Chapter 84. Aesthetic otoplasty (bat ear correction










869
84
Aesthetic otoplasty (bat ear correction)
LEO FA STASSEN
INTRODUCTION
Children frequently present, or their parents or friends
advise them to come, complaining of ‘not liking their ears’.
eir ears are too prominent, too big, too small, unusual
shapes, unusual positions and, because of them, they are
being teased. e problem is made worse for the child
because the ears approach adult size early in the grow-
ing face. e psychological problems associated with this
deformity are signicant and oen only come to light aer
discussion (Figure 84.1).
ese defects are very common (3%–5%) and relatively
easily corrected. e usual problem is lack of denition of
the anti-helical fold and/or conchal overdevelopment. A
choice of techniques is necessary. ere is not one tech-
nique for all cases although it is best to rely mainly on one
technique to begin with. ere are so far over 100 methods
described. Ely, in 1881, was the rst to describe a technique
for correction of prominent ears.
PRE-OPERATIVE ASSESSMENT
e most important aspect in management is assessment.
Compare le with right and with normal population (n)
for racial group from in front, behind and above:
Level of ear (n = level with eyebrow): high, normal and
low
Angle between ear and mastoid process >30° is
prominent
Distance between helical rim and skull (n = 1–2 cm)
Vertical axis: 20°–30° posteriorly (lobule to dome)
Vertical height: approximately 56.5 cm (males >
females and right slightly > le)
Width = 55% of length
Conchal size and depth
Helix and antihelix form: poor, decient, normal and
excessive
Scapha: size and form
Cartilage: quality, thickness and rmness
Presence or absence of Darwinian tubercles, sinuses
and pre-auricular tags
Photographs front, rear and individual ear ± models for
dicult cases
e surgeon should know and understand the anatomy
of the normal ear (Figure 84.2) and its three-dimensional
position (Figure 84.3).
e ear has a very rich blood supply via the super-
cial temporal, posterior auricular and occipital vessels.
e sensory nerve supply is via the auriculotemporal,
the lesser occipital and the greater auricular nerves,
and the concha also receives sensory innervation via
the vagus nerve. e vascular supply and innervation
are such that the procedures can easily be carried out
under local anaesthetic, local anaesthetic and sedation
or general anaesthesia (which should be used for chil-
dren <14years). e aim is to achieve ears of equal and
normal prominence and shape with a so gentle appear-
ance and no evidence of breaks or pinch eects. Ideally,
CONTENTS
Introduction 869
Pre-operative assessment 869
Timing of correction 871
Techniques 871
Post-operative care 874
Complications 875
Suggested readings 875

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86984Aesthetic otoplasty (bat ear correction)LEO FA STASSENINTRODUCTIONChildren frequently present, or their parents or friends advise them to come, complaining of ‘not liking their ears’. eir ears are too prominent, too big, too small, unusual shapes, unusual positions and, because of them, they are being teased. e problem is made worse for the child because the ears approach adult size early in the grow-ing face. e psychological problems associated with this deformity are signicant and oen only come to light aer discussion (Figure 84.1).ese defects are very common (3%–5%) and relatively easily corrected. e usual problem is lack of denition of the anti-helical fold and/or conchal overdevelopment. A choice of techniques is necessary. ere is not one tech-nique for all cases although it is best to rely mainly on one technique to begin with. ere are so far over 100 methods described. Ely, in 1881, was the rst to describe a technique for correction of prominent ears.PRE-OPERATIVE ASSESSMENTe most important aspect in management is assessment. Compare le with right and with normal population (n) for racial group from in front, behind and above:• Level of ear (n = level with eyebrow): high, normal and low• Angle between ear and mastoid process >30° is prominent• Distance between helical rim and skull (n = 1–2 cm)• Vertical axis: 20°–30° posteriorly (lobule to dome)• Vertical height: approximately 5–6.5 cm (males > females and right slightly > le)• Width = 55% of length• Conchal size and depth• Helix and antihelix form: poor, decient, normal and excessive• Scapha: size and form• Cartilage: quality, thickness and rmness• Presence or absence of Darwinian tubercles, sinuses and pre-auricular tags• Photographs front, rear and individual ear ± models for dicult casese surgeon should know and understand the anatomy of the normal ear (Figure 84.2) and its three-dimensional position (Figure 84.3).e ear has a very rich blood supply via the super-cial temporal, posterior auricular and occipital vessels. e sensory nerve supply is via the auriculotemporal, the lesser occipital and the greater auricular nerves, and the concha also receives sensory innervation via the vagus nerve. e vascular supply and innervation are such that the procedures can easily be carried out under local anaesthetic, local anaesthetic and sedation or general anaesthesia (which should be used for chil-dren <14years). e aim is to achieve ears of equal and normal prominence and shape with a so gentle appear-ance and no evidence of breaks or pinch eects. Ideally, CONTENTSIntroduction 869Pre-operative assessment 869Timing of correction 871Techniques 871Post-operative care 874Complications 875Suggested readings 875 870 Aesthetic otoplasty (bat ear correction)Figure 84.1 Patient with prominent ears.Superior andinferior cruraHelixScaphoidfossaAuriculartubercleConchaAnteriorhelixTragusLobule(b)(a)Figure 84.2 (a and b) Normal ear.(a)(b)Level of eyebrow5–6.5 cmLB3–3.5 cm20°(c)Figure 84.3 (a through c) Three-dimensional ear position. Techniques 871size should be equal, but not necessarily so. It is promi-nence that is more obvious to the on-looker rather than size (Figure 84.4).TIMING OF CORRECTIONere is good evidence now that, if the deformity is obvious in a child at birth, it can be corrected by the application of ear moulds held in place for a month. e cartilage can be moulded signicantly and permanently at this stage. Most prominent ears are not detected, however, until later.e next best time to correct the deformity is when the child is older (>14 years), under local anaesthetic and seda-tion, unless the deformity is obvious and causing psychologi-cal problems and then the ears should be corrected at the age of 5 years before the child starts school. ere is no indication to correct the deformity surgically before the age of 5 years.TECHNIQUESere are multiple techniques: they must eliminate tension and le and right ears should be exposed and symmetry obtained.Mustarde techniqueis is a very simple, ecient and reliable technique for the inexperienced surgeons, but does not address con-cha or scapha problems and oen gives an unnatural and poorly dened appearance (Figure 84.5).Converse techniqueis is a fairly complicated but excellent aesthetic technique involving incising, mobilizing and deforming the cartilage with sutures to develop an anti-helical rim with prominent superior and inferior crura (Figure84.6).(a)(b)Figure 84.4 (a) Right normal ear; (b) left ear following exci-sion of lesion 3 × 3 cm.(a)(b)Figure 84.5 (a and b) Mustarde technique. 872 Aesthetic otoplasty (bat ear correction)Furnas techniqueis technique involves creating space posterior to the concha to allow the concha to be pinned back with-out the cartilage bulging forward and occluding the external auditory meatus. It requires two stitches of non- resorbable material to be placed between the peri-chondrium of the concha and periosteum of the mastoid (Figure 84.7).Stark and Saunders techniqueis technique is the mainstay of the author’s management supported by the Furnas conchal–mastoid suture.Both ears are prepared with an antiseptic and exposed (Figure 84.8). e proposed antihelix and superior and inferior crura and their junction are tattooed with the use of a 22G green needle (Figure 84.9).A dumb-bell ellipse of skin is outlined in the post- auricular area; the amount of skin to be excised is proportional to the prominence of the ears and can be judged by folding back the ear to simulate the proposed ear position. is should be excised mainly from the ear aspect (Figure84.10).When the ear is folded back into its proposed position, feel the maximum area of resistance and look to see if the external acoustic meatus has been compromised by the conchal cartilage bulging forward. Outline the areas of excess tension. If the conchal cartilage is bulging forward, a Furnas suturing technique is required.Inltrate the post-auricular area with 2% lignocaine and 1:80,000 epinephrine (adrenaline). e dumb-bell ellipse is excised and the post-auricular muscle identied and preserved (Figure 84.11).Dissection is continued in a subperichondrial plane until the tattoo marks plus 5 mm are visible. epro-posed antihelix and superior and inferior crura are Figure 84.7 Furnas technique.Figure 84.8 Both ears exposed.