- Prominauris (prominent ears) occurs in approximately 5% of the population.
- Conchal prominence and the absence of an antihelical fold represent the most common causes of prominence of the ears.
- Although there are hundreds of techniques to correct auricular prominence, the most common are suture techniques for conchal setback (technique of Furnas) and for creation of an antihelical fold (technique of Mustarde).
- Otoplasty refinement techniques exist for deformities such as large earlobes and excessive helical prominences.
- Complication rates from otoplasty range from 7% to 12% and may be subdivided into early, late, and aesthetic/anatomic in etiology.
- Auricular hematoma occurs in 1% of otoplasties. Complaints of unilateral pain or tightness within the first 48 hours postoperatively require prompt removal of dressings to examine the wound site for hematoma collection.
Preoperative Evaluation/Timing of Surgical Correction
The incidence of excessively prominent ears is about 5%. It is inherited as an autosomal dominant trait with 25% partial penetrance; it most commonly results from two anatomic irregularities, specifically the absence of an antihelical fold and excessive depth or projection of the conchal bowl.
Precise analysis of auricular deformities is paramount to achieving successful outcomes. Surgeons must identify the specific cause of auricular prominence in the formulation of an appropriate surgical plan. Although frequently bilateral, asymmetries in ear protrusion should be noted. As such, standard preoperative photography should be performed, including frontal, full right and left oblique, full right and left lateral, and close-up right and left lateral views.
Although there exist proponents of earlier surgical correction, most authors agree that the ideal age for otoplasty is between 5 and 6 years. Physiologically, the auricle is roughly 90% of adult height by 6 years of age. Psychosocially, correction is undertaken before or soon after a child's entrance to grammar school, where children are subject to peer ridicule. Moreover, by 5 or 6 years, children are able to participate in their own postoperative care (ie, not pulling off bandages or disturbing the wound).
Gosain AK, Kumar A, Huang G. Prominent ears in children younger than 4 years of age: what is the appropriate timing for otoplasty? Plast Reconstr Surg
(This article provides a retrospective analysis of the efficacy of otoplasty in patients younger than 4 years of age.)
Techniques of Surgical Correction
Over 200 techniques have been described for correction of the prominent ear. Conceptually, they can be subdivided into procedures that address an absent antihelical fold, procedures that reduce excess in the conchal bowl, and those that reduce prominent or enlarged lobules. Most of the latter techniques involve reshaping auricular cartilage, which can be accomplished through a number of cartilage-manipulating techniques such as suturing, scoring, and excision/repositioning, to name a few. Herein, the most commonly used technique for correction of an absent antihelical fold, originally described by Mustarde, is discussed in greater detail. In addition, the Furnas technique for reduction of an excessive conchal bowl is described.
In 1963, Mustarde first described a technique for creating an antihelical fold by using permanent conchoscaphal mattress sutures. Since that time, many subtle refinements of this technique have been described, but the fundamentals of the procedure remain unchanged.
Pediatric patients most commonly undergo general anesthesia for this procedure, and perioperative broad-spectrum antibiotics are administered. The face is prepped into a sterile field such that both ears can be visualized simultaneously. After infiltration with lidocaine 1% with epinephrine 1/100,000, an eccentric fusiform incision is made into the postauricular surface. Typically, more skin is excised from the postauricular surface than from the mastoid, in an effort to camouflage the resultant scar into the postauricular sulcus following setback.
Once the fusiform of skin is excised, the remaining skin of the posterior aspect of the helix, antihelix, and concha is undermined with scissors, leaving perichondrium attached to the auricular cartilage. The extent of antihelical fold creation is determined by pinching the anterior auricle with a thumb and index finger. Alternatively, some surgeons mark cartilaginous landmarks with several ink-dipped fine needles. Permanent horizontal mattress sutures (eg, 4–0 Mersilene [Ethicon, Inc., Somerville, NJ]) are placed into the helical cartilage, parallel with the helical rim at the lateral extent of the desired antihelical fold (Figure 79–1). It is critical that sutures are placed through the cartilage and lateral perichondrium but not the lateral helical skin. The first helical suture is placed at the level of the helical root to create the superior crus. The second suture is typically placed just inferior to the junction of the superior and inferior crura. Third and fourth sutures are placed as needed. Some overcorrection is necessary during placement of the most superior suture, because it has been demonstrated that as much as 40% loss of correction at this site may occur within the first postoperative year.
Technique of Mustarde for creation of the antihelical fold—three permanent horizontal mattress sutures are placed parallel with the helical rim. Care is taken to place sutures through the anterior perichondrium without violating the anterior skin. (Reproduced, with permission, from Adamson PA, Constantinides MS. Otoplasty. In: Bailey BJ, Calhoun KH, Coffey AR, Neely JG, eds. Atlas of Head & Neck Surgery—Otolaryngology. Philadelphia: Lippincott-Raven, 1996:429.)
The wound is irrigated with antibiotic solution and closed with resorbable sutures. Antibiotic ointment, along with cotton impregnated in mineral oil, is applied to the new antihelix and postauricular sulcus, and a mastoid dressing is applied.
The dressing is removed on the first postoperative day to check for hematomas, and replaced for 3–4 more days. Subsequently, a head band is worn continuously for 2 weeks and at night for an ...