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A Modification of the Posterior Perichondrio-Adipo-Dermal Flap for Protruding Ear Correction

A Customized Technique

Ersen, Burak MD, FEBOPRAS

doi: 10.1097/SAP.0000000000002025
Aesthetic Surgery
Free
SDC

Prominent ear deformity is a common congenital deformity of the external ear affecting 5% of the general population. Because of the deformity's displeasing nature, corrective prominent ear surgery is widely common and performed as a prophylactic surgery. More than 200 surgical techniques for the correction of prominent ear deformity have been described to improve the cosmetic outcome and decrease complication rates. The aim of the study was to present a modified post auricular flap technique that increases the control of reshaping the ear cartilages, decreases the operation time, and provides a symmetrical long-lasting cosmetic outcome.

One hundred sixty-two patients (141 male and 21 female) had ear correction surgeries performed by the same surgeon using the described technique between January 2015 and January 2018. One hundred sixty patients were gone through bilateral ear correction, whereas only 2 patients had unilateral ear correction procedures. A modified posterior perichondrio-adipo-dermal flap technique for protruding ear correction was applied to all patients.

The patients' ages ranged from 18 to 40 years, with a median of 28.3 years. The mean follow-up time was 22.5 months (6–36 months). Total operation time was 35 minutes on average (25–45 minutes). As more experience was gained in flap harvesting, operation time became shorter. The mean preoperative upper third ear proportion-scalp distance was 33.1 mm and the middle third ear proportion—scalp distance was 29.8 mm. At the sixth month of the surgery, the measurements were 9.8 and 11.6 mm.

Measuring and adjusting flap's width provided to achieve symmetry in initial technique. Locating the postoperative scar along the posterior surface of the helical groove also provides a natural view. Different from traditional posterior fascial flap, the width of the flap was narrowed to 8 to 10 mm. In the traditional technique, the flap was dissected along the incision margins. Narrowing the width of the flap decreased the operation time. The preserved skin between the helix and the mastoid bone has the same width with perichondrio-adipo-dermal flap. That increases the control over the helix-mastoid distance and posterior auricular fold not to mention provides permanent results. The previously mentioned method can be a simple, useful, and practical technique for protruding ear deformity.

From the Odunluk Mahallesi, Mihrapli Cad; and Plastic Reconstructive and Aesthetic Surgery Department, Jimer Hospital, Nilüfer/Bursa, Turkey.

Received January 11, 2019, and accepted for publication, after revision May 30, 2019.

Conflicts of Interest and sources of funding: none declared.

Formal consents with patients' own signatures were gathered from each patient before all surgical interventions in which it was described in detail the purpose of before, intraoperative, and after photos.

Reprints: Burak Ersen, MD, FEBOPRAS, Jimer Hospital, OdunlukMahallesi, Mihrapli Cad. Orhaneli Yolu Beşevler Kavşaği No. 6, 16110 Nilüfer/Bursa, Turkey. E-mail: Drburakersen@gmail.com.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.annalsplasticsurgery.com).

Prominent ear deformity is a common congenital deformity of the external ear affecting 5% of the general population.1 Because of the deformity's displeasing nature, corrective prominent ear surgery is widely common and performed as a prophylactic surgery. More than 200 surgical techniques for the correction of prominent ear deformity have been described to improve the cosmetic outcome and decrease complication rates.2 However, there is currently no universally favored technique and long-term results of the various techniques are lacking in the literature.

The postauricular fascial flap was described as by Horlock et al3 as an adjunct to suture otoplasty. In the initial publication, the role of postauricular flap was to cover the surgical field as a protective shield for suture extrusion and to provide an additional force for preventing deformity recurrence.3 Shortly after its description by Horlock et al,3 the postauricular fascial flap increasingly gained popularity. Several publications have been demonstrated that combining the postauricular fascial flap as known as perichondrio-adipo-dermal flap with other prominent ear correction techniques decreased the postoperative complication rates and increased the quality of cosmetic outcomes.3–7 Recent publications have demonstrated that the utilization of the posterior perichondrio-adipo-dermal flap as a stand-alone prominent ear correction technique provided satisfactory postoperative results.8–10

This article aims to present a modified posterior perichondrio-adipo-dermal flap technique that increases the control of reshaping the ear cartilages, decreases the operation time and postoperative complication rates, and provides a symmetrical long-lasting cosmetic outcome.

