Facial Plastic Surgery: An Essential Approach - e

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Facial Plastic Surgery: An Essential
Approach Step by Step
Chapter: Otoplasty
Edited by: Raffaelo Rauso
Published Date: May, 2016
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Otoplasty
Pierfrancesco Bove*
Consultant Maxilo-Facial Surgery, Private practitioner in Salerno, Italy, Co-founder of
the surgical brand “chirurgiadellabellezza.”
*
Corresponding author: Consultant Maxilo-Facial Surgery, Private practitioner
in Salerno, Italy, Co-founder of the surgical brand “chirurgiadellabellezza”, E-mail:
dr.pierfrancesco.bove@gmail.com
Introduction
The so-called “jug ears” or “protruding ears” are the most common deformity of the ears
requiring plastic surgery. Protruding ears are commonly characterized by the lack of the
anti-helix (a physiological curved prominence anterior to the helix) (Figures 1 and 2) but, in
some cases, even though the anti-helix is present, the excessive protrusion of the ear can
be related to an excess of concha (external ear cartilage) (Figure 3); sometimes the auricular
deformity is related to the presence of both deformities (Figures 3 and 4) [1-3]. Preoperative
clinical examination and aesthetic analysis is fundamental to achieve a good result in this
way the surgeon will assess how to perform surgery and he will understand when to perform
the plastic of the auricular in order to create the anti-helix and in order to remove the excess
of concha, or to perform both the procedures simultaneously. Moreover, this operation is
usually performed in local anesthesia and the sedation is performed by the anesthesiologist,
so the surgical plan is very important for the injection of local anesthetic that is injected by
the surgeon himself [4].
Figure 1: Absence of anti-helix.
Figure 2: Pre-operative surgical mark that shows where the anti-helix will be reconstructed and the concha will be excised.
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Figure 3: Excess of auricolaris concha, anti-helix is normally present.
Figure 4: A case with both deformities: the absence of anti-helix and the hypertrophy of the auricolaris concha.
Psychosocial Aspects
Children with protruding ears are often exposed to substantial psychological pressure,
such as being teased at school or in kindergarten. Low self-esteem, general lack of selfconfidence, and social isolation are amongst the reasons why parents of affected children or
even affected adults decide for otoplasty. In the light of these problems, it is recommended
to perform otoplasty in children suffering from protruding ears when they are between 5-6
years of age, before the start of school [5]. However, despite of the convincing arguments in
favor of otoplasty, it should be kept in mind, during the time of assessment, that protruding
ears do not necessarily result in the affected patients who are experiencing psychosocial
problems. It has to be considered that children, aged 5-6 years old, can already provide
information about their psychological strain or possible problems of socialism with other
children that are associated to their protruding ears [6]. So it is not surprising those parents
of the affected children often desire otoplasty to be performed, while the children themselves
deny having problems because of their ear deformities. Consequently, the indication for
otoplasty should always be discussed together with the parents and the child in order to
avoid later problems or misunderstandings at an early stage [7-9].
Problem Analysis
An accurate problem analysis of the anti-helix fold, helix-mastoid angle, helix-head
distance, position of the lobule and of the cavum conchae is really crucial. Another aspect
with a significant impact on procedure planning is the analysis of the cartilage consistency
and at this point, in particular, the stiffness and thickness of the cartilage. The consistency
of the cartilage is typically evaluated by palpitation and cautious, controlled bending.
Additional ear abnormalities, such as auricular appendages, Darwin tubercle etc., can also
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simply be excluded in many cases by an inspection-based diagnosis [10]. Occasionally,
threshold audiometry with impedance testing may be required to exclude possible conductive
or perceptive hearing losses. Apart from an ENT examination, it is prepared a pre- and
postoperative photographic documentation showing rontal, lateral, oblique, and dorsal
views. The purpose of the photographic documentation is to document the preoperative
situation, and it can also be used to sketch problem areas or steps of the procedure. Taking
postoperative photos at intervals of 6 and 12 months helps to monitor postoperative success
and it is also recommended for medical- legal reasons.
