A, Protrusion evident in the coronal plane. B, Predominant protrusion in the axial plane. C, Protrusion of the remaining auricle, with inherent shape causing a concavity.
Dissection allows for better control of the axial angular protrusion of the lobule by advancement of the posterior flap superiorly. A, Illustration; B, anatomic cadaver dissection; C, clinical intraoperative image.
Left panels are illustrations; middle panels, cadaver dissections; right panels, intraoperative clinical images. A, Suture dissection and transection of the lobular soft-tissue insertions via the fillet technique; the extent of this dissection may be modified intraoperatively as dictated by the deformity. B, After dissection, the anterior and posterior surfaces of the lobule may move and advance freely in relation to each other. C, Advancement of the posterior flap allows for correction of angular protrusion in both the axial and the coronal plane by anterior to posterior and superior to inferior advancement, respectively. Inferior to superior advancement also allows for effective correction of lobular concavity.
A, Illustration; B, photograph.
A, Visual analog scores (VAS) for preoperative and postoperative evaluations of study participants. B, Mean preoperative and 3-month postoperative VAS scores. In the VAS scale, 1 indicates very good; 2, good; 3, satisfactory; 4, unsatisfactory; 5, poor; and 6, very poor.
Sadick H, Artinger VM, Haubner F, Gassner HG. Correcting the Lobule in Otoplasty Using The Fillet Technique. JAMA Facial Plast Surg. 2014;16(1):49-54. doi:10.1001/jamafacial.2013.2146
Correction of the protruded lobule in otoplasty continues to represent an important challenge. The lack of skeletal elements within the lobule makes a controlled lobule repositioning less predictable.
To present a new surgical technique for lobule correction in otoplasty.
Design, Setting, and Participants
Human cadaver studies were performed for detailed anatomical analysis of lobule deformities. In addition, we evaluated a novel algorithmic approach to correction of the lobule in 12 consecutive patients.
Otoplasty with surgical correction of lobule using the fillet technique.
Main Outcomes and Measures
The surgical outcome in the 12 most recent consecutive patients with at least 3 months of follow-up was assessed retrospectively. The postsurgical results were independently reviewed by a panel of noninvolved experts.
The 3 major anatomic components of lobular deformities are the axial angular protrusion, the coronal angular protrusion, and the inherent shape. The fillet technique described in the present report addressed all 3 aspects in an effective way. Clinical data analysis revealed no immediate or long-term complications associated with this new surgical method. The patients’ subjective rating and the panel’s objective rating revealed “good” to “very good” postoperative results.
Conclusions and Relevance
This newly described fillet technique represents a safe and efficient method to correct protruded ear lobules in otoplasty. It allows precise and predictable positioning of the lobule with an excellent safety profile.
Level of Evidence
Correction of the lobule during otoplasty continues to represent a challenge.1 The lack of skeletal elements within the lobule makes controlled repositioning of the lobule more difficult and less predictable. Techniques that rely on long-term tension such as anchoring sutures may be associated with long-term recurrence because of the soft-tissue memory of the lobule and a possible cheese wire effect of the retaining suture.2- 5 Moreover, to our knowledge, comprehensive anatomic analysis of lobular deformities has never been undertaken. It appears that the angle of protrusion of the lobule may be analyzed in more detail by studying the angle of protrusion separately both in the axial and in the coronal plane. Even more importantly, the lobule has an inherent shape that is determined by its soft-tissue configuration.
Current techniques include resection or suture repositioning of the cauda helicis.6,7 Also, suture techniques have been described in which the soft-tissue core of the lobule is grasped and pulled medially by anchoring the suture to the posterior surface of the conchal bowl.2,8,9 Both modification of the cauda helicis and lobular anchoring stitches address the angle of protrusion of the lobule mostly in the coronal plane. These techniques do not address the inherent shape of the lobule itself. Because of the limited anchoring provided by the points of suture attachment within the lobular soft tissue, the sutures may actually cause or accentuate concavities of the lobule by distortion. They are certainly not able to correct inherent lobular deformities in a controlled fashion.
