INTRODUCTION
Prominent ear occurs in 5% of the Caucasian
population and is the most common congenital
auricular deformity [1,12,13]. While it is a mild
congenital defect within the spectrum of ear anomalies,
its aesthetic and psychological impacts should
not be neglected. Two-thirds of the prominent ear
cases result from an underdeveloped antihelical
fold, while one-third of the cases result from an
excess of conchal bowl cartilage [2].
153
The first operation described for the correction
of prominent ear was in 1845 by Dieffenbach [15].
The primary goal of auricular reconstruction is to
preserve function and restore form in the anterior
and lateral views. Specifically, McDowell described
the following reconstructive principles: 1- Eliminate
the protrusion in the superior third of the ear, 2-
Both helices should be visible lateral to the antihelix
from the frontal view, 3- Create a smooth and
regular helical contour, 4- Minimize distortion to
the postauricular sulcus, 5- Avoid placement of
the ear too close to the head, and 6- Contours and
positions of the two ears should be matched closely
but not necessarily symmetric [3,14].
Surgical techniques can be divided into two
basic strategies: Incision techniques that rely on
incision and sometimes excision of cartilage to
allow for repositioning and reducing of the ear
structure, and bending techniques in which no
incision is made and the cartilage is curved to
create the desired positioning. Bending of the
cartilage is accomplished by scoring and/or pulling
the cartilage into position using sutures.
This dichotomy is somewhat oversimplified
because many techniques that emphasize incisions
may bend cartilage at a specific location, and
bending techniques that are based on anterior
scoring may use cartilage incisions for access [4].
Modern otoplasty techniques are based on two
main surgical categories, cartilage sparing and
cartilage cutting, along with many nuances. The
anterior scoring methods are the most commonly
performed cartilage-scoring procedures.
However, these methods have been criticized
for their complications, such as hematoma, anterior
skin necrosis, chondritis, and irreparable cartilage
damage. Conchoscaphoid suturing to create the
antihelical fold and conchomastoid suturing to
rotate the conchal angle are commonly described
cartilage sparing methods [5].
Techniques that are based on scoring can be
subdivided further into those that only superficially
score the cartilage and those that score deeply
enough to cut through the newly created antihelix.
The scoring can be accomplished on either the
anterior or posterior surface of the ear cartilage;
however, full-thickness penetration of the cartilage
usually results in a sharper antihelical fold, which
is not desirable [5].
A disadvantage of anterior scoring is that to
gain access either an anterior skin incision or a
through-cartilage incision from a posterior skin
incision must be used. The anterior skin incision
has the obvious concern of being placed on the
more visible side of the ear. A through cartilage
incision creates the same potential for problems is
that unnatural sharp, crenellated edges, ridges, and
step-offs may be created which will lead to an
operated-on appearance. Further, treating the anterior
surface of cartilage has the potential for creating
irregularities on the visible side of the cartilage
[4].
In this article, we describe a technique that is
effective in treating prominent ear while avoid the
disadvantages of anterior scoring and investigate
its complications rate, risk of recurrence and patients'
satisfaction.
PATIENTS AND METHODS
Forty-six patients, 36 males and 10 females,
were enrolled in the study in the period between
2015 and 2018. Patient's age at time of surgery
ranged from 4 to 15 years, with an average age of
9.5 years. The main of author conducted the surgery
on all the patients.
Surgical technique:
Under general anesthesia, the face and ears
were prepared with an aqueous antiseptic solution
and then draped. The site of the new antihelical
fold was drawn anteriorly by folding the ear in the
normal position without tension by digital pressure,
then 10mm four skin abrasions were marked at the
two limits of the new antihelical fold. A dumbbell
shape skin excision was also marked posteriorly
Fig. (1).
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The four skin incisions were done first followed
by placement of the cartilage modifying sutures
to create a smooth natural antihelical fold. Two
4/0 non-absorbable 'horizontal mattress style' sutures
were placed to maintain the position of the
new antihelical fold through the anterior skin
incisions. The sutures were carefully tied with no
excessive tension to avoid overcorrection. The
knots were buried in a small subcutaneous pocket.