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MATERIALS AND METHODS

One hundred sixty-two patients (141 male and 21 female) had ear correction surgeries performed by the same surgeon using the described technique between January 2015 and January 2018. One hundred sixty patients were gone through bilateral ear correction, whereas only 2 patients had unilateral ear correction procedures. The described technique was applied to all protruding ear types. Among these patients, 78 patients had antihelical deficiency, 73 patients had both antihelical deficiency and mild conchal hypertrophy, whereas only 11 patients had isolated conchal hypertrophy.

The helix-mastoid distances and concha-mastoid angles of the patients were measured preoperatively and at the sixth month of the surgery for the late postoperative assessment. Patients were also evaluated for suture extrusion, granuloma formation, deformity recurrence, and postauricular area sensitivity.

Operations were undertaken under local anesthesia plus intravenous sedation in adult group. Lidocaine and 1:200,000 epinephrine was injected to postauricular and mastoid area. An elliptic incision was planned for de-epithelization. The lateral margin of the incision was planned along the posterior surface of the helical groove. The medial margin of the incision is adjusted upon patient's preference for the helix-mastoid distance. The average distance between the medial margin of the incision and the concha-mastoid angle was 10 mm in our study. To achieve that, the distance between the medial margin of the incision and the concha-mastoid angle and flap width was planned 10 mm wide. The inferior tip of the incision reached to the intersection between the ear lobule and concha. That prevents the necessity of any additional incisions while changing the ear lobule's shape (Fig. 1). After de-epithelization, a U-shaped laterally based fascial flap was planned. The average width of the flap was 10 mm (Figs. 2, 3). The width of the flap is important for this technique because the width of the flap determines the distance between the helix and the mastoid bone. The distance between the medial margin of the skin incision margin and the concho-mastoid angle and width of the fascial flap should be equal to achieve patient's desired posterior auricular fold and the distance between helix and the mastoid bone. It is important to keep in mind that these two layers (remaining medial skin and perichondrio-adipo-dermal flap) will 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 (Fig. 4). A laterally based perichondrio-adipo-dermal flap was elevated. When preparation of the flap was completed, dissection was conducted medially within the supraperichondrial plane toward the mastoid bone. The postauricular muscle was preserved during dissection. A 2 × 5-cm dermal pocket was prepared over the mastoid bone for flap insertion (Fig. 5). Laterally based perichondrio-adipo-dermal flap was fixed to the mastoid bone periosteum from the 3 different points (superior, middle, and inferior proportion of the ear) with 4–0 poliglecaprone sutures (Fig. 6). It is possible to perform an additional ear lobe set back with an extra suture without any additional incisions. Skin closure was done via continuing mattress suture (The cornerstones of the procedure were recorded and demonstrated in the video content, http://links.lww.com/SAP/A380). The incision scar sits along the posterior surface of the helical groove and creates a natural view.

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There was no need to insert suction or Penrose drain. Anterior and posterior sections of auricular skin were covered with gauze so as to fit to the contours of the ear and elastic head bandages used. Patients were monitored in hospital for several hours and intravenous antibiotics were provided. Patients were discharged in the same day.

The bandages of patients were removed on the forth postoperative day and head bands were advised for the patients. Patients kept their bandages on until the 21st postoperative day. Bandages were advised to be worn overnight for 3 additional weeks.

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RESULTS

The patients' ages ranged from 18 to 40 years, with a median of 28.3 years. The mean follow-up time was 22.5 months (6–36 months). Total operation time was 35 minutes on average (25–45 minutes). As more experience was gained in flap harvesting, operation time became shorter. The mean preoperative upper third ear proportion-scalp distance was 33.1 mm and the middle third ear proportion—scalp distance was 29.8 mm. At the sixth month of the surgery, the measurements were 9.8 and 11.6 mm.

None of the patients experienced any early postoperative complications, such as skin necrosis, suture extrusion, hematoma, or wound infection. Twenty patients experienced long-term complications, such as deformity recurrence, asymmetry, palpable suture material, and prolonged sensation problems in the posterior auricular surface. Unilateral recurrence was noted in 3 patients, bilateral recurrence was noted in 13 patients, and revisions were performed (Figs. 7–16). Fixation sutures were palpable in 4 patients and sutures were removed in 2 patients. Two patients described sensitivity with palpation at the end of the sixth month. Patients' discomfort decreased within time and did not completely dissolve (Figs. 17–19).

