Prominent ear deformity is a common congenital deformity of the external ear affecting 5% of the general population.1 Although this is a harmless deformity, it has been claimed that the deformity can inflict psychological distress, emotional trauma, and behavioral problems on children. As a result of these concerns, corrective p rominent ear surgery is now widely performed as a prophylactic surgery.2
Prominent ear correction was first reported over 150 years ago by Dieffenbach3; since then, more than 200 techniques have been described in the literature for prominent ear correction, and debate regarding which operative method achieves the best results is ongoing.4 Among these techniques, the anterior scoring methods of Stenstroem5 and Chongchet,6 as well as the posterior suturing technique of Mustarde7,8 and Furnas,9 been the most commonly utilized techniques for many years. However, anterior scoring techniques are prone to the risk of anterior hematoma and related complications, such as skin necrosis or deformed cartilage, which may be difficult to correct surgically.10–12 Whereas cartilage-suturing techniques are relatively safe compared with anterior scoring, cartilage-suturing techniques possess variable suture extrusion rates and a recurrence rate of up to 24%.7
To overcome the undesirable complications of cartilage-suturing techniques, the postauricular fascial flap was described by Horlock et al13 as an adjunct to suture otoplasty. In the initial publication, the roles of the postauricular flap were to cover the surgical field as a protective shield for suture extrusion and to provide additional force for preventing deformity recurrence. Moreover, the authors found that cartilage-sparing techniques, in combination with a postauricular fascial flap, produce a normal-looking ear with a natural antihelix and a low rate of recurrence and complications. It has also been claimed that the postauricular fascial flap is a simple and quick additional step that adds an additional vascularized layer between the skin closure and the sutures. Notably, Mandal et al14 suggest that the fascial flap acts as a double breasting layer over the sutures preventing extrusion, increases postauricular support, and reduces recurrence.
Shortly after its description by Horlock et al,13 the postauricular fascial flap technique gained increasing popularity. Recently, the number of publications demonstrating the utilization of this technique as a stand-alone prominent ear correction procedure has increased.15,16 Furthermore, recent articles have claimed that it is highly possible to secure cosmetically pleasing results for prominent ear correction procedures through utilizing the posterior fascial flap technique as a stand-alone treatment.
The ultimate goal for prominent ear correction surgery is to establish natural, symmetrical-looking ears with minimal complications or recurrence. This article aims to present a new postauricular flap technique that increases the control in the reshaping of ear cartilage, decreases operation time, and provides symmetrical long lasting cosmetic outcomes.
MATERIAL AND METHODS
A total of 22 patients (14 male and 8 female patients) underwent prominent ear correction surgery with the same surgeon between January 2017 and January 2018. Patient ages ranged from 22 to 36 years. In total, 21 patients underwent bilateral prominent ear correction, whereas only 1 patient underwent unilateral prominent ear correction procedure.
The helix-mastoid distances and concha-mastoid angles of patients were measured preoperatively and at the end of the first year for the late postoperative assessment. Patients were also evaluated for suture extrusion, granuloma formation, deformity recurrence, and postauricular area sensitivity.
Operations were performed under local anesthesia plus intravenous sedation. Lidocaine and 1:200,000 epinephrine was injected to the postauricular and mastoid area. An elliptical incision was then planned for de-epithelialization (Fig. 1). The lateral margin of the incision was planned along the posterior surface of the helical groove. Then, the medial margin of the incision was adjusted based on each patient's preference for the helix-mastoid bone distance. The average distance between the medial margin of the incision and the concha-mastoid joint was an average of 10 mm. The inferior tip of the incision reached the intersection between the ear lobule and concha, which negates the need for additional incisions in need of changing the shape of the ear lobule. Following de-epithelialization, a U-shaped laterally based fascial flap and another U-shaped medially based fascial flap were planned (Fig. 2). The observed width range of the laterally based flap among patients was 8 to 10 mm. Flap width was important because of it determining the distance between the helix and the mastoid bone. Notably, the distance between the medial margin of the skin incision and the concha-mastoid joint must be equal to the width of the fascial flap because these 2 layers form the posterior auricular fold. The flap was incised in the sagittal plane, 8 to 10 mm medially from the lateral margin of the skin incision. Dissection was performed on the subperichondrial plane and carried out laterally. A laterally based perichondrioadipodermal flap was elevated. When flap preparation was completed, dissection was conducted medially within the subdermal plane toward the mastoid bone, and postauricular muscle was preserved during dissection. A 2 × 5-cm dermal pocket was then prepared over the mastoid bone for flap insertion (Fig. 3). After preparation of the subdermal pocket, dissection of the medially based U-shaped adipoperichondrial flap was planned. The dissection was carried out medially on the subperichondrial plane, and the dissection ended on the margin of the posterior auricular muscle (Fig. 4).
When the dissection was completed, the medially based adipoperichondrial flap was fixed to the posterior helical skin using a pull-out pattern (Fig. 5). The adipoperichondrial flap was located under the perichondrioadipodermal flap. The flap was fixed from 3 different points (superior, middle, and inferior proportion of the posterior helical skin) with 4-0 polyglactin sutures.
