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tionwithalowrateofrecurrence.Whiletheprocedureaffordedapow-
erful technique, Furnas also noted its drawbacks; sutures placed too
faranteriorlyonthemastoidorposteriorlyontheconchalcartilagewill
causeexaggerationoftherotationoftheearandcouldleadtonarrow-
ing of the external auditory canal. Sie and Ou
23
pointed out that the
prominentconchalbowlalsolackstherootofthehelixthatdividesthe
conchaintotheconchacavumandtheconchacymba.Theysuggested
additionalpermanentsuturesontheposteriorconchalbowltore-create
the root of the helix and reduce the prominent conchal bowl.
Frequently, optimal results are obtained by combining the tech-
niquesofshavingconchalcartilagefromtheposterioraspectofthecon-
chal bowl and the use of conchomastoid sutures as described herein.
Ourpreferredtechniqueinvolvesresectionofanellipseofpostauricu-
lar skin, removal of an ellipse of conchal cartilage at the 3 eminentia,
followedbytheuseofnonabsorbablemattresssuturesplacedthrough
theconchalcartilageandsecuredtothemastoidperiosteum(
Figure3
).
In some cases, the amount of excess conchal cartilage requires
more aggressive techniques to achieve a satisfactory result. In rare
instances, excision of conchal cartilage and skin may be necessary
in cases inwhich the conchal cartilage joins the antihelix. If only car-
tilage is to be resected, it can be performed via a posterior ap-
proach. Resecting only cartilage near the conchoscaphal anglemay
leave redundant skin that results in a noticeable deformity. There-
fore, inmost cases of severe conchal excess, both cartilage and skin
are resected through an anterior approach. Excessive resection of
skin should be avoided to minimize the risk of creating hypertro-
phic scars. It should be noted that we have not found it necessary
to use the techniques described herein in our own practice.
Incisionless Otoplasty
As with the trend in other facial plastic surgery procedures, the de-
sire to have a less invasive otoplastymethod prompted Fritsch
24
to
publish his first description of an incisionless otoplasty technique in
1995. Since that time, he has published subsequent revisions to the
original technique that have incorporated modifications in the su-
ture placement procedure and application of the technique to other
deformities other than the absent antihelical fold. The most recent
revision, published in2012,
25
incorporates incisionless cartilage scor-
ing and retention suture placement for correction of the antihelical
fold, conchal bowl, and lobule. Since Fritsch
24
published his initial
description of the incisionless otoplasty technique, others have de-
scribed their own modifications to the procedure.
26
Outcomesoftheincisionlessotoplastytechniquehavebeenvery
favorable when compared with traditional open techniques. Mehta
and Gantous
27
published a retrospective series of 72 adult and pedi-
atric patients who underwent incisionless otoplasty and found it to
be an effective technique with a low complication rate. Some of the
complications seenwith this approachwere suture failure, suture ex-
posure,granulomaformation,andantibioticointmentreaction.Their
revision ratewas 13%, butMehta andGantous
27
noted thatmany re-
visions couldbeperformedwith local anesthesia in the clinic and that
most neededonly a single suture. They found that this techniquewas
reliable, safe, and had longevity comparable with the more tradi-
tional techniques. In another recent study,
28
2 different incisionless
techniqueswere compared. Theauthors found similar outcomes and
complication rates between their modified technique when com-
pared with that described by Fritsch.
24
Outcomes
Specific objective or patient-reported outcomes studies are rela-
tivelylimitedforotoplasty.Aswithotheraestheticprocedures,patient-
reportedquality-of-life(QOL)outcomesaretypicallyconsideredtobe
themost important measures. In 2010, Braun et al
29
reported one of
the first retrospective studies looking at health-related quality-of-life
(HRQOL) outcomes in 62 adult and pediatric patients who under-
went otoplasty with suture techniques. They used the Glasgow Ben-
efit Inventory, a validated retrospective questionnaire that is used to
measure the effect of otolaryngology- and facial plastic surgery–
related procedures on HRQOL. They reported that the primary rea-
sons their patients underwent otoplasty were teasing, aesthetic im-
pairment, reduced self-confidence, andpreventionof teasing. Nearly
two-thirds of their patients reported having been teased about their
Figure 3. Techniques to Correct Conchal Excess
To achieve the desired setback of the conchal
bowl, permanent 4-0 clear nylon sutures may
need to be placed between the conchal
cartilage and the mastoid periosteum.
In patients with excess conchal cartilage, shave excisions of cartilage
discs from the posterior aspect of the concha are required for optimal
results. The removal of excess conchal cartilage and soft tissue over the
mastoid allows for additional setback of the auricle.
A
Cartilage excision
B
Conchal setback
Eminentia
fossa triangularis
Eminentia
cymba concha
Eminentia
concha cavum
Areas of
excision
POSTERIOR VIEW
OF CARTILAGE
Treatment of Prominent Ears and Otoplasty
Review
Clinical Review & Education
jamafacialplasticsurgery.com(Reprinted)
JAMA Facial Plastic Surgery
November/December 2015 Volume 17, Number 6
50