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DISCUSSION

The main purpose of prominent ear correction surgery is to provide natural, symmetrical-looking ears with minimal complications and recurrence. However, a perfect technique for surgical correction has remained elusive. Traditionally, prominent ear correction surgeries can be divided into two categories: cartilage cutting and cartilage sparing. Cartilage-cutting techniques cause irreversible cartilage and soft tissue changes that may lead to high complication rates and ear deformities. Therefore, cartilage-sparing techniques have gained popularity. Among the available cartilage-sparing techniques, cartilage suturing techniques are perhaps the most well-known and most commonly applied techniques.11,12 However, using these techniques alone for prominent ear correction surgery has previously led to other complications, including suture protrusion, granuloma formation over the suture line, and pain due to buried sutures. To overcome these complications, various techniques have been described.3–7 Previous studies have observed that short and long complication rates of the perichondrio-adipo-dermal flap used in the present study are considerably lower compared with traditional techniques,13,14 which is possibly due to the preservative manner of the technique. Notably, cartilage-cutting techniques tend to cause irreversible changes. On the other hand, in cartilage-sparing techniques, it is essential to use surgical sutures between cartilages. Therefore, complications, such as suture exposure or recurrence, tend to occur at the locations where sutures are placed. In addition, recurrence and long-term asymmetry problems are common complications observed in these techniques because of cartilage memory acting as a counter force against repair. In these techniques, fixation sutures are the main force that encounters cartilage memory. The perichondrio-adipo-dermal flap technique overcomes these problems because of its nature and preservative manner. The preservation of ear cartilage as a whole carries great importance because it prevents additional problems caused by cartilage scoring, scraping, cutting, or suturing. Notably, the preservative nature of the technique is considered the main reason for low complication rates. No short-term complications were observed in the present study because ear cartilage remained untouched. Such meticulous flap preparation and insertion tends to prevent possible dead spaces in the operation area, which decreases the possibility of hematoma.

However, because 18 patients required revision surgery, the perichondrio-adipo-dermal flap is evidently not a perfect technique. This technique requires an intact perichondrium and correctly located sutures to maintain a satisfactory result. If one fails to elevate the flap without damaging perichondrium, the possibility of long-term complications increases because the perichondrium prevents the flap from stretching and elongating.4,8–10 It was also observed that if the fixation sutures were placed medially to the medial border of the skin incision, the risk of palpable sutures increases in the long term. As such, the fixation sutures should be located within the borders of the skin incisions. In the present study, palpable fixation sutures were observed in 4 patients over the long term, and they needed to be removed in 2 patients. The short- and long-term complications rates of our study were 0 and 11%, respectively, which is lower than traditional otoplasty techniques.3–5

The application of the posterior fascia flap was first used by Horlock et al3 and Shokrollahi et al4 as a supportive component to Mustarde and Furnas concha-mastoid sutures. This fascial flap covers the permanent sutures to prevent suture extrusion, whereas advancement of the flap acts as a supportive structure. Horlock et al3 reported a 0% suture extrusion rate and a recurrence rate of 8% with postauricular fascia flap refinement of the cartilage-sparing technique. Sinha and Richard7 reported a similar result. These authors described the postauricular flap as a supportive technique to decrease complication rates, as opposed to a trustworthy stand-alone correction method. Shortly after the description of the posterior fascial flap, the method gained popularity and was used as a stand-alone technique for protruding ear correction surgery in several publications.8–10 This technique has now been applied to all protruding ear deformity types in the present study. The patients in our sample had overwhelmingly isolated antihelical effacement or antihelical effacement with mild conchal hypertrophy, and it was observed that this technique is quite effective and useful in treating these deformities. However, the number of isolated conchal hypertrophy cases remains limited in the general population, which is also reflected in our patient profiles. Although the results were satisfactory in 11 cases, there is no doubt that more isolated conchal hypertrophy cases must be performed to claim that the technique is suitable for all protruding ear types. However, it remains fair to claim that the technique is highly efficient in the context of antihelical effacement and antihelical effacement with mild conchal bowl hypertrophy. If the conchal bowl hypertrophy is prominent or the ear cartilages are thick, the possibility of long-term complications increases. In such cases, selecting a combination of posterior fascial flap with another technique is logical.

