A, A 27-gauge needle tipped in methylene blue is used to mark the position of the planned superior and common antihelical crus on both sides of the ear. B, Exposure of the 3 eminentia of the right ear after postauricular soft tissue wedge excision. The posterior methylene blue marks are noted immediately inferior to the fossa triangularis eminence.
A narrow subperichondrial pocket is created along the length of the planned antihelical crus on the lateral face of the auricular cartilage (left ear is shown). The serrated end of an Adson-Brown forceps is inserted into the pocket and is used to abrade the lateral auricular cartilage to reduce tension and allow the creation of a permanent crease to form the new antihelical crus.
A, A No. 15 blade is used to scrape the protuberant portions of the eminentia to achieve a better conchomastoid angle result. The two inferior eminentia are abraded as indicated, with the superior eminence similarly abraded if necessary. B, Preoperative and postoperative views show the corrected conchoscaphal and conchomastoid angles.
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Markey J, Mace J, Anderson Y, Wang TD. Hybrid Cartilage-Modifying Otoplasty Technique and Outcomes. JAMA Facial Plast Surg. 2018;20(1):57–62. doi:10.1001/jamafacial.2017.1139
Is the hybrid cartilage-modifying technique a safe and effective procedure, allowing precise surgeon control of outcome?
In this observational study of 41 ears, for bilateral cases the measurements were symmetrical between ears to less than 1 mm. For unilateral cases measurements were similarly symmetrical. One patient’s ear required revision, 1 patient experienced a same-day hematoma at the surgical site, and 2 patients required debridement of an irritated suture.
The hybrid cartilage-modifying technique is safe and effective and results in a high rate of symmetry and low revision rate.
Otoplasty is performed to correct prominauris, one of the most common head and neck congenital deformities. Advances in combination hybrid approaches enable surgeons to achieve greater precision and accuracy.
To describe a hybrid cartilage-modifying approach and evaluate the procedure’s effectiveness and safety.
Design, Setting, and Participants
Medical record review including patients undergoing otoplasty by the present technique from January 2006 to December 2016 as performed by the senior author at a tertiary academic referral center. Twenty-three patients underwent 24 total procedures including both bilateral (n = 17) and unilateral (n = 7) procedures. Two procedures were revisions.
Hybrid cartilage-modifying otoplasty procedure.
Main Outcomes and Measures
Preoperative and postoperative measurements were recorded. Paired sample t testing was performed to assess changes between preoperative superior, middle, and inferior helical measurements and corresponding postoperative measurements for all operated ears. Two-tailed, independent sample t testing was performed to compare postoperative differences between right and left ears within separate superior, middle, and inferior measurements in patients undergoing bilateral otoplasty.
Twenty-four surgeries were performed on 23 patients. The mean (SD) age at surgery was 16.3 (13.6) years with 13 patients (58%) between the ages of 4 and 10 years. Preoperatively, the mean (SD) superior, middle, and inferior helical rim-to-mastoid distance of the 41 discrete ears measured 16.5 (3.1) mm, 24.1 (3.8) mm, and 19.3 (4.4) mm, respectively. Mean (SD) postoperative measurements were 12.1 (2.4) mm, 14.7 (2.5) mm, and 14.0 (2.8) mm, respectively, for mean (SD) decreases of 4.4 (2.7) mm, 9.4 (3.4) mm, and 5.3 (3.6) mm. For the 17 bilateral procedures, the mean (standard error) postoperative scores between ears measured 0.7 (0.9) mm for the superior, 0.5 (0.9) mm for the middle, and 0.2 (1.0) mm for the inferior. The unaffected ear was measured in 4 of 7 (57%) of patients undergoing unilateral otoplasty, and the mean (SD) postoperative differences between left and right ears were 1.3 (0.8) mm, 3.0 (1.2) mm, and 1.0 (0.7) mm for the superior, middle, and inferior, respectively. Preoperative-to-postoperative differences for all ears (n = 41) were significant (P < .001 for all) for superior, middle, and inferior measurements. There were no significant absolute differences identified for superior (P = .41), middle (P = .58), and inferior (P = .88) measurements regarding left vs right postoperative comparisons for bilateral otoplasties. One patient undergoing bilateral repair required subsequent revision surgery of 1 ear. Two patients developed chronic suture site irritation, and 1 patient developed a hematoma.
