Various techniques have been proposed to correct prominent ears. The author presents a simplified method of auriculoplasty with sutures by needle perforations only, without incisions. The key point of the operation is a line of sutures along the planed antihelix fold to transfix the fold at the antihelix tail, bending the scapha over the conchal cartilage to make the earlobe fall into place. The results are satisfactory, with a normal looking antihelical fold.
This surgery is usually done to set prominent ears back closer to the head or to reduce the size of the visibly large ears. Prominent ears usually concern children from 4 to 14 years old, but also adults. Such surgery usually takes about two to three hours, although complicated procedures may take longer 1, 2, 3. Most of the methods use incisions in the back of the ear. The cartilage is then sculped 1, 2, 3, 4. Occasionally, a piece of cartilage could be removed to provide a more natural-looking fold 1, 3, 5. Non-removable stitches are mostly used to help maintain the desired shape and position of the ear. Other techniques involve a similar incision in the back of the ear. Skin is removed and stitches are used to fold the cartilage back on itself to reshape the ear without removing cartilage.
Author’s suture without incision offers a simplified method to suture cartilage both sides from the desired fold, without to incise or excise skin or cartilage.
The most common deformity of the ear is the uni- or bilateral prominent ear. This deformity is caused by the lack of formation of the natural fold along the antihelix, a hypertrophied concha or a combination of both. The auriculo-mastoid angle is normally 20–30° from the skull. The helical rim lies about 17–20 mm from the skull. The scapho-conchal angle is 90°, and if this angle is flattened the ear appears protruding. The size and depth of the concha affect the deformity and the surgical technique for correction 1, 2, 5.
To pin the ears closer to the head, bring the ear elements into harmony, refine ear shape and reduce large elements.
Inferiority Complex, Aesthetic Own Requirements and Personal Needs
PRELIMINARY PREPARATIONS AND EVALUATION
Surgeon and parents should never insist on surgery until the child wants the change. Preoperative evaluation includes clinical and photographical examination. Preoperative photographs help to study and evaluate the deformities and to make the decisions. Photographs show the problem from many angles. Surgery on both ears could be suggested for balance, even if only one ear appears prominent.
In all cases we use local anesthesia in combination with i.v. sedation
MATERIAL AND METHOD
Twenty-five patients with prominent ears (without necessity of excision of a strip of the deep concha) were included in this study: 13 patients with unilateral protruding ears and 12 cases with bilateral prominent ears. Ages ranged between 5 and 35 years (15 females and 10 males).
Ear surgery was performed as an outpatient procedure. All the cases were operated under local anesthesia with adrenaline 1/1 000 000 injection of the posterior surface of the auricle. If anterior approach is necessary, local anesthesia is used subcutaneously in the specific area.
The suture method aims to suture the cartilage both sides of the desired antihelix fold using skin punctures only.
The sutures were done starting from the upper part of the tail to the lower end of the antitragus in order to break the strongest point where the helix, antihelix and antitragus join.
Fig.1. A.Before, B. Suture is done, C. Knot is done under elastic tension and helix is rotated. The ear is pinned and the antihelix fold is now present
We mark two 0,7-0,8 cm long parallel lines both sides of the planed antihelix fold - for example: AB and A1B1. If necessary we plan a row of additional sutures such as BC and B1C1, CD and C1D1 etc. In most Asians, black patients or some Caucasian kids 1 (one) suture on the specific point is enough, but in stronger cartilages 2 or 3 sutures are usually necessary to bend the cartilage and form the desired fold. The lines AB and A1B1, BC and B1C1, CD and C1D1 etc. mark the parallel subperihondreal transcartilagenous passes. The connecting lines between: AA1, BB1, CC1 and DD1 are only subcutaneous to connect the transcartilagenous passes and bring them together. The length of the parallel transcartilagenous and connecting subdermal lines is planed previously due to ear size and desired result. We do not do subcutaneous dissection in the area of the sutures, but it can be done. To perform the suture, we use the “Serdev mini-mini” 1mm thick needle, 3/0 thread and 4 skin perforations per suture in the posterior or anterior ear surface. The order of the passes depends on the surgeon (left or right handed), ear side, and surgeon skills.
We start with a transcartilagenous needle pass - for example AB, take the thread end and position the thread through the needle pass, after that we make the subcutaneous connecting bite and introduce the thread subcutaneously, make the second transcartilagenous pass A1B1 and finally, we fulfill the suture with the second subdermal connecting pass. The tightening of the knot should be done under elastic medium tension to adapt, but not to squeeze, cut or trauma the cartilages.
Fig. 2. A. The first suture AA1(subdermal) -A1B1(transcartilagenous) -B1B(subdermal) -BA(transcartilagenous) is finished and the ends of the thread are located at the point A but the knot is still not done. The needle is located intracartilagenous B1C1 parallel to the future antihelix fold and the end of the thread is in the needle hole; B. The thread is introduced in the B1C1 intracartilagenous plane and the needle starts the subdermal CC1 connecting line to take the thread end; subdermal CC1 connecting line to take the thread end;
C, D, E. The thread is introduced in the connecting subdermal C1C line, and the next transcartilagenous BC pass is done; F. The thread is introduced in the intracartilagenous CB line;
G. The needle is introduced in the subdermal BB1 connecting line; H. The thread end is taken in the connecting subdermal BB1 line and the full circle of the suture circle BB1(subdermal) – B1C1(transcartilagenous) – C1C(subdermal) - CB(transcartilagenous) is ready. Both ends of the thread are at point B C1C(subdermal) - CB(transcartilagenous) is ready. Both ends of the thread are at point B;
I, J, K, L, M, N. Making the 3rd suture circle CC1(subdermal) – C1D1(transcartilagenous) – D1D(subdermal) -DC(transcartilagenous)
O, P, R. All 3 suture circles are tightened under elastic tension, the anthelix fold is created, and the ear is pinned.
