Otoplasty

Author Credentials 

Yan Ho Lee, MD
Assistant Professor
Department of General Surgery
Division of Otolaryngology
Yale School of Medicine
Phone: 203-785-5430
Yan.lee@yale.edu

Jonathan Y. Lee, MD, MPH
Assistant Professor
Department of Surgery
Division of Plastic and Reconstructive Surgery 
University of Massachusetts Medical School – Baystate
Phone: 413-794-0363
Jonathan.LeeMD@baystatehealth.org

Module Summary

Otoplasty can be performed by age five to six since at this age, the ear is almost adult-sized and this will usually precede ridicule by peers. This surgery requires careful preoperative evaluation and counseling. Surgery involves correcting the various abnormalities observed during the evaluation, and usually involves a combination of techniques, which can be categorized into cartilage-cutting vs cartilage-sparing techniques. Surgeon should be aware of early and late complications so as to take precautions to avoid them.

Module Learning Objectives 
  1. Explain basic ear anatomy as it relates to otoplasty
  2. Cite the types of ear deformities
  3. Summarize various techniques of correcting the prominent ear.
  4. Recognize pitfalls and complications of otoplasty and how to avoid them

 

Anatomy

Embryology

  • Develops at five weeks in utero from six “hillocks of his”
  • Derived from first and second branchial arches 

Development

  • Ear becomes 85% of adult size by age three
  • Neonate ear cartilage is softer, more malleable, and in elderly more calcified and stiff

Vascular supply

  • Branches of the external and internal carotid artery via the posterior auricular, the superficial temporal, the occipital arteries

Innervation

  • Anterior and posterior branches of the great auricular nerve, Auriculotemporal nerve, Branch of vagus (Arnold’s nerve)

Surface Anatomy

  • Five important elements: Helix, Antihelix, Concha, Tragus, Lobule (Others: antitragus, intertragal notch, Darwin’s tubercle

Ideal Proportions of the ear

  • The long axis of the ear inclines posteriorly at 15-30 degrees from vertical meridian.  
  • The top of the helix lines up roughly with the top of the arch of the eyebrow and the bottom of the lobule roughly with columella
  • Ear width is approximately 50-60% of the length 
  • In relation to the skull, the superior rim of the helix should project approx 10-12 mm, the most lateral mid-rim should project approx 16-18mm, and the cauda helix should project approx. 20-22mm
  • Concho-mastoid angle should be 45-90 degrees. Concho-scaphal angle is less than 90 degrees

 

References

  1. Adamson PA, Litner JA. Otoplasty Technique.  Facial Plast Surg Clin North Am. 2006 May;14(2):79-87
  2. Hoehn JG, Ashruf S. Otoplasty: Sequencing the Operation for Improved Results.  Plast Reconstr Surg. 2005 Jan;115(1):5e-16e
  3. Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg. 2005 Apr;115(4):60e-72e
  4. Kelley P, Hollier L, Stal S. Otoplasty: Evaluation, Technique, and Review. J Craniofac Surg. 2003 Sep;14(5):643-53
  5. Richards, SD, Jebreel A, Capper R. Otoplasty: a review of the surgical techniques. Clin Otolaryngol. 2005 Feb;30(1):2-8

 

 

Patient Evaluation/Timing of Repair

Preoperative Assessment should include the following:

  1. Degree of antihelical folding (Along with superior and inferior crus)
  2. Depth of the conchal bowl
  3. Plane of the lobule and deformity if present
  4. Angle between the helical rim and the mastoid plane (should measure at 3 points: superior rim, most lateral mid rim, intertragal incisura)
  5. Quality and spring (pliability) of the cartilage
  6. Symmetry of size, shape, position, projection, contour
  7. Understanding of patient motivations and involvement in seeking help
  8. Behavioral or developmental abnormalities (if existing, then psychological evaluation may be needed)

 

Timing

  • Nonsurgical molding should start within the first few days of life (within three days of birth) 
  • Surgical repair may be performed at ages six to seven (some as early as three years of age) Assessment can be started as early as age three to five

Type of Ear Deformities 

  • Otoplasty involves the correction of several auricular deformities including the prominent ear, constricted ear, Stahl’s deformity, and cryptotia, macrotia, shell ear (insufficient furling of the helix), cup ear, Darwin tubercle
  • Prominent ear (or Prominauris)
    • usually caused by:
      • underdevelopment of the antihelical fold  
      • overdevelopment of the conchal bowl 
      • the deformity can cause significant emotional and psychological distress, ridicule by peers, contributes to behavioral disturbances, social phobias

