Abstract Over the last 100 years, more than 200 different methods have been described to correct prominent ear deformity. These techniques revolved around various combinations of postauricular incision, cartilage scoring, and strategic suture placement to reapproximate the antihelical fold and correct angular deformity. In the last two decades, fascial flap techniques have become prominent in otoplasty. This article gives a comprehensive review of the different surgical techniques employed to construct fascial flaps and their contributions to otoplasty. Enlargement of the helix-mastoid angle and an underdeveloped antihelix are central to the pathology of prominent ear deformity. Antihelical fold reconstruction is classified as either cartilage invasive or cartilage sparing (Table 1).1 Cartilage invasive techniques may involve incision, scoring, and excision of auricular cartilage.2-9 Cartilage sparing techniques rely on suturing techniques.10,11 Cartilage sparing techniques are associated with decreased incidence of postoperative hematoma and skin necrosis compared to cartilage invasive techniques,10,11 but have higher rates of recurrence and suture extrusion.12-15 However, in experienced hands, cartilage invasive techniques can be performed safely with low complication rates. In a large case series using a cartilage invasive technique with anterior scoring, Caouette-Laberge et al reported low early and late complication rates in a minimum of 2 years follow-up interval. Patient satisfaction was excellent (94.8%).16 Table 1. Otoplasty Techniques Could Be Separated Two Main Groups: Cartilage Invasive and Cartilage Sparing Techniques Cartilage invasive Converse2 and Becker3 Incision and suturing technique Strenstom4 Incision and scoring technique Crikelair5 and Congchet6 Anterior scoring with a rasp Weerda7 Posterior cartilage thinning using a drill Walter8 Cartilage incision and excision technique Pitanguy9 Cartilage island flap technique Cartilage sparing Mustarde10 Suturing technique Furnas11 Suturing technique Cartilage invasive Converse2 and Becker3 Incision and suturing technique Strenstom4 Incision and scoring technique Crikelair5 and Congchet6 Anterior scoring with a rasp Weerda7 Posterior cartilage thinning using a drill Walter8 Cartilage incision and excision technique Pitanguy9 Cartilage island flap technique Cartilage sparing Mustarde10 Suturing technique Furnas11 Suturing technique View Large Table 1. Otoplasty Techniques Could Be Separated Two Main Groups: Cartilage Invasive and Cartilage Sparing Techniques Cartilage invasive Converse2 and Becker3 Incision and suturing technique Strenstom4 Incision and scoring technique Crikelair5 and Congchet6 Anterior scoring with a rasp Weerda7 Posterior cartilage thinning using a drill Walter8 Cartilage incision and excision technique Pitanguy9 Cartilage island flap technique Cartilage sparing Mustarde10 Suturing technique Furnas11 Suturing technique Cartilage invasive Converse2 and Becker3 Incision and suturing technique Strenstom4 Incision and scoring technique Crikelair5 and Congchet6 Anterior scoring with a rasp Weerda7 Posterior cartilage thinning using a drill Walter8 Cartilage incision and excision technique Pitanguy9 Cartilage island flap technique Cartilage sparing Mustarde10 Suturing technique Furnas11 Suturing technique View Large In the last two decades, fascial flap based techniques, first described by Horlock et al,12 have been used to correct prominent ear deformity otoplasty. In this paper, the author will describe the different fascial flap techniques and discuss the advantages and specific applications of each technique based on a comprehensive literature search. Relevant Anatomy The soft tissue of the postauricular region covers the cartilaginous framework, which is composed of the following 4 layers: (1) skin, (2) subcutaneous fat, (3) postauricular fascia, and (4) perichondrium.17,18 Postauricular fascia is referred to as intrinsic postauricular fascia in the posterior surface of the ear and as extrinsic postauricular fascia in the mastoid region.19 The intrinsic postauricular fascia is a fibroareolar tissue with vascular supply from the superficial temporal artery and posterior auricular artery and nervous innervation from the greater auricular nerve and lesser occipital nerve.19,20 The schematic demonstration of the anatomy is seen in Figure 1. Figure 1. View largeDownload slide The layers of a normal ear are demonstrated: cream, pink, yellow, dark green, purple, light green, red, light gray, dark gray mark to epidermis, dermis, subcutaneous fat, postauricular fascia, deep mastoid fascia, deep temporal fascia, temporal muscle, perichondrium, cartilage, respectively. Figure 1. View largeDownload slide The layers of a normal ear are demonstrated: cream, pink, yellow, dark green, purple, light green, red, light gray, dark gray mark to epidermis, dermis, subcutaneous fat, postauricular fascia, deep mastoid fascia, deep temporal fascia, temporal muscle, perichondrium, cartilage, respectively. Postauricular Fascial Flap (Proximally Based Fascial Flap) The postauricular fascial flap is the first fascial flap utilized for prominent ear correction as described by Horlock et al12 in 2001. They criticized anterior riberation methods due