Otoplasty: What You Need to Know About Prominent Ear Deformity

Prominent ear deformity is relatively common; this defect- inherited as an autosomal dominant trait-affects approximately 5% of white children.¹ As such, surgical correction is a common operation performed by plastic surgeons.

Although its physiological consequences are minimal, multiple studies attest to the psychological distress and negative emotional sequelae that prominent ear deformity can impart on children and their caregivers.^1,2 Consequently, many surgical techniques have been developed to correct the abnormal ear shape-specifically, the malformed antihelical fold and hypertrophic conchal bowl with or without ear lobule setback.

Here I outline the background and rationale for treatment of prominent ear deformity. I also highlight treatment options and review postoperative care and possible complications.

TREATMENT RATIONALE AND PSYCHOLOGICAL SEQUELAE

For children and young adolescents undergoing otoplasty, the motivation for surgery may be aesthetic dissatisfaction, psychosocial distress, or distress anticipated by caregivers. ^1-3 Children with aesthetic deformities such as prominent ears are often the subjects of peer ridicule, which may give rise to emotional instability for the affected child.

For most children, the motivation for surgery is predominantly psychological and social distress. From a psychosocial perspective, favorable outcomes are produced postcorrection. Most children and their families reported increased self-confidence after corrective surgery, and more than half of children reported that teasing and bullying diminished postoperatively.^2,3 In a study of psychological and social outcomes of prominent ear correction, well-being had improved in an overwhelming majority of children 12 months postoperatively. Psychological evaluation should be sought for any child showing evidence of marked social isolation or acute distress preoperatively.²

ANATOMY

The outer ear is a composite complex of cartilage and skin made up of 3 critical elements-the helixantihelix- fossa triangularis complex, the conchal bowl, and the lobule. Other external anatomical landmarks include the tragus, antitragus, intertragic notch, and tubercle of Darwin.

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The anatomical divisions of the ear have embryological origins, based on the first (mandibular) and second (hyoid) branchial arches. The major difference between the neonatal ear and the adult ear is that the cartilage is more malleable and soft in the neonate; by adulthood, the ear's cartilage becomes stiffer and more calcified and surgically more difficult to sculpt.

The ear achieves about 85% of its adult size by age 3 to 4 years. Ear width reaches its mature size in boys at 7 years and in girls at 6 years, while ear length matures in boys at 13 to 15 years and in girls at 12 to 14 years. The ear has several proportions or "canons" that are common in the normal ear-as originally described by Da Vinci in his descriptions of normal facial aesthetics. Some of these canons include:

• The width of the ear is about half the height.

• The ear's height is generally equal to the distance between the lateral margin of the ipsilateral orbital rim and the root of the ear.

• The ear inclines posteriorly about 20 off the vertical axis.

The arterial supply to the external ear is from branches of the external carotid artery, specifically, the posterior auricular and the superficial temporal arteries. The primary innervation to the external ear consists of the great auricular nerve and the auriculotemporal nerve. Other sensory nerve branches to the ear include the lesser occipital, vagus, and glossopharyngeal nerves.

PATIENT EVALUATION

During preoperative evaluation, the following focused assessment^1,5 should be performed by the pediatrician to determine whether to refer the patient for correction of the prominent ear deformity:

• Evaluation of the ear:
  - Superior third of the ear (antihelical fold development).
  -Middle third of the ear (conchal bowl deformity).
  -Lower third of the ear (lobule prominence).

• Psychological sequelae as a result of the deformity.

• Motivations for surgery (patient and family).

The optimal timing of surgical correction is usually when the ear is almost fully developed-by age 4 to 6 years, around the time of the child's entry into first grade. Given the largely aesthetic nature of the operation, informed consent with a detailed discussion of complications and postoperative course is critical to the optimization of patient and family expectations and outcomes.

NONSURGICAL CORRECTION

Some authors have achieved acceptable results in the neonatal period with nonsurgical molding of the prominent ear deformity.^1,6 This principle is based on circulating neonatal estrogens that render the ear cartilage relatively pliable. There is evidence that this intervention is successful within the first few days of life until 3 to 4 months postnatally. Early initiation of treatment continued to about 6 months of age can produce improvements in ear shape.

