Prominent ear correction was first reported many years ago, and since then numerous techniques have been described (14). The most popular of these are suture techniques to create an antihelix fold and set back the concha, or cartilage scoring techniques. The anterior scoring techniques of Chongchet (1) and Stenström (12) are gradually falling out of favour due to the considerable degree of tissue trauma and the high incidence of serious complications, including skin necrosis and ear deformity. On the other hand, suturing to recreate the antihelix fold (Mustardé) (7) and conchal setback procedure (Furnas) (2), often (5%) (5, 14) leads in the recurrence of protrusion in the upper part of the ear.
Otoplasty techniques continue to evolve towards the goal of a simple operation that provides natural results with less tissue trauma and low rates of recurrence or other complications (5). We describe a simple modification of suture techniques (antihelixmastoid sutures – extra fixation of Mustardé sutures) that can be used to reinforce the repair of a prominent ear. The combined technique presented here is safe, easy to perform and can be used for treating patients with any magnitude of defect.
PATIENTS AND METHODS
Seventy eight patients with prominent ears (146 ears) underwent otoplasty performed by the senior author at the IASO Hospital of Athens between 2005 and 2009. The age of the patients varied from 7 to 46 years (mean: 27 years). According to suture technique, the patients were divided into two groups: Group 1 (Mustardé & Furnas sutures – 34 patients/66 ears), and Group 2 (Mustardé, Furnas & antihelixmastoid sutures – 44 patients/80 ears).
Operations were performed with local anaesthesia infiltration into the posterior surface of the ear. A posterior approach was utilized via excision of a skin ellipse in the auriculocephalic sulcus (Fig. 1). The ear was then everted. The remaining anterior skin on the back of the ear was dissected as far as the helical rim. Reaching almost to the rim is important to provide good exposure for suture positioning. Then, using sharp scissors, dissection was continued posteriorly until the mastoid periosteum was reached. This provides good exposure around the mastoid area for conchamastoid and antihelixmastoid sutures. In Group 1 a row of three or four 3/0 prolene sutures on a round-bodied needle was inserted to recreate the fold of the antihelix (in the style of Mustardé), starting caudally. Suture knots were tied with the desired tension. Then a 2/0 or 3/0 prolene suture was placed between the concha and the mastoid periosteum in order to decrease the concha-scaphoid angle (in the style of Furnas) (Fig. 2, 3).
In Group 2 the sutures (at least one) that were used to recreate the antihelix fold (in the style of Mustardé), were not cut, and an artery clip was applied to each suture (Fig. 4). Then a 2/0 or 3/0 prolene suture was placed between the concha and the mastoid periosteum in order to decrease the concha-scaphoid angle (in the style of Furnas). After that, the ends of the Mustardé sutures were used for additional fixation to the mastoid periosteum (antihelixmastoid sutures) – in order to precisely correct preoperative deformity - and were tied again with the desired tension (Fig. 5, 6). Desired tension in this context means that we did not overcorrect in any of the patients, trying instead to achieve a natural appearance (Fig. 7). With Mustardé sutures the surgeon can fine-tune the degree of correction of antihelix by altering the tension on the sutures. The concept of this extra adjustment is to approximate the antihelix to the mastoid periosteum with a second secure and tight knot. The ear deformity is almost invariably greater at the superior pole than inferiorly, and consequently this extra knot fixation is more useful at the upper pole of the ear. If the ear requires a greater degree of correction, another antihelixmastoid knot can be placed. Furthermore, the conchal angle is also rotated, such as with conchamastoid sutures.
In both groups the skin was closed using 3/0 prolene mattress sutures that were removed at eight to ten days postoperatively. A standard head bandage was applied that was replaced after two days with a headband worn at night for four weeks.
From 2005 to 2009, 78 patients (146 ears) underwent otoplasty performed by the senior author at the IASO Hospital of Athens. All operations were performed under local anaesthesia. The mean age was 27 years (range 7 to 46). Patients were invited for follow-up examinations 1 month and 1 year after surgery, and all of them attended both these follow-up checks, where recurrence and suture extrusion were evaluated. It was assumed that both ears on the same patient were independent variables. Group 1: the clinical recurrence rate was 4.55% (3 ears). Two patients had undergone revisional surgery. The suture extrusion rate was 7.6% (5 ears). All five required local anesthetic procedures for removal of sutures. Group 2: the clinical recurrence rate was 1.25% (1 ear). This one patient had undergone revisional surgery. The suture extrusion rate was 7.5% (6 ears). Three of these required local anesthetic procedures for removal of sutures.
Patients were generally satisfied with the results in terms of shape and symmetry (Fig. 8). There were no complications such as haematoma, ear deformity and skin necrosis (Table 1, 2).
Our data was analyzed using the Pearson Chi-Square test (utilizing the IBM SPSS Statistics v.19 software). Our analysis revealed a statistically significant difference between groups on one of the variables analyzed. Specifically, the clinical recurrence rate was 4. 55% (3 ears) for Group 1 and 1.25% (1 ear) for Group 2; our analysis showed a statistically significant difference for this variable, i.e. X2= 0.474, p = 0.02. For the variable suture extrusion our rate was 7. 6% (5 ears) for Group 1 and 7. 5% (6 ears) for Group 2; our analysis did not reveal a statistically significant difference i.e. X2= 0.000, p = 0.986 (n.s). For the variables, hematoma and skin necrosis due to the zero percentages recorded no statistical analysis was conducted.