to the relatively high incidence of postoperative hematoma and surgical site infection which can lead to irreparable cartilage irregularities and deformations. In contrast, cartilage sparing techniques, described by Mustarde10 and Furnas,11 have decreased rates of postoperative hematoma and infection, but are associated with increased recurrence rates (up to 25%), suture extrusion, and pain secondary to buried sutures.21 Postauricular fascial flap construction evolved in an effort to refine the Mustarde technique and alleviate the associated complications. In a retrospective review, Horlock et al12 related his experience with 51 patients (45 bilateral, 6 unilateral) who underwent prominent ear correction with a postauricular fascial flap. In a stepwise fashion, a postauricular fascial flap was elevated, the antihelical fold was reconstructed using the Mustarde technique, the conchal angle was corrected with Furnas’ concha-mastoid sutures, and lastly, the elevated fascial flap was secured to the posterior aspect of the helical rim to cover these sutures. Posterior advancement and attachment of the fascial flap may require trimming of the flap. While the authors do not record operative time, it may be deduced that flap construction and reattachment will increase the length of the procedure. This flap, however, serves an important purpose as it improves postauricular support and provides a protective cover over the layer of sutures thereby reducing recurrence and suture extrusion. Recurrence occurred in 8.3% of patients and suture extrusion occurred in 4% of patients over an 11 month median follow up period (range, 4-30 months). In 2006, Mandal et al13 published a retrospective comparative study including 203 patients who underwent 3 different types of operations for bilateral prominent ear correction. In this study, group A (68 patients) received the standard Chongchet6 procedure (anterior cartilage scoring), group B (94 patients) underwent cartilage sparing posterior suture otoplasty, and group C (41 patients) underwent cartilage sparing postauricular fascial flap construction with posterior suture otoplasty. Outcomes assessed included early complications (bleeding, hematoma formation, delayed healing), late complications (anterior skin necrosis, residual pain, cartilage spur formation, scarred notch formation), recurrence rates, revision rates, operative time, and satisfaction and symmetry scores. While there was no increase in bleeding in the cartilage invasive group compared to other techniques, complications included anterior skin necrosis, residual pain, cartilage spur formation, and scarred notch. These complications were seen only in group A and occurred at occurred at a rate of 0.7%, 1.4%, 0.7%, and 0.7% respectively. The postauricular fascial flap technique (group C) resulted in less suture granuloma (0% vs 1.1%) and suture extrusion (1.1% vs 2.1%) than posterior suturing alone (group B); however, these results were not statistically significant. Although the postauricular fascial flap technique required the longest operative time, overall complication, recurrence, and reoperation rates were lowest in this group. Additionally, satisfaction and symmetry scores were higher in this group. The postauricular fascial flap technique was reported as the treatment of choice for prominent ear correction by Mandal et al.13 In 2009, Schaverien et al14 employed the postauricular fascial flap technique in a case series of 60 pediatric patients. Over a 3.9 year follow-up period, 4.5% had recurrence requiring revision in 60% of these patients. Mean time to recurrence was 2.5 yrs (range, 1-5.8 years). Minor complications (wound dehiscence, bleeding, suture extrusion, and scarred notch) occurred in 5.4% requiring revision in 30% of these patients. Both Horlock et al12 and Schaverien et al14 described using a postauricular fascial flap as an adjunct to posterior suturing, but the techniques differed significantly. Schaverien et al14 elevated the perichondrium together with the flap and extended the dissection in the subperichondrial plane towards periosteum whereas Horlock et al12 worked in the supraperichondrial plane. Schaverien et al14 also did not divide the posterior auricularis muscle routinely as he worked in the subperichondrial plane (division of the posterior auricularis muscle occurs in the supraperichondrial plane as it originates from the mastoid portion of the temporal bone and inserts into the perichondrium of the concha). In 2011, Sinha et al15 reported the largest study of patients undergoing prominent ear correction where he employed a postauricular fascial flap technique in 227 pediatric patients. The author reported the following complication rates: 4.8% recurrence, 2.64% suture extrusion, 1.32% keloid formation, and 0.44% skin necrosis. When describing the technique, Sinha et al15 state that an incision was made, “Through the adipo-fascial layer and perichondrium.” Here, it is not entirely clear whether dissection is in the subperichondrial or supraperichondrial plane. Considering the published images of the postauricular anatomy, it seems that the intrinsic postauricular fascia was dissected in the supraperichondrial plane, extending all the way to the mastoid area where it transforms