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O R I G I N A L A R T I C L E FACIAL SURGERY
Aesthetic Otoplasty: Principles, Techniques and an Integrated
Approach to Patient-Centric Outcomes
Andrew Ordon
1
•Erik Wolfswinkel
2
•Orr Shauly
1
•Daniel J. Gould
2
Received: 16 January 2019 / Accepted: 12 May 2019
ÓSpringer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2019
Abstract
Background Otoplasty is a century-old procedure that,
through continued modifications, now has over two hun-
dred 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 contribu-
tions 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 opti-
mal 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.
Keywords Minimally invasive plastic surgery Aesthetic
otoplasty Patient-centered plastic surgery
Scaphomastoid sutures Perichondrio-adipo-dermal flap
technique Incisionless otoplasty Patient-centric
outcomes
Introduction
Prominent ears are a relatively common auricular defor-
mity. The aesthetic and psychological sequela of this
deformity can be profound. This article reviews the rele-
vant anatomy, key contributions and surgical principles of
otoplasty. The variety of treatments and techniques reveal
the complexity of this deformity. Herein, we present a
review of the literature and describe our integrated
approach with patient examples and outcomes.
The Adult Auricle, ‘‘Normal’’ Ear
The dimensions of the normal ear include length of the adult
auricle of approximately 5.5–6.5 cm, while the width is nor-
mally 50–60% that of the length (Fig. 1). Projection is mea-
sured at 1–1.2 cm from the scalp in the superior third of the
helical rim, 1.6–1.8 cm from the scalp at the midpoint of the
helix and 2–2.2 cm at the lobule (Table 1)[1–3]. The auricle
develops quickly after birth: 85% of verticalear growth occurs
by the third year of life, while 90% of the adult width occurs
within the first year of life (Fig. 2). Vertical growth reaches
93% and width reaches 97 to 99% by 10 years of age [1,4,5].
Because of early growth and social implications, most pro-
cedures are performed between 5 and 7 years [1].
&Daniel J. Gould
dr.danjgould@gmail.com
1
Keck School of Medicine of USC, 1975 Zonal Ave,
Los Angeles, CA 90033, USA
2
Department of Plastic and Reconstructive Surgery, Keck
Hospital of USC, 1510 San Pablo Street, Suite 415,
Los Angeles, CA 90033, USA
123
Aesth Plast Surg
https://doi.org/10.1007/s00266-019-01441-2
Fig. 1 Normal auricular
measurements
Table 1 Normal proportions of an aesthetic ear
The long axis of the ear inclines posteriorly at no greater than a 20°angle from the vertical plane
The ear is positioned at approximately one ear length (5.5–6.5 cm) posterior to the lateral orbital rim between horizontal planes that intersect
the eyebrow and columella
The width is approximately 50–60% of the length (width, 3–4.5 cm; length, 5.5–6.5 cm)
The anterolateral aspect of the helix protrudes at an angle no larger than 35°from the scalp
The anterolateral aspect of the helix measures approximately 1–1.2 cm from the scalp in the superior third of the helical rim, 1.6–1.8 cm from
the scalp at the midpoint of the helix and 2–2.2 cm at the lobule (although there is a large amount of racial and gender variation)
The lobule and antihelical fold lie in a parallel plane at an acute angle to the mastoid process
The helix should project 2–5 mm more laterally than the antihelix on frontal view
Fig. 2 Embryology and anatomy of the external ear and landmarks
Aesth Plast Surg
123
Prominent Ear
Ears are considered prominent when they protrude more
than 20 mm and at an angle greater than 35°from the
occipital scalp though there may be personal and ethnic
influences on individual preferences [4,6,7]. Incidence has
been reported as low as 11 per 10,000 to as high as 47% of
all births [5]. Frequency is thought to be approximately 5%
of Caucasian population, and a positive family history may
be seen in 59% of affected individuals with transmission in
an autosomal dominant pattern with variable penetrance
[4].
A general assessment of the auricles noting asymmetries
and irregularities should follow, with evaluation of the
helix for contour deformities and to assess its prominence
at the superior pole, mid-portion and just above the lobule.