Another established technique is posterior fusiform or Y-shaped skin resection.10 The fusiform skin resection addresses angulation of the lobule mostly in the axial plane. The Y-shaped excision may add some correction in the coronal plane as well. However, skin resection may be regarded as less than optimal because of the resulting scar and because of the nonphysiologic nature of the procedure. Moreover, it does not correct the inherent shape of the lobule. In some cases, skin resection techniques may actually overaccentuate a preexisting concavity of the lobule.
The present study includes both a human cadaver model and a retrospective clinical review. The study was approved by our institutional review board, and all identifiable patients or their parents or guardians provided written informed consent.
A total of 4 fresh frozen human cadavers were used to better understand and analyze all anatomic components contributing to lobular deformity. Dissections were performed using headlight illumination and loupe magnification with standard instrumentation. Key findings and surgical maneuvers were documented using macrophotography (Nikon D90, Sigma 17 to 70). In all specimens, a standard retroauricular incision and dissection of the conchal bowl down to the retroauricular sulcus was performed in the supraperichondrial plane.
Subsequently the lobule was dissected in a slowly progressive manner, and each step of dissection was analyzed for its effect on the form of the lobule. First the cauda helicis was identified and freed. Next, various movements and manipulations of the cauda helicis were analyzed. The effect of repositioning of the cauda helicis was found to be somewhat limited. It allowed for inward rotation of the lobule mainly in the coronal angle. More accentuated inward rotation of the cauda helicis caused dimpling and concave deformity of the lobule. It therefore became obvious that overaccentuated repositioning of the cauda helicis alone would be insufficient to correct more pronounced lobular deformities.
The dissection was then taken further posteriorly, and all soft-tissue attachments along the conchal bowl all the way down to the base of the antitragus were released. This maneuver achieved a large degree of additional mobility of the lobule, allowing for more substantial apposition of the lobule in the axial angle. However, the inherent shape observed in some lobules could not be addressed with this maneuver. Lobules with inherent concavity where the tip of the lobule protruded laterally because of inherent soft-tissue attachments remained unchanged.
The next step of dissection was then careful soft-tissue release of the lobular soft tissue. This was performed under direct microscopic vision using scissors. The lobule was divided parallel to its outer surfaces using sharp dissection. This resulted in a partial filleting of the lobule and allowed very effective reshaping of the lobule and very precise control of the angle of protrusion in both the axial and the coronal plane. This could simply be achieved by advancement of the posterior flap superiorly to control the coronal angle as well as posteriorly to control the axial angle. The length of the filleting division of the lobule allowed for effective control of the inherent lobular shape.
This stepwise approach was then repeated in 3 consecutive specimens (6 ears) and resulted in the following algorithm (1) retroauricular incision and dissection of the conchal bowl; (2) dissection of the cauda helicis; (3) dissection posteriorly and inferiorly toward the base of the antitragus; (4) successive filleting of the lobule; and (5) advancement and fixation of the posterior lobular flap. These anatomic observations confirmed our surgical observations and experience.
The algorithmic approach to lobular correction is based on a detailed analysis of lobular deformity. Three components were analyzed. First, the angle of lobular protrusion along the axial plane was studied. Second, the protrusion of the lobule along the coronal plane was analyzed in relation to the protrusion of the entire auricle. It must be noted that the correction of the lobule should parallel the correction of the auricle to achieve a harmonious result. Third, the inherent shape of the lobule was analyzed. Not infrequently, a concavity of the lobule causes protrusion of the tip of the lobule. This may result in an overaccentuated correction by pulling the base of the lobule with anchoring sutures too far medially, which may actually overaccentuate the concave deformity.
