Otoplasty

The most frequent reasons of outsticking ears:

• • Concha differences: the concha is overdeveloped, the cave is too deep. This may affect the upper (cimba) and the deeper (cavum) areas more strongly.
• • The differences of the antihelix: the natural curve of the antihelix is underdeveloped, flat or did not develop at all. This can mean the whole curve or any part of it in various combinations.
• • The joint difference of the concha and the antihelix: the previously mentioned deformities occur together most frequently. In these cases the disturbing effect of one deformity increases that of the other one (which may be hardly visible otherwise). The stronger form of this creates the impression of Mickey Mouse or Dumbo figures, despite the normal sizes (height and width) of the ear. The real reduction of the ear is rarely necessary in the course of the correction, although we may include one or two elements of reduction in the operation.
• • Macrotia: or an extremely big ear, is a rare deformity. The correction of this is shown in the next figure.

Sometimes the ear can be smaller than normal, or deficient apart from sticking out. The precise anatomical analysis is even more important in the case of the correction of formal and functional deformities combined with cartilage deficiencies. It is essential to realize these, and only those surgeons should undertake to correct them, who has sufficient operational practice.

 Operational Techniques

The Correction of the Concha Cave

• • with sutures: we can simply fix the concha cartilage to the mastoid fascia by hooking the cartilage to the mastoid process with full mattress stitches. The secondary effect of this operation is the reduction of the depth of the retroauricular sulcus. We apply a laurel leaf shaped excision accordingly.
• • with cartilage excision (Ely): we can reduce the cartilage stock by the half-moon shaped excision affecting the full thickness of the concha cartilage. The excision should be made on the surface of the cartilage fitting the skull (the mastoideum), thus we can avoid uneven development. The cartilage can be excised from a frontal and a rear approach. In the latter case when we excise a big amount of cartilage, we can avoid the wrinkles of the superfluous skin on the frontal part of the ear with a wide undermining of the skin. In extreme cases we need to perform a skin excision as well.
• • scarification: the scarifiction of the vertical incisions on the frontal part or of the outer edge of the concha cave (i.e. in a depth of app. 2/3 of the cartilage), makes the crease of the cartilage possible so that the depth of the cave reduces and thus the form of the ear changes. The outer part of the concha cartilage seemingly becomes part of the scapha, by developing a new curve at the lateral side.

 Possibilities of the Correction of the Antihelix Curve

• • with cartilage sutures: the flat or missing curve can be developed with sutures that completely pass through the cartilage. According to the Mustardé description, we place the mattress sutures in a way that by pulling them appropriately, the missing antihelix curve can be developed.
• • with the partial incision of the frontal part of the cartilage: Gibson described that the inner forces resulting from the structure of the cartilage, keep the flexible fibers of the cartilage stock in a constantly tight position. This is why the cartilages are flexible to such a big degree. If we injure one side of the cartilage and thus hurt the integrity of the structure with an incision or scarification, we can immediately observe the bending of the cartilage in the opposite direction. The application of this principle in otoplasty is connected to the name of Stenström. It can be achieved with an open approach, or through a subcutaneous tunnel. The latter is a very popular method. The narrow subcutaneous tunnel is developed according to the antihelix curve with a diamond-head gimlet. We can also perform the abrasion on the frontal part of the cartilage with a micro-scarificator. The great value of the abrasion of the frontal part of the cartilage is that the form of the ear develops spontaneously, without the tightening forces of stitches.
• • the thinning and breaking of the rear part: the curve can be developed in the opposite direction to the previous one. With the thinning of the rear part, the strength of the cartilage can be weakened according to the antihelix curve. In this case sutures are needed in order to fix the antihelix curve. These are often combined with the Mustardé stitches.
• • the cross cut of the antihelix curve: Lückett simply cross cut the cartilage according to the antihelix curve and fixed it with perichondrial stitches at the rear part. This procedure often resulted in an unnaturally sharp antihelix curve, nevertheless it was popular because of its simplicity. Later several variations have been suggested in order to eliminate the disadvantage.
• • Tanzer suggests two parallel incisions according to the two edges of the antihelix curve, thus creating a ‘bridge flap’ on the cartilage. Its edges are stitched together to a drain, which results in a softer antihelix curve. 

The Correction of the Upper Pole of the Ear

• • stitching the cartilage to the temporal fascia: the forward or lateral bending of the upper pole of the ear creates the image of slovenly ears. A separate stitch may be necessary for the appropriate fixation of the upper pole. The stitch that goes through the cartilage, can easily be fixed to the temporal fascia. The lack of this stitch is often the reason for the dissatisfaction of patients with the operation.
• • with the incision of the frontal cartilage (Gibson): the Stenström abrasion on the frontal area of the crus superior on the antihelix curve can also correct the upper pole. The cross cutting of the antihelix curve may be necessary in some cases. This is always done on the part of the helix that is in touch with the temporal fascia. We should not cross cut the free curve of the helix!

The Correction of the Soft Tissues

• • the lobe: Often the outsticking earlobe remains after having carried out the rest of the ear correction. According to its position, it can be corrected with one single stitch. We place the stitch in the fibrotic lobe and fix it to the lower pole of the helix, or the sterno-mastoidal aponeurosis, depending on the direction of its position. The appropriate planning of the skin excision behind the lobe helps us to modify the position of the lobe. The innate form of the lobe is individually different. The most disturbing deformities are, if it is too big or if it is hanging. (The figures show the possibilities of correction.)

The weight of the earring or if it is caught in something often causes aesthetic deformities, because the hole on the lobe can widen, or the lobe can be cut through. The wound edges can be unified with sutures after the refreshing of the wound. (Later we can make another tiny hole with a serum1 needle, placing the earring further from the scar.)

• • the excision of the muscles and soft tissues behind the ear: in some cases there may be more muscle and connective tissue behind the ear than normally, which prevents the sufficient fitting of the concha. In such cases we excise as much from the muscle and the connective tissue which makes it possible to develop a proper nest. It is also recommended, if the concha lies directly at the mastoideal fascia.

How to choose the Proper Operation Technique?

The operation types that are described above designate the basic possibilities for the correction of certain deformities. The number and possibility of variations is huge. There are more than one hundred descriptions of operations that deal with the correction of outsticking ears. In fact they are all the modification of one of the above techniques. Our choice is determined by the anatomical situation and by our operational routines and practice. The anatomical deformity has to be evaluated precisely before the operation. The single occurrence of any of the above deformities is rare, usually the reason for the aesthetic disturbance is the joint occurrence of these (cf. pictures in colour appendix).