into the extrinsic postauricular fascia. Surgical Technique A postauricular kidney bean shaped skin is excised superficially leaving the subcutaneous tissue attached to the posterior surface of the cartilage tissue. The postauricular skin flap is elevated at the subdermal plane distally toward the helical rim. The postauricular fascial flap that is previously left on the cartilage is then elevated at the supraperichondrial plane toward the mastoid area and retracted posteriorly. Furnas and Mustarde sutures are placed using 4.0 Ethibond sutures and the postauricular flap is advanced to the helical rim to cover these sutures. Excess flap tissue, which occurs after posterior rotation of the ear and advancement of the flap, is then trimmed. The posterior auricularis muscle is preserved. The skin is closed with a 5.0 Prolene suture. A padded head bandage is applied for one week. The Prolene suture is removed on postoperative day 5 to 7 at the first follow-up visit. A schematic demonstration of the technique is seen in Figure 2. Figure 2. View largeDownload slide The technique of postauricular fascial flap is demonstrated. Figure 2. View largeDownload slide The technique of postauricular fascial flap is demonstrated. Distally Based Fascial Flap In 2008, Shokrollahi et al22 described prominent ear correction using a distally based postauricular flap in a case series of 15 patients ages 8 to 16. The author enumerated several limitations of the proximally based flap. First, proximally based fascial flaps are performed mainly to cover Mustarde and Furnas sutures, but an additional suture is placed to resuture the flap to the helical rim leaving a suture exposed and thus, defeating the purpose of the flap. Second, exposure of the mastoid is limited, making correct placement of concha-mastoid sutures more difficult. Lastly, there is an increased risk of entrapment of the flap edges when tying suture knots. Shokrollahi et al22 described a distally based fascial flap that could be used with or without Furnas and Mustarde sutures to correct prominent ear deformity. The author described the creation of a thin, wide flap that may be prone to injury during dissection (especially at the inferior portion of the flap) in the hands of inexperienced otoplasty surgeon. Challenges of the single suture operation not only include the creation of a thin, wide flap, but also defining the correct “sweet spot” on the mastoid area to which the flap would be sutured. The authors believe that surgeons who undertake to perform this procedure should use Furnas and Mustarde sutures with a distally based fascial flap cover until they familiarize themselves with the technique. In this small pediatric case series, the authors used distally based postauricular fascial flap only as an adjunct to suturing techniques and reported no complications over the 11 month follow-up period. Advantages of this technique listed by the author include intraoperative decision flexibility, potential for single suture repair, and improved healing and scarring potential secondary to the juxtaposition of two live tissues. Although, this technique has a great success rate in the pediatric population, the effectiveness of this procedure in the long term and when employed as a sole repair for prominent ear should be clarified. Surgical Technique Local anesthesia is administered using a lidocaine with 1:200-,000 epinephrine solution. A superficial elliptical excision is made in the postauricular region. It is very important to keep the skin excision as superficial as possible to create the fascial flap as thick and robust as possible. Then the fascia is incised to the level of the cartilage throughout the inferior border of elliptic skin excision and the fascial flap is elevated distally with tenotomy scissors until the helical rim in the supraperichondrial plane. If a distally based flap is employed as the primary otoplasty technique, to create and enhance the antihelical fold, the distal dissection has to be carried almost to the rim. Then the author defines a particular area over the mastoid which corrects the prominence of the ear and creates a natural antihelical fold when the flap is anchored. This “sweet spot” is defined by grasping the fascia and approximating it to different locations in the mastoid area. Alternatively, flap can be used either as a cover to Mustarde and Furnas sutures by closing the skin and letting the fascia naturally overlay the sutures or as a reinforcement to these sutures by placing a single fascial-mastoid suture. After the flap is sutured to the mastoid process using a figure of eight suture or mattress suture, additional fascial sutures may be placed to separately address earlobe or lower pole deformity. Although Shokrollahi et al22 used only 4/0 Ethibond suture on round-bodied needle for fascial anchoring, authors stated that an absorbable suture may be an acceptable alternative. The procedure is concluded by suturing the naturally opposing skin edges. This technique is believed to require minimal or indeed no usage of hand bandage dressings in the postoperative period when skin glue is used to fixate the ear to the postauricular area.23 By using skin glue, an additional clinic appointment is avoided for suture or head bandage