Prominent Ear Correction: A Comprehensive Review of Fascial Flaps in Otoplasty

The Ideal Proportion of the Auricle Exposure via a Morphometric Analysis in Asian Women

BACKGROUND

Ears are an important aesthetic feature that is vital to the overall attractiveness of the face. Although there have been many studies on the aesthetics of the auricle, there is currently a lack of consensus on the ideal proportion of auricle exposure for Asian women in frontal view.

OBJECTIVES

This study aimed to investigate ideal proportion of auricle exposure in Asian women.

METHODS

An observational study was carried out on the photographs of 84 women on the list of the 100 most beautiful faces in Asia (published by TCC Asia in 2020). The proportion of the distance between the outer canthus and the outermost point of auricle to the distance between the inner canthus and the outermost point of auricle was calculated as the auricle exposure proportion. Evaluators were asked to rank a set of photographs of the volunteer with varying auricle exposure proportions from most attractive to least attractive.

RESULTS

Measurements of the photographs of the 84 women showed a mean ear exposure proportion of 0.600. With 487 questionnaire responses received, the proportion of auricle exposure that the evaluators considered most attractive was 0.600. People with aesthetic experience considered 0.625 the most attractive proportion, while the general group considered 0.600 the most attractive.

CONCLUSIONS

The ideal proportion of the auricle exposure for Asian women is in the range of 0.60-0.625, which may help surgeons reconstruct aesthetically pleasing ears.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Utilization of Free Soft-tissue Grafts in Otoplasty: A Simple Yet Effective Way to Avoid Suture Extrusion

BACKGROUND

Prominent ear deformity occurs in 5% of the general population and has been treated by otoplasty for many years to address the psychosocial challenges of having such a deformity. There is extensive literature but no consensus on the best method to address potential surgical complications, including suture extrusion.

OBJECTIVES

In this article, we describe a surgical technique designed to reduce suture extrusion following otoplasty surgery by using free soft tissue grafts placed between Mustardé sutures and post-auricular skin.

METHODS

Two hundred eleven patients who underwent otoplasties using soft tissue grafts from January 2017-January 2020 were included in this study. All surgeries were performed by 2 facial plastic surgeons with more than 20 years of experience each, practicing in Toronto. Patients were followed up to assess for suture extrusion between 12-36 months (median, 21 months) postoperatively. The rate of suture complications and extrusion was compared to previous literature.

RESULTS

Only 2 patients out of 211 (0.47%) had unilateral suture extrusion and were treated with suture removal. This is dramatically lower than the upper values reported in literature, averaging 5.55% (range, 0%-22.2%).

CONCLUSIONS

A soft tissue graft separating the Mustardé sutures and post-auricular skin acts as a barrier, which can be used in conjunction with traditional surgical techniques. By adding this graft in the proposed manner, there is additional tissue reinforcing the suture repair, thereby reducing the rate of suture complications and extrusion without increasing operative time.

Modified bilateral fasciaperichondrial flap for prominent ear correction

OBJECTIVE

Various techniques have been described in the literature for prominent ear correction. These cartilage-preserving or cartilage-shaping techniques have their own advantages and disadvantages. We aim to achieve aesthetic and stable results with low complication rates using combinations of these methods. Herein, we present our results of prominent ear surgery with a modified bilateral fasciaperichondrial flap in combination with concha-mastoid and concha-scaphal sutures.

METHODS

Patients whose surgeries included a modified bilateral fasciaperichondrial flap for prominent ear deformities were included in the study. Patients' demographic data, pre- and postoperative Concha-Mastoid Angle (CMA) and upper-middle Helix-Mastoid Distances (HMD), follow-up time, complications, secondary operations, and postoperative Visual Analogue Scale (VAS) results were evaluated. With a postauricular fish-mouth incision, the bilateral fasciaperichondrial flap was planned into two: proximal- and distal-based. They were then elevated from the cartilage subperichondrially on the proximal side and supraperichondrially on the distal side. Concha-scaphal sutures were used to form an antihelical rim along with concha-mastoid sutures to reduce the concha-mastoid angle. Conchal cartilage resection was done if needed. Then, the bilateral fasciaperichondrial flaps were sutured together to cover the concha-mastoid and concha-scaphal sutures.