The stepwise technique of correction is shown in Figures 1, 2, 3, 4, and 5. Figure 1 illustrates a lobule with predominant protrusion in the coronal plane (Figure 1A) and in the axial plane (Figure 1B). These deformities often parallel the protrusion of the remaining auricle. A deformity of the inherent shape of the lobule should be corrected at the same time to achieve a harmonious result (Figure 1C).
Figure 2 illustrates dissection along the inferior conchal bowl up to the antitragus and release of soft tissue attachments. This allows for better control of the axial angular protrusion of the lobule by advancement of the posterior flap superiorly. Figure 3 shows dissection and transection of the lobular soft-tissue insertions via the fillet technique. At the intraoperative point illustrated in Figure 3B, the anterior and posterior surfaces of the lobule may be moved and advanced freely in relation to each other. The extent of this dissection may be modified intraoperatively as dictated by the deformity. Advancement of the posterior flap allows for correction of angular protrusion in both the axial and the coronal plane by anterior to posterior and superior to inferior advancement, respectively (Figure 3C). Inferior to superior advancement also allows for effective correction of lobular concavity. Figure 4 shows the final positioning of the lobule after correction.
The dissection of the lobule in some cases required transsection of auricular piercings. Written informed consent was obtained from all patients or their parents or guardians prior to the procedure. The anchoring suture was completed using a 4-0 nylon suture (Seralon; Serag-Wiessner KG/Germany). The remainder of the auricle was corrected in standard fashion. We avoided all cartilage incisions and typically combined resection of postauricular muscle, anterior percutaneous needle scoring technique of the antihelix, Mustardé sutures, and conchal setback sutures. The postauricular skin incision was closed with 5-0 Monocryl resorbable sutures (Ethicon Inc). The ear was dressed with a mold formed of sterile cotton and Vaseline petroleum jelly (Unilever) and a light pressure dressing over fluffs. This dressing was left on overnight and, in most cases, removed the following morning and replaced by a headband that was worn for 10 days.
A total of 4 cadavers (eight ears) were dissected. The first 2 ears were used to understand the various soft-tissue attachments of the lobule and their biomechanical behavior. In these first 2 dissections, the position and shape of the lobule were determined, and important soft-tissue attachments were identified. These included attachments to the cauda helicis, to the inferior aspect of the conchal bowl all the way to the antitragus, and in some cases to the transition to the mastoid bone. More importantly, soft-tissue attachments and insertions between the anterior and the posterior surface of the lobule maintained an important shape memory effect. Release of these insertions allowed for controlled correction of lobular deformities in 3 aspects: the angular axis, the coronal axis, and the inherent soft-tissue shape. Correction of the soft-tissue shape required a varying extent of dissection. Pronounced concavities of the lobule, and in some cases convexities, may require dissection of two-thirds of the length of the lobule.
In the remaining 3 specimens (6 ears) these findings were reproduced and confirmed. Moreover, the surgical techniques described herein were studied and modified in minor detail. These surgical maneuvers were found to allow for consistent correction of the lobule in all described aspects.
The described surgical modifications were integrated into our surgical routine over time. For the present study we reviewed the 12 most recent consecutive patients (operated on by the senior author, H.G.G.) available with at least 3 months of follow-up and photographic documentation. Inclusion criteria were as follows:
Otoplasty and lobuloplasty performed
Lobuloplasty performed using the fillet technique as described herein
Follow-up for at least 3 months
Preoperative and postoperative photographic documentation available
Among the 12 patients, follow-up ranged from 3 to 12 months. All patients and/or their parents were noted to be very satisfied with the result. Postsurgical results were also independently reviewed by a panel of noninvolved experts. These individuals were 3 medical students who evaluated the preoperative and postoperative photographs and rated the results on a 6-point visual analog scale (VAS) (1, very good; 2, good; 3, satisfactory; 4, unsatisfactory; 5, poor; 6, very poor). As presented in Figure 5A, the assessors were asked to rate preoperatively and postoperatively the overall global appearance. They were not informed about the surgical details, and they had no specialized interest in otoplasty.
