Otoplasty for Prominauris

Considerations

• • Anatomy

    • Arterial supply 

      • Superficial temporal artery

      • Posterior auricular artery 

    • Innervation (sensory)

      • Greater auricular nerve (anterior and posterior branches) 

      • Lesser occipital nerve

      • Auriculotemporal nerve

      • Field block

        • Infiltrate at the base - anteriorly and posteriorly 

      • Vagus (Arnold's) nerve - posterior wall of EAC

    • Size

      • Auricle height

        • ~ 6 cm 

        • Between horizontal lines at the levels of the

          • superior orbital rim 

          • nasal spine 

      • Auricle horizontal length

        • ~ 3.3-3.9 cm 

      • Auricle depth from the concha to the tragus is ~ 8 mm

    • Positioning

      • Helical rim

        • The rim should be positioned just lateral to the antihelix 

      • Distance from the rim and scalp over mastoid 

        • Slightly less than 2 cm (usually 12-20 mm) 

        • Distance superior most rim and scalp

          • ~ 1 cm

      • Horizontal position

        • In the Frankfurt horizontal plane, the distance between the tragion and subnasale (or otobasion inferius given EAC atresia) 

      • Inclination - the angle between the longitudinal axis of the ear and the true vertical (in the Frankfurt horizontal plane)

        • ~ 24.8 degrees 

        • Note: The angle between the longitudinal axis of the ear and the nasal dorsum

        • ~ 14.9 degrees 

    • Angles

      • Concho-mastoid angle

        • ~ 90 degrees

      • Scapha-conchal angle

      • ~ 90 degrees

      • Auriculocephalic angle

        • ~ 25-35 degrees

  • Indications

    • The most common indication is the most common congenital deformity of the auricle, called prominauris 

      • Anatomic deformity usually consisting of excess lateral projection of the superior helix from one of or a combination of 

        • poorly developed antihelical fold

          • poor definition between the concha and scapha

      • excessive conchal cartilage, mostly in the posterior conchal wall 

    • Other deformities include

      • protruding earlobe, helix irregularities such as an unrolled rim, anteromedially displaced insertion of the postauricular muscle 

  • Surgical technique

    • Historically, skin and cartilage were incised or excised

    • In 1970s the cartilage-sparing Mustarde technique gained popularity 

    • Since, many techniques have evolved 

    • 1997: Modification of the Mustardé otoplasty technique using temporary contouring sutures

    • 2000: Otoplasty: anterior scoring technique and results in 500 cases

    • 2006: Nuances of otoplasty: a comprehensive review of the past 20 years

    • 2007: Otoplasty – techniques, characteristics and risks

    • 2012: Minimally invasive otoplasty: technical details and long-term results

    • 2014: Incisionless otoplasty: a reliable and replicable technique for the correction of prominauris

    • 2015: Treatment of Prominent Ears and Otoplasty: A Contemporary Review

    • Today, multiple methods exist, mostly consisting of suture only, cartilage splitting, cartilage weakening, or a combination 

    • The goal is to choose the method(s) that treats the patient's specific defect(s) 

    • Three key methods are reviewed:

    • Davis method

      • • Cartilage splitting (excising) 

        • Indicated for excessive posterior concha 

      • Mustarde method (conchal-scaphal suturing) 

        • Cartilage weakening 

        • Often combined with the Davis method 

        • Indicated for deficient antihelical fold

      • Furnas method (concha-mastoid suturing) 

        • Indicated for excessive conchal cupping, to reduce space between the concha and mastoid 

  • Timing

    • Age 6 or older 

      • Allows cartilage maturity 

    • Adult cartilage is less flexible and more brittle, adding challenge to the surgery

Preparation

• • Counseling

    • Ask the patient to obtain a comfortable wide elastic headband that he/she feels comfortable wearing for the first 6 weeks after surgery