removal. The schematic demonstration of the technique is seen in Figure 3. Figure 3. View largeDownload slide Distally based fascial flap. Figure 3. View largeDownload slide Distally based fascial flap. Triangular Fascioperichondrial Flap The triangular fascioperichondrial flap technique was studied by Frascino24 in 2009 in an 82 patient case series. The mean age of patients was 19.2 (range, 6-49 years old) and the average follow up was 3.4 years (range, 6-90 months). The technique involves elevating a distally based triangular flap in the superior third of the postauricular region in the subperichondrial plane, placing a Furnas conchal-mastoid 4-0 Nylon suture, placing an additional suture from the posterior portion of superior crus to the temporal fascia, and then the scoring of anterior surface of the antihelix if needed. The flap is folded to give the ideal shape to the antihelical fold and to medialize the upper pole. Mustarde sutures are described as optional. The author reported no early complications (hematoma, surgical site infection, skin necrosis). Late complications included recurrence in 7.45%, suture extrusion in 4.34%, and hypertrophic scar formation in 1.86%. Accumulated reoperation risk was 10.85% over 9 years and loss of medialization of the upper pole was the most common indication. The author believes this technique to be advantageous as it allows precise traction and positioning of the delicate cartilage flap which is then anchored by a single stitch. Also, the author states that mattress sutures that are placed to create helical rim in Mustarde technique, only bring cartilaginous surfaces to close proximity as opposed to flap technique where 2 raw surfaces are approximated and true tissue coaptation is promoted. By this was, potentially a greater efficacy in terms of long-term fixation can be provided. The author indicates his technique cannot be used with a closed or anterior approach and/or when there is a helical rim defect (as this is where the triangular flap is anchored). Even though overall reported outcomes were comparable with previously described techniques, need for cartilage scoring/excision procedures, placement of a permanent suture at the superior crus (which potentiates for suture extrusion) might be seen as disadvantages of this technique. Surgical Technique An elliptic skin island that is 3 to 4 mm from the postauricular sulcus and 5 to 6 mm from the helical rim is marked at the postauricular region. The subperichondrial plane is then hydrodissected by injecting an anesthetic solution of lidocaine with epinephrine (1:200,000). After the superficial skin excision is completed, the upper part of the denuded subcutaneous tissue is marked creating a triangular shaped distally based flap with a 1.5 to 2.5 cm pedicle originating from upper 1/3 posterior helical rim. Using a freer, this triangular flap is elevated in the subperichondrial plane with blunt dissection. The lower part of the incision is undermined by detaching the posterior auricular muscle from its insertion which created the necessary space to eventually rotate the conchal bowl medially. After placing a Furnas 4.0 Nylon suture, an additional 4.0 Nylon suture is passed from the posterior portion of the superior crus to the temporal fascia and left untied. The flap is then folded over once or twice and fixated with a 4.0 Nylon U stitch. The flap is then held in traction in different positions until the desired antihelix shape and upper pole medialization is achieved. During rotation of the conchal bowl, if there is too much resistance, an anterior antihelix cartilage scoring can also be performed as described by Stenstrom. Once the fixation point is decided, the flap is anchored by using clear 4.0 Nylon suture. After tying the previously untied temporal fascial suture, the skin is closed with a 5.0 Monocryl suture. The ear is covered with 80 mg topical Gentamicin ointment and a 0.9% saline soaked cotton gauze. An elastic band is wrapped over the cotton dressing. After 24 hours, the dressing is taken down. An elastic athletic headband is recommended to be worn continuously for 2 weeks and for another month while sleeping. The schematic demonstration of the technique is seen in Figure 4. Figure 4. View largeDownload slide Triangular fascioperichondrial flap. Figure 4. View largeDownload slide Triangular fascioperichondrial flap. Distally Based Perichondrio-Adipo-Dermal Flap Cihandide et al16 introduced the “distally based perichondrio-adipo-dermal flap” technique in 2016 in a 20 patient case series of patients 7 to 31 years old (mean 18.5 years) with a mean follow-up time of 8.3 months (2-16 months). In this technique, a distally elevated fascial flap was anchored to the mastoid fascia which simultaneously reconstructed the antihelix and decreased the conchamastoid angle with 2 permanent sutures. Cartilage scoring was performed routinely in adult patients to weaken the tissue memory and prevent recurrence. Mean operation time was 72 minutes. No early complications (hematoma, skin necrosis, or suture extrusion) were reported. Only 1 patient (5%) suffered recurrence. Postoperatively, patients were seen on days 3, 10, 30, 90, and 180 at which time pictures were taken and the distance between the upper helical