The posterior skin of the ear exists as a fascial layer; it contains blood vessels, nerves, perichondrium, and fibro-fatty tissue. Thus, the described flap can be considered as a dermofascial flap. Histological examination of this region has revealed a rich vascular network. This flap is feasible because of the anatomical basis of the vascular network.15 The laterally based posterior fascial flap contains the following 3 layers: perichondrium, subcutaneous adipose tissue, and dermis. These layers provide high vascularity for tissue healing, elasticity for a natural-looking antihelical fold without sharp edges, and stability for long-lasting cosmetic results. Therefore, measuring and adjusting flap width provide satisfactory symmetry in the perichondrio-adipo-dermal flap technique. Locating the postoperative scar along the posterior surface of the helical groove also provides a natural view. Keeping the perichondrium intact is possibly the most important part of the flap elevation because—if one fails to do so—the possibility of long-term asymmetry increases.

The perichondrio-adipo-dermal flap also enables the movement of the ear backward in the sagittal plane because of its continuity throughout the rim of the helix, which can correct both the concho-mastoid and concho-scaphal angles.8 Because the flap attaches to 3 different points over the mastoid bone, tension over the sutures can be more evenly distributed and shared between the suture and along the entire flap. That creates an obvious advantage compared with sutures used in the Mustarde technique, because the flap itself is in continuation along the rim of the helix.8 This tension distribution minimizes the counter force caused by cartilage memory (which leads to deformity recurrence) and provides ideal immobilization to achieve symmetrical, balanced cosmetic results. In cartilage suturing techniques, ear cartilage bends according to the suture placement points. Using the previously mentioned technique, ear cartilage bends from its weakest point, thus decreasing the possibility of recurrence and creating a more natural appearance. Because ear cartilage bends from the weakest point, the counter force caused by cartilage memory remains minimal. In traditional Mustarde and Furnas otoplasty, the permanent sutures are placed in the middle portion of the ear cartilage, and this short distance between the permanent suture and the bending point creates a strong counter force against the repair, which subsequently increases the possibility of recurrence. However, using perichondrio-adipo-dermal flap technique, the pivot point of the flap is along the lateral edge of the ear cartilage. As such, the distance between the flap and the bending point is longer compared with traditional cartilage suturing techniques, which creates less tension over sutures and the flap. Moreover, this force is distributed equally to 3 different points; therefore, it becomes possible to provide a more stable surgical repair without scoring, cutting, scraping, or damaging ear cartilage and without using permanent mattress sutures. Furthermore, bending of the ear cartilage creates a natural-looking antihelical fold. Meticulously tailored flap width also contributes to this natural appearance through adjusting the conchomastoid and conchascaphoid angles.

Different from the traditional posterior fascial flap, the width of the flap is narrowed to 8 to 10 mm. In the traditional technique, the flap is dissected along the incision margins. Narrowing the width of the flap naturally decreases the operation time. The preserved skin between the helix and the mastoid bone has the same width as the fascial flap, which increases control over the helix-mastoid distance and provides more predictable results. The perichondrio-adipo-dermal flap helps the conchal bowl in partially rolling over the mastoid bone and decreases the antihelical angle. This maneuver results in the described technique being useful for both mild conchal hypertrophy and antihelical deficiency. Because the flap covers both the helical and conchal area, improvement of the conchomastoid and antihelical angle is considered to be independent from the type of deformity. However, in cases of severe conchal bowl hypertrophy, the rolling effect does not provide satisfactory results because a thick and large conchal bowl remains visible. This is why the previously mentioned technique does not seem suitable for severe conchal hypertrophy cases.

Notably, the described technique is particularly advantageous over other techniques in terms of asymmetry. Because of the meticulous measurement of flap width and the remaining skin over the posterior helical groove, it is easy to achieve the exact same distance as the nonoperated ear. The amount of skin to be resected is wide and long compared with other otoplasty techniques, which plays an important role in achieving satisfactory results. Moreover, the nature of the skin resection pattern helps establish an easy-to-hide scar and creates a natural-looking posterior auricular sulcus.

The dissection planes of the flap and the pocket in which flap is inserted also provide additional advantages. Scar formation, which occurs in between the different tissue layers, increases the quality and firmness of the method.8,10 The most important component of scar formation is certainly neochondrogenesis. The development of neochondrogenesis between the perichondrium and the cartilage surface at the corner where the perichondrio-adipo-dermal flap is elevated plays a crucial role in the long-lasting satisfactory results of this method. The antihelical fold sustains its new shape for a long time, and the results of the perichondrio-adipo-dermal flap technique will be long-lasting because of the neochondrogenesis caused by the elevation of the perichondrium.10,16

It was believed that no short-term complications would occur `because of the preservative nature of the technique. Although the long-term complication rate was 11%, none of the observed complications were irreversible or problematic, and all were easily corrected with revision otoplasty.