The ideal corrected distance suggested by Tanzer was
1.7 cm from mastoid to helical rim, though the upper limit
of normal projection is accepted at 2 cm [1,8]. The anti-
helix should form a 75°to 105°angle between the scaphoid
fossa and the concha. Often, one deformity seen in
prominent ears is an underdeveloped antihelix at a greater
than 90°angle, with a prominent lateral projection of the
conchal bowl. The lobule should be examined, and the
lateral margin of the lobule should lie along the plane of an
appropriately positioned helix. The lateral conchal wall
may extend excessively and can cause excessive lateral-
ization of the helix and antihelix despite appropriate anti-
helical folding. Cartilage flexibility should be assessed and
determined as stiff versus normal versus weak.
Through further evaluation, the concha can be thought
of as a three-tiered four-plane structure, with the helix
oriented in the zplane, the scapha antihelix in the x/yplane,
the conchal wall in the zplane and the conchal floor in the
x/yplane (Fig. 3). This conceptual framework allows the
surgeon to consider moves in different planes to address
the specific anatomic anomalies of the patient.
Methods
A review of the literature was performed to examine the
plethora of treatment options and surgical techniques
available when considering otoplasty in a patient. PubMed
and Embase databases were searched for the following
terms: ‘‘surgical otoplasty,’’ ‘‘evidence-based approaches
to otoplasty,’’ ‘‘otoplasty techniques,’’ ‘‘patient-centered
outcomes in otoplasty,’’ ‘‘non-surgical otoplasty,’’ and
‘‘reconstructive otoplasty.’’ Subsequent searches were
performed to derive detailed evidence for the techniques
presented herein as well as clinical outcomes. Additionally,
the pathophysiology of the prominent ear was considered
in our search.
Results
Pathophysiology
The etiology of the prominent ear is thought to be due to
several key factors. Matsuo theorized that the high level of
circulating maternal estrogens in neonates makes the
auricular cartilage soft and malleable [9]. Consequently,
the force of a weak posterior auricular muscle can be
overpowered by forces in the intrinsic muscles of the
anterior surface of the ear. As estrogen levels diminish, the
cartilage acquires more elastic resilience and a more
retentive memory, and the shape of the cartilage is altered
permanently [9,10]. Rogers has reported a familial ten-
dency to prominent ears, and other auricular deformities
and syndromic malformations are well documented [11].
The most common findings in protrusion of the external
ear include a valgus deformation of the concha with a
cranioauricular angle greater than 40°, under folding of the
antihelix, and rarely, hypertrophy of the concha [12,13].
Some think that the posterior auricular muscle, through its
insertion into the ponticulus, the cranial surface of the
concha, may pull the auricle back toward the head.
Guyuron showed that a proximally (anteromedially) dis-
placed insertion site decreases the length of the effective
momentum of the muscle, leading to protrusion of the
auricle [14].
Observationally, patients with prominent ears have an
underdeveloped or flat antihelix, an overdeveloped deep
concha or both. These features can be exaggerated by a
prominent mastoid process, protrusion of the lower auric-
ular pole (cauda helicis, lobule, cavum concha), or a
prominent, tipped upper auricular pole.
Fig. 3 Four-plane, three-tier concept of auricular design. (1) Conchal
floor; (2) posterior conchal walls; (3) scapha–antihelix complex; and
(4) helix
Aesth Plast Surg
123
Non-surgical Interventions
Non-surgical interventions are an option, especially if
performed early on. These were reported early by Kur-
ozumi and Matsuo with good results if performed in the
first 6 weeks of life [9,15]. Importantly, only one-third of
defects will self-correct within the first week of life and
molding must be started within the first 2 to 3 weeks of life
to have good outcomes [2,4,5,9,12,16].
Otoplasty Candidates
Many authors have noted the psychological effects of
protruding ears [1,17,18]. Recent studies have examined
the ideal timing for otoplasty and suggest it should be
performed before 4 years of age as otoplasty has been
shown to improve quality of life in children, which has
been validated through both the Glasgow Children’s Ben-
efit Inventory and the Pediatric Quality of Life Inventory
[19,20]. Assessment should focus on age of the patient as
prominent ears typically do not affect a child’s self-image
until they are older than 5 or 6 years, surgery is best per-
formed prior to this age. Patients often present as referrals
from pediatric primary care doctors, or late as adults
seeking otoplasty for aesthetic purposes.
