67
When should the ear be set back by surgery? The development of the ear is virtually completed by the age of five, when operative measures can be under- taken. If the parents want the operation, then – ac- cording to some authors – it may be assumed that the child also wants. This will avoid possible emotional damage to the child from teasing. Some surgeons, however, prefer to wait until the children themselves are aware of their deformity and develop a positive motivation for the operation. One should surgically correct this deformity by the time of puberty if the children are bothered by it.
67.1 Introduction
As a result of developmental abnormalities, some children have very prominent ears, especially so- called ectomorphs, that is individuals with long- boned, asthenic, athletic body types. There are a large number of variations and possible deformities in the region of the ear and ear lobe. The size of the ear and the severity of its prominence can also vary. Some- times one ear is very prominent and the other less so or not at all.
Ear Corrections
Dimitrije E. Panfilov
Fig. 67.1. a The left ear is prominent, which disturbs the patient; front view. b Front view 3 weeks after surgery. c Ectomorphic patient: both ears are prominent. d One week postoperatively
Fig. 67.2. a Bilateral otopostasis of an 8-year-old boy. b Three months after otopexy. c Side view of prominent ear.
d Harmonious architecture of the auricular cartilage 3 months postopera- tively. e Depressed look of a 7-year-old girl. f Relaxed, satisfied postoperative look
In nature, no two ears are identical, neither before nor after surgery. After the operation, parents and friends usually view the ears much more critically
than before. Any lack of absolute symmetry after the operation should not be that troublesome because both ears are only rarely seen at the same time.
Fig. 67.2. Continued. g A 6-year-old girl, our youngest otoplasty patient. h Six months postoperatively. The same girl – back aspect – i before and j after surgery
Fig. 67.3. a Dermographic markings – front view. b Small spindle-like excision in the back of the auricle, lower third.
Back view c before and d after otopexy.
Both ears e before, left side more pro- truded, and f 1 week postoperatively:
the ears are not absolutely symmetrical, but the patient is satisfied
67.2
The Operation
There are a large number of surgical procedures to set back the ears (otopexy or otoplasty). The operative method in which only a spindle-shaped strip of skin is excised from behind the ear should be rejected. If the natural architecture of the ear cartilage is not recon- structed, then the ear will bend forward again after a few months.
I personally prefer a combination of three methods where a spindle-shaped incision of up to 1 cm length is made on the lower third of the ear after the anterior cartilaginous sheet has been scored under the skin in a longitudinal direction. This bends the cartilage back, giving the ear its otherwise natural fold. The ear cartilage is then fixed under the skin with two or three special mattress sutures of transparent, nonab- sorbable 4-0 nylon sutures. Only rarely are these su- tures not tolerated by the body, in which case they can be replaced by another type of suture material. At the end of the operation the wound on the back of the ear is sutured, with absorbable material if required. The
1-cm-long scar behind the ear usually remains mostly inconspicuous. There are of course other methods to set back the ear which also produce good results; most of them are more aggressive and complicated.
There was a method to fix the helix tail to the peri- osteum of the mastoid, but it was painful. Muelbauer from Germany has suggested shortening and fixating it deep on the back side of the concha. We went one step further: we evert and suture the shortened helix tail on the posterior side of the concha. The eversion itself rotates the lower third of the auricle backwards.
It remains to fixate the upper two thirds of the au- ricle. This is very easy to achieve with Kaye’s method of introduced three-stitch-mattress sutures which re- sult in stable otopexy of the upper two thirds of the auricle. Sometimes these sutures are enough after fil- ing the antihelix to keep the auricular cartilage in the desired place.
Also adults suffer from otopostasis and they some- times say they have wanted to have their ears fixed for years, sometimes since puberty. Our oldest patient was a 45-year-old woman.