Conclusions and Relevance
The present technique allows multiple opportunities to adjust the auricular parameters. The results indicate a low revision rate and high degree of symmetry.
Level of Evidence
Otoplasty is a commonly performed procedure for one of the most common head and neck congenital deformities. The chief outcome goals include restoring acceptable auriculocephalic, conchoscaphal, and conchomastoidal angles and achieving a symmetric result.1
The current study describes a hybrid approach that uses cartilage-sparing and cartilage-modifying techniques to achieve precise control of auricular shape and positioning. A review of patients having undergone this technique is also presented to illustrate surgical outcomes. We first hypothesized that within-patient postoperative measurements would be significantly improved regarding helical projection from the mastoid measurements for independent regions of the superior, middle, and inferior auricle. Additionally, we hypothesized that there would be no significant difference for patients undergoing bilateral otoplasty when comparing the postoperative measurements of the left vs right superior, middle, and inferior helical projection measurements.
After obtaining university internal review board approval and patient consent, we reviewed the medical records of patients who underwent the hybrid cartilage-modifying otoplasty technique. The procedures were performed by the senior author between January 2006 and December 2016 within the Department of Facial Plastics and Reconstructive Surgery at Oregon Health and Science University (Portland). Final analyses were completed using commercially available software (SPSS version 24.0 [IBM Corporation]). Demographic data were collected including age at surgery, sex, and medical comorbidities. Surgical data including preoperative and postoperative distance from the superior, middle, and inferior auricle to the mastoid were collected. Measurements of the nonoperative ear were also collected for patients undergoing unilateral otoplasty. The change in distance from preoperative measurements to postoperative measurements was calculated for each surgery. Absolute differences between postoperative and nonoperative ears for patients undergoing unilateral otoplasty (when data were recorded) were calculated. Descriptive statistics are provided while mean (SD) and 95% CIs are reported where appropriate. P values are reported for each comparison, and statistical significance was determined using a convention .05 α-level threshold. Paired sample t testing was performed to compare within-patient preoperative and postoperative differences for the superior, middle, and inferior measurements, independent of each other, with manual Bonferroni adjustments of the α level for multiple comparisons, if needed. Mean differences (standard errors [SE]) are reported for matched pairings. Two-tailed, independent sample t testing was performed to compare postoperative differences between left and right ears across the superior, middle, and inferior measurements for bilateral otoplasty cases to assess symmetry. All operated ears were also considered regardless of whether they were bilateral or unilateral procedures (Table).
The preoperative distance of the helical rim to the lateral mastoid is measured at 3 precise points—the superior margin of the helix, the midheight helical rim, and the inferior margin. This is done on both sides for left and right comparison as well as preoperative and postoperative comparison.
The desired superior and common antihelical crus is marked along the patient’s affected lateral ear with a surgical marking pen. If the prominauris is unilateral, precise measurements can be taken from the contralateral ear and applied to the affected ear to identify appropriate points for demarcation and the subsequent crease formation. If both ears are affected, the point along the superior helix that is most projected is gently set back to the mastoid with 1 finger. The crease that forms along the scapha toward the fossa triangularis is marked with a pen in 3 to 4 points. The lateral and medial surface of the auricle is then precisely tattooed at these points with methylene blue. A 27-gauge needle tipped with methylene blue is inserted from lateral to medial through the auricular cartilage. Before the needle is removed from medial to lateral, it is retipped with methylene blue to leave surgically precise marks both on insertion and removal to mark both sides. The medial marking is performed to allow for visualization of the desired neo-antihelical crus following the posterior incision for subsequent cartilage-sparing manipulation. Depending on preferred antihelical length, 4 to 5 marks are required.