  • Pre-operative photos

    • Frontal, oblique, lateral, posterior, bird's eye

  • Special equipment 

    • Methylene blue 

    • 25 gauge needle 

    • 3-0 clear Nylon suture 

  • Local anesthesia 

    • .5% Bupivacaine with 1:200,000 Epinephrine - or - 

    • 1% Lidocaine with 1:100,000 Epinephrine

  • Consider a field block if performing under local anesthesia only 

    • Local anesthesia

      • .25% Bupivacaine - or - 

      • 1-2% Lidocaine

    • Nerves to be blocked

      • Greater auricular nerve

      • Auriculotemporal nerve

      • Lesser Occipital Nerve

      • Auricular branch of the Vagus nerve 

    • Instructional pages

    • Open Access Atlas of Otolaryngology-Head and Neck Surgery - Loca and Regional Anesthesia Techniques for Otologic Surgery

    • eMedicine - Ear Anesthesia

    • 2004: Regional Anesthesia for Office Procedures: Part I. Head and Neck Surgeries

    • Videos

    • YouTube (2:13) - Ear block instructional video

      • Vimeo (3:42) - Ear block instructional video 

Procedure

• • Davis method

    • Mark the concha to be excised in a kidney bean shape

      • Preserve 8 mm of posterior conchal wall height 

      • Transfer the marking to cartilage with methylene blue using a 25 gauge needle 

    • Mark the postauricular skin to be excised in an ellipse

    • Infiltrate local anesthesia both anteriorly and posteriorly

      • Attempt to hydrodissect, posteriorly in the subcutaneous plane and, especially, anteriorly in the subperichondrial plane

    • Complete the postauricular skin incision

    • Dissect posteriorly in the subcutaneous plane to expose the conchal cartilage to be excised and identify the methylene blue markings 

    • Incise the cartilage and enter the anterior face of the concha in the subperichondrial plane 

    • Dissect anteriorly in the subperichondrial plane to expose the conchal cartilage to be excised

    • Excise the conchal cartilage 

    • Allow the auricle to rest passively and re-examine

      • If needed, excise additional cartilage

    • Excised excessive postauricular skin

    • Excise underlying postauricular subcutaneous tissue and muscle over the mastoid fascia

    • Sew four mattress transfixion (through and through) sutures using 3-0 Silk tied over a cotton roll

    • Approximate the postauricular skin incision with absorbable suture 

      • Leave a small opening inferiorly to allow drainage 

    • Place cotton roll into the external auditory canal

    • Remove the dressing/suture in 2 weeks 

  • Mustarde method

    • Press the superior helical rim against the scalp to fold the scapha and recreate the antihelical fold 

    • Mark the planned antihelical fold both laterally and medially, spaced 7 mm apart 

      • Transfer the lateral marking to cartilage with methylene blue using a 25 gauge needle 

    • Mark the postauricular skin to be excised in an ellipse (as in the Davis method) 

    • Infiltrate local anesthesia both anteriorly and posteriorly

      • Attempt to hydrodissect, posteriorly in the subcutaneous plane and, especially, anteriorly in the subperichondrial plane

    • Complete the postauricular skin incision

    • Dissect posteriorly in the subcutaneous plane to expose the conchal cartilage methylene blue markings 

    • Incise the inferior most cartilage of the planned antihelical fold and enter the anterior face of the concha in the subperichondrial plane using a Freer  

    • Weaken the crest of the planned antihelical fold 

      • Multiple options exist: Cartilage scoring, crunching with a forceps, or rasping

    • Sew 3-4 horizontal mattress perpendicularly across the planned antihelical fold using permanent suture (options: 3-0 clear Nylon or 4-0 Mersilene)

      • Key: The anterior skin is not violated; The suture only passes through cartilage and perichondrium 

    • Tie the knots sequentially to achieve a natural appearing antihelical fold 

    • Approximate the postauricular skin incision with absorbable suture 

    • Place gauze bolster anteriorly and posteriorly for compression

      • Secure with head wrap

    • Remove dressing in 1-3 days 

  • Furnas method 

    • Press the floor and posterior wall of the concha against the mastoid using a cotton tip applicator until the desired position is achieved 

    • Mark the lines of junction between the posterior concha and the mastoid and the planned antihelical fold on the anterior surface 

      • Transfer the lateral marking to cartilage with methylene blue using a 25 gauge needle 

    • Mark the postauricular skin to be excised in an ellipse (as in the Davis method) 

    • Infiltrate local anesthesia both anteriorly and posteriorly

      • Attempt to hydrodissect, posteriorly in the subcutaneous plane and, especially, anteriorly in the subperichondrial plane