When we have to perform an otoplasty
The appropriate time for the correction of prominent ears depends on some factors, such
as auricular growth, cartilage consistency, psychological strain, and patients’ wishes. At
an age of six years old, the ear has completed most of its growth; therefore, an otoplasty at
this time does usually not affect auricular growth at any significant extent. The softer the
auricular cartilage is , the easier it is to shape the cartilage or auricle into the appropriate
form and pin it back, using gentle surgical techniques [11,12]. Nevertheless, most authors
typically recommend the surgical correction of protruding ears in general anaesthesia
between the age of 5 to 6 years, before the start of school. On the other hand, the procedure
can be performed in older children, starting from age 11-12 years old, or adults with
adequate compliance, under local anaesthesia.
Brief Anatomy
The auricula (Figure 5), from a functional standpoint, is of limited importance in men.
Nevertheless, its roles in localizing sound sources in space and in directing sound energy
toward the external acoustic meatus have been confirmed. The morphology of the concha
and of the auricular eminences may strongly contribute to the execution of these functions,
as their constitutive features would allow them to displace a sound wave which means
a process of great importance in the localization of the acoustic message in space. The
auricula is shaped as an irregular lamina, located on the side of the head, anterior to the
mastoid region, and it is in relation with the temporal region, with the temporo-mandibular
joint and with the parotid region. It is approximately oval and its main, vertical axis is
slightly oblique downward and forward: it develops to its full size at the age of 7 years old
and its major axis is 65-69 mm long on average, whereas the size of its minor axis is 30-35
mm. two surfaces are present in the auricle t: lateral and medial surfaces.
Figure 5: Schematic view of the ear.
The lateral surface of the auricle presents peculiar eminences and depressions: the major
concavity is the concha, located at the centre, which leads to the external acoustic meatus.
The helix is the most peripheral and auricular prominence, and its commencement divides
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the concha into a superior part (cymba conche) and into an inferior part (cavum conchae);
the rim of the helix contours the superior half of the auricle and projects downward, with
its tail, to the lobule. The lobule is a cartilage-lacking cutaneous fold, located in the inferior
part of the auricle, underneath the tragus, the antitragus and the tail of the helix. It is
frequently present, in the free border of the postero-superior part of the helix, a more or
less pronounced eminence, the tubercule of Darwin. The anti-helix is another prominence
located between the concha and the helix; the latter divides it with the helical sulcus. The
antihelix rises in the upper region from the conjunction of two legs which delineate the
triangular fossa. In front of the concha and below the origin of the helix there is the tragus
that is a laminar, triangular prominence that partially covers the opening of the external
acoustic meatus. The antitragus is an eminence which marks the posterior part of the
concha and itis located behind the tragus, from which it is separated by the deep intertragic
notch.
The medial surface of the auricle is free in its posterior part, whereas it anteriorly adheres
to the lateral surface of the head. The auricular sulcus separates the lateral surface of the
head from the free portion of the auricle; this region presents eminences and depressions that
are complementary to those that are described in the lateral surface. The auricular greatly
varies in size, insertion, and shape. The arteries of the auricle branch from the posterior
auricular artery and from the temporal superficial artery (external carotid). The posterior
auricular artery feeds the whole auricula, except the anterior part of the lateral surface that
is instead fed by the temporal superficial artery. The veins of the auricle converge forward
in the temporal superficial vein and, backward, in the auricular posterior veins, all of them
merging in the external jugular vein. The lymphatic vessels of the auricle are arranged in a
dense network that stems from three groups of lymph nodes. There are motor and sensory
nerves in the auricula. The motor nerves, which are directed to the extrinsic and intrinsic
muscles of the auricle, branch from the facial nerve. The sensory innervation is primarily
guaranteed by the trigeminal nerve and by the cervical plexus. The trigeminal nerve provides
innervations to the tragus and the superior part of the helix through the auriculo-temporal
(mandibular) nerve; the cervical plexus innervates the whole medial surface and most of the
lateral surface of the auricular, through the great auricular nerve. The skin in the concha
is served by sensory fibers from the vagal and the glossopharyngeal nerves, mainly deriving
from the auricular vagal branch.