Preserving the integrity of the perichondrium during flap elevation is the most important surgical step in preventing long-term complications and securing permanent results. It was believed that if one fails to elevate the perichondrio-adipo-dermal flap without damaging the perichondrium, it would typically lead to long-term asymmetry or recurrence. However, it remains possible to harvest the flap without damaging the perichondrium in revision cases. In revision cases, it was noted that scar formation has the tendency to fill the previously created holes in the perichondrium and increase the firmness of the flap.

This article aimed to describe a modification of the posterior perichondrio-adipo-dermal flap as a customized technique. By narrowing the flap width and harvesting it in a U-shaped pattern, operation time was reduced, tension distribution was balanced, control over postoperative symmetry and cosmetic results increased, and the necessity of additional incisions for earlobe reshaping was overcome. As such, the previously mentioned method represents a simple, useful, and practical technique for correcting protruding ear deformity.

With this in mind, there are 2 main drawbacks of the technique. First, the technique is not as efficient in correcting severe conchal bowl hypertrophy cases as it is for other protruding ear deformity types. A combination of this technique with other otoplasty techniques might be necessary to secure long-lasting results in such cases. Second, meticulous dissection of the flap is required for satisfactory postoperative results; however, if one fails to harvest the flap without damaging the perichondrium, the possibility of long-term complications increases.

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ACKNOWLEDGMENT

Informed consent was received for publication of the figures in this article.

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REFERENCES

1. Coltro PS, Alves HR, Gallafrio ST, et al. Sensibility of the ear after otoplasty. Ann Plast Surg. 2012;68:120–124.
2. Bajaj Y, Rokade A, De PR. Otoplasty: experience with a modification using a drill, and literature review. J Laryngol Otol. 2007;121:61e4.
3. Horlock N, Misra A, Gault DT. The postauricular fascial flap as an adjunct to Mustardé and Furnas type otoplasty. Plast Reconstr Surg. 2001;108:1487–1491.
4. Shokrollahi K, Cooper MA, Hiew LY. Single suture otoplasty-a new strategy. J Plast Reconstr Aesthet Surg. 2009;62:774–778.
5. 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. 2006;59:1170–1176.
6. Schaverien MV, Al-Busaidi S, Stewart KJ. Long-term results of posterior suturing with postauricular fascial flap otoplasty. J Plast Reconstr Aesthet Surg. 2010;63:1447–1451.
7. Sinha M, Richard B. Postauricular fascial flap and suture otoplasty: a prospective outcome study of 227 patients. J Plast Reconstr Aesthet Surg. 2012;65:367–371.
8. 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. 2016;27:892–897.
9. Basat SO, Askeroğlu U, Aksan T, et al. New otoplasty approach: a laterally based postauricular dermal flap as an addition to Mustarde and Furnas to prevent suture extrusion and recurrence. Aesthetic Plast Surg. 2014;38:83–89.
10. Taş S, Benlier E. A new way for antihelixplasty in prominent ear surgery. Ann Plast Surg. 2016;76:615–621.
11. Mustarde JC. Correction of prominent ears using buried mattress sutures. Clin Plast Surg. 1978;5:459–464.
12. Furnas DW. Correction of the prominent ears by conchamastoid sutures. Plast Reconstr Surg. 1968;42:189–193.
13. Smittenberg MN, Marsman M, Veeger NJGM, et al. Comparison of cartilage-scoring and cartilage-sparing otoplasty: a retrospective analysis of complications and aesthetic outcome. Plast Reconstr Surg. 2018;141:500e–506e.
14. Scuderi N, Tenna S, Bitonti A, et al. Repositioning of posterior auricular muscle combined with conventional otoplasty: a personal technique. J Plast Reconstr Aesthet Surg. 2007;60:201–204.
15. Shokrollahi K, Taylor JP, Le Roux CM, et al. The postauricular fascia: classification, anatomy, and potential surgical applications. Ann Plast Surg. 2014;73:92–97.
16. 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. 1994;33:371–376.
Keywords:

protruding ear; perichondrium; posterior auricular flap

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