The ultimate goal for prominent ear correction is the production of natural and symmetrical-looking ears with minimal complications or recurrence. A review of the literature shows that many techniques have been developed for treatment of the protruding ear (1, 2, 4, 6, 7, 9–14). Unfortunately, all otoplasty techniques have a clinical recurrence rate. Galdel et al. found a complication rate of 16% (3). Horlock et al. found recurrence in eight patients (8%). Yugueros et al. found undercorrection in 5%. In our department posterior suturing in the manner of Mustardé & Furnas, combined with antihelixmastoid sutures, has been shown to be a technique associated with low recurrence rate and fewer complications (Table 1, 2).
Modern otoplasty techniques consist of two main surgical categories, cartilage sparing (2, 7) and cartilage cutting (1, 12), along with many variations (4, 6, 9, 13). Scoring or cutting can be accomplished on either the anterior or the posterior surface of the cartilage. Furthermore, scoring techniques can be subdivided into those that only superficially score the cartilage and those that score deeply enough to cut through the newly created antihelix (8). It is evident that cartilage cutting otoplasty may result in irreparable complications because of anterior skin necrosis, cartilage destruction and cartilage irregularities secondary to hematoma and infection (3, 5). On the other hand, cartilage sparing otoplasty seems a safe procedure because the cartilage is relatively undisturbed and anterior dissection of the skin is not required. However, the balance of favoured techniques has moved away from cartilage sparing techniques due to the high incidence of recurrence and problems with suture extrusion (3). These problems indicate that cartilage sparing otoplasty needs further refinement.
In our department, the sutures that were used to recreate the antihelix fold in the style of Mustardé was taken a second bite on the mastoid periosteum (antihelixmastoid sutures) and tied with the desired tension. The concept of this extra adjustment is to approximate the antihelix to the mastoid periosteum with a second secure and tight knot. The authors find that cartilage-sparing techniques in combination with antihelixmastoid sutures produce a natural-looking ear with a low rate of recurrence and complications.
Posterior suturing with conchomastoid sutures and extra fixation of antihelixmastoid sutures is a simple operation which can be performed quickly. It appears that the addition of the antihelixmastoid sutures to Mustardé & Furnas otoplasty is a useful refinement that minimizes recurrence rates (especially in the upper segment). Furthermore, this variation maintains a relatively simple and safe otoplasty that avoids irreparable complications and has a reproducible final cosmetic outcome.
The authors declare that they have no conflicts of interest to disclose.
Address for correspondence:
Konstantinos Panagiotopoulos MD, Ph D.
186 Dionusou St., Amarousion
15124 Athens, Greece
1. Chongchet V. A method of antihelix reconstruction. Br. J. Plast. Surg., 16, 1963, p. 268.
2. Furnas DW. Correction of prominent ears with multiple sutures. Clin. Plast. Surg., 5, 1978, p. 491.
3. Galder JC., Naasan A. Morbidity of otoplasty: A review of 562 consecutive cases. Br. J. Plast. Surg., 47, 1994, p. 170.
4. Horlock N., Misra A., Gault DT. The postauricular fascial flap as an adjunct to Mustardé and Furnas type otoplasty. Plast. Reconstr. Surg., 108(6), 2001, p. 1487–1490.
5. Jeffery SL. Complications following correction of prominent ears: an audit review of 122 cases. Br. J. Plast. Surg., 52, 1999, p. 588.
6. Kaye BL. A simplified method for correcting the prominent ear. Plast. Reconstr. Surg., 40, 1967, p. 44.
7. Mustardé JC. Correction of prominent ears using buried mattress sutures. Clin. Plast. Surg., 5, 1978, p. 459.
8. Laberge G. et al. Otoplasty: anterior scoring technique and results in 500 cases. Plast. Reconstr. Surg., 105, 2000, p. 504.
9. Pilz S., Hintringer T., Bauer M. Otoplasty using a spherical metal head dermabrador to form a retrauricular furrow: Five-year results. Aesth. Plast. Surg., 19, 1995, p. 83.
10. Sevin K., Sevin A. Otoplasty with Mustardé suture, cartilage rasping and scratching. Aesth. Plast. Surg., 30(4), 2006, p. 437–441.
11. Shokrollahi K., Cooper MA., Hiew LY. A new strategy for otoplasty. J. Plast. Reconstr. & Aesth., 62, 2009, p. 774–781.
12. Stenström SJ. A natural technique for correction of congenitally prominent ears. Plast. Reconstr. Surg., 32, 1963, p. 509.
13. Tramier H. Personal approach to treatment of prominent ears. Plast. Reconstr. Surg., 99, 1997, p. 562.
14. Yugueros P., Friedland J. Otoplasty: the experience of 100 consecutive patients. Plast. Reconstr. Surg., 108(4), 2001, p. 1045–1051.