Following the trend of using only transcutaneous stitches to change facial appearance, we would like to revisit the probably most minimally invasive otoplasty in the armamentarium of plastic surgery.
The great majority of the patients who seek improvement present with protruding ears due to the lack of an antihelix or due to an antihelix that is ill defined. In some patients, an enlarged earlobe is the problem.
The pinna (ear) is emerging from the lateral scalp in a 30-degree angle and consists of skin, elastic cartilage and soft tissue (lobule). The skin adheres to the cartilage in the anterior auricle and is mobile in the posterior auricle. The antihelix is located between the concha and the scapha walls and diverges into two crura anterior and superior, enclosing the triangular fossa. The scapha is located in a deep furrow between the helix and antihelix. The lobule is the caudal part of the ear and is fleshy.
Blood supply is ample and derives principally from the superficial temporal and posterior auricular vasculature. Innervation is via anterior and superior branches of the greater auricular nerve with less contribution from the lesser occipital and aurticular temporal nerves.
The surgical techniques already reported are based on reshaping or constructing the antihelical fold, skin excision and sometimes removing cartilage from the high concha and correcting enlarged earlobes. There are various surgical methods that can be employed and surgeons should choose the method they are comfortable with to treat the patient's particular problem.
Mattress sutures applied to the bent cartilage will secure the new shape of the antihelical fold. This step is the main detail in the modification of the antihelix.
Evolution of technique
The technique that we want to report is the evolution that started in 1979 (Dingman and Peled) and gradually developed to this simple method of performing surgical otoplasty.
Reasons for changes in otoplasty approach include the following:
- Avoidance of skin excision decreases scar formation.
- Subcuticular stitches alone can be used to reshape the antihelix, sparing skin undermining.
- If cartilage can be bent without scoring it, it is better. However, this is not always possible.
- By placing the stitches through minimal holes made by the guiding needle, scarring can be minimized.
These modifications in selected cases can greatly simplify the procedure. This particular procedure takes us 20 minutes to complete, compared to 60 minutes or more for our regular otoplasty. By manually bending the ear, surgeons create the desired antihelical fold and mark the site of the future permanent subcuticular mattress sutures, four dots (corners) for each stitch.
Step by step approach
Usually it takes four stitches per ear to complete this procedure, although less or more can be used as necessary.
- The ear is anesthetized with local lidocaine infiltration.
- The needle pierces the skin at point 1 and after a transcartilaginous traject, exits at point 2.
- The needle enters the same exiting hole (point 2) and passes subcutaneously to point 3.
- The needle enters the hole at point 3 and pierces the cartilage to exit at point 4.
- The needle enters the same hole at point 4 and runs subcutaneously to exit at point 1.
- The assistant bends the ear to a new shape and the surgeon ties it using clear sutures. The skin hole at point 1 is slightly undermined as to allow the knot to rest under the skin. The edges of the undermined hole 1 can be sutured with a 6-0 nylon stitch to ensure skin coverage over the knots.
- This is repeated at the other markings for the three or more planned sutures.
In our practice, the patient is provided with comprehensive written material and there is discussion about risks and reoccurrence with the possibility of additional treatments. Patients should be re-evaluated six months to one year post-op.
Dr. Mordcai Blau is a board-certified plastic surgeon and a diplomat of the American Society of Plastic Surgery. He is in private practice in Westchester, N.Y. Dr. Isaac Peled is a board-certified plastic surgeon in Israel and past president of the Israeli Plastic Surgery Association. He is the head of Plastic Surgery department, Haifa, Israel. He is the author of a chapter on otoplasty in a plastic surgery textbook.