Ear Correction Surgery: when and how?

Issues and History of Otoplasty

In the middle of the 19th century the first suggestions appeared in surgery regarding the setback of prominent ears. These research efforts, involving principally the names Dieffenbach and Ely, focused on the setback of protruding ears by a resection of the skin behind the auricle. It was not until 1903 when Gersuny found out that the long lasting ear correction requires the elimination of the recovery property of the elastic cartilage. Since the 1950s, the researchers have increasingly developed operative techniques for the correction of prominent ears which have been focused on the reshaping of the cartilaginous tissue. Since then, the surgical procedures have been divided for several decades, at least in German-speaking countries, in “Incision Techniques”, “Scratching Techniques” and “Suture Techniques” according to the way in which the cartilage is reshaped. A lot of surgical procedures combining different techniques have meanwhile been developed.

Clinical Definition of a Prominent Ear

In medical literature an ear is referred to as “prominent”, if the angle between the skull and the auricle exceeds 30 degrees. However, in practice the exact measurement of the angle proves to be difficult without special tools. It is easier to measure the distance from the skull to the helical rim (Wodak method). According to this method of measurement the distance of the outer ear rim from the mastoid should not considerably exceed 18 mm in three measurement points (on top, in the middle, on the bottom). This measurement can be easily performed even during the operation. The protrusion of the ear is under morphological aspects due to three factors which frequently occur simultaneously.  

  • Underdeveloped antihelical fold in the cartilage  
  • Oversized cavum conchae  
  • Protrusion of the pinna   

The correction surgery depends on the existing external ear anomalies. The otoplasty may be performed to create an aesthetic antihelical fold, reduce or flatten the cavum conchae or set back a prominent ear.

Choice of the Operation Technique, Risks and Potential Complications  

The risks inherent in the surgical correction of a protruding ear depend largely and essentially on the chosen operative technique. It is easily understandable and experience has shown that more invasive incision and scratching techniques involve greater risks than the use of suture techniques. A destruction of the cartilage and ear deformation due to an infection with purulent secretion are really very rare complications of such a surgical intervention. However, the incision techniques bear the risk of the development of ugly visible sharp edges and folds in the ear. Given the experience that this kind of surgery may cause deformities which are more striking and embarrassing than the original malformation, hence the protruding ear, the incision techniques are increasingly abandoned by the surgeons and replaced by suture techniques. This is a very desirable evolution, since the aesthetic repair of an ear deformed by the incision technique can be a very difficult and sometimes hardly manageable challenge. The cosmetic reshaping of such a “calamity ear” (O. Staindl) requires to restore the original shape of the ear cartilage and in some cases it is even necessary to resort to transplantation or implants.

The traditional operation procedures often involved the excision of a strip of skin behind the ear to support the setback of the ear. This technique is still occasionally used today. Although it is widely known since the middle of last century that the excision of the skin behind the auricle is not suitable to achieve an aesthetic surgery result, surgeons still occasionally perform the postauricular skin resection. Furthermore, this approach tends to flatten to a certain extent the postauricular fold. This in turn not only may cause unpleasant excessive corrections, notably in the central part of the pinna, but may also make it difficult or even impossible to wear a hearing aid or glasses. 

Given his experience, Prof. Dr. Berghaus is convinced that the excision of postauricular skin is absolutely unnecessary for the correction of protruding ears whereas it is eligible to cause complications, such as keloid scars (=excessive scarring tendency), which can develop after an otoplasty, when the suture is exposed to tensile stress potentially due to skin excisions.

The excessive or insufficient correction is another surgical risk, which can however be avoided by performing the measurement according to the Wodak method described above to compare the position of both ears. The overly tight setback of the ear, notably in the central part of the pinna, causes the so-called “telephone deformity”. The correction of the prominent auricle is sometimes considered as a particularly difficult problem, but it can definitely be resolved by skilfully performed sutures.

Despite greatest carefulness in the execution of the surgical correction of the protruding ears, a completely symmetrical operation result cannot be guaranteed. The surgeon is required to inform the patient of this problem. Furthermore, regardless of the used surgical technique, it cannot be excluded that there is a suture intolerance or rejection. In such a case remnants of thread may appear on the postauricular skin after a longer period of time of 6 to 12 months. However, since the surgery scars have completely healed after such a long time, the remnants of the stitches can be removed without problem.

Today, the surgical correction of prominent ears can be considered as an efficient and rather safe surgery, provided that minimally invasive techniques and appropriate materials are used. The ear correction surgery has scientifically proven benefits for the affected patients. If the surgeon chooses an adequate operative technique which ensures the entire preservation of the cartilage and does not damage the integument, the patient must not fear undesirable results and a second surgical intervention to correct them.

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