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Review Clinical Review & Education

Treatment of Prominent Ears and Otoplasty

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 12 ( 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. 13 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 14 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 15 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 16 described a cartilage-splitting technique, initially described by Jost, 17 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.

The nonsurgical correction of auricular deformitieswas first re- ported in the literature in the 1980s. Kurozumi et al 8 reported the successful correction of a child with lop ear deformity after splint- ingof theearwith foam.Matsuoet al 7 reported their experiencewith 150patientswith auricular deformitieswhowere treatedwith non- surgical taping andmolding during the first year of life. The authors 7 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 9 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. 6 Acommerciallyavail- abledevice(EarWellInfantEarCorrectionSystem;BeconMedical)has beendeveloped that addresses someof the limitations ofmorebasic splinting techniques. In their initial series, Byrd et al 6 reported a suc- cessratehigherthan90%,withgoodtoexcellentresultsinnewborns aftera6-weektreatmentperiod.Thistreatmentsystemhasalsobeen successful inaddressing conchal bowl deformities, includingapromi- nent conchal crus. In another recent study, Doft et al 10 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, 11 who first described silk mattress sutures

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