Laterally based perichondroadipodermal flap was also fixed to the mastoid bone periosteum also from 3 different points (superior, middle, and inferior proportion of the ear) with 4-0 poliglecaprone sutures (Fig. 6). Additional ear lobe setback can be performed with an extra suture and without any additional incisions. Skin closure was performed via continuous mattress suture (Figs. 7–11). (The cornerstones of the procedure were recorded and demonstrated in the video content, http://links.lww.com/SAP/A348). The incision scar sits along the posterior surface of the helical groove, creating a natural appearance.
There was no need to insert suction or Penrose drain. Anterior and posterior sections of auricular skin were covered with gauze to fit to the contours of the ear, and elastic head bandages were used. Patients were monitored in hospital for several hours, and intravenous antibiotics were administered. Patients were discharged the same day.
The bandages of patients were removed on the fourth postoperative day, although headbands were advised for the patients. Patients kept their bandages on until the 21st postoperative day. Bandages were advised to be worn full time for 2 weeks and overnight for 1 additional week.
Patient ages ranged from 18 to 45 years, with a median of 27.6 years. The mean follow-up time was 15.5 months (12–20 months). Average total operation time was 45 minutes (35–60 minutes). As more experience was gained in flap harvesting, operation time became shorter. The mean preoperative upper third ear proportion–scalp distance was 33.5 mm, and the middle third ear proportion–scalp distance was 29.2 mm. At the first year following the surgery, these measurements were 10.2 and 10.4 mm, respectively.
None of the patients suffered from skin necrosis, suture extrusion, hematoma, or wound infection at the early or late postoperative period. Asymmetry was noted in 2 patients, and revision was performed. The postoperative scar healed suboptimally and was palpable in 6 patients. The fixation sutures were palpable in 4 patients and needed to be removed 6 months after surgery, which was the most common complaint after surgery (Figs. 12–18).
Application of the posterior fascia flap was first used by Horlock et al13 and Shokrollahi et al17 as a supportive component to the concha-mastoid sutures of Mustarde7,8 and Furnas.9 This fascia flap technique involved covering the sutures to prevent suture extrusion, with advancement of the flap as a supportive structure. Horlock et al13 reported a 0% suture extrusion rate and 8% recurrence using the postauricular flap refinement of Mustarde's technique in 51 patients. Furthermore, Mandal et al14 reported a similarly operated cohort of 41 patients with a 7.3% suture extrusion rate and 4.9% recurrence. Shokrollahi et al17 used the distally based fascial flap without perichondrium adjunctively to reinforce suture-based techniques in 15 patients. Because the fascia is a loose connective tissue, using the distally based fascial flap alone, recurrence rates in suture-based techniques could not be reduced. This reality also highlights the importance of including the perichondrium into the fascial flap. The aforementioned authors described the postauricular flap as supportive technique to decrease complication rates, as opposed to a reliable stand-alone correction method. Shortly after the description of the posterior fascial flap, the method gained popularity and applied as a stand-alone technique for protruding ear correction surgery in several publications.15,16
One of the primary reasons for the popularity of the posterior fascial flap technique is its low rate of complications such as pain, extrusion, and recurrence. Several publications demonstrated that using the posterior fascial flap alone or combined with other techniques provides less complication rates compared with suture otoplasty techniques.15,16,18,19 Importantly, no patient in the study suffered from pain or suture extrusion. Only 2 patients required revision otoplasty procedure because of asymmetry.
The posterior skin of the ear differs from the anterior skin and can be conveniently moved by adjusting the loose connective tissue between the skin and the perichondrium. The posterior skin of the ear has a complex anatomy; it contains blood vessels, nerves, perichondrium, and fibrofatty tissue. Thus, the described flap technique can be considered a dermofascial flap. Histological examination of this region has revealed a rich vascular network. This flap technique is feasible due to the anatomical basis of the vascular network.20
It was believed that in order to secure a long-lasting, cosmetically pleasing result it is important that the flaps include the perichondrium, because the perichondrium is an inelastic and strong tissue. The importance of the scar formation was also underlined in the literature. It was advocated that scar formation between different layers could prevent recurrence. In this technique, perichondrium-included postauricular flaps not only increased the number of the layers in which scar formation occurs but also creates strong supportive tissues that spread the mechanical force of the ear cartilage.15,19
The most important component of scar formation for this technique is surely neochondrogenesis. The development of the neochondrogenesis between the perichondrium and the cartilage surface at the corner where the perichondrioadipodermal flap is elevated and adipoperichondrial flap is inserted plays a crucial role in the lasting results of this method. The antihelical fold sustains its new shape for a long period, and results of the perichondrioadipodermal flap technique should be enduring because of neochondrogenesis caused by the elevation of the perichondrium.16,21
The present study aimed to increase the number of the layers in which scar formation occurs, adding an additional flap for the distribution of the mechanical force being applied by the ear cartilage and for the protection of the ear cartilage from tearing due suture use in suture otoplasty techniques. Thus, the technique described in the present study is based on wound healing and scar formation concepts. It is important to spread the mechanical force caused by ear cartilage during wound healing and scar formation.22 An important advantage of this technique is the tension that occurs when the auricle setback dissolves along 2 separate flaps instead of the sutures, as in the Mustarde technique. Thus, the mechanical force applied to the flaps by ear cartilage is reduced.
