2017 Sec 1 Green Book

The nonsurgical correction of auricular deformitieswas first re-

ported in the literature in the 1980s. Kurozumi et al

reported the

successful correction of a child with lop ear deformity after splint-

ingof theearwith foam.Matsuoet al

reported their experiencewith

150patientswith auricular deformitieswhowere treatedwith non-

surgical taping andmolding during the first year of life. The authors

reportedexcellent resultswhenpatientswere treatedwithin the first

6weeks of life; however, patients treated after 6weeks of life rarely

achieved correction of their deformity.

Manymethodsofsurgicalsplintingand/ormoldinghavebeenre-

ported in the literature. These include theuseof readily availablema-

terials, such as dental rolls and surgical tape, to prefabricated, com-

mercially available systems. Historically, defects of the conchal bowl

were more difficult to correct with molding compared with abnor-

malities of the helix and antihelix. For example, van Wijk et al

re-

ported their experience with 132 patients with auricular deformities

whowere treatedwith ear molding and/or splinting. The authors re-

ported that 69.8% of antihelical rim deformities were satisfactorily

corrected compared with only 26.8%of conchal deformities.

Conchalbowlabnormalitiescancontributetoaprominentearde-

formitybyincreasingtheconchomastoidangle.

Acommerciallyavail-

abledevice(EarWellInfantEarCorrectionSystem;BeconMedical)has

beendeveloped that addresses someof the limitations ofmorebasic

splinting techniques. In their initial series, Byrd et al

reported a suc-

cessratehigherthan90%,withgoodtoexcellentresultsinnewborns

aftera6-weektreatmentperiod.Thistreatmentsystemhasalsobeen

successful inaddressing conchal bowl deformities, includingapromi-

nent conchal crus. In another recent study, Doft et al

reported their

experiencewithearlytreatment(before2weeksoflife)usingtheEar-

Well system.With early initiation of treatment, theywere able to use

a 2-week duration of therapy (as opposed to 6weeks) and achieved

outcomesreportedasexcellentorgreatlyimprovedby96%ofparents.

Successful earmoldingoutcomes in theneonatal periodmayprevent

the need for future surgery to correct these auricular deformities.

Techniques to Address Underdevelopment

of the Antihelix

The appropriate technique to address the underdevelopment of the

antihelix is perhaps the most debated topic in otoplasty. Techniques

to address the antihelix are divided broadly into cartilage sparing vs

cartilagecuttingbasedonwhethertheauricularcartilageisinciseddur-

ing the procedure. Multiple techniques have been described within

eachgroup,eachwithpurportedadvantagesanddisadvantages.Ade-

tailed reviewof all techniques isbeyond the scopeof this article; how-

ever, themost popular techniques in each categorywill be discussed.

Cartilage-Sparing Techniques

Cartilage-sparing techniques are the most frequently used proce-

dures toaddress theunderdevelopment of theantihelix andare ideal

in patients with pliable cartilage and in patients with mild to mod-

erate antihelical deformities. Cartilage-sparing techniques often re-

quire less underminingof the auricular skin, yielding a decreased risk

of postoperative hematoma; require less operative time; anddo not

injure the native cartilage.

The most cited cartilage-sparing technique in otoplasty is that

described by Mustarde,

who first described silk mattress sutures

in 1963. The mattress sutures were placed through a postauricular

excision of skin andwere described as passing through both the an-

terior and posterior auricular perichondrium. While many authors

describe the use of methylene blue or similar dyes to mark the

planned location of the horizontal mattress sutures, the senior au-

thor (C.M.) prefers to use the technique described by Hilger et al

(

Figure 2

). They describedusing temporarymarking horizontal mat-

tress sutures placed through the anterior auricular skin and carti-

lage to give the desired auricular contour. Once the contour is se-

cured with temporary anterior sutures, permanent clear nylon

sutures areplaced through theposterior surfaceof the cartilage. The

anterior marking sutures are then removed, leaving the corrected

auricle. One criticismof theMustarde technique is that it addresses

only the superior third of the auricle. We have not found this to be

true and consistently use Mustarde sutures to correct deformities

in the superior two-thirds of the auricle. Additional sutures can also

be placed to independently enhance the superior and inferior crus.

Cartilage-Cutting Techniques

Otoplasty techniques that involve cutting the cartilage aremost ap-

propriate for stiff cartilage that is commonly encountered in adult

patients. The cartilage in these patients requires the elastic spring

of the cartilage to be broken to achieve a satisfactory result and re-

duced risk of recurrence over time. There have been many ap-

proaches to cartilage-cutting techniques described in the litera-

ture. These techniques vary based on whether cartilage is incised

full thickness vs partial thickness and whether they involve an an-

terior vs posterior approach.

One example of a cartilage-cutting technique is that described

by Converse et al.

In this method, full-thickness incisions are

made through the cartilage along the area where the desired anti-

helical fold will be formed as well as at the conchal rim. This creates

an island of cartilage, which can then be tubed to form the neoanti-

helical fold. Pitanguy and Rebello

described a similar method,

which they called the “island technique,” in which full-thickness

incisions are also made on either side of the new antihelical fold.

Sutures are then used to approximate the cartilage on the sides of

the incision, which causes protrusion of the cartilage island and for-

mation of the antihelical fold. Farrior

described another cartilage-

cutting technique in which both partial-thickness and full-thickness

incisions are used. Partial-thickness incisions are made along the

conchal rim, whereas full-thickness excisions of cartilage are per-

formed along the superior crus and the desired antihelical fold to

give a gentle contour.

In a recent article, Obadia et al

described a cartilage-splitting

technique, initially described by Jost,

that does not rely on su-

tures but rather on a complete separation of the helix and antihelix

followed by scoring of the antihelical cartilage under direct visual-

ization to facilitate folding. More than 90% of the patients in their

series reported satisfactory outcomes.

While cartilage-cutting techniques can be powerful tools in pa-

tients with stiff cartilage, they are not without their disadvantages.

Contour irregularities, such as unnatural-appearing postoperative

prominences and angulations, are thought to be more prevalent in

patients who have undergone cartilage-cutting techniques. In ad-

dition, revision surgery is more difficult in patients who have previ-

ously undergone cartilage-cutting procedures owing to the injury of

the cartilage inherent in these techniques.

Treatment of Prominent Ears and Otoplasty

Review

Clinical Review & Education

jamafacialplasticsurgery.com

(Reprinted)

JAMA Facial Plastic Surgery

November/December 2015 Volume 17, Number 6