Caution should be granted in patients with unrealistic
expectations those who are unable or unwilling to coop-
erate with postoperative care. Also, surgeons must be alert
to the occasional adult who magnifies the severity of a
small defect or who sees serious deformity in ears that most
others would judge as being normal or symmetrical
[21,22].
Surgical Management
Surgical techniques are roughly broken into three cate-
gories, sculpting (through incision or scoring of the carti-
lage), suturing or combination of both methods (Table 2)
[23–30]. Goals should include correction of protrusion,
with visibility of helix and antihelix, achievement of a
smooth antihelical fold, an undisturbed postauricular sulcus
and the avoidance of plastered down look or a sharp anti-
helical fold (Table 3).
Historical Techniques
The first to describe an operation for repair of the ear was
Ely in 1881 [31–33]. The procedure was described as a
continuous, crescentic resection of a strip of cartilage and a
conchomastoid fixation suture in order to correct bilateral
prominent ears. Later, Luckett [24] assumed that the
deformity of the ear was due to underdeveloped or unfol-
ded antihelix and proposed a posterior surgical approach
and skin–cartilage excision technique. Luckett [24] com-
bined the skin–cartilage excision with horizontal mattress
sutures to achieve better formation of the scapha. In con-
trast, Becker published in 1952 his technique with only a
single incision along the antihelical rim and was able to
achieve in combination with posterior mattress sutures
aesthetic and successful shaping of the antihelical fold
[34,35]. With this advent in aesthetic otoplasty, Giba
demonstrated that cartilage that is incised on only one side
could warp to the opposite side [36]. The popularization of
this phenomenon became the starting point for modern
scoring and incision otoplasty techniques.
Most notably, Converse in 1955 described performing
incomplete cartilage incisions from the posterior in com-
bination with several fixation sutures as performed by his
predecessors [37–39]. In contrast, Mustarde [40] proposed
molding the antihelical fold with horizontal mattress
sutures in a popularized technique that is still widely per-
formed and manipulated today. Furnas in 1968 proposed a
conchal–mastoid suture for large concha, and then Sten-
strom proposed a postauricular approach with cartilage
scoring in 1978 [27,41]. In subsequent years, many sur-
geons modified these techniques, and most influential was
Spira who modified the Furnas technique in 1985 by add-
ing a flap of conchal cartilage sutured to the periosteum
[7,42].
Over the years, several surgical techniques have proven
effective in the correction of prominent ears, most notably
the incision–suture technique described by Converse, the
incision technique described by Stenstrom and the suture
technique described by Mustarde [27,38,40]. In addition
to the various techniques available for correction of the
prominent ear, several procedures are also available for
fixation of the lobule, cavum reduction or cavum rotation
Table 2 Otoplasty techniques
can be separated into three main
categories—sculpting, suturing
or combination techniques
Cartilage invasive (sculpting) Cartilage sparing (suturing) Combination techniques
Stenstrom [27] Mustarde [40] Cihandide [55]
Weerda [29] Furnas [41] Ersen [63]
Walter [28] Spira [7]
Pitanguy [25] Scaphomastoid [53,54]
Luckett [24]
Ne
´grevergne [30]
Aesth Plast Surg
123
as previously described by Furnas and more recently by
Janis, Naumann and Sinno [4,34,43,44]. In modern
otoplasty, many of these techniques are considered and
concurrently utilized to match unique patient problems.
Procedure planning as such should be patient-centric, with
the following presentation of otoplasty techniques matched
to specific problems to aid in decision making.
Modern Otoplasty
Modern advances in otoplasty include the identification
that, with time, the cartilage thickens and becomes more
resilient, so suture techniques may work in younger chil-
dren, under the age of 6, but surgery may often be required
in older people. Newer innovations include incisionless
techniques and hydro-dissection for recreation of the anti-
helical fold [45,46]. Observation that scoring one side of
cartilage causes it to bow out on the scored side and con-
tract on the other (known as the ‘‘Gibson effect’’) has led to
the development of more minimally invasive techniques
over the past several decades [46,47].