A postauricular skin and soft tissue wedge excision is then performed. The incision is shaped like an 8, with the narrowest point centered over the concha cymba eminence posteriorly to avoid a “telephone ear” deformity. Monopolar cautery is used to remove the skin and soft tissue wedge to an auricular supraperichondrial plane anteriorly. The bulk of the subcutaneous tissue and posterior auricularis muscle removed is centered over the lateral skull rather than posterior ear to ensure the ear can settle posteriorly when completed.
The 3 eminentia of the posterior auricle—the fossa triangularis (superior), the concha cymba (middle), and concha cavum (inferior)—are now clearly visible (Figure 1). The posterior methylene blue marks are noted immediately inferior to the fossa triangularis eminence. Three 2-mm incisions through the cartilage are performed perpendicular to the long axis of the desired antihelical crus. Scissors are used to free a subperichondrial pocket along the lateral face of the auricular cartilage. The pocket should extend superoanteriorly nearly to the margin of the ear and should be approximately 6 to 8 mm in width both to allow adequate entry for softening the lateral cartilage and to free the lateral auricular skin to accommodate subsequent stretching over the newly formed lateral convexity. Then the serrated end of an Adson-Brown forceps is placed into the pocket parallel to the planned antihelical crease. The forceps is used as a rasp to abrade the cartilaginous surface to encourage the subsequent crease formation (Figure 2).
Next, the 3 eminentia are softened to encourage their lying flat against the mastoid. This is done by scraping or rasping to thin the protuberant portions with a No. 15 blade from superior to inferior. The eminentia are adequately abraded when they are soft and less elastic and lie flat against the mastoid at the desired angle (Figure 3). This is best determined by both direct visualization and palpation of cartilage strength. The ear is then pressed gently against the lateral skull and the middle and inferior measurements are repeated to ensure symmetry. Some additional refinement can be performed with tightening of the antihelical sutures and upon skin closure. Repeating measurements with each significant adjustment is vital to ensuring one will obtain final symmetry and patient satisfaction.
Next, Mustarde-type 4-0 polydioxanone sutures are placed: the sutures are 16 mm apart, 8 mm on either side of the marked line, 1 cm in width, and separated from one another by approximately 2 mm. Three 4-0 polydioxanone retention sutures are then placed from the eminentia to the periosteum overlying the mastoid. The needle should travel approximately 1 cm subcutaneously on the anterior face of the auricle at the deepest point of the eminentia without buttonholing the lateral surface. The retention sutures are tightened carefully.
Final measurements conducted in an identical fashion to the preoperative measurements are then repeated and recorded to ensure adequate positioning. If a symmetric result is achieved, the wound is closed with 5-0 Vicryl Rapide absorbable suture (Ethicon US, LLC).
Twenty-four surgeries were included involving 23 patients after 2 procedures were excluded for missing measurements. The mean (SD) age at surgery was 16.3 (13.6) years with 13 patients (58%) between the ages of 4 and 10 years. Seventeen of the 24 surgeries (71%) were bilateral otoplasties. Two patients received revision otoplasties: 1 who underwent primary otoplasty at a separate institution, and 1 who underwent primary bilateral otoplasty and revision unilateral otoplasty by the senior author. Both procedures were included for analysis.
The mean (SD) preoperative measurements for the 41 ears were 16.5 (3.1) mm, 24.1 (3.8) mm, and 19.3 (4.4) mm at the superior, middle, and inferior points, respectively (Table). Postoperative measurements were 12.1 (2.4) mm, 14.7 (2.5) mm, and 14.0 (2.8) mm for an average decrease of 4.4 (2.7) mm, 9.4 (3.4) mm, and 5.3 (3.6) mm from preoperation to postoperation.