rim and mastoid was measured. A statistically significant difference was found between the pictures of postoperative day 30 and postoperative day 90. Similar to the point made by Shokrollahi et al,22 the author states that because the perichondrio-adipo-dermal flap is continuous throughout the entire helical rim, tension should be equally distributed over this wide flap. Furthermore, including perichondrium in the fascial flap potentially creates a thicker flap as compared to Shokrollahi’s distally based flap. The author warns about cartilage rupture which causes the postoperative shape problems, could be occurred while elevation of the perichondrium. The perichondrium in ⅓ upper pole and in distal ear becomes thinnest part,24 so during the flap elevation, flap perforation or cartilage rupture should be care to avoid these serious complications. Using one flap to create an antihelix and reduce the concha-mastoid angle may cause unpredictable and inappropriate scapha- mastoid angle and shoaling of postauricular sulcus and using permanent sutures seems the other possible disadvantages of this technique. Surgical Technique After successful administration of local anesthesia, the desired location for the new antihelical fold is demonstrated by pushing the helical rim posteriorly and marking the location with a skin marker. The skin on the postauricular side of this line is then marked with methylene blue. A bean shaped superficial skin island centered on the dyed area is excised from the posterior auricular region. The flap including perichondrium is elevated distally and carried 2 to 5 mm beyond the methylene blue markings to create the antihelical fold and scaphoid fossa. Then proximal dissection is carried out toward the mastoid, sparing the postauricular muscle. For adult patients, the conchal cartilage is scored with a #15 blade scalpel to stabilize the weakened conchal cartilage in the desired position. Using a ruler, the elevated flap is divided into thirds and anchored to the mastoid periosteum with a 4-0 Prolene suture at the inferior most point of the upper third of the flap and the superior most point of the lower third of the flap. In this way, a new antihelical fold and scapha are created. Skin was closed with a 5-0 Prolene suture on a cutting needle in a continuous fashion. Postoperative dressing consists of an antibiotic soaked gauze tampon and an elastic head wrap. Dressing is removed on postoperative day 3, sutures are removed on postoperative day 10, and the elastic head wrap is applied for 2 weeks continuously followed by 1 week only while sleeping. The schematic demonstration of the technique is seen in Figure 5. Figure 5. View largeDownload slide Distally based perichondrio-adipo-dermal flap. Figure 5. View largeDownload slide Distally based perichondrio-adipo-dermal flap. Bilateral Fascioperichondrial Flap The bilateral fascioperichondrial flap a combination of proximally and distally based fascial flap techniques, was described by Irkoren et al25 in 2013 in a study of 100 patients. The average age was 20.6 (6-55 years) and the mean follow-up time was 16.3 months (12-42 months). They used the bilateral fascioperichondrial flap as an adjunct to anterior scoring, Mustarde sutures, and Furnas sutures. There were no early complications. Two patients (3 ears) required reoperation to improve symmetry which were not counted as recurrence incidences. On postoperative day 15, all patients had the auriculomastoid angle and mastoid to helical rim distance at the level of the Frankfort line measured. All measurements were reported to be within the normal range based on guidelines of anthropometry. In terms of surgical technique, the authors described the distribution of tension vectors over two separate flaps as an advantage. Distributing the tension opposing the flaps (cartilage retraction) over two different bases should decrease the tension on each flap, but the fact that the authors unite the two flaps in the midline, essentially creating a singular flap, effectively negates this benefit. Furthermore, the authors also state that an advantage of using dual flaps is the ability to cover both Mustarde and Furnas sutures separately, decreasing suture extrusion rate. However, many other authors employed a single flap to cover both of these sutures with no evidence of increased suture extrusion. The practice of elevating a flap in the subperichondrial plane as an adjunct to standard scoring and suturing techniques will likely decrease recurrence rates, but the risk for cartilage tear when placing Mustarde and Furnas sutures may increase in the absence of perichondrium. Overall, the authors have created a sound mechanism of prominent ear correction by using a fascioperichondrial flap to reapproximate the concha-scaphoid angle and Mustarde sutures to create an antihelical fold. Thereby, this high patient volume case series is a valuable study that demonstrates another applicable technique for prominent ear correction. Surgical Technique After induction of general anesthesia, a wide and thin elliptical postauricular skin excision is performed. The underlying fascia is divided along the vertical axis of the elliptical wound. Using sharp dissection at the subperichondrial plane, proximally based