The goal of otoplasty in the treatment of prominauris is symmetrical restoration of the ears to an aesthetic position with respect to the side of the head. Most commonly, this is accomplished by the creation or enhancement of the antihelical fold. In addition, reduction in the projection of the conchal bowl may be required with manipulation of the antihelical fold. While myriad techniques exist to correct the poorly formed antihelical fold, most involve cartilage weakening and suture placement. Herein we describe a simple and effective technique for cartilage weakening using electrocautery. Using this technique, otoplasty can be performed in a reproducible fashion with a low incidence of complications. In the more than 60 patients treated with this technique, there were no complications related to the use of electrocautery, and excellent results were consistently obtained. (Arch Facial Plat Surg. 1999;1: 204-207)In the early part of this century, most otoplasty techniques relied on full-thickness incisions or excisions of cartilage to create the antihelical fold. One substantial disadvantage of these techniques is the unnatural-appearing sharp contour imparted to the antihelical fold. Most contemporary otoplasty techniques use cartilage sculpting to weaken the spring of the cartilage, thus reducing the tension on subsequently placed mattress sutures that serve to secure the position of the antihelical fold. This suture fixation is necessary until fibrosis of the perichondrium provides permanent fixation. The original sculpting techniques relied on the characteristic of auricular cartilage to curl away from its scored anterior surface. Subsequently developed posterior surface cartilage sculpting techniques are the approach of choice for most contemporary otoplastic surgeons. Many methods of posterior surface weakening have been described. These maneuvers include longitudinal wedge excision, scoring, abrading, and partial-thickness incision. The shortcomings of these different maneuvers are their varying degrees of complexity, the need for special instrumentation, and unreliability in producing consistent results. Herein we describe a method of cartilage weakening unique in its simplicity, convenience, and reproducibility.
TECHNIQUE
Preoperative evaluation of prominauris determines the amount of conchal setback and antihelical fold restoration necessary. The desired outcome is ears that appear symmetrical and natural, with helices located 15 to 20 mm from the mastoid skin. For convenience in the operating room, the mastoid-to-helix distance can be approximated by the width of the index finger. Slight (1- to 2-mm) overcorrection is attempted to compensate for the loss of correction that occurs postoperatively. Otoplasty is typically performed under local anesthesia in adults and general anesthesia is children. Hair control is obtained using a fishnet, and the most protruding ear is operated on first. The desired antihelical fold is simulated by applying gentle pressure along the antihelical rim. The cartilage and skin along the desired fold are marked by inserting four 22-gauge needles through the ear at 4 reference points: the superior crus, the inferior crus, the point of convergence of the crura, and the inferior antihelical fold. The ends of the inserted needles are painted with methylene blue, then withdrawn.The skin incision is designed completely on the posterior surface of the ear, avoiding extension onto the mastoid skin in anticipation of the posterior drift of the scar onto the visible mastoid skin that occurs with healing.
Figure 1. The rounded edge of the spatula tip of the electrocautery makes a partial-thickness trough in the posterior surface of the auricular cartilage along the desired antihelix and superior and inferior crura.
An hourglass-shaped elliptical incision is designed to avoid overcorrection of the middle third of the ear (telephone ear deformity). The ends of the elliptical incision should be no closer than 1 cm to the superior and inferior extents of the posterior attachment of the pinna. The skin is incised and the ellipse is excised in the supraperichondrial layer. Supraperichondrial dissection is performed laterally to the helical rim and medially over the mastoid to permit placement, if indicated, of conchal-mastoid setback sutures. Any excess conchal cartilage along the free edge of the external auditory meatus is excised, avoiding protrusion into the external auditory canal.Next, the cartilage must be weakened in preparation for the placement of scaphal-conchal mattress sutures. The previously marked methylene blue dots along the desired antihelical fold and crura mark the lines of cartilage weakening. The electrocautery is adjusted to a setting sufficient to create, sufficient to create, in cutting mode, a partial-thickness trough through the cartilage. The rounded tip of the spatula blade is used to connect the dots, resulting in a Y-shaped trough (Figure 1).
Several passes are made, between which char is wiped away. The goal is to weaken the fold while maintaining sufficient resilience to prevent a sharp angle at the fold. Typically, this occurs when the trough extends approximately halfway to two thirds through the cartilage.
Figure 2. Cross-sectional view demonstrating a partial-thickness incision of cartilage with mattress sutures.
Following cartilage weakening, any necessary conchal-mastoid sutures are placed, test tied with a single throw of a simple knot to assure achievement of the desired effect, then loosened and tagged. Three to 4 Mustarde-type scaphal-conchal horizontal mattress sutures of 4-0 clear nylon or Mersilene (Ethicon, Sommerville, NJ) are then placed, tested, and tagged in the same fashion. Once all the sutures have been tagged, the conchal-mastoid sutures are secured. The Mustarde-type scalphal-conchal sutures are then sequentially secured, adjusting tension so that the desired antihelical fold is created (Figure 2).
The incision is then closed in 1 layer with 4-0 plain gut sutures. If indicated, the contralateral otoplasty is then performed. A conforming dressing of mineral oil-soaked cotton covered with fluffs and head wrap is applied. Antibiotics are prescribed for 5 days. On the first postoperative day, the dressing is removed and proper ear position is confirmed. The dressing is replaced and kept in place for 1 to 2 more days in adults and 7 to 10 days in children. An elastic headband is worn nightly for 4 to 6 weeks following dressing removal to prevent accidental disruption of the healing cartilage.
RESULTS
This technique has been used in more than 60 patients. Results have been consistent and reproducible, with a very low incidence of complications. There have been no cases of chondritis or cartilage necrosis, of theoretic concern given the method of cartilage scoring. In 6 cases a revision procedure was performed to repair partial loss of correction in 1 ear. The created antihelical folds are uniformly smooth (Figure 3 and Figure 4), avoiding the sharp edges that can often result from cartilage-splitting techniques.
Figure 3. An 18-year-old man before (A,B) and 6 months after (C,D) otoplasty using the technique described that resulted in smooth neofolds.
Figure 4. A 37-year-old woman before (A,B) and 6 months after (C.D) otoplasty using the technique described, also with smooth neofolds.
COMMENT
The goal of otoplasty is to create natural-appearing ears with symmetrical size and shape and a harmonious relationship with the side of the head. For the facial plastic surgeon performing otoplasty, a reproducible technique is vital to assure consistent results.
The technique described uses a simple method of cartilage weakening combined with Mustarde-type retention sutures to achieve the desired configuration of the antihelical fold. Subsequent healing reinforces the mattress sutures, although some loss of correction typically occurs over time.
Cartilage weakening may not be necessary in all patients. Scrimshaw reserves thinning maneuvers for thicker cartilage to avoid the kinking that can sometimes occur in thin, excessively weakened cartilage. Ohlsen and Verdung justify not weakening the cartilage in patients younger than 10 years because the cartilage in these younger patients is thinner and more pliable. Adamson et al describe cartilage strength increasing proportionately with age. The success of Millay et al in recontouring neonatal auricular deformities by the application of several weeks of pressure dressing attests to the pliability of auricular cartilage at a young age.
The advantages of our technique include its reliability, simplicity, and the convenience of using a surgical instrument already present in the surgical field. Using this technique, otoplasty can be performed in reproducible fashion with a low incidence of complications. There were no cases of chondritis or any other evidence of thermal damage to the auricular cartilage or skin.
Accepted for publication May 28, 1999
Reprints: Jeffrey S. Epstein, MD, 6280 Sunset Drive, Suite 509, Miami, FL 33143 (e-mail: [email protected].com)
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