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A large number of techniques have been described for the correction of prominent ears to improve the cosmetic outcome and reduce the complication rates. The procedure favoured by the senior author brings together a number of refinements, notably, percutaneous anterior scoring using a modified green needle, control over the degree of fold created and a simple but effective dressing. 114 consecutive patients underwent the correction of 214 ears, with a mean follow up of 3 years and 11 months (9 months to 9 years and 6 months). The senior author performed 100 of these procedures and supervised a senior trainee for the remainder. The mean patient age was 18 years 3 months (3 to 66 years). 57 males and 57 females. 56 general anaesthetic and 58 local anaesthetic. Post-operative complications were; haemorrhage, one ear (required a dressing change); infection, four ears (treated with antibiotics); hypertrophic scarring, two ears which settled (no keloid); recurrence one ear (repeated surgery); continued prominence six ears (two had repeated surgery). No prominent sutures, no anterior skin necrosis, no visible irregularity of the anterior surface of the cartilage and no haematoma occurred. We feel that the low complication rate is due to maximising the advantages and minimising the disadvantages of the different techniques and refinements. We recommend this technique for the routine correction of prominent ears due to a poorly formed antihelical fold or deep conchal bowl.
There are a number of refinements in surgical technique for prominent ears that have arisen out of the desire to improve cosmetic results and reduce the complication rate which can be high.
used a needle with a bend in one axis for scoring, combined with subcutaneous trans-cartilaginous sutures. The preferred technique of the senior author is described here for the correction of prominent ears due to a poorly formed antihelix or a deep conchal bowl using a new modification that converts the green needle into a blade.
2. Patients and methods
All patients operated on for correction of prominent ears from May 1992 to June 2001 were included in a retrospective case note analysis and follow up. Patients were followed up with regard to the final outcome (residual prominence and recurrence) and occurrence of complications (haematoma, infection, keloid/ hypertrophic scaring, anterior skin necrosis).
2.1 Operative procedure
The patient, under general anaesthesia or local anaesthesia, is prepped and draped. Local anaesthetic with adrenalin is infiltrated along the line of the desired position of the refashioned antihelix between the cartilage and the subcutaneous tissues in order both to hydro-dissect and aid haemostasis. Local anaesthetic is also infiltrated posteriorly.
A green hypodermic needle and 10 ml syringe is held, bevel up, and grasped by a clip half way along the bevel. It is then bent through 70° and then twisted through 90°. This converts the needle into a fine vertically orientated blade (Fig. 1) . By relating the cutting position of the needle to the markings on the syringe one can judge the precise position of the blade after it has been inserted.
Fig. 1The bending of the green hypodermic needle. A green needle is grasped by a clip half way along the bevel (top left), bent through 70° (top right) and then twisted through 90° (bottom left). The cartilage scoring blade (bottom right).
The modified blade is inserted into the local anaesthetic puncture site and is advanced with the blade parallel to the surface of the cartilage with the aid of further infiltration (Fig. 2) . The blade is then turned through 90° and used to score the cartilage while withdrawing. This cycle is repeated as many times as is required to soften the cartilage and allow easy formation of the antihelical fold. Special care must be taken not to score over the same point as one may cut through the cartilage. In the event of this occurring the cartilage must be repaired to avoid an unsightly ridge under the skin. Repeated milking of the anterior surface of the antihelical fold removes any collection throughout the procedure.
Fig. 2Needle insertion into the local anaesthetic puncture sight and advanced with the blade parallel to the surface of the cartilage. The blade is then turned through 90° and withdrawn to score the cartilage. This cycle is to adequately soften the cartilage.
type sutures (5/0 nylon) are used to hold the antihelical fold. By placing a double (pulley) stitch in the desired position it allows for very precise tightening and thereby controls the degree of folding of the antihelix (Fig. 3) . Skin is closed using 5/0 absorbable or pull-out suture.
Fig. 3A double pulley Mustarde type stitch (5/0 nylon) is placed in the desired position. This allows for very precise tightening and accurately controls the degree of folding of the antihelix.
Both ears are dressed separately with a minimal dressing. The cavum concha, cymbum concha, scapha, triangular fossa and the retro auricular sulcus are packed with cotton wool. A tailored piece of mefix is placed over the ear and the pre- and post-auricular skin (Fig. 4) . There are a number of advantages to this form of dressing, it is easy to put on, tends not to fall off, is cool in hot weather, and has no risk of pressure ulceration. This is left in place for a week. The use of a night-time headband is advised for three weeks.
Fig. 4The minimalist otoplasty dressing. The cavum concha, cymbum concha, scapha, triangular fossa and the retro auricular sulcus are packed with cotton wool and a tailored piece of mefix is placed over the ear and the pre and post auricular skin.