RESULTS

Between May 2017 and May 2021, 32 ears of 17 patients were operated on due to prominent ear deformity. No hematoma or infection was observed in any patient, and there were no instances of recurrence, suture exposure, hypertrophic scars, or keloids. The satisfaction level of all patients was 8.2 ± 0.9 points on average according to the VAS. In the anthropometric measurements, a statistically significant difference was found between preoperative and postoperative sixth month CMA and HMD values.

CONCLUSION

A combination of suture techniques and a modified bilateral fasciaperichondrial flap may be used in prominent ear cases, with low recurrence rates and high patient satisfaction.

LEVEL OF EVIDENCE

III.

Ear Abnormalities

Congenital ear abnormalities present an aesthetic and psychosocial concern for pediatric patients and their parents. Diagnosis of external ear deformities is based on clinical examination and is facilitated by an understanding of normal ear anatomy. Ear anomalies can be categorized as malformations or deformations. Malformations are characterized by absent anatomical structures of the ear (or absence of the ear itself), as exemplified by microtia and anotia. Ear deformations are characterized by ear anatomical landmarks that are present but are distorted or abnormal, with Stahl ear, constricted ear, and prominent ear being common presentations. Ear malformations will not improve with growth of the patient and uniformly require surgical intervention to recreate an anatomically typical ear. Although a small percentage of ear deformations can self-resolve, most patients with ear deformations will require nonsurgical or surgical reconstruction to achieve a normal or more aesthetic ear. In recent decades the use of nonsurgical ear splinting or molding has been recognized as a highly effective method in correcting a variety of congenital ear deformations when treatment is initiated in the first 8 weeks of life. The urgency in initiating nonsurgical treatment of ear deformations at an early age makes prompt recognition of these ear deformations essential because surgical correction remains the only viable reconstructive option in older infants and children.

Cartilage-Sparing Otoplasty: The Effects of Adipo-Perichondrial Flap-Assisted Posterior Auricular Muscle Complex Flap Technique on the Repair of Prominent Ear Deformities

BACKGROUND

In the repair of prominent ear deformities, the main objectives are to recreate the antihelical fold, reduce projection in patients with a large concha, and normalize the distance between the ear and the cranium. This study evaluated the efficacy of the adipo-perichondrial flap-assisted posterior auricular muscle complex (PAMC) flap technique, which involves a new approach to the repair of prominent ear deformities.

MATERIALS AND METHODS

A medially based PAMC flap and a laterally based adipo-perichondrial flap were elevated in 22 patients with prominent ear deformities. In order to shape the ear, the PAMC flap was sutured to the transition zone between the helix and antihelix, and the adipo-perichondrial flap to the periosteum of the mastoid bone. The ear-cranium distances were measured preoperatively and at postoperative first and sixth months.

RESULTS

Thirteen patients were female and 9 were male. The mean age of the patients was 19.4 years, and the mean follow-up period was 10.6 months. The ear-cranium distance significantly decreased in the postoperative first-month and sixth-month evaluations compared to the preoperative values (P < .05). No relapse, suture exposition, hematoma, keloid scar, or infection was observed.

CONCLUSION

Posterior auricular muscle complex is a strong anatomical structure that includes the trapezius muscle, occipital muscle, extrinsic ear muscles, temporal fascia, and sternocleidomastoid fascia. By elevating this structure as a flap and combining it with an adipo-perichondrial flap, successful results can be achieved in the repair of prominent ear deformities, which prevents relapses and maintains the shape of the ear in the long term.

Aesthetic Otoplasty: Principles, Techniques and an Integrated Approach to Patient-Centric Outcomes

BACKGROUND

Otoplasty is a century-old procedure that, through continued modifications, now has over two hundred different procedures described in the literature. In this article, we seek to describe the anatomy and principles of aesthetic otoplasty, as well as some of the key contributions to aesthetic otoplasty. This article will also outline some of the most commonly used techniques today and associated patient outcomes.

METHODS

We present a review of the literature of relevant anatomy, pathophysiology and common techniques and outcomes. We also provide a discussion of several patients with associated techniques and outcomes.

RESULTS

The treatment of prominent ear has developed through manipulation and experimentation. The outcomes are defined by the native anatomy, the surgical technique and the attention to patient-centered outcomes.

CONCLUSION

Aesthetic otoplasty remains one of the most important surgical techniques and common procedures in plastic surgery. Using an integrated approach guided by known principles as well as patient goals allows for optimal outcome in aesthetic otoplasty.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .