ARTICLE | BEST PRACTICE | Key points
■ Otoplasty using suture techniques is both safe and effective for correcting the antihelix, the concha cavum and the lobule. It leads to a long-lasting increase in patients’ health-related quality of life
■ The routine use of cutting or scoring techniques, as well as skin resections, seems out-dated owing to significant risks of severe deformities difficult or impossible to reverse
■ A clear trend can be seen in otoplasty in favour of less aggressive operation techniques, which has also been made possible by the availability of modern biocompatible suture materials
surgeons did not recognise that the use of absorbable suture material is not indicated when performing otoplasty with the Mustard• technique. Owing to the elastic restoring forces of the cartilage, relapses were common. Fortunately, technical advances have led to a huge
decrease in problems with suture materials. The modern surgeon has access to suture material with long-term biocompatibility and good knotting characteristics, so thread granulomae and inflammations have become something of a rarity. For these reasons, the authors have relinquished all
aggressive cutting or scoring techniques and invariably use suture techniques, not just for folding of the antihelix. The good controllability of sutures when combined with intraoperative measurements of the distance of the auricle to the skull, according to Wodak35
,
helps to achieve a symmetrical result. Only in very rare cases with extremely stiff cartilage or real hyperplasia of the cavum conchae, can careful scoring or cutting of the cartilage be necessary. The widespread procedure to correct a large-looking
than the preoperative state of protruding ears32
(Figure 2). Compared with all cutting or scoring techniques, the risk of undesired edges, defects, or deformities that are difficult to correct is lower with cartilage-sparing suture techniques7, 33, 34
. The authors
therefore recommend otoplasty using suture techniques in particular. Any resection, incision or scoring of the cartilage, as well as skin resection, should be avoided if possible, to reduce the risk of a postoperative auricular deformity that is difficult to correct.
State-of-the-art otoplasty using suture techniques The authors invariably recommend performing suture techniques in their own patients, following the modern concepts of Mustard• 26
,
combined with conchaÐ mastoid sutures and a rotation of the concha cavum29
. In cases Any resection, incision or
scoring of the cartilage, as well as skin resection, should be avoided if possible, to reduce the risk of a postoperative auricular
deformity that is difficult to correct.
of a protruding lobule, this deformity is also corrected with a single suture30
. The authors access the cartilage
via a postauricular incision in the area of the antihelical sulcus, and almost never excise the skin before closure. Understandably, results of this technique are
dependent on the optimal position of the sutures, as well as the long-term biocompatibility of the suture material. In the past, suture complications were named as a major disadvantage of the Mustard• technique33
.
Suture material with low biocompatibility caused intolerance reactions with inflammation, and in some cases even abscess formation. Furthermore, some
52 ❚ April/May 2012 |
prime-journal.com
concha cavum by cartilage resection, sutures and cavum rotation often leads to a narrow, long auricle, and in some cases, to severe deformities. As the same considerations with regard to the risks of aggressive procedures hold true as for the antihelix, the authors almost invariably correct the concha cavum with sutures between the cartilage and the periosteum of the mastoid. The contents of the postauricular groove (postauricular muscle and fibrofatty tissues) are removed beforehand to enhance the controllability and the approximating effect of the sutures. For these sutures the authors use long-term absorbable material and start antero-medially, followed by latero-dorsal sutures if necessary. Therefore, the external auditory canal is not narrowed. Surgical techniques using cartilage or
postauricular skin resection to correct a protruding lobule often look promising in the schematic drawings of surgical textbooks, but are disappointing in practice. Fortunately, it has been shown that the lobule can be relocated in an approximated position with good controllability and long-term stability by a cleverly positioned suture30
. Basically, this
suture is a modified Mustard• suture with the lateral fixation point the soft tissue of the
lobule or the helical cauda, rather than the helical rim. For this very effective suture, the authors use non-resorbable material. For the further minimisation of risk, the authors avoid
postauricular skin resections when performing otoplasty. The skin always smoothly attaches itself to the auricle in the postoperative course, so the postauricular sulcus maintains its typical depth. With this course of action, keloids have vanished from the spectrum of postoperative complications. If a revision is necessary, the prospect for success is excellent because of the preserved cartilage and skin.
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