flap is elevated till postauricular sulcus and distally based flap till helical rim. The postauricular muscle is not routinely divided. The location of the desired antihelical fold on the anterior surface of the pinna is marked and the cartilage was scored by tunneling a needle forceps through a stab incision along the proposed line of new antihelical fold. Next, 4.0 clear Nylon Mustarde and Furnas sutures are placed to reconstruct the antihelical fold and to reduce the conchamastoid angle, respectively. Bilateral fascioperichondrial flap edges are approximated and sutured with 5.0 Vicryl sutures to reduce the auriculocephalic angle. After closure of the skin with a subcuticular 4.0 Prolene suture, a standard head bandage is applied. The Prolene suture is removed 1 week postoperatively and an elastic head wrap is applied for 6 weeks to be worn at night time only. The schematic demonstration of the technique is seen in Figure 6. Figure 6. View largeDownload slide Bilateral fascioperichondrial flap. Figure 6. View largeDownload slide Bilateral fascioperichondrial flap. Proximally Based Dermo-Fascio-Perichondrial Flap Taş et al26 used a proximally based dermo-fasyo-perichondrial flap technique to recreate the antihelix. In fact, it is an antihelixplasty technique more specific than the otoplasty technique. Unlike previously described flap techniques, the fascial flap is used to reconstruct the antihelical fold without additional suturing methods, and all suture materials are used in the technique, are absorbable. This was accomplished through strategic positioning of the flap and through the inclusion of perichondrium in the fascial flap. Using the flap to reconstruct the antihelical fold allowed surgeon to eliminate the use of cartilage scoring and permanent Mustarde sutures and their associated risks including cartilage tear, suture extrusion, and suture granuloma. On the distal side of the incision, dissection was carried out in the supraperichondrial plane. By using two different surgical planes in proximal and distal side of the incision, the surgeon aimed to approximate two live tissues (perichondrial tissue) when anchoring the flap to distal antihelix border. Also, by leaving the perichondrium on the antihelix surface, cartilage damage would be reduced when anchoring the flap. When exposing mastoid bone to place the Furnas sutures, subdermal plane (superficial to the elevated flap) is entered so that the flap remains attached to the conchal surface from which it is nourished. Taş et al26 described this technique in a 24 patient case series in 2013 including both children and adults ages 6 to 27. Mean follow-up time was 18 months (range, 12-36 months). There were no early (bleeding, hematoma, wound dehiscence, infection) or late complications (suture extrusion, suture granuloma, skin necrosis, recurrence). One patient reported a skin ulcer on the anterior surface of the antihelix which resolved in 2 to 3 days. This was attributed to tight elastic headband application postoperatively. Auriculocephalic distances were measured preoperatively, 1 month postoperatively, and 12 months postoperatively at the level of the upper and middle helix demonstrating significant differences between pre- and postoperative distances (P < 0.001). Despite the small number of subjects, the low complication rate over a 1 year follow up was promising. Surgical Technique The desired antihelix position is determined by pinching the posterior surface of the outer ear between the thumb and index finger with the distance between the thumb and index finger measured as the desired fascial flap horizontal width. The distal and proximal borders of the new antihelix are marked on the postauricular region with a methylene blue stained needle tip. The pavilion is then released and the length of the antihelical fold is, marked into thirds at the along the helical rim which will ultimately define the distal border of the flap. After skin markings are completed, a thin hemielliptical skin island within the demarcated region is de-epithelialized from the postauricular region. At the level of the distal border of the flap, an incision is made down to the perichondrium with a #15 scalpel blade. The dissection begins distally toward the distal border of the new antihelix in the supraperichondrial plane. Proximally, the dissection is carried out in the subdermal plane until the mastoid fascia was reached. The skin is then separated from the flap. Next, a thin layer of perichondrium is incised from the distal border of the flap and elevated until the marked proximal border of the new antihelical fold. After flap elevation is completed, conchal cartilage excision is performed if conchal hypertrophy is present. For patients with a conchamastoid angle greater than 30 degrees, Furnas sutures are placed using 3-0 polydioxanone sutures, and if needed, the postauricular muscle is excised to create space for the conchal bowl. The flap is sutured to the distal antihelix with 3-0 polydioxanone at the upper, middle, and third portions of the distal antihelix. By using two different surgical planes at the proximal and distal aspects of the incision, the author deliberately approximates two live tissues (perichondrium to perichondrium) while anchoring