Fig. 67.4. a A simplified Kaye’s method of otopexy with
“Panfilov’s file”. b Side view of the right file in front and the left file behind turned upside down; only a few move- ments can break the anterior cartilage layer of the antihelix
Fig. 67.5. a After skin excision the helix tail (cauda helicis) has been isolated; with the tip of Stevens scissors, we advance to the subcutaneous space b and prepare a tunnel up to the top of superior crus of the antihelix. c Joseph’s file simulated in front of the auricle. d Superior crus of the antihelix to be smooth- filed e turning Joseph’s file to follow the curve of the antihe-
lix and smooth filing, so that the front layer of cartilage has been broken, otherwise the architecture of the cartilage would tend to revert to its initial condition – we can palpate it. Use of straight Joseph’s file is not so easy as that of the author’s file.
f Panfilov’s file simulated over the antihelix which is following its own curvature
Fig. 67.6 a–e. Helix tail a shortened and b everted. c The 4-0 nylon suture fixates d this eversion. e Intradermal suture with absorbable suture
Fig. 67.7. a First step: Mini incision of 1 mm on the front side of the antihelix. Stitch from front to back side of antihelix; cau- tion – the suture has to perforate both cartilage leaves but not the skin on the back side of the auricle, otherwise infection will cause recurrence, because a nonabsorbable nylon 4-0 suture was used. b Second step: Through the skin punction – the same location where the suture comes out – we put another stitch to proceed the suture subcutaneously in a caudal direction.
c Third step: Punction of the stitch out is taken to stitch again through both leaves of the cartilage (but not skin of the back side of the ear). d Tightened suture pulls the helix backwards and gives more profile to the antihelix. e The same mattress suture in the middle third of the antihelix. f Suture strips for 1 week. It is advisable to sleep with an elastic headband for 3 weeks after surgery
Fig. 67.8. a Adult female patient; otopostasis more left than right. b Three weeks postoperatively. c Adult male patient: asymmetric otopostasis more right than left. d Postoperative look is more symmetrical
The operation can be performed under local an- aesthesia in adults and older children. The youngest patient on whom I performed this operation under lo- cal anaesthesia was 9 years old. He was so strongly motivated that he patiently endured the whole proce- dure without saying a word. This operation should be done under mild general anaesthesia in smaller chil- dren.
67.3
Shortening of the Ear Lob
Sometimes the ear lobe holes are too large. They can be easily eradicated with radiosurgery. Or if the ear lobes are found to be too long they can be shortened.
We should make the back incision 3–4 mm higher than the front incision, avoiding visibility.
67.4
Axial Rotation of the Ear
Very seldom patients find the axis of their ears to be too oblique. To correct this, we excise some spindle- like skin area behind the lower pole and in front of the upper pole. Additionally we fix the back lower part of the concha backwards to the mastoid periosteum and the upper cartilage pole forwards to the temporal fas- cia. In such a manner, we can rotate the ear by up to 15°. Details have to be discussed precisely with the pa- tient prior to the surgery.
67.5 Aftercare
A head dressing is worn for 1 day after the operation – preferably one made of elastic netting. After that an elastic headband should be worn at night for a further 3 weeks. This is to prevent the ear from inadvertently being bent over during sleep, which would put the good operative result at risk. After the operation, the patient should refrain from sport for 4 or 5 weeks.
Fig. 67.9. a Ear lobe hole excised with radiosurgery. b Too long an ear lobe. c Dermographic marking: front incision blue line; back incision dotted red line. d Three months after surgery
67.6
Complications
Apart from slight bleeding, swelling, and pain, the other usual complications such as infection, excess scar formation, and the like are very rare. Sensitivity to nonabsorbable suture material is also extremely rare.
Bibliography
Please see the general bibliography at the end of this book.
Fig. 67.10. a Forward rotation of the upper pole of the ear in- dicated by dermography. b Backward rotation of the lower pole of the ear; it is important to fix the cartilages in the rotated positions. Suture between cartilage of the upper pole of the ear and temporal fascia c placed and d tightened. e The
patient (physician) himself found the axis of his ear and nose (“Leonardo’s quadrilateral”) to be too oblique. f Both ear and nose axis have been set more upright; nose correction done by slight augmentation with cartilage chips made from the helix tail