One hundred and fourteen consecutive patients underwent the correction of 214 ears, with a mean follow up of 3 years and 11 months (9 months to 9 years and 6 months). Of these patients 100 had bilateral procedures and the remaining 14 unilateral. The senior author performed 100 of these procedures and supervised a senior trainee for the remainder. The mean patient age was 18 years 3 months (3 to 66 years) and there was an equal split between males and females with 57 each (Fig. 5) . Patients undergoing the procedure could elect the level of anaesthesia with 56 choosing general anaesthetic and 58 local anaesthetic.
Fig. 5The age and sex distribution of the 114 patients.
There have been few post-operative complications (Table 1) . One patient was assessed for post-operative bleeding and only required a change of dressing. No patients developed a haematoma. Four patients developed early signs of infection (redness, pain) and were started on oral antibiotics. These were started empirically and no positive cultures developed. Two patients developed what could be described as hypertrophic scars, both of which settled with time. No patients developed keloid scarring.
Table 1The post-operative complications (numbers and percentage of total)
Patient satisfaction was high (Fig. 6) . Out of 114 patients one developed a recurrence and required a further operative procedure for correction. The perception of continued prominence occurred in six patients, however, only one of these decided to have a second procedure. No patients complained of prominent suture material. No one developed anterior skin necrosis. No patients developed visible cartilage irregularities.
Fig. 6A before and after series of a 17-year-old female. (A) Marked asymmetry in size and three dimensional architecture between the ears. (B) Post-operative result showing a pleasing cosmetic result.
to improve patient happiness and confidence in the large majority of patients studied, and is therefore, a worthy and beneficial undertaking. Many techniques for prominent ear correction have been published in an attempt to improve the cosmetic outcome and reduce the not insignificant post-operative complication rates.
The surgical procedure described here combines a number of well-established methods of prominent ear correction, both anterior scoring and Mustardé type sutures, with personal refinements by the senior author.
The advantage of anterior cartilage scoring was demonstrated by Stenstrom
in both cadaveric ear cartilage and the clinical cases published. The percutaneous introduction of the modified green needle is used to score and soften the anterior surface of the ear cartilage. This requires minimal dissection or degloving of the ear cartilage. Mahler
described how the hypodermic needle was simply hooked to the desired curvature, however, by turning this surface through a further 90° a precise blade can be formed. This enables one to produce blades of varying depths depending on the thickness of the cartilage in order to adequately break the cartilage spring but not completely to transect the cartilage. The entry point for scoring enables the milking of any collection that may form anterior to the cartilage.
The post-operative complication rates compare well to other published series.
We feel that as a combination technique of cartilage scoring and cartilage holding sutures that the advantages can be maximised and disadvantages minimised of the individual parts. Mustardé
described the use of 3–0 white silk mattress sutures to create the desired antihelical fold. The technique described in this paper uses a double mattress suture that acts as a pulley enabling the placement of the exact amount of tension required to produce the fold without tying the knot. This is especially important when dealing with cases of asymmetry. A number of cartilage holding sutures are used to create an attractive curve to the antihelix, as one suture alone may cause a straight fold. Due to the cartilage being weakened a finer suture can be used to hold the cartilage in the desired position, resulting in no palpable knots.
A known risk is post-operative irregularity of the anterior cartilage surface when using a scoring technique such as described by Chongchet.
However, no irregularity occurred due possibly to the fact that less aggressive anterior scoring was needed as sutures were used to hold the antihelix during the healing period. If the cartilage was completely transected the defect was repaired.
No patient developed a haematoma due to the minimal degloving anteriorly and the milking of any collection during the procedure through the percutaneous entry site. Anterior skin loss did not occur due to the minimal degloving anteriorly, no haematoma formation and the use of non-pressure dressing. We feel that the low recurrence rate of 0.9% may be due to holding the desired antihelical fold of the already weakened cartilage with the Mustardé type suture. It ensures a consistent result in matching the two ears. The six patients who complained of persistent prominence (upper pole) were early in the series. This was remedied by ensuring the placement of further cartilage holding sutures more superiorly.
5. Conclusion
This long-term retrospective study shows that this technique, combining and refining a number of well established techniques for the correction of prominent ears, is safe, easy to perform, has few complications and gives reproducible and good cosmetic results.
References
Calder J.C
Naasan A
Morbidity of otoplasty: a review of 562 consecutive cases.
N. W. Bulstrode BSc, FRCS, MD, Specialist Registrar in Plastic Surgery
S. Huang FRCS, Senior House Officer in Plastic Surgery
D. L. Martin FRCS, Consultant Plastic Surgeon
Department of Plastic Surgery, Chelsea and Westminster Hospital, Fulham Road, London, UK
Article info
Publication history
Accepted:
March 7,
2003
Received:
November 30,
2002
Footnotes
☆This paper has been presented to the 13th European Association of Plastic Surgeons (EURAPS) Annual Meeting, Crete GREECE, 30th May–1st June 2002, and the British Association of Plastic Surgeons (BAPS), Summer Meeting, London, 3–5 July 2002.
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