The auricular muscles (or extrinsic muscles) are the three muscles surrounding the
auricula or outer ear:
• Anterior auricular muscle
• Superior auricular muscle
• Posterior auricular muscle
In human beings these muscles possess very little action. The anterior auricularis draws
the auricula forward and upward; the superior auricularis slightly raises it; and the posterior
auricularis draws it backward. The posterior auricular muscle, in particular, consists of two
or three fleshy fasciculi, which arise from the mastoid portion of the temporal bone by short
aponeurotic fibers. They are inserted into the lower part of the cranial surface of the concha.
Anesthesia Performed by the Surgeon
In this procedure the loco regional anesthesia that is performed by the surgeon plays a
key-role; if it is well performed the anesthesiologist could perform very superficial sedation;
at the beginning the sedation must be a bit deeper because, during the injection of local
anesthetic, it is quite most painful for the patient; whereas the sedation can be reduced
afterwards. This makes easily understand why inaccurately loco-regional anesthesia will be
associated with strong discomfort for the patient, but also for the surgeon, who may have to
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face movements of his patient; due to the pain the patient is feeling. This is a basic notion
which helps understand why loco regional anesthetics are administered with different
concentrations of vasoconstrictor for this procedure: lower concentration in the anterior
infiltration solution, higher in the posterior region. The least but not the last, it is important
to highlight that the infiltration with local anesthetic must be performed only after the
preoperative mark that is done by the surgeon himself; you have to remember that once the
infiltration of local anesthetics is done, the anatomy of the target region is totally deformed.
Two different mixing bowls (A and B), containing 20 mL of 3% of lidocaine each (20 mL
total), are prepared (Figure 6). In A bowl , which is meant to be used for the infiltration of
the posterior portion of the auricula, 0.4 mL of adrenaline are added; in B bowl , which will
be used instead for the infiltration of the posterior region, 0.1 mL of adrenaline are added. 1
and 3 mL syringes with luer lock connection are used, and needles 27-28 G (Figure 7). The
infiltration starts from the side chosen by the surgeon (left or right) and, after the side is
finished, it is not directly followed by the contralateral infiltration; it is best to carry out the
procedure on the side which is homolateral to the infiltration and, then it is best to proceed
with the other. This is recommended because some intra-operative complications during the
“first ear” may increase the time of the procedure, in this way the surgeon will not have to
re-infiltrate the contralateral ear with local anesthetic. However it is a good rule, to wait 15
minutes before starting surgery, after having injected local anesthetic.
Figure 6: Two different cups for two different anesthetic solutions.
Figure 7: All the stuff needed by the surgeon in order to perform the local anesthesia.
The first anatomical structure that has to be injected is the Great Auricular Nerve,
branch of the medial cervical ansa of the cervical plexus, which provides sensitivity to the
auricular lobe and the lower part of the helix.
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About 1 mL of bowl A solution is injected with the 28 G needle (Figure 8), then, it is
possible to proceed with the injection over the perichondrium of the posterior region of
the auricula and over all the marked area plus 1 cm around it. About 3 mL of the same A
solution are injected, but this time the27 G needle is used due to the fact that it is longer
and it allows the infiltration of the whole area that was marked preoperatively, retrogradely,
through one or two entry sites at most. The infiltration is always performed retrogradely in
order to avoid intra vascular injections. Infiltration is easy to perform in this area, because
the plane over the pericondrium is easily accessible by lifting the ear anteriorly, then you
enter with the needle into the subcutaneous tissue and keep it parallel to the skin plane
(Figure 9). In order to establish the right plane has been reached. No resistance has to be felt
while pressing the plunger to release the anesthetic solution; besides, it shall be possible to
observe skin “ballooning” phenomenonas the infiltration goes on (Figure 10).
Figure 8: Great Auricular Nerve blockage.
