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Treatment of Prominent Ears and Otoplasty

Figure 3. Techniques to Correct Conchal Excess

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

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.

Areas of excision

Eminentia fossa triangularis

Eminentia cymba concha

Eminentia concha cavum

POSTERIOR VIEW OF CARTILAGE

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

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

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

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