the flap to distal antihelix border. By leaving the perichondrium on the antihelix surface, the author aims to improve healing and eliminate the risk of cartilage damage when suturing the flap. Subcuticular 4-0 Polydioxanone sutures are used to close the skin. Saline laden gauze are applied for 24 hours followed by an elastic wrap worn continuously for 2 days to control edema and then for one week at bedtime. The schematic demonstration of the technique is seen Figure 7. Figure 7. View largeDownload slide Proximally based dermo-fascio-perichondrial flap. Figure 7. View largeDownload slide Proximally based dermo-fascio-perichondrial flap. DISCUSSION Firstly, all attention is given to chonca-mastoid angle in a prominent ear, however there are 3 important angles; chonca-mastoid, scapha-choncal, and scapha-mastoid angle. Generally, distal based flaps use one flap to change these three angles. In frontal view, the helical rim should be seen lateral to the lateral most exposure of the antihelix, but distal based flaps tend to be hide the helical rim which is an unfavorable result in otoplasty. On the other hand, proximal based flaps play only with the scapha-choncal angle, which is why it does not cause a hidden helical rim and gives an opportunity to the surgeon for changing angles one by one separately. When employing postauricular fascial flaps in otoplasty, it remains controversial whether the perichondrium should be included in the flap. Perichondrium is composed of an outer vascular layer that serves as the primary vascular supply to the auricular cartilage19 and consequently plays an important role not only in flap strength26 but also in flap viability27 and cartilage healing as well known. Inner cellular layer of perichondrium that merges with the cartilage matrix contains chondroblast stem cells which are primarily responsible from neocartilage formation.28 So, theoretically, including perichondrium in the flap should provide vascularity and regenerative properties which are essential to flap growth and healing. Both Horlock12 and Mandal13 created fascial flaps without perichondrium. Although it is unclear, based on the technical description of their procedures, the author believes that Schaverien14 and Sinha15 also did not include the perichondrium in their flaps. When elevating the delicate perichondrium, the surgeon should see it clearly as a separate layer distinct from glossy cartilage tissue with overlying arterioles (Figure 8). Figure 8. View largeDownload slide (A) This is an intraoperative photograph of a 23-year-old woman who underwent prominent ear surgery with the proximally based dermofasciaperichondrial flap technique. The elevation of the perichondrium is a hard step and needs effort. The elevated flap with perichondrium is a robust, dense, and thicker flap, the cartilage which its perichondrium is elevated appear as clear white as (B) the perichondrium is seen clearly as a separate layer distinct from glossy cartilage tissue. Figure 8. View largeDownload slide (A) This is an intraoperative photograph of a 23-year-old woman who underwent prominent ear surgery with the proximally based dermofasciaperichondrial flap technique. The elevation of the perichondrium is a hard step and needs effort. The elevated flap with perichondrium is a robust, dense, and thicker flap, the cartilage which its perichondrium is elevated appear as clear white as (B) the perichondrium is seen clearly as a separate layer distinct from glossy cartilage tissue. Horlock,12 Mandal,13 Schaverien,14 and Sinha15 all employ postauricular flaps as an adjunct to the Mustarde technique to avoid suture extrusion and decrease recurrence rate (Table 2). Fascial flaps can also be used alone, without Mustarde sutures, but that necessitates a reliable flap. As discussed above, including both perichondrium and fascia in the flap creates a more robust flap as it not only adds strength, but decreases the elasticity of the loose dermofascial tissue. On the other hand, perichondrium elevation causes more fragile cartilages which needs pure attention while inserting sutures (Mustarde and Furnas) to avoid possible cartilage ruptures and shape deformities. Thereby, for a perichondrial flap combination with a suture technique it seems sense to tie and leave the knot in perichondrial areas instead of naked cartilages. Moreover, suturing two vascular tissues to each other, flap healing and neocartilage formation may be enhanced.22,26 Table 2. Fascial Flap Techniques in the Literature and Their Complication Rates Technique Technical detail Authors Patient no. Recurrence (%) Suture extension (%) Proximally based techniques Postauricular fascial flap + Mustarde Horlock et al 51 8.9 0 + Mustarde Mandal et al 41 4.9 7.3 + Mustarde Sinha et al 227 3.7 2.64 + Mustarde Schaverien et al 60 4.5 5.4 Proximally based dermo- fascio-perichondrial flap No Mustarde Taş et al 24 0 0 Distally based techniques Distally based fascial flap +/- Mustarde Shokrollahi et al 15 NA 0 Triangular fascioperichondrial flap +/- Mustarde +/- cartilage invasive Frascino et al 82 7.5 4.34 Distally based perichondrio- adipo-dermal flap + Mustarde +/- cartilage invasive Cihandide et al 13 5 0 Bilateral based techniques Bilateral fascioperochondrial flap + Mustarde