Figure 5B represents the average preoperative and postoperative VAS score. The preoperative VAS score averaged 5.33 (range, 4-6). The postoperative VAS score averaged 1.25 (range, 1- 2). Average duration of the otoplasty including lobule correction on both sides per patient was 104 minutes. Ten of 12 patients were admitted to the hospital and observed per routine. Two of 12 patients were treated in an outpatient setting. No complications were noted. No hematoma and no extensive swelling particularly of the lobule were observed or documented.
Lobuloplasty is regarded as a more difficult aspect of otoplasty. Ideal results are challenging to achieve because of various factors. First, a comprehensive and practical system of lobular analysis appears to be lacking. We believe that the system used in our study is simple enough for routine use yet comprehensive enough to guide the physician in selecting the appropriate surgical steps. It is important to address the 3 aspects of lobular deformity: axial angular protrusion, coronal angular protrusion, and inherent shape.
Second, lobuloplasty is challenging because the shape and position of the lobule is determined by soft-tissue attachments and not by bony or cartilaginous skeletal elements. Therefore, modification of the shape must rely on soft-tissue mass movements rather than repositioning of skeletal elements. The methods of analysis and correction described heretofore not have not completely accounted for this characteristic.4,6,7,9
We present an alternative technique that differs in important aspects from those previously described in the literature. The fillet technique described herein allows for complete release of all soft-tissue insertions that maintain the deformity. The lobule in its entirety is divided along its longitudinal axis into 2 halves, enabling a shearing movement in opposing directions. This movement can be adapted and controlled to allow for predictable repositioning of the lobule in all 3 dimensions: axial angular protrusion, coronal angular protrusion, and inherent shape.
This technique differs in important aspects from the lobular anchoring stitch described by Siegert.9 The Siegert method encompasses the placement of an absorbable mattress suture through the prominent soft-tissue edge of the lobule and the conchal bowl. It changes shape and position of the lobule with suture tension, but does not release the soft-tissue memory of the lobule along its entire length or allow for rearrangement of the lobular soft tissues to alter its inherent shape.
We believe that the fillet technique adds versatility over established techniques. It allows for control in all 3 dimensions (axial, coronal, and inherent shape). The degree of soft-tissue release may be adapted in a “cut as you go” manner until all relevant soft-tissue memory has been released. The suture subsequently placed only serves the purpose of immobilizing the lobule in the new position until this position is fixated by scar tissue. No tension is applied to the suture material, and fine, quickly resorbable suture material is sufficient for this purpose.
The authors recommend the newly described technique for correction of lobular deformities. The described technique must be based on comprehensive anatomic analysis, which includes the analysis of the angles of protrusion in both the coronal and the axial plane as well as analysis of the inherent shape of the lobule.
Corresponding Author: Holger G. Gassner, MD, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, University of Regensburg, Franz-Josef-Strauss-Allee 11, 93042 Regensburg, Germany (firstname.lastname@example.org).
Submitted for Publication: July 19, 2013; accepted August 8, 2013.
Published Online: November 21, 2013. doi:10.1001/jamafacial.2013.2146.
Author Contributions: Dr Gassner had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Artinger, Gassner.
Acquisition of data: Sadick, Haubner.
Analysis and interpretation of data: Sadick, Gassner.
Drafting of the manuscript: Sadick, Gassner.
Critical revision of the manuscript for important intellectual content: Sadick, Artinger, Haubner, Gassner.
Statistical analysis: Sadick.
Obtained funding: Gassner.
Administrative, technical, or material support: Sadick, Artinger, Haubner, Gassner.
Study supervision: Gassner.
Conflict of Interest Disclosures: The nonprofit organization Facial Plastic Surgery Europe eV provided an unrestricted educational grant to finance the artwork for the manuscript.
Role of the Sponsor: Facial Plastic Surgery Europe eV had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: Markus Voll, a professional graphic designer, created the artwork for the manuscript. He was compensated for his contribution.