The described technique was used for all prominent ear types in the present study, but it was noted that manipulation of ear cartilage was easier with effacement of the antihelical fold and wide scaphoconchal angle. Using the described technique for cases of aberrant conchal hypertrophy could create a deformity in the conchal region, because additional conchal cartilage excision can be necessary in these cases. There were no patients in this study who had isolated conchal hypertrophy. One-third of the patients suffered from isolated antihelical effacement, and the rest suffered from a combination of antihelical effacement and conchal hypertrophy. Two-flap otoplasty technique is highly advantageous and versatile in terms of antihelical effacement. The pulling forces of the flaps successfully repair helical deformity and help concha to roll over mastoid bone. That maneuver creates a secondary beneficial effect for conchal deformity and relatively reduces surface area of the concha. However, in case of isolated conchal hypertrophy, it is hard to claim that this technique is suitable because pulling forces of the flaps originate from the lateral border of helix and the medial border of concha.
It was noted that the medially based flap plays a stabilizing role for helix positioning and securing antihelical fold. Authors' previously preferred technique for otoplasty was laterally based perichondrioadipodermal flap for many years, but it was noted that management of helix in the long term could be troublesome with only 1 flap, and it was seen that adding a medially based perichondrial flap next to laterally based flap increased the stability of helix in the long term and decreased the rates of recurrence and asymmetry. It was also noted that the medially based perichondrial flap rotates helix laterally and decreases auriculomastoid angle even more.
The two flap otoplasty is a simple and versatile technique for protruding ear surgery. Preserving the integrity of the ear cartilages helps the surgeon to avoid irreversible and sometimes catastrophic complications or consequences that cartilage-cutting techniques have.10,13,14 Elevation and preparation of auricular perichondrium as a whole prevent long-term pain problems, which can be seen in cartilage-suturing otoplasty techniques.18,19 The location of the fixation sutures are deep seated and covered with flaps; as a result, suture exposure is not an expected complication with 2-flap otoplasty, whereas suture exposure is a common complication in cartilage-suturing and cartilage-cutting otoplasty technique.10,13,14,18,19 So, it is possible to claim that 2-flap otoplasty is a safe and practical technique compared with traditional methods because the integrity of the ear cartilages remains untouched, and the fixation sutures are deep seated and covered with 2 separate flaps.
This article aims to describe a novel posterior fascial flap technique. By preparing a medially based U-shaped adipoperichondrial flap and a laterally based U-shaped perichondrioadipodermal flap, the aim was to increase the number of the layers in which scar formation occurs and to add an additional flap for the distribution of mechanical force being applied by ear cartilage. A decrease in average operation time was observed, tension distribution was balanced, and control over postoperative symmetry and cosmetic result increased; furthermore, the necessity for additional incisions for earlobe reshaping was overcome. Therefore, the method described in the present study can serve a simple, useful, and practical technique for correcting protruding ear deformity. The primary drawback of the present study is the number of patients in our sample. The technique's effectiveness over isolated conchal hypertrophy cases is also obscure. It was observed that the technique is highly advantageous in terms of effacement of the antihelical fold and wide scaphoconchal angle with or without mild conchal hypertrophy. Additionally, complication rates of this technique remain debatable in 22 cases. Importantly, the need for further prospective comparative studies on this subject remains.
Informed consent was received for publication of the figures in this article.
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14. Mandal A, Bahia H, Ahmad T, et al. Comparison of cartilage scoring and cartilage sparing otoplasty—a study of 203 cases. J Plast Reconstr Aesthet Surg
15. Cihandide E, Kayiran O, Aydin EE, et al. A new approach for the correction of prominent ear deformity: the distally based perichondrio-adipo-dermal flap technique. J Craniofac Surg
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17. Shokrollahi K, Cooper MA, Hiew LY. A new strategy for otoplasty. J Plast Reconstr Aesthet Surg
18. Ersen B, Sarialtin Y, Cihantimur B, et al. A new otoplasty procedure: combination of perichondrio-adipo-dermal flap, posterior auricular muscle transpositioning and cartilage suturing to decrease the post-operative complication rates. Eur J Plast Surg
19. Basat SO, Ceran F, Askeroglu U, et al. Preventing suture extrusion and recurrence in mustarde and furnas otoplasties by using laterally based postauricular dermal flap, long-term results. J Craniofac Surg
20. Shokrollahi K, Taylor JP, Le Roux CM, et al. The postauricular fascia: classification, anatomy, and potential surgical applications. Ann Plast Surg
21. Weinzweig N, Chen L, Sullivan WG. Histomorphology of neochondrogenesis after antihelical fold creation: a comparison of three otoplasty techniques in the rabbit. Ann Plast Surg
22. Park C, Roh TS. Anatomy and embryology of the external ear and their clinical correlation. Clin Plast Surg
perichondrium; posterior auricular flap; protruding ear
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