Incisions should ideally be placed in the postauricular
sulcus, and some will excise an ellipse or ‘‘dumbbell’’ of
tissue, while others feel that redundant skin is not a com-
mon issue postoperatively. Many will attempt the creation
of antihelix and a decrease in the conchoscaphoid angle.
This is achieved through rasping the lateral side, or the
medial side if used in conjunction with Mustarde sutures.
Mustarde sutures are usually placed as a row of horizontal
mattress sutures from concha to scapha to recreate anti-
helical fold; many use nonabsorbable sutures, though PDS
has been reported and the sutures are thus tightened to
create a 90°conchoscaphoid angle [40].
Conchal reduction may also be achieved through a
variety of suturing and excisional techniques [41,48,49].
The goal is to reduce the depth of the conchal bowl by
decreasing the height of the back wall (i.e., the anterior
wall of the antihelical fold). Excision can be done through
either anterior or posterior approaches, and conchal–mas-
toid sutures (C–M sutures) can be placed. These are hori-
zontal mattress sutures that lower or flatten the protruding
concha, diminishing the distance between the conchal rim
and the mastoid area and they pass from the posterior
conchal wall to the mastoid periosteum and fascia (Fig. 4).
Fossa–fascia sutures may be useful for treatment of a
prominent upper pole. Occasionally, the upper pole of a
prominent ear is so exaggerated that the usual combination
of Mustarde and C–M sutures is inadequate. In such situ-
ations, anchoring to the mastoid fascia and the deep tem-
poral fascia may be required. One adverse effect is an
inconspicuous effacement or elevation of the superior
auricular sulcus [50,51].
Novel Surgical Techniques
Prominent Ear Deformities
Cartilage sparing techniques have become increasingly
common in the past decade and make use of the Stenstrom
scoring technique and portions of the Mustarde and Furnas
suturing techniques [52]. Bauer et al. [48] also advocated
that cartilage sparing techniques reduce conchal hypertro-
phy and recurrence of prominent ear defects. The undesired
result in otoplasty frequently arises from excessive folding
of the antihelix and a hidden appearance to the helical rim
which may be avoided in cartilage sparing techniques.
Furthermore, excessive attention to the antihelix typically
results in the failure of surgeons to recognize conchal
hypertrophy as a major component of the original conchal
prominence. Hence, by correcting the underlying conchal
hypertrophy alone or in conjunction with other techniques
surgeons may avoid the recalcitrant prominent ear [48].
Guidelines that have been summarized earlier for the
height of the antihelical fold, conchal setback and
scaphoconchal distance help to ensure a reproducible and
patient-centric aesthetic result [52].
A popular incision-only technique described by Walter
[28] primarily consists of cartilage excisions. Following
retroauricular skin incision and preparation of the dorsal
aspect of the auricular cartilage, an incision is placed 5 mm
along the helical rim and anteriorly placed around the
auricle down to the inferior crus. Below the inferior crus,
Table 3 Basic goals of otoplasty
All upper third ear protrusions must be corrected
The helix of both ears should be visible beyond the antihelix from the anterior view
Achievement of a smooth antihelical fold
The postauricular sulcus should be undisturbed, and a plastered down look or sharp antihelical fold should be avoided
The helix to mastoid distance should demonstrate the normal range of 10–12 mm in the upper third, 16–18 mm in the middle third and
20–22 mm in the lower third of the ear
The position of the lateral border of the ear to the head should be within 3 mm at any point between either of the two ears
Aesth Plast Surg
123
the incision is directed toward the concha and extends
below the intended antihelical position. In addition, the
cauda helices are severed or partially excised to relieve
tension in recreating the antihelix. If necessary, concha
reductions by crescentic cartilage excision can also be
performed in this plane.
