An effective technique of helical cartilage scoring for correction of prominent ear deformity.

Otoplasty has a long history starting from 1948, when Dieffenbach described it first. Multiple technical modifications have been reported since. We propose a technique of scoring the helical cartilage without a visible incision on the lateral aspect of pinna for easier remolding of cartilage through posterior approach. The results have been excellent.

INTRODUCTION

Protruding ears may be a source of psychological distress in either sex and at any age. Children though brought by parents for correction, are highly motivated and cooperative. A truly gratifying psychological response to a well-performed otoplasty is the rule. Adults who have appreciable auricular prominence and a healthy attitude about an image change are equally gratifying candidates.

The most common causes of protrusion of the external ear are an underdeveloped or flat antihelix, an overdeveloped, deep concha, or a combination of both of these features. Contributing features which may accentuate auricular prominence are protrusion of the mastoid process, prominence of the lower auricular pole (cauda helicis, lobule, and cavum concha), or a prominent, tipped upper auricular pole.

Various techniques have been described to address individual problems following Dieffenbachs[1] pioneering work. This paper focuses on a technical modification of the scoring technique to weaken the cartilage for easy molding.

Proposed technique

We propose a modified technique of cartilage scoring without using any trans-cartilaginous incisions or lateral skin incisions. We have used this technique in four patients so far and found it very simple and rewarding. Proper patient selection is of utmost importance. Biomechanically, patients suitable for cartilage scoring are those with stiff cartilage. Patients with floppy cartilage may not benefit much from cartilage scoring.

The proposed area of antihelical fold is marked over the lateral surface of auricle [Figure 1a] before the local anesthetic is administered. A hemostatic local anesthetic solution is then infiltrated. In adults this is usually sufficient. In children general anesthesia is preferred. Both the ears are prepared and draped. We utilize No.21 hypodermic needle each of which is tunneled subcutaneously along the desired line of scoring [Figure 1b]. The needle is brought out at the distal end of the subcutaneous tunnel and its tip is bent using a heavy needle holder [Figure 1c]. The needle is then rotated so that the bent sharp tip faces the cartilage surface and withdrawn [Figure 1d] through the tunnel simultaneously scoring the cartilage surface with the sharp tip. The effectivity of the technique in creating deep scoring has been demonstrated over the back of the same ear [Figure 1e].

Figure 1

(a) The proposed area of the antihelical fold is marked over the lateral surface of pinna. (b) The needle is tunneled subcutaneously along the proposed line of scoring. (c) The tip of the needle is bent with a heavy artery/needle holder. (d) The needle is withdrawn after turning the sharp edge toward the cartilage. (e) The effectiveness of the technique has been demonstrated over the back of the same pinna

Needle once used has to be discarded. This is repeated using the other needles along adjacent lines on the lateral surface of the cartilage. Usually three to four passages make the cartilage sufficiently weak to be turned posteriorly. This can be manually compared with the opposite side. The end result is a soft and pliable cartilage which can be easily folded backwards. The procedure is then completed with a posterior incision (elucidated in the subsequent patient), though which sutures are taken to create antihelical fold with ease like routine otoplasty.[2-4] Images in Figures 2a and b show the frontal and occipital views of 30-year-old male patient. Lack of formation of the antihelical fold and the obtuse concomastoid angle can be appreciated. The images in Figure 2c–f show the postoperative photograph of the same patient, where the natural contour and lack of prominence of pinna can be observed.

Figure 2

(a) Frontal view of a 30-year-old male, [Figure 1]. The prominent ears can be easily made out. (b) Occipital view of the same patient. (c–f) Postoperative images

Second patient was a 21-year-old female. The images in Figures 3a and b show the frontal and occipital views of the patient respectively. Figures 3c and d show lateral views of both pinnae, while Figure 3e shows the true lateral view of the patient. Lack of formation of antihelical fold making the superior and the middle third prominent and deep concha along with wide separation of concha from mastoid has been responsible for prominence of both ears. The planned position of antihelical fold along with the proposed scoring lines has been marked [Figure 3f]. Additionally blue dots have been marked on either side of the proposed antihelical fold. These are proposed sites of placing sutures on the posterior surface of the pinna. These can be transposed on the posterior surface of pinna by piercing these marked places with the needle dipped in ink. This will effectively mark the medial surface of ear. The image in Figure 3g shows posterior aspect of pinna after completion of suturing to create antihelical fold shown by the black arrow. The ink marks on the posterior aspect show the effectivity of this marking technique. Additionally conchomastoid sutures are being placed (blue arrow). All the sutures are preplaced before tying them, as has been shown. The images in Figure 3h and i show postoperative result 10 months following the surgery. Figures 3j and k are lateral views of both sides. The natural-looking contour in the frontal, occipital, and lateral surface can be appreciated. There is no mark on the lateral surface and the correction is maintained. Postoperatively we keep a bulky dressing for a week and the patient is asked not to lie on sides. After a week the patient is off all dressings but avoids lying on sides for 2 more weeks.

Figure 3

(a) Frontal view of a 20-year-old girl, superior and middle thirds are prominent. (b) Posterior view of this patient. (c–e) Lateral view showing the deep concha, lack of antihelical curve, and conchomastoid angle. (f) Markings on the lateral surface of the ear. (g) Intraoperative image showing the sutures in place. Blue dots are proposed sites of suturing. Black arrow shows the completed suturing for antihelical fold creation, while the blue arrow shows preplaced concho-mastoid sutures. (h–k) Postoperative photographs of the same patient after 10 months

DISCUSSION

The goals of correction of prominent ears is to set back ears in such a way that it appears natural, the contours are soft, and the correction is uniform without leaving evidence of surgical intervention. In natural-looking correction, when viewed from front, the helical rim should be visible, from back the pinna should appear straight without undue prominence at upper or lower end; while in lateral view the contours should be soft and natural, without evidence of manipulation.

Since the term “otoplastik” was first used in 1948 by Dieffenbach, to describe repair for microtia, physicians have continuously contributed to the understanding and treatments for the protuberant ear.[1] If the cartilage is so stiff and heavy; the force needed to reposition the ear could conceivably provoke relapse by erosion of the cartilage by the sutures. Additional steps are required to reduce this resistance. In 1963 Stenström,[2] Chongchet,[3] and Ju et al.[4] described an anterior scoring technique based on the investigations of Gibson and Davis,[5] who described the interlocked stress in cartilaginous structures. The anterior scoring of cartilage over the area of the proposed antihelix will break the cartilage spring (release the interlocked stress), resulting in bending of the cartilage to the opposite side and a natural-looking antihelix. Stenström confined his dissection to a tunnel beneath the perichondrium, scoring blindly with a special scratching instrument. Chongchet used a posterior approach, incising the cartilage and scoring the antihelix area (anteriorly) with parallel incisions through perichondrium and partially through the cartilage. Although the latter approach gives more control, it is still difficult to achieve symmetry with the opposite ear. Also the cut edge of the cartilage is likely to cause an unnatural look in lateral view. Recently an incisionless otoplasty technique described by Fritsch,[6] avoiding posterior incision altogether, is a technically demanding operation and may not be suitable for stiff cartilage. We also feel that the control over the needle will be less in their method.

CONCLUSIONS

The technique mentioned leaves no marks on the lateral aspect, gives smooth contour of new antihelical fold, and can be easily mastered.