth in thicker (older patients) or thinner (younger patients) cartilages. Since no anterior dissection is performed, anterior skin necrosis is never a concern; in our series, no anterior skin necrosis or irregularities were recorded (Figures 2 and 3). Another important addition in our method is the novel use of a “scapho-temporal” suture to control the upper pole in prominent ears. This suture is in the opinion of the senior author an important tool to control the upper pole without the need for a third Mustarde suture superiorly which can
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Figure 2 Preoperative and 1 year postoperative results of a 7-year-old girl. Note the symmetrical correction and the natural shape and appearance of the antihelical fold.
Figure 3
Preoperative and 1 year postoperative results of a 17-year-old girl.
create an excessively vertical axis to the antihelical fold when the ear is viewed in profile and extends the antihelical fold too superiorly and close to the helical rim. By placing the scapho-temporal suture it also allows the antihelical fold to curve anteriorly and broaden along its superior third which creates a more natural and anatomical fold. This is
desirable in most prominent ears and secondarily corrects any excess upper pole lidding as needed in some prominent ear corrections. This suture is distinct in its execution and purpose from the “mastoid hitch” (and in our opinion incorrectly named as their method hitches to the temporoparietal fascia rather than the mastoid fascia) of Horlock, et al4
‘WiFi’ otoplasty for correction of prominent ears which specifically attempts to correct severe upper pole lidding in constricted ears. All varieties of prominent ears can be corrected with this “WiFi” technique. If a meatal occlusion test indicates any significant obliteration of the external auditory canal, a conchal wedge excision is warranted. Rotational asymmetry of the axis of the ear can be corrected with considered placement of the conchamastoid sutures at either side of the auricular posterior muscle. In dissecting the pockets for the conchamastoid sutures, care should be taken to preserve the posterior auricularis muscle and posterior auricular nerve. Not only will this contribute to sensation and perfusion of the ear, the function of the muscle—even though minimal in most patients—is to pull the ear towards the head17 which works in favour in the context of a setback otoplasty. Emphasis should be placed on the use of permanent Mustarde sutures and conchamastoid sutures. On the long term, this method is not relying on suture hold, but we feel that in the first 3 months the hold of permanent sutures is needed to prevent recurrence; after this time scar tissue will maintain the result. Therefore, any exposure of permanent suture material requiring removal after this time should not be a concern. The use of temporary suture material would lead to a higher early recurrence rate in our opinion and to avoid palpability of the permanent sutures, some surgeons may prefer to use the posteriorly based mastoid flap to cover the knots. In addition, care is taken to bury conchamastoid and scaphotemporal suture knots deeply near the mastoid and temporal fascia respectively or to cover them with a posteriorly based de-epithelialized skin flap.
Conclusion The myriad of techniques of setback otoplasty described in the literature probably indicates that there is no superior method. Moreover, some of the techniques are quite complicated to perform for the beginning surgeon. Here, we describe a simple and efficient technique for otoplasty that is as powerful and versatile as possible without sacrificing safety. It is a reliable technique, with no need for extensive dissection and is applicable to various degrees of deformity in all age groups. Importantly the technique is unique in allowing antihelical fold formation (guided and initially maintained by sutures) without sacrificing significant cartilage strength making it unique amongst reported methods. While our method or aspects of it do not need to be applied to every case of prominent ears we offer it as a unique method that is applicable to all types of prominent ears with a low
905 complication rate consisting entirely of rare upper pole recurrence or minor suture exposure issues.
Conflict of interest and funding The authors declare that there is no conflict of interest or funding involved with this work.
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