The helical ligament is then incised, with great care and
attention to the course of the temporal artery and vein that
travel adjacent. At the base of the inferior crus and in the
intertragal region, cartilage excisions are performed to
reduce tensions in these areas and increase the malleability
of the antihelix. Manipulation of the antihelix is then
achieved by small cartilage resection, with all excessive
skin excised. Following cartilage resection, percutaneous
mattress sutures are placed to shape the antihelix and the
crura. Walter’s otoplasty technique is suitable for all types
of protruding ears as well as revision procedures in the case
of both overcorrection and protruding lobule or uneven
antihelix [2,28].
The scaphomastoid suture has been demonstrated as an
alternative new surgical technique for prominent ear
deformities [53,54]. The surgery begins with the tradi-
tional postauricular incision on each ear under local anes-
thesia. The process was continued at the suprapericondrial
plane. This was followed by the placement of four
scaphomastoid sutures that were inserted from the posterior
Fig. 4 Operative sequence. aNeedles placed to delineate posterior
border of antihelix. bNeedles placed to delineate superior crus of
antihelix. c,dIncisions are made through the cartilage of the
proposed antihelical roll. eThinning of antihelical roll by means of a
sharp No. 5 rasp. fTubing of antihelix is achieved with 4–0 Mersilene
mattress sutures starting superiorly. gFurther placement of antihelical
roll mattress sutures. hPlacement of ‘‘conchal–mastoid inset’’
mattress suture. iRow of ‘‘5’’ mattress sutures placed (including tail
of helix). Radial placement produces curved roll
Aesth Plast Surg
123
aspect of scaphoid fossa to the mastoid periosteum of each
prominent ear. After bleeding was controlled, the skin was
closed with absorbable sutures. Although some complica-
tions were observed by the surgeon, results were extremely
satisfactory for both parties. Advantages of this technique
are primarily that the external ear canal is not disturbed,
and thus there is no keloid formation of the external ear
[53].
Another new approach for prominent ear deformities
was recently introduced by Cihandide in early 2016 [55].
The distally based perichondrio-adipo-dermal flap tech-
nique coined by this study makes use of a distally elevated
fascial flap that is anchored to the mastoid fascia. It
simultaneously reconstructs the antihelix and decreases the
conchal–mastoid angle. This procedure may be used in
both children and adults, and cartilage scoring was per-
formed routinely in adults to weaken the tissue memory
and prevent recurrence of prominence. As such, only one
patient in the study reported recurrence (5%), and a sta-
tistically significant difference was found between all pic-
tures of patients on postoperative day 30 and postoperative
day 90 [55].
The triangular fascioperichondrial flap technique was
studied by Frascino [56] in a large patient case series. The
technique involves elevating a distally based triangular flap
in the superior third of the postauricular region in the
subperichondrial plane, placing a Furnas C–M suture, and
then placing an additional suture from the posterior portion
of superior crus to the temporal fascia. This is also sup-
plemented by scoring of anterior surface of the antihelix if
needed in adult patients. The flap is folded to give the ideal
shape to the antihelical fold and to medialize the upper
pole. The author reported no early complications (he-
matoma, surgical site infection, skin necrosis), and few late
complications, primarily recurrence in 7.45% of patients,
suture extrusion in 4.34% and hypertrophic scar formation
in 1.86%.
The author believes this technique is extremely advan-
tageous as it allows for precise adhesion and positioning of
the delicate cartilage flap which is anchored by only a
single stitch. However, even though overall reported out-
comes were comparable with or even better than many of
the previously described techniques, the need for cartilage
scoring and excision in the procedure, as well as placement
of a permanent suture at the superior crus (which may
result in long-term complications of suture extrusion),
might be a significant disadvantage.
Absent Antihelical Fold
The Ne
´grevergne otoplasty technique is a simple method of
cartilage weakening that is mainly preferred in young
children to recreate the antihelical fold (under the age of
4 years old) [30]. This method is effective and extremely
rapid, which is able to maintain the natural contours of the
auricle by addressing the poorly developed or completely
absent antihelix. This technique is versatile as it may also
address an abnormally large concha or a prominent lobule.
The simplicity of the Ne
´grevergne also lends itself to being
easily replicable among many surgeons.