Seventeen patients underwent bilateral otoplasty, with a mean (SE) postoperative absolute difference between left and right ears measuring 0.7 (0.9) mm, 0.5 (0.9) mm, and 0.2 (1.0) mm for the superior, middle, and inferior region, respectively. Four patients undergoing unilateral otoplasty included measurements of the unaffected ear for comparison (Table). The 3 remaining patients undergoing unilateral otoplasty did not have unaffected ear measurements included in the record. The postoperative measurements at the superior, middle, and inferior points were within a mean (SD) of 1.3 (0.8) mm for the superior, 3.0 (1.2) mm for the middle, and 1.0 (0.7) mm for the inferior when comparing the postoperative ears to the ears that did not undergo surgery.
Total study follow-up ranged from 0 to 35 months. The mean (range) follow-up was 234 (111–358) days with a median of 83 days. Eight patients (35%) had a greater than 6-month follow-up while 14 patients (61%) had a greater than 2-month follow-up.
Preoperative to postoperative differences when all ears were included (n = 41) were significant for superior (P < .001), middle (P < .001), and inferior (P < .001) measurements, even after Bonferroni adjustments for multiple comparisons. No significant differences were identified when assessing laterality between postoperative left and right ears for patients undergoing bilateral otoplasty (P = .41, P = .58, P = .88 for superior, middle, and inferior measurements, respectively) (Table).
Two patients required removal of persistent conchomastoid sutures. The first underwent bilateral otoplasty and, while 1 incision healed without complication, the other experienced persistent intermittent drainage and tenderness. Five months following the initial procedure, a nylon suture was removed from the incision, which subsequently healed without redevelopment of prominauris. The second patient also underwent bilateral otoplasty and experienced unilateral persistent scabbing and mild erythema of the incision. Seven months after the procedure, the patient underwent suture removal. The patient experienced gradual redevelopment of prominauris and required unilateral revision otoplasty 2 years following the initial surgery. Lastly, 1 patient experienced a surgical site hematoma requiring local evacuation the night of surgery.
McDowell2 noted in 1968 that the lateral edge of the helix to the mastoid should be 10 to 12 mm at the superior border, 16 to 18 mm in the middle, and 20 to 22 mm near the lower border. The most common etiology for deviation from this ideal is secondary to an unfurled antihelix with the second most common being an excessively deep conchal bowl.3
To recreate the antihelical fold, cartilage-cutting and cartilage-preserving suture techniques have been described. Cartilage-cutting techniques are currently used for thickened, unpliable auricular cartilage that requires sharp dissection to better control positioning. Ozturan and colleagues4 found that cartilage-cutting techniques may be more applicable in older patients, as cartilage stiffens and malleability decreases with age. Converse and colleagues5 described fixating a tubed cartilaginous strip with sutures to set the superior ear at a preferred distance from the mastoid. Pitanguy and colleagues6 detailed making parallel full-thickness incisions in the region of the desired antihelix to create a cartilage strip “island.” The underlying cartilage edges are then sutured together deep to the island to project the strip laterally to create the antihelical fold. Farrior7 described a combination of full- and partial-thickness incisions to recreate the superior fold while minimizing angular external deformities.
While effective, cartilage-cutting techniques have been criticized for creating noticeable sharp contours rather than smooth anatomic folds. Cartilage-preserving techniques gained popularity as a way to minimize this issue. Mustarde8 described placing horizontal mattress sutures along the desired antihelical fold without incising the cartilage. Stenstrom9 described abrading the anterior face of the desired fold to enable posterior folding of the cartilage. Since then, scalpels, task-specific rasps, bipolar cautery, diamond burr drills, and carbon dioxide lasers have all been described for cartilage scoring. The technique described here uses the readily available Adson-Brown forceps to soften the anterior face prior to suture manipulation.
Finally, among the cartilage-preserving techniques are approaches requiring no incision. Fritsch10 describes a technique in which a hypodermic needle is used to transdermally abrade the cartilage at the site of the desired antihelical fold. Percutaneous Mustarde-type sutures are then placed in the precise aperture of the prior suture’s placement to bury the knot to avoid external suture visibility.