Figure 9: Injection of local anaesthetic in the posterior part of the auricle.
Figure 10: Ballooning effect.
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Once the infiltration of the posterior portion of the auricula is completed, it will be
possible to proceed with the infiltration of the anterior part, using, at this time, the B
bowl solution. Whereas the infiltration of the posterior portion of the ear is “standard”, the
anesthesia of the anterior portion requires specific adjustments if the treatment has to
target the anti-helix, the concha, or both.
Infiltration of the concha
Typically 1-3mL of solution is needed; a 27 needle is used, and the infiltration is sub
perichondrial. In this case the infiltration of the correct plane is more complex than the
posterior side; the angle of insertion of the needle has to be 45° on the infiltration area (Figure
11) and, above all, during the infiltration, a slight resistance has to be felt while pushing
the plunger due to the fact that the perichondrium is tightly linked to the cartilage. It is
during this phase that the advantage of using syringes with luer lock is noticeable; the use
of conventional syringes may lead to the detachment of the needle, as a consequence of the
resistance encountered. Once the resistance has been overcome thanks to the application
of a gentle and progressive strength on the plunger, the swelling of the injected area will be
visible (Figure 11).
Figure 11: Anesthetic injections of the anterior part of the ear.
Infiltration of the auricular
The infiltration procedure is quite similar to the previous one as the same needle and
the same anesthetic solution are used. The infiltration is again, sub perichondrial, thus,
resistance will be felt when starting the injection. Typically, 1-2mL of solution suffice to
infiltrate the area where the surgeon will perform cartilage plasty in order to create the
missing anti-helix (Figure 13). If the infiltration is performed correctly it won’t need to be
repeated during the operation. After completing the infiltration it is important to wait about
15 minutes before proceeding with the incision, in order to allow to the anesthetic and to
the vasoconstrictor to fully exert their action.
Figure 12: Anesthetic injection of the anti-helix.
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Surgery
Two stickers (usually 5/0 silk) are usually placed, one up to the ear lobe and one in the
helix (Figure 13). These stickers allow the traction of the ear and let the surgeon have the
surgical field ready to operate. With a Number 15 blade, we perform an incision following
the pre-operative marking area (Figure 14). Then, we perform the excision of the skin and
subcutaneous tissue, saving the perichondrium.
Figure 13: The stitches are placed in order to lift the posterior part of the ear.
Figure 14: Skin and subcutaneous tissues surgical removal.
Now that we have an excess of concha, placed in the anterior part of the ear, we mark
the part that must be excised, with some needles (Figure 15). In this way, we can exactly
perform the excision of the concha in the posterior part with number 15 blades (Figures 16
and 17). At this point, the needles are removed and some perichondrial dissection of the
anterior part of the concha can be made with forceps or freer. At this time, the dissected part
of the excess of concha can be removed (Figures 17 and 18).
Figure 15: With the needles inserted, following the pre-operative surgical mark, the upper part of auricularis concha is
remarked.
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Figure 16: Cut of the cartilage of the auricolaris concha.
Figure 17: Conchal cartilage removal.
Figure 18: The cartilage has been removed.
If it’s also present the absence of the anti-helix, we mark with needles the anti-helix
on the anterior part of the ear (Figure 19). That tab incision is performed with a 11 knife
in the lower part of the marking area, in the posterior part of the ear. At this point, the
needles are removed and using an elevator we perform a wide dissection of the area of the
antihelix (Figure 20). Then, this area will be wrapped (Figure 21). Now, with a 3 stitches
(4/0 long absorbable) we perform the plication of the anti-helix (Figure 22). These sutures
are placed anchoring the periostium vertically in a fashion mattress. With this procedure we
can exactly note howthe anti-helix is created (Figure 23).
Figure 19: With the insertion of needles through the pre-operative mark, the new anti-helix is remarked.
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Figure 20: Sub-periosteal dissection of the anterior part of the auricle.
Figure 21: A gentle saw for thecartilage is used in orderto reduce the strength of the auricle.