After all necessary sutures are done and tightened on both ears, symmetry is checked. Symmetry is usually obtained by the method itself. In 3 cases symmetry was perfected with additional suture one side and in 2 cases with additional sutures both sides.
The prominent ears were corrected by no incision and excision of skin from its posterior surface, no excision of cartilage. The antihelix was weakened by the line of sutures on its posterior surface and the antihelix fold was obtained successfully by the sutures only.
Fig. 3. A. Before, B. Immediate result, C. Result after 12 months
Fig. 4. A. Before, B. Result after 30 months
All patients had no need or have refused excision of the concha. If lowering of the concha was necessary we have performed sutures of the concha cartilages to the occipital periosteum or mastoid in 5 cases.
Anterior surface sutures were used in 6 cases in easier cases, when patients ask for minimal corrections, in 2 cases of difficulties with the equality and in 2 cases of secondary corrections.
Fig. 5. A suture is done on the right ear from the anterior surface. B, D. Result after 3 years.
Fig. 6. An additional suture is done on the left ear from the anterior surface to fulfill equality of both years. B. Immediate result, C., D, E. Result after 18 months
Adults and children are usually up and around within half an hour after surgery.
Any activity in which the ear might be bent should be avoided for a month or so. Most adults can go back to work next day after surgery. Children can return to school activities 2 to 3 days after surgery, if they are motivated and careful about playground activity.
The operation was accepted very well both by children and adults and the results were described as very satisfying.
Fig. 7. and 8. Immediate result after suture. No wounds. Bandages can be used overnight. We suggest elastic bands for a month.
Complications are infrequent and usually minor. Nevertheless, as with any operation, there are risks associated with surgery and specific complications associated with this procedure. Incomplete correction of prominent ears is probably the most common undesirable outcome of otoplasty. Overcorrection of a prominent ear can lead to obliteration of the postauricular sulcus. Hematomas or seromas can complicate recovery and should be managed as soon as possible. Hypertrophic scars or keloids may form along the incision line.
In our patients we have not observed hypertrophic scars or keloids. No infection or blood collection was observed.
In 3 patients, 4 to 6 month after the primary surgery, we have added additional one side sutures to complete aesthetic desire. We have had no overcorrection or chondritis.
The goal of the suture technique is improvement and beautification, but not perfection. Perfect symmetry is unlikely and unnatural in human body and in ears. Both ears never match perfectly (Fig. 9, 10). Patient’s and parent’s expectations should be discussed before the operation.
Fig. 9 and 10. Results after 3 and 4 years.
If the child is young, some surgeons may recommend general anesthesia1-5. For older children or adults, the surgeon may prefer to use local anesthesia. Children, who want the surgery and are motivated, cooperate better during the operation. In all cases we have used local anesthesia, combined with intravenous sedation.
For the most part, the operation is done on children between the ages of four and fourteen. Ears are almost fully grown by age four. Ear surgery on adults is also possible, and there are generally no additional risks associated with ear surgery on an older patient.
Discussion on state of the art techniques is always necessary like descriptions of the techniques such as Zplasty and Sandwich methods2. In cases of inferiorly bulging concha a Z-shaped operation is suggested to correct the lobule to keep it posteriorly5. Anterior scratching of the ear cartilage and superior crus is suggested by Stenstrom9 or the exposed cartilage is weakened by the diamond burs under water irrigation to avoid heat3. The use of the diamond burs to thin down the cartilage avoids ugly sharp edges of the corrected antihelix5. In different techniques the auricle can be attached to the skull around the external meatus. Other authors use removal of cartilage where it is attached to the mastoid with the aim to prevent the spring action of the auricle on the skull bone. The size of the concha will is taken into consideration for its correction and the proper evaluated size of cartilage excised 6-14.
Proper preoperative evaluation is an essential step for the satisfactory results. Sticking to the decisions taken before the operation will avoid unnecessary excision, which cannot be corrected later5.
Good otoplasty makes the ears more proportional to the size and shape of the head and face.
Main function of the ear is to hear with. Surgery is rated by those who observe ear shape. Cosmetic ear surgery can reshape deformed or protruding ears and restore proportions.
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15. Serdev N. Auriculoplasty Serdev Suture, Int J Cosm Surg 2000, Video time: 24:30 min. | Screen Size: 320 x 240 | File size: 36.2 | File Name: auriculoplasty_serdev_suture.wmv
16. SERDEV N., Auriculoplasty for beautification – a post-congress workshop, Asia Pacific Craniofacial Association. Third Conference, Shanghai, P.R. China, Oct. 30th – Nov. 1st, 2000
17. SERDEV N. Principles of Face Beautification, XIas Jornadas Mediterraneas De Confrontaciones Terapeuticas En Medicina y Cirugia Cosmetica, 21-25. 03. 2001, Barcelona
Address for correspondence:
Nikolay P. Serdev, MD, PhD
Medical Center "Aesthetic Surgery and Aesthetic Medicine"
11, "20th April" St., 1606 Sofia, BULGARIA
Phone (mobile) +359 888 802004
Fax +359 2 9515668
The Bulgarian Society of Aesthetic Surgery and Aesthetic Medicine