The second-most common indication for prominauris correction is a deep conchal bowl. This can also be corrected using cartilage-cutting and/or cartilage-preserving techniques. Cartilage excisional techniques were found in early descriptions and are rarely used today. Furnas3 in 1968 detailed the use of conchomastoid retention with permanent sutures. Sie and Ou11 further described recreating the deficient helical root by placing additional sutures at the posterior and superior concha cavum eminence.
The technique described here employs a hybrid cartilage-preserving approach. The posterior eminentia corresponding to the fossa triangularis, concha cymba, and concha cavum are softened with repeated abrading performed with the sharp edge of a fresh scalpel. This allows additional control of cartilage stiffness while minimizing the risk of undesired cartilage malformation. By removing discs or placing full-thickness incisions in the eminentia, the surgeon performing the procedure unnecessarily loses a degree of control in the cartilage sculpting, as well as possible formation of a visible crease in the area of full-thickness cartilage resection. Posterior retention sutures are then placed to achieve a symmetric distance from the mastoid while avoiding telephone or reverse telephone deformities. One possible complication that must be avoided while placing a conchomastoid suture is displacement of the concha and subsequent obstruction of the lateral external auditory canal. To avoid this complication, Werdin and colleagues12 described a technique involving the resection of a rim of conchal cartilage around the lateral external auditory canal.
The current technique begins with measuring the distance from the lateral mastoid to the superior, middle, and inferior margins of the auricle—on both the operative and nonoperative side, if applicable. The goal auricular shape should be symmetric to the contralateral side, and recording objective measurements before, during, and after the correction is essential. The technique presented here provides multiple opportunities to make small, sequential adjustments to the final shape. The initial adjustment is made to the desired antihelical crease with horizontal mattress sutures and then the auriculocephalic, conchoscaphoid, and conchomastoid angles are sequentially manipulated. The auricular projection distance is further refined when the 3 eminentia are sutured to the mastoid. The degree of cartilage weakening is also done in a precise, graduated fashion. For stiffer, inelastic cartilage, a greater degree of abrading with the Adson-Brown forceps at the antihelical fold and scalpel at the eminentia is required to ensure easy flattening against the mastoid. For soft cartilage, little to no abrading is required. The surgeon should travel from conservative cartilage modification to more aggressive modification to ensure no unnecessary cartilage is removed.
The complications noted in the patient cohort included persistent irritation at the wound site of permanent suture placement and 1 postoperative hematoma. Partly because of the former complication, the senior author has altered his practice from using nylon suture to create the antihelical crease to slowly absorbable polydioxanone suture. No long-term redevelopment of prominent ears has, as yet, been identified following this change in practice. Furthermore, the presently described technique has been performed on patients of greatly varying ages without having to adjust for cartilage pliability and fragility. By maintaining a technique that allows for gradual adjustment and continual measurement, a successful result can be achieved no matter the variations in age or anatomy.
The study design presents predictable limitations. The described technique was performed by 1 surgeon at 1 academic center, limiting its generalizability. The patient consecutive series does not directly compare techniques or patient populations, but rather illustrates the efficacy of the technique in this setting.
A combination of cartilage modification with preservation enables the otoplasty surgeon to precisely achieve an ideal result without harm. Using suture techniques with careful cartilage abrasion is a safe and replicable approach.
Corresponding Author: Jeffrey Markey, MD, Facial Plastic & Reconstructive Surgery and Otolaryngology-Head & Neck Surgery, New York University Medical School, 240 E 38th St, 14th Floor, New York, NY 10016 (firstname.lastname@example.org).
Accepted for Publication: June 4, 2017.
Published Online: November 22, 2017. doi:10.1001/jamafacial.2017.1139
Author Contributions: Dr Markey 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: Markey, Wang.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Markey, Mace, Anderson.
Critical revision of the manuscript for important intellectual content: Mace, Wang.
Statistical analysis: Markey, Mace, Anderson.
Administrative, technical, or material support: Mace, Anderson.
Study supervision: Wang.
Conflict of Interest Disclosures: None reported.
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