In this technique, the surgeon should carefully drape the
patient so that both ears simultaneously are on view to
provide intraoperative comparison of symmetry. A deep
mastoid pocket is then created to accommodate the repo-
sitioning of the conchal cup. This facilitates posterior
conchal rotations, removes the postauricular tissues that
may produce the excessive conchal prominence and
enhances the setback by reducing conchal height [30].
Lobule Projection
For aesthetic reasons, the lobule should also be considered
in a patient-centered approach to otoplasty. The lobule
should normally be positioned parallel to the plane of the
upper one-third of the ear. Numerous retrolobular incisions
and excisions have been described that function in repo-
sitioning a protruding or projecting lobule [4,43,57]. This
is more so relevant following the creation or revision of the
antihelix because the lobule often appears to protrude with
antihelical manipulations. Many types of skin excisions can
be performed, such as in the shape of a fish tail, a z-plasty
or an ellipse, in combination with fat resection adjacent to
the lobule [2,43,57].
Conchal Manipulation
To achieve a reduction in height, size or shape of the
concha or the cavum conchae, procedures such as cartilage
excisions, double triangular cartilage excisions, cartilage-
weakening scoring incision techniques, scoring techniques
and suture techniques are available at the surgeon’s dis-
posal [34,58,59]. Theses excisions of the concha can be
performed in one of two ways. The surgeon may use an
anterior approach resulting in a combined skin–cartilage
excision. In contrast, by using a retroauricular approach,
conchal manipulation can be achieved in a skin–sparing
manner.
‘‘Incisionless’’ Otoplasty
A common theme in modern otoplasty has been the inci-
sionless otoplasty. Patients are prepared and draped using a
head drape, body sheet and adhesive ear drapes. The pinnae
are injected with lidocaine and epinephrine, with attention
to proper blanching and avoiding overinjection. A 22-G
hypodermic needle is then used to percutaneously score the
Aesth Plast Surg
123
cartilage where the antihelical fold is to be recreated by the
surgeon. Several sutures (usually 2–4) are placed percuta-
neously using the Mustarde horizontal mattress suture
technique to recreate the antihelical fold and achieve a
reduction in the conchal prominence. When the procedure
is completed, the ears are cleansed with sterile saline
solution and dabbed with an antibiotic ointment to prevent
postoperative infection or perichondritis [46,60].
Strychowsky and Mehta both found very few compli-
cations in their study of 19 and 72 patients (pediatric),
respectively, with none reporting signs of short-term
complications (infection, hematoma, skin necrosis, peri-
chondritis or bleeding) [46,60–62]. Incisionless otoplasty
also gives adult patients a chance to correct the ear
deformities that were not managed at a younger age (before
the age of 4, or in the teenage years) [61]. Outcomes were
favorable in the adult cohort reported by Mehta, with only
one patient needing a revision [62]. Fritsch has also proven
the efficacy of this technique with almost a decade of
experience and positive patient outcomes [46].
Incisionless otoplasty by this technique has proven to be
effective in correcting prominent ears caused by an absent
antihelical fold, conchal hypertrophy or both. This mini-
mally invasive technique also offers easy recovery with no
need for long-term dressings, and outpatient advantage of
incisionless otoplasty makes it a more ideal option versus
open otoplasty in patients that must return to work or
school as soon as possible without noticeable signs of
surgical intervention [5,46,61].
Combined Approaches
In early 2018, Ersen has reported an even more novel
technique which combines the use of a perichondrio-adipo-
dermal flap, posterior auricular muscle transposition and
cartilage suture [63]. This study argues that a combination
of these techniques draws from each of the individual
strengths while ultimately reducing postoperative compli-
cations. The technique is described to first elevate the
perichondrio-adipo-dermal (PAD) flap. The posterior
auricular muscle is then dissected and transected from its
insertion. After the placement of a C–M suture, the pos-
terior auricular muscle was transposed, and the PAD flap
was placed. Fourteen patients were treated with bilateral
prominent ear deformities, and none suffered any postop-
erative complications. No recurrences were also noted 1
year after surgery.