Repair techniques (may be combined)

  • generally categorized as cartilage cutting or cartilage sparing techniques 
  • overcorrection is often needed

Restoration of antihelical fold 

  • scoring or rasping lateral scaphal cartilage (warping of auricular cartilage occurs away from the injured side)
  • conical antihelical tubing with sutures (Mustarde)

Conchal repair 

  • conchal cartilage excision 
  • cartilage scoring 
  • cartilage suturing (Furnas) 

 

References

  1. Adamson PA, Litner JA. Otoplasty Technique.  Facial Plast Surg Clin North Am. 2006 May;14(2):79-87
  2. Hoehn JG, Ashruf S. Otoplasty: Sequencing the Operation for Improved Results.  Plast Reconstr Surg. 2005 Jan;115(1):5e-16e
  3. Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg. 2005 Apr;115(4):60e-72e
  4. Kelley P, Hollier L, Stal S. Otoplasty: Evaluation, Technique, and Review. J Craniofac Surg. 2003 Sep;14(5):643-53
  5. Richards, SD, Jebreel A, Capper R. Otoplasty: a review of the surgical techniques. Clin Otolaryngol. 2005 Feb;30(1):2-8
Common Pitfalls and Complication

Early complications

  • Bleeding/Hematoma 
  • Infection/Chondritis 
  • Pain 
  • Pruritis
  • Necrosis 

Long-term complications

  • Scar – hypertrophic or keloid
  • Suture Problems 
  • Hypoesthesias 
  • Patient Dissatisfaction 
  • Persistent or acquired deformity 

 

References

  1. Adamson PA, Litner JA. Otoplasty Technique.  Facial Plast Surg Clin North Am. 2006 May;14(2):79-87
  2. Hoehn JG, Ashruf S. Otoplasty: Sequencing the Operation for Improved Results.  Plast Reconstr Surg. 2005 Jan;115(1):5e-16e
  3. Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg. 2005 Apr;115(4):60e-72e
  4. Kelley P, Hollier L, Stal S. Otoplasty: Evaluation, Technique, and Review. J Craniofac Surg. 2003 Sep;14(5):643-53
  5. Richards, SD, Jebreel A, Capper R. Otoplasty: a review of the surgical techniques. Clin Otolaryngol. 2005 Feb;30(1):2-8
Revision Otoplasty
  • Obliterated posterior sulcus 
  • Vertical post deformity 
  • Telephone deformity 
  • Reverse Telephone deformity 
  • Hidden Helix deformity 

 

References

  1. Adamson PA, Litner JA. Otoplasty Technique.  Facial Plast Surg Clin North Am. 2006 May;14(2):79-87
  2. Hoehn JG, Ashruf S. Otoplasty: Sequencing the Operation for Improved Results.  Plast Reconstr Surg. 2005 Jan;115(1):5e-16e
  3. Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg. 2005 Apr;115(4):60e-72e
  4. Kelley P, Hollier L, Stal S. Otoplasty: Evaluation, Technique, and Review. J Craniofac Surg. 2003 Sep;14(5):643-53
  5. Richards, SD, Jebreel A, Capper R. Otoplasty: a review of the surgical techniques. Clin Otolaryngol. 2005 Feb;30(1):2-8

 

Case Studies

Case 1: A 45 year old man underwent bilateral otoplasty with postauricular approach. 3 Mustarde sutures were placed. He was initially very happy with the results, but over the next 2 months was less happy because his ears were starting to return to the original shape.

  • In an adult ear, the cartilage of the ear is stiffer and more likely to recoil
  • Anterior cartilage scoring can help to decrease cartilage memory and help facilitate a lasting correction

Case 2: 20 year old man undergoes BL otoplasty.  On postop day 1 calls the office reporting that his ear is very painful despite taking pain medication.

  • It is important to evaluate the patient in the office or emergency room because this can be a sign of infection or hematoma
  • A hematoma should be evacuated promptly and a drain may be needed.  If infected may need PO antibiotics if just cellulitis, but if involves the cartilage may need IV antibiotics and possible operative management.