    • Complete the postauricular skin incision

    • Expose a 1 x 2 cm area of deep fascia over the mastoid process 

    • Place the auricle into the desired position

    • Sew four horizontal mattress through the concha posterior to the ponticulus, slightly behind the line of junction, and through the mastoid process periosteum using permanent suture (options: 4-0 clear Nylon or 4-0 Mersilene)

      • Key: The anterior skin is not violated; The suture only passes through cartilage and perichondrium 

      • Key: Avoid displacing the auricle forward, superiorly, or inferiorly 

    • Tie the knots sequentially to achieve a natural appearing auricle  

    • Place gauze bolster anteriorly and posteriorly for compression

      • Secure with head wrap

    • Remove dressing in 1-3 days 

Sample operative report

Findings:

Bilateral prominauris related to *** excessive conchal cartilage and deficient antihelical fold

Performed bilateral otoplasty

Procedure in Detail:

In the operating room, the patient was positioned supine and the pre-operative briefing was completed. GETA applied and bed turned 180 degrees. The bilateral post-auricular region was infiltrated with 10 ml of .5% Bupivacaine with 1:200,000 Epinephrine.

Bilaterally, the planned antihelical fold was marked using methylene blue and a 25 gauge needle. A post-auricular linear vertical incision was completed with the 15 blade. The soft tissue was raised from the perichondrium using the tenotomy scissor; The methylene blue markings were exposed.

The excessive conchal bowl cartilage was identified and excised in split-thickness. The posterior aspect of the antihelical cartilage was weakened with split-thickness hashes.

Three horizontal mattress (Mustarde) sutures were placed to reconstruct the antihelical fold and superior crus using 4-0 clear Nylon. Three conchal-mastoid mattress sutures were placed using 3-0 clear Nylon. Symmetry was observed between the ears.

Wound hemostasis was maintained using Bovie and Bipolar cautery. The skin incision was approximated primarily using running, locking 5-0 Fast Absorbing Gut.

The auricles were dressed with Xeroform and Fluffs. Kling was wrapped around the patient's head, maintaining moderate compression.

GETA was discontinued, and the patient was transported to PACU without issue. No complications occurred during the surgery. Debriefing completed; Final count correct.

Post-op

• • Medications 

    • Bacitracin ointment to post-auricular skin incision starting when the head dressing is taken down and continuing TID-QID for 1-2 weeks or until sutures dissolve and crusting resolves 

    • Optional: oral antibiotic until POD 4-7

    • Analgesic: Percocet, etc. 

    • Optional: Zofran

    • Colace

  • Clinic follow-up

  • RTC POD 2-3 for initial dressing take down and wound examination, most importantly for hematoma 

    • At this point, remove the Xeroform and Fluffs

    • Replace Fluff behind ear for support and wrap gently (avoid pressure necrosis) with Kling or elastic band 

  • RTC 1 weeks for wound check

  • RTC 5-6 weeks for wound check and post-operative photos

  • Dressing

    • POD 3 remove head dressing 

    • After POD 3, allow the patient to wet the ears in the shower but avoid direct water contact 

    • POD 3 through 3 weeks post-op, wear the wide elastic headband constantly (24/7) except when showering 

    • 3 weeks through 6 weeks post-op, wear the wide elastic headband only at night when sleeping and when napping and when performing any physical activity that could injure the ear

      • Still, avoid strenuous activity for the first month post op 

  • Complications

  • 2009: Complications of otoplasty: a literature review

    • 2013: Complications of otoplasty (Dr. Shih) 

Pearls & Pitfalls

Links

• eMedicine: Congenital Ear Deformities

• eMedicine: Prominent Ear

• eMedicine: Otoplasty

• UTMB Grand Rounds 2010: Otoplasty and other auricular reconstruction

• YouTube (3:40) - Incisionless Otoplasty

• YouTube (4:49) - Live Surgery: Otoplasty (Ear Pinning, Ear Shaping, Ear Repair) for prominent ears

• YouTube (8:58) - VALENTE`S OTOPLASTY - A NEW TECHNIQUE

• YouTube (14:30) - Otoplasty surgery by John E. Sherman, MD

• YouTube (16:36) - 4K EAR SURGERY (Otoplasty) BIOMECHANICAL TECHNIQUE TUTORIAL, with Dr Hermann Raunig.