The combination of these three commonly used and
well-described techniques produce very reliable results and
has demonstrated a decrease in postoperative complication
rates. This technique also provides a primary otoplasty
technique that is dependable and standardized across many
patients. However, the primary limitation of this study was
the very small number of patients included. Although
promising, following studies are necessary to corroborate
the observed decrease in postoperative complications.
Outcomes
Generally, overcorrection is not necessary and avoided,
and long-term outcomes are good in many of the otoplasty
techniques described, with excellent long-term morpho-
metric results [64]. Suture-only repair has the benefit of
offering precise control but has a higher rate of relapse and
need for revision [40,65,66]. Whereas sculpturing is more
permanent, it is less predictable and can deform the shape
of the ear, so many modern techniques combine both
methods [13,66].
Discussion
The approaches summarized herein may all be utilized to
approach different patient problems. The following are
several patient examples and a description of the tech-
niques utilized to address their patient-specific problems.
Fig. 5 Preoperative (a,b), and postoperative (c,d) otoplasty results
Aesth Plast Surg
123
Pediatric Patients
Figure 5demonstrates a young patient with bilateral
prominent ear. This patient suffers from conchal hyper-
trophy and lack of the antihelical fold. As such, this patient
benefited from a combined resection of the conchal bowl
and suture-based otoplasty. The superior crus was recreated
utilizing Mustarde sutures. The ear was further set back
with Furnas sutures, and a tail of the helix suture was used
to control the lobule.
Figure 6demonstrates a young man who had prominent
ear secondary to conchal hypertrophy on the right, and lack
of the superior crus on the left (not shown). This patient
underwent a combined approach of conchal bowl partial
excision on the right with bilateral Mustarde suture tech-
nique at 4-year follow-up. This demonstrates longevity of
the procedure over time.
Adult Patients
Figure 7shows recent patients all with 6-month follow-up
times, each addressed with combined techniques. Panels
(a) and (b) are of a patient who had a scaphal reduction
with combined suture-based otoplasty; (c) and (d) show a
patient who had a cymbal reduction with suture technique;
and (e) and (f) show a young boy with malleable cartilage
who had a composite reduction in the scapha and cymba
and suture-based otoplasty. The three patients herein
demonstrate a slight overcorrection of the helix, and as
such one could argue that the basic goals of aesthetic
otoplasty have not been met (namely—‘‘the helix of both
ears should be visible beyond the antihelix from the ante-
rior view’’). However, in this case the patients were
extremely satisfied with the results. As such, it is important
for the aesthetic surgeon to weigh both the overall goals of
aesthetic otoplasty and the expectations of the patient,
leaving both the surgeon and patient satisfied with the
outcome as in this case.
In Fig. 8, an elderly patient with an aged ear requested a
reductive otoplasty. To decrease the size of the lobule, a
simple wedge resection of the lobe was performed. To
correct this patient prominent ear, resection of a portion of
the antihelix and helix was performed. The correction is
shown immediately postoperatively. Older patients with
prominent ears may also seek out reduction in the scapha if
that is the anatomical cause of the prominent superior ear.
Figure 9shows another older patient who had a scaphal
resection with helical advancement flaps and a lobe
reduction immediately postoperatively.
Fig. 6 Preoperative (a) and postoperative (b) views. Note the gentle
roll and no sharp edges of antihelix. Lobule is controlled with tail of
helix suture
Fig. 7 Preoperative (a–c), and postoperative (d–f) otoplasty results
Aesth Plast Surg
123
Conclusion
These cases all demonstrate that no two otoplasties are
alike, and multiple techniques and approaches should be
utilized to provide long-lasting aesthetic outcomes for
these patients, with consideration of age and extent of
deformity. It is also important to deliberate both the gen-
erally accepted goals of aesthetic otoplasty and the goals
and expectations of the patient. As such, aesthetic otoplasty
involves an integrated approach, with considerations for
native anatomy, surgical technique and patient-centered
outcomes.
Funding The authors of this manuscript have no financial disclosures
to report. No funding was received for this article.
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflict of
interest.
Human and Animal Rights This article does not contain any studies
with human participants or animals performed by any of the authors.
Informed Consent For this type of study, informed consent is not
required.
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