(a)(b)Figure 84.6 (a and b) Converse technique. Techniques 873drawn on the cartilage. An acrylic or diamond burr is used to weaken a 1-cm area simulating the crura and antihelix (Figure 84.12).e cartilage is weakened until the ear can be easily bent back with no tension and no sharp ridge. Attention needs to be paid especially to the helical tail and antitra-gus which may require further trimming (burr or knife) to prevent the lobule protruding (Figure 84.13).e ear is allowed to lie freely and then gently placed in its new position to allow the surgeon to decide the most advantageous position for the two to four holding sutures. e number of sutures is dependent on the extent of the original deformity. e proposed holding suture sites are outlined on the anterior ear lateral to the proposed antihe-lix. A 2–3-mm incision with a No. 15 scalpel blade is made down to the cartilage and then, with scissors, the cartilage is gently cleaned (Figure 84.14).For each external incision, a 3/0 clear nylon suture is then passed from the retro-auricular dissection through the car-tilage and then back again, with a millimetre bite of carti-lage. is technique avoids xation to the overlying skin.e need for a mastoid conchal stitch is now decided. It is best to place at least one of these and, if placed, it will involve dissecting the posterior auricular muscle free from its auricular attachment to create space for the conchal ret-ropositioning. e ear is held in its proposed position and the mastoid fascia marked to allow the holding stitches to get the best purchase and best direction of support. e holding stitches are used to pick up mastoid fascia Figure 84.9 Ear markings.Figure 84.10 Dumb-bell skin excision.Figure 84.11 Post-auricular dissection. 874 Aesthetic otoplasty (bat ear correction)(and periosteum). e attachment to the fascia should be tested by traction on the suture before the nal position is accepted (Figure 84.15).e sutures are then clipped and the other ear is pre-pared. In unilateral cases, the holding sutures are tight-ened until the ear is slightly over-reduced. In bilateral cases both ears are reduced, one suture at a time and again slightly over reduced (Figure 84.16).e post-auricular incision is closed with an inter-rupted subcuticular resorbable suture, the skin with inter-rupted (or continuous) 4/0 nylon. Bupivacaine 0.5% (2 mL) is inltrated into the retro-auricular area.POST-OPERATIVE CAREe wound and the three stab wounds are liberally dressed with chloramphenicol eye ointment. A proavine wool dressing is applied just to support the posterior of the ear and also to cover and shape the lateral surface of the ear. A crepe dressing in the form of a mastoid-like bandage is applied which is kept in situ for 7 days (Figure 84.17).Analgesics are prescribed and the patient told to attend if moderate pain is experienced. A support dress-ing, such as a hairband or a knitted hat, is then worn at night for a further 2–3 weeks. e nal result is shown in Figure 84.18.Figure 84.13 Weakening of cartilage to allow a tension-free ear position.Figure 84.14 External ear incisions.Figure 84.12 Burr to weaken cartilage. Suggested readings 875COMPLICATIONSe most common complication is relapse, usually owing to an inappropriate technique or suture slippage. is warrants recorrection. Inappropriate placement of sutures can lead to the deformity known as telephone ear with the mid portion of the ear pinned back and prominence of the superior and inferior aspects of the ear. e most serious complications are chondritis, haematoma and infection. Haematomas require immediate drainage. Infection requires drainage and antibiotics. Haematoma and infec-tion can lead to severe destruction and distortion of auric-ular cartilage, correction of which can be very dicult.SUGGESTED READINGSBradbury ET, Hewison J and Timmons MJ. Psychological and social outcome of prominent ear correction in children. Br J Plast Surg. 1992; 45: 97–100.Brent B. Auricular repair with autogenous rib cartilage gras: Two decades of experience with 600 cases. Plast Reconstr Surg. 1992; 90: 355–374.Converse JM. A technique for correction of lop ears. Plast Surg. 1955; 15: 411–418.Ely ET. An operation for prominence of the auricles. Arch Otolaryngol. 1884; 10: 97.Farkas LG. Anthropometry of the normal and defective ear. Clin Plast Surg. 1990; 17: 213–221.Figure 84.15 Mastoid cartilage sutures.Figure 84.16 Holding sutures in place.Figure 84.17 Dressing in place.Figure 84.18 Final post-operative result. 876 Aesthetic otoplasty (bat ear correction)Furnas D. Correction of prominent ears by concha-mastoid sutures. Plast Reconstr Surg. 1968; 42: 189–193.Langdon JD, Patel MF (eds). Operative Maxillofacial Surgery. London: Chapman and Hall; 1998.MacDowell AP. Goals in otoplasty for protruding ears. Plast Reconstr Surg. 1968; 41: 17–27.Mustarde JC. e correction of prominent ears by using sim-ple mattress sutures. Br J Plast Surg. 1963; 16: 170–178.Rubin LR, Bromberg BE, Walden RH and Adams A. An anatomic approach to the obtrusive ear. Plast Reconstr Surg. 1962; 29: 360–370.Stark RB and Saunders DE. Natural appearance restored to unduly prominent ears. Br J Plast Surg. 1962; 15: 385–397.

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