Afterwards, the dumbbell excision of the posterior
skin was done to expose the conchal cartilage. This
was followed by exposure of the mastoid fascia to
set the stage for the chocomastoid. All fibromuscular
tissues were judiciously excised before placement
of the sutures. The wound was closed using
4/0 absorbable sutures. A light bandage was applied
at the end of surgery.
Post-operative care:
The light bandage was applied for at least
seven weeks. All patients had a weekly visit to
the surgeon during the first month followed. The
scar was managed afterwards using silicone preparations.
Study measures:
The patients were followed-up at a regular
interval of 1 month for one year. The patient was
examined for contour irregularities and wound
healing complications in addition to any changes
in the antihelix contour. A standard photograph
were taken and compared with the previous one.
At the time of final evaluation, the final aesthetic
outcomes were assessed using parents reported
outcomes in addition to opinion of two consultant
plastic surgeon in terms of their satisfaction regarding
the final aesthetic outcomes. Besides, the
conchomastoid angle was measured to assess the
conchomastoid sutures.
RESULTS
All the parents of the patients were satisfied at
the end of follow-up period except for 3 patients
who believed that the antihelix needs more definition.
Moreover, the two consultant surgeons were
satisfied with the aesthetic outcome in 81% of the
patients. Only two patients developed mild partial
skin necrosis Fig. (4) that was attributed to tight
bandages. This was managed conservatively. One
patient developed hypertrophic scar which was
managed with compression.
Egypt, J. Plast. Reconstr. Surg., January 2020 155
Fig. (1): Marking of the ear.
Fig. (2): Post-operative pictures of a child operated using our technique.
(A) (B) (C)
(A) (B)
(D) (E)
Fig. (3): Pre-operative and post-operative pictures of a child operated using our technique.
Fig. (4): Mild partial skin necrosis post-operative and after healing.
156 Vol. 44, No. 1 / Modified Mustarde Otoplasty in Pediatric Patients
(A) (B)
Egypt, J. Plast. Reconstr. Surg., January 2020 157
DISCUSSION
Prominent ears are the most common congenital
anomaly affecting ears making them a common
clinical encounter. Several surgical procedures
were described to address this problem. Among
the procedures, Mustarde suturing otoplasty with
cartilage scoring is a very common procedure.
Contour irregularities and unnatural sharpe antihelical
fold is a common unsatisfactory outcome. In
this study, we describe modification to Mustarde
technique to preclude complications and improve
the aesthetic outcomes.
Over the years, hundreds of techniques have
been described for the correcting of a prominent
ear reaching up to 200 [10,11]. Surely, anterior
scoring is one of the most widely used techniques
however; its disadvantages are also widely described
such as hematoma, anterior skin necrosis,
chondritis, and irreparable cartilage damage [5].
A disadvantage of anterior scoring is that to
gain access either an anterior skin incision or a
through-cartilage incision from a posterior skin
incision must be used. The anterior skin incision
has the obvious concern of being placed on the
more visible side of the ear [4]. In our described
technique we use a posterior incision to avoid this
disadvantage. Moreover, posterior incision of anterior
scoring via a-through cartilage incision is
used with potentials of unnatural sharp, crenellated
edges, ridges, and step-offs creation. This has been
linked to an operated-on appearance which we
avoid in our technique. In our described technique
we use a posterior rhomboid incision instead of
the liner incision in the anterior scoring. The rate
of complication reported in literature range between
0 to 47.3% [6,10]. It has been reported that the rate
of infection after otoplasty is between 0 to 15.5%
[7,8,10] while the rate of bleeding is up to 7.9% and
the rate of keloid formation is up to 6.2% [6,10].
In our study, we did not encounter any complications
such as infection, bleeding or hematoma. In
the literature, recurrence rate is between 0 to 12%
[6,9,10] while in our study no patient had recurrence.
Some limitations that faced us are the necessity of
general anesthesia to perform the operation due to
the average age of patients and it is only effectively
performed in patients with soft auricular cartilage
so it will not be a sufficient technique to correct
hard auricular cartilage type.
Conclusion:
Visible irregularities can be avoided in otoplasty
for prominent ears by omitting extensive cartilage
dissection, and the cartilage sutures can be safely
placed from an external approach.
Conflict of interest statement:
The authors declare that they have no conflict
of interest.
The authors declare that they have not received
any funds.
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