Figure 22: With stitches pulled trough the cartilage and the pericondrium, a plication of the auricle is performed in order to
create the new anti-helix.
Figure 23: The anti-helix has been reconstructed.
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Figure 24: Skin closure.
We perform an accurate haemosthasis with the cautery, and then we close the Skin with
a long absorbable 4/0 stitches placed with mattress fashion style (Figures 24 and 25).
Figure 25: The end of the suture: interrupted suture ispreferred toa draining suture.
Then we place two gauzes which are dried with antibiotic ointment percutaneously with a
3/0 absorbable stitches that will be removed after 48 hours. Finally, a compressive garment
is placed (Figures 26, 27 and 28) [13-18].
Figure 26: During dressing application.
Figure 27: Post operative dressing.
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Figure 28: Post-operative dressing: ready to be finished.
Postoperative Period
The wound should be cleaned and disinfected, then you can proceed to put gauze, soaked
with antibiotic ointment both in the region of the helix and both in the anti-helix, and
place it anteriorly and posteriorly of the concha. Surgeon wraps the patient with a band of
medium elasticity and leaves him blindfolded for 48 hours. The drug therapy prescribed is
based on antibiotics and painkillers. In order to spend 48 hours, the patient may replace the
dressing with a tennis-model headband; making sure to cover his/her ears. The headband
must be kept on site 24 hours a day for about a week. After all this , the patient may only
use it at night for about a week again in order to prevent the temporary lack of sensitivity
that may occur in residual ear and it may cause problems with the sutures [19].
Complications of Otoplasty
On principle, it can be differentiated between early complications and late complications
about otoplasty. Early complications include haematomas, wound infections, which may
be associated with perichondritis, pain, postoperative bleeding, allergic reactions, and,
most devastatingly, cartilage-skin necroses. In contrast, hypertrophic scars, keloids,
suture material rejection with fistula formation, hypoaesthesia or paraesthesia, auricular
deformities or a recurrence, occur as late complications. When it comes to the early detection
of complications, regular follow-up examinations and care are strongly recommended and
should be performed by the surgeon. Haematomas are more frequently associated with
cartilage weakening methods of anti-helix reconstruction, such as incision and/or scoring
techniques. Each surgical operation carries the risk of perichondritis which, in extreme
cases, may result in cartilage-skin necrosis with cosmetically unsatisfactory auricular
deformity.
Pain, during the first postoperative days, may herald complications and require
immediate attention, including examination and change of dressing. Significant local it chat
the ear may indicate an allergic reaction to the suture material or to the dressing material,
and further clarification should be attempted. Due to the fact that late complications,
such as hypertrophic scars or keloids, may occur even months after otoplasty, follow-up
examinations are recommended at longer intervals up to one year. If the patient has a
history of hypertrophic scars or keloids, he or she should be informed about the associated
increased risk and a potential second surgical intervention may be required. In addition to
this, these patients should apply a scar ointment, which inhibits excessive collagen synthesis
in the region of the scar. Fistula formation may indicate rejection of the suture material or
they may indicate the presence of knots that are placed too superficially underneath the
retro auricular skin, and for this reason it may require surgical revision with fistula closure
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and removal of the originally used suture material. Even if the surgical technique is correctly
performed, it may occur a recurrence with renew protrusion of the ears. Therefore, during
the first appointment or, at the latest, during the informed consent discussion, the patient
or the parents of the child should be comprehensively informed about the associated risks
and possible complications and they should be asked about their expectations regarding
the outcome of the intervention [20]. Going into details, knowledge of suitable surgical
techniques and the correct performance of the otoplasty procedures are crucial for a good
cosmetic result (Figures 29, 30 and 31).
Figure 29: A case of caucasian female patient, 20 y.o., affected by absence of the anti-helix, pre- operative and post-operative
views.
Figure 30: Three/quarter pictures of pre-operative and post-operative views of the patient after anti-helix reconstruction.
Figure 31: A case of a caucasian male patient, 26 years, affected by concha hypertrophy and anti-helix absence pre-operative
and postoperative pictures.
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