SURGICAL APPROACH AND POSTOPERATIVE CARE

Various treatments and approaches have been developed to correct prominent ear deformity,^1,4,5 These include techniques that modify or reposition the auricular cartilage and soft tissues using a combination of suturing, scoring, and/or excision. The goals of the operation are to provide a natural-appearing auricle, without an "operated" look. Operative approaches for the correction of the prominent ear can be considered as techniques used to recreate the antihelical fold (suture techniques or scoring techniques), to reduce the conchal defect (cartilage excision), and to correct lobule positioning (suture fixation techniques or skin excision techniques). The details of these techniques are beyond the scope of this review; however references are provided for in-depth explanations.^4-6

Figures 1 and 2 illustrate 2 patients treated with surgical correction intraoperatively and postoperatively with a combination of suture techniques for the correction of the superior third deformity of the antihelical fold as well as cartilage excision for the conchal bowl deformity.

Figure 1 - Preoperative (A) and 6-month postoperative (B) images are shown of a 4-year-old boy who had undergone surgical correction of deformities of the superior third and middle third of the ear.

Figure 2 - Intraoperative photos are shown of a 5-year-old boy preoperatively (A) and with excision of hypertrophic conchal bowl cartilage and postauricular skin (B). The patient is shown immediately after surgical manipulation of ear cartilage following excision and suture repositioning technique (C).

After surgery, the ears are maintained in position by a bulky dressing of vaseline gauze, 4 x 4-in gauze, and Kerlix gauze rolls. The initial dressing is left in place for approximately 1 week, and is then removed in the clinic. Postoperatively, a conforming ear bandage is worn by the patient for 3 weeks around-the-clock and then for the following 3 weeks only at night (Figure 3). Postoperative oral antibiotics (cephalexin) and analgesics (acetaminophen with codeine) are prescribed for 5 to 7 days. In addition, children are to refrain from sports or other activities that may traumatize the ears for 6 weeks postoperatively.

Figure 3 - This 6-year-old boy wore a headband for 6 weeks following otoplasty.

COMPLICATIONS

Numerous undesirable sequelae are associated with otoplasty.^1,7 Hematoma, one of the most common immediate postoperative complications, presents with unilateral acute and severe pain. This complication must be managed with dressing removal and hematoma evacuation to prevent an otohematoma and subsequent cartilaginous deformity.

Infection is another potentially devastating complication of otoplasty because it can lead to chondritis and residual ear deformity. If pain, tenderness, swelling, and drainage are encountered, treatment with intravenous antibiotics is imperative- with or without wound debridement. The commonly implicated organisms include Staphylococcus, Streptococcus, and occasionally Pseudomonas. Pseudomonal chondritis is a surgical emergency since, without treatment, an ear cartilage deformity may result. As such, prompt debridement of infected cartilage is required.

Recurrence of the prominent ear deformity, a known complication of otoplasty in 15% to 25% of patients, usually becomes evident 5 to 6 months postoperatively. Trauma, infection, hematoma, and poor surgical planning and surgical technique are the causes of postoperative asymmetries, potentially necessitating a second otoplasty to correct residual deformities. Otoplasty may result in other postoperative complications, including an obliterated postauricular sulcus, fracture of the antihelical fold (excessive cartilage scoring), a telephone ear deformity (excessive excision of the conchal bowl), and a prominent lobule.

TAKE-HOME PEARLS

• Prominent ears are a relatively common deformity and are associated with limited functional consequences. However, they may produce significant aesthetic and psychological effects on the patient and family.

• Outcome studies show that after otoplasty, overall patient satisfaction is high and recurrence rates are minimal.

• With accurate preoperative diagnosis of the deformity, detailed informed counsel with the patient and family, proper preoperative planning, proficient technical execution of the procedure, and meticulous postoperative care, optimization of outcomes is possible.

• It remains uncertain whether physicians should refer patients for surgical correction of the prominent ear deformity before or after a child begins to feel self-conscious about his or her appearance and potentially suffer deleterious and often irreversible psychological sequelae.

References:

• Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg. 2005;115:60e-72e.

• Bradbury ET, Hewison J, Timmons MJ. Psychological and social outcome of prominent ear correction in children. Br J Plast Surg. 1992;45:97-100.

• Cooper-Hobson G, Jaffe W. The benefits of otoplasty for children: further evidence to satisfy the modern NHS. J Plast Reconstr Aesthet Surg. 2007 Nov 19; [Epub ahead of print].

• Hoehn JG, Ashruf S. Otoplasty: sequencing the operation for improved results. Plast Reconstr Surg. 2005;115:5e-16e.

• Kelley P, Hollier L, Stal S. Otoplasty: evaluation, technique, and review. J Craniofac Surg. 2003;14: 643-653.

• Matsuo K, Hayashi R, Kiyono M, et al. Nonsurgical correction of congenital auricular deformities. Clin Plast Surg. 1990;17:383-395.

• Elliott RA Jr. Complications in the treatment of prominent ears. Clin Plast Surg. 1978;5:479-490.