The Surgical Correction of Protuberant Ears

E. Bisaccia, MD, FACP¹, A. Lugo, MD1, B. Johnson, MD1, D. Scarborough, MD<sup>2

1</sup>Columbia University, College of Physicians & Surgeons, New York, NY, USA
²Department of Dermatology, Ohio State University Hospitals, Columbus, OH, USA

ABSTRACT

While prominent ears are considered a sign of good fortune in the Far East, Western society looks upon prominent ears in a far less positive manner. Children with prominent ears are often the subjects of verbal and at times physical abuse by their peers, resulting in adverse psychological effects. Advances in otoplasty have made it possible not only to “pin back” the ears, but also to reshape them, reduce their size, or make them more symmetrical. For a dermatologic surgeon, an otoplasty may be an unfamiliar surgical procedure, however, the surgery itself does not significantly differ from ear wedges or cartilage removal procedures for skin cancer, procedures with which the dermatologic surgeon is quite familiar.

Key Words:
prominent ears, otoplast

Otoplasty is the surgical correction of protuberant ears and ear deformities. Like other forms of cosmetic surgery its goal is to enhance the patient’s appearance. Specifically, it is aimed at making the protuberant ears less apparent by restoring them to a normal form and position in a symmetrical fashion.
It is a surgical procedure being performed by several surgical specialties and for the dermatologic surgeon, an otoplasty may be an unfamiliar surgical procedure. The procedure itself, however, does not significantly differ from ear wedges or cartilage removal procedures for skin cancer, procedures with which the dermatologic surgeon is quite familiar.

Historical Background
In 1845, Diffenbach reported the first surgical approach for the correction of prominent ears.¹ He combined simple excision from the posterior sulcus with sutures subsequently fixing the ear cartilage to the periosteum of the mastoid. Subsequently, multiple surgical techniques have been described, with over 170 being reported in the literature. These can be basically categorized into three groups:
1) leaving the cartilage intact and using only sutures to reconstruct the ear, as used in the permanent suture insertion of the Mustarde technique² and the incisionless otoplasty of Fritsch³
2) incising the cartilage in order to make it more pliable, without resecting it (e.g., the Converse’s cartilage incision technique⁴ and the anterior approach technique described by Chongchet⁵ and Stenstrom⁶)
3) a technique that includes excision of the cartilage.

There is also a relatively new nonsurgical approach that is effective when prominent ears are noted in infancy. The use of external temporary appliances to set the ears in a correct position for several months results in a successful permanent correction.^7-9 The drawback with this method is that it takes highly motivated parents to follow the protocol.

Surface Anatomy of the External Ear
A thorough knowledge of the anatomy of the ear is essential for performing a safe and successful otoplasty. Although it comprises a small anatomic area, the surface anatomy of the external ear is quite complex (Figure 1).

Figure 1: Anatomy of the external ear

The external ear consists of the auricle and the external auditory canal. The helix rim arises anteriorly and inferiorly from a crus extending horizontally above the external auditory meatus, thus creating the outer frame of the auricle. The helix merges inferiorly into the cauda helices and connects to the lobule. The region located between the crura of the antihelix is referred to as the triangular fossa, while the scapha lies between the helix and antihelix. The antihelix borders medially to the rim of the concha and the concha proper. The concha is composed of the conchal cymba superiorly and the conchal cavum inferiorly, which are separated by the helical crus and meet the antihelix at the antihelical rim. The intertragic notch separates the tragus and antitragus. The lobule does not contain cartilage and displays a variety of shapes and attachments to the adjacent cheek and scalp.

The superficial temporal and posterior auricular arteries preserve the arterial supply of the external ear. The sensory innervation involves the anterior and posterior branches of the greater auricular nerve and is reinforced by the auricular temporal and lesser occipital nerves. A portion of the posterior wall of the external auditory meatus is supplied by the auricular branch of the vagus nerve.

Surgical Correction Techniques
External ear deformities are very diverse, with protuberant ears being the most common complaint of patients. Ear prominence is generally the result of one or more of the following anatomic malformations: failure of antihelical folding, overdeveloped conchal cartilage, protrusion of the upper third of the ear and/or protrusion of the earlobe.10-11 For adequate surgical correction, the surgeon must recognize and address all of the anatomic malformations contributing to the patient’s ear prominence. Surgical correction of these common ear deformities will be discussed briefly.

Figure 2: Anterior view; A) Pre-operative B) Post-operative

Figure 3: Posterior view; A) Pre-operative B) Post-operative

The antihelix is commonly unfolded giving the appearance of prominent ears. In this case, simple pressure in the scaphoid region toward the scalp will define the antihelix and superior crus. A further increase in pressure will elevate the conchal rim, outlining the excess conchal rim. This excess conchal rim cartilage and skin is removed, creating an antihelix and a normal appearing ear.
Conchal enlargement represents another common ear deformity. The excess conchal cartilage can extend throughout or be confined to a particular region. The removal of the excess cartilage in the appropriate areas resolves the abnormal contour of the ear.

