2017 Sec 1 Green Book

Reprinted by permission of JAMA Facial Plast Surg. 2015; 17(6):449-454.

Clinical Review & Education

Review

Treatment of Prominent Ears and Otoplasty A Contemporary Review

Sachin S. Pawar, MD; Cody A. Koch, MD, PhD; Craig Murakami, MD

Prominent ears affect approximately 5% of the population and can have a significant psychological impact on patients. A wide variety of otoplasty techniques have been described, all sharing the goal of re-creating the normal appearance of the ear and achieving symmetry between the 2 sides. Recent trends in otoplasty techniques have consistently moved toward less invasive options, ranging from nonsurgical newborn ear molding to cartilage-sparing surgical techniques and even incisionless, office-based procedures. Herein, we review anatomy of the external ear, patient evaluation, the evolution of nonsurgical and surgical otoplasty techniques, otoplasty outcomes, and future trends for treatment of prominent ears.

Author Affiliations: Author affiliations are listed at the end of this article. Corresponding Author: Sachin S. Pawar, MD, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226 ( spawar@mcw.edu ).

JAMA Facial Plast Surg . 2015;17(6):449-454. doi: 10.1001/jamafacial.2015.0783 Published online July 9, 2015.

P rominent ears, or prominauris, are defined as the abnormal protrusion of the ears from the head. It has been estimated that approximately 5%of the population are affected by this conditiontovaryingdegrees. 1 Whilethephysiologiceffectsofthecon- dition are negligible, the psychological impact, as a result of de- creased self-esteem and teasing by peers, can be severe. 2 Treatment of prominent ears is primarily surgical except innew- borns. Hundreds of surgical techniques have been published in the past century describing the correction of prominent ears. While no one technique is universally favored in all cases, they all share the same goals of re-creating the normal appearance of the auricle and achieving symmetry between the 2 sides. Anatomy The appropriate diagnosis and treatment of prominent ears relies onadetailedknowledgeof auricular development andanatomy. The length of the adult auricle measures approximately 5.5 to 6.5 cm while the width is normally 50% to 60% of the length. The auricle develops quickly after birth, reaching90%of the adultwidthwithin the first year of life and 97% to 99% of the adult width by 10 years of age. 3 The length of the auricle developsmore slowly and reaches 75%of the adult length by 1 year of age and 93%by 10 years of age. The auricle rotates slightly posteriorly at an angle of 15° to 30°. The projection of the ear from the head ismeasured by the con- chomastoidangle.Normalvaluesfortheconchomastoidangleareap- proximately 25° in males and 20° in females. Larger conchomastoid angles are commonly encountered in patients with prominent ears. The auricular cartilage provides support and definition for the skin and soft tissue of the auricle. The gentle curves of the normal auricle create multiple different named convexities and concavities in the normally developed ear, as illustrated in Figure 1 . These struc- tures may be underdeveloped or absent in the prominent ear and must be re-created during surgery to obtain satisfactory results.

Twoauricularstructuresofparticularimportanceforotoplastyin- clude the antihelix and conchal bowl. The antihelix parallels the heli- cal rim and splits near the superior pole of the auricle into the supe- rior and inferior crus. The conchoscaphal angle defines the antihelix and is approximately 90°, with more obtuse angles being encoun- tered in patients with prominent ears. The conchal bowl is a depres- sion of cartilage at the entrance to the external auditory canal and is divided by the helical crus into the concha cavum inferiorly and con- cha cymba superiorly. The average depth of the conchal bowl is less than1.5cmbutisfrequentlyenlargedinpatientswithprominentears. 3 Patient Evaluation Age is a critical factor in the evaluation and surgical decision- making regarding prominent ears. During the first several weeks of life, nonsurgical ear-moldingoptionsmaybe able to successfully cor- rect a variety of auricular deformities. Beyond this period, surgical correction of prominent ears can be undertaken when the patient isasyoungas5years.Thenormalauriclereachesapproximately90% of adult size by 3 years of age. Initialconcernsthatoperatingonpatientsbeforetheauricleisfully grown will lead to growth restriction have been unfounded. For ex- ample, Balogh and Millesi 4 studied 76 patients who underwent oto- plasty at ages 5 to8years andwhohadauricularmeasurements avail- ablebothpreoperativelyandatages20to30years.Theauthors 4 found thatthesizeoftheauriclesinpatientsundergoingotoplastyweresimi- lar to those in controls who had not undergone otoplasty. Thus, un- dertaking otoplastywhen the patient is approximately 5 to 6 years of agehasbeenconsideredoptimalowingtomostauriculargrowthbeing achieved, maintenance of pliability of cartilage, and intervening prior to significant psychological damage secondary to teasing by peers. In addition to age, the surgeon shouldpay close attention to the morphologic characteristics of the auricle. In particular, the concho- mastoid and conchoscaphal angles should be estimated and re-

(Reprinted) JAMA Facial Plastic Surgery November/December 2015 Volume 17, Number 6

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