The auricle and the earlobe generally meet the adjacent scalp tissue at an angle of approximately 30 degrees. An angle over 40 degrees usually results in protrusion of the ear. To achieve proper surgical correction, the skin of the posterior earlobe and posterior auricle, as well as the skin over the mastoid, needs to be dissected and then sutured together. Dissection of the lobule skin alone will change the anatomy of the lobule, without improving the protrusion of the ear.

Complications
The most common immediate postoperative complication of otoplasty is the formation of a hematoma, requiring immediate, meticulous treatment.¹² Generally, if a patient complains of increasing, persistent pain under the dressing, a hematoma must be suspected.
If a hematoma is present, immediate evacuation should be performed, and the patient should be started on oral antibiotic therapy in order to diminish the incidence of perichondritis. Inadequate correction, contour distortion, and an asymmetric correction are the most common untoward outcomes of otoplasty.¹³ Even though some degree of retroprotrusion can be expected with most otoplasty techniques, it appears to be particularly common and significant when permanent sutures alone are used to reconstruct the ear. For that reason and in order to obtain optimal cosmesis, we favor the technique that includes excision of cartilage. This is a simple surgical procedure, which provides the best and most reliable results, making the deformity less apt to recur.
Surgical Correction for Children
Children with protruding ears are often the subjects of verbal, and at times physical, abuse by their peers, resulting in adverse psychological effects. These psychological concerns often cause parents to be the first to initiate the steps toward surgical correction of the prominent ears. However it is very important to have the child voice his or her desire for surgery, because the child is best able to judge the degree of distress this condition imposes. Nevertheless, the patient’s age plays an important role in the decision for or against surgery. Eighty-five percent of the final size of the ear is achieved by age of 3 years, and surgery prior to school age could result in marked inhibition of auricular growth.
For these reasons, we prefer to limit otoplasty in our office to patients who have achieved adolescence or adulthood without completely adjusting to their appearance, as they are more capable than young children of describing the auricular features of concern to them and their desire for correction. Thus, successful correction of the protuberant ears can be of significant help to a patient’s social life and self-esteem.
Conclusion
Otoplasty is a simple surgical procedure with which the dermatologic cosmetic surgeon should be familiar. It is performed in an out-patient setting and under local anesthesia with or without conscious sedation. With minimum complications and risks, a successful otoplasty can be of significant help to a patient’s social life and self-esteem.
References

1. Dieffenbach JF. Die Operative Chirurgie. Leipzig: FA Brockhaus; 1845. Cited by Tanzer RC. Deformities of the auricle. In: Conversae JM, ed. Plast Reconstr Surg 2nd ed. Philadelphia: Saunders; p. 1710 (1977).
2. Mustarde JC. The treatment of prominent ears by buried mattress sutures: a ten-year survey. Plast Reconstr Surg 39(4):382-6 (1967 Apr).
3. Fritsch MH. Incisionless otoplasty. Laryngoscope 105(5 Pt 3 Suppl 70):1-11 (1995 May).
4. Converse JM, Nigro A, Wilson FA, Johnson N. A technique for surgical correction of lop ears. Plast Recontr Surg 15(5):411-8 (1955 May).
5. Chongchet V. A method of antihelix reconstruction. Br J Plast Surg 16:268-72 (1963 Jul).
6. Stenstrom SJ. A natural technique for correction of congenitally prominent ears. Plast Reconstr Surg 32:283-93 (1963).
7. Kurozumi N, Ono S, Ishida H. Non-surgical correction of a congenital lop ear deformity by splinting with Reston Foam. Br J Plast Surg 35(2):181-2 (1982 Apr).
8. Matsuo K, Hayashi R, Kiyono M, Hirose T, Netsu Y. Nonsurgical correction of congenital auricular deformities. Clin Plast Surg 17(2):383-95 (1990 Apr).
9. Muraoka M, Nakai Y, Ohashi Y, Sasaki T, Maruoka K, Furukawa M. Tape attachment therapy for correction of congenital malformations of the auricle: clinical and experimental studies. Laryngoscope 95(2):167-76 (1985 Feb).
10. Elliot RA Jr. Otoplasty: a combined approach. Clin Plast Surg 17(2):373-81 (1990 Apr).
11. Bisaccia E, Scarborough DA. The surgical correction of the protuberant ear. Cosmet Dermatol 8:10-2 (1990).
12. Calder JC, Nassan A. Morbidity of otoplasty: a review of 562 consecutive cases. Br J Plast Surg 47(3):170-4 (1994 Apr).
13. Bisaccia E, Scarborough DA. Otoplasty: treatment for protuberant ears. In: Columbia Manual of Dermatologic Cosmetic Surgery. New York:McGraw-Hill; 2002:357-361.