Irkoren et al 100 1.5 0 Technique Technical detail Authors Patient no. Recurrence (%) Suture extension (%) Proximally based techniques Postauricular fascial flap + Mustarde Horlock et al 51 8.9 0 + Mustarde Mandal et al 41 4.9 7.3 + Mustarde Sinha et al 227 3.7 2.64 + Mustarde Schaverien et al 60 4.5 5.4 Proximally based dermo- fascio-perichondrial flap No Mustarde Taş et al 24 0 0 Distally based techniques Distally based fascial flap +/- Mustarde Shokrollahi et al 15 NA 0 Triangular fascioperichondrial flap +/- Mustarde +/- cartilage invasive Frascino et al 82 7.5 4.34 Distally based perichondrio- adipo-dermal flap + Mustarde +/- cartilage invasive Cihandide et al 13 5 0 Bilateral based techniques Bilateral fascioperochondrial flap + Mustarde Irkoren et al 100 1.5 0 View Large Table 2. Fascial Flap Techniques in the Literature and Their Complication Rates Technique Technical detail Authors Patient no. Recurrence (%) Suture extension (%) Proximally based techniques Postauricular fascial flap + Mustarde Horlock et al 51 8.9 0 + Mustarde Mandal et al 41 4.9 7.3 + Mustarde Sinha et al 227 3.7 2.64 + Mustarde Schaverien et al 60 4.5 5.4 Proximally based dermo- fascio-perichondrial flap No Mustarde Taş et al 24 0 0 Distally based techniques Distally based fascial flap +/- Mustarde Shokrollahi et al 15 NA 0 Triangular fascioperichondrial flap +/- Mustarde +/- cartilage invasive Frascino et al 82 7.5 4.34 Distally based perichondrio- adipo-dermal flap + Mustarde +/- cartilage invasive Cihandide et al 13 5 0 Bilateral based techniques Bilateral fascioperochondrial flap + Mustarde Irkoren et al 100 1.5 0 Technique Technical detail Authors Patient no. Recurrence (%) Suture extension (%) Proximally based techniques Postauricular fascial flap + Mustarde Horlock et al 51 8.9 0 + Mustarde Mandal et al 41 4.9 7.3 + Mustarde Sinha et al 227 3.7 2.64 + Mustarde Schaverien et al 60 4.5 5.4 Proximally based dermo- fascio-perichondrial flap No Mustarde Taş et al 24 0 0 Distally based techniques Distally based fascial flap +/- Mustarde Shokrollahi et al 15 NA 0 Triangular fascioperichondrial flap +/- Mustarde +/- cartilage invasive Frascino et al 82 7.5 4.34 Distally based perichondrio- adipo-dermal flap + Mustarde +/- cartilage invasive Cihandide et al 13 5 0 Bilateral based techniques Bilateral fascioperochondrial flap + Mustarde Irkoren et al 100 1.5 0 View Large Creating a robust flap, decreasing overall tension load on the flap is also an important consideration in prominent ear correction as it implies decreased recurrence. To decrease tension on the flap, the flap should be employed in antihelix construction alone and remains unburdened by tension associated with decreasing the conchamastoid angle. The conchamastoid angle can easily be addressed by Furnas sutures which are associated with decreased risk of extrusion and improved aesthetics due to their deep location. Although, scoring cartilage techniques were commonly used in the literature and can resolve the recurrence problems related to cartilage elasticity, complications can be devastating and hard to fix. When cartilage tear occurs, hard revision procedures are required. Given successful appliance of multiple different flap and suturing techniques with low recurrence and complication rates in the recent literature, cartilage sparing techniques seem more favorable. The author believes that there is no single technique that applies to all patients. Because of there are over 200 otoplasty procedures, prominent ear deformity has a lot of subdeformities, but in the literature there are attempts to solve all deformities of the ear with just one technique and this approach causes recurrence and dissatisfaction and numerous nonconsensus techniques. The existing deformity in the prominent ear should be diagnosed in each patient separately and appropriate interventions should be planned. In the senior author’s (S.T.) clinical practice, the dermo-fascio-perichondrial flap is usually used to create a new antihelical fold. Furnas sutures are used to correct the conchamastoid angle. Postauricular muscle is divided only if additional space is needed to place Furnas sutures. An elliptical conchal cartilage excision is employed for patients with conchal hypertrophy. Incision techniques are used to overpower the resistance cartilages. For patients with a coexisting prominent ear lobe deformity, absorbable mattress sutures are used to approximate ear lobe dermis to conchal cartilage, the excision of the Darwin tubercles could be planned if needed or total reduction of the ear may be planned if there is macrotia. CONCLUSION The correction of prominent ear deformity remains challenging with no clear consensus about the optimal technique for repair. The heterogeneity and lack of standardization in otoplasty reflects its complex nature and the ever dynamic field of medicine. The repair of prominent ear deformity has evolved tremendously over the last two decades to favor flap reconstruction. Regardless of the technique employed, absolute understanding of the auricular anatomy and surgeon experience correlate with better outcomes. The field continues to evolve and the flap techniques are currently used as a very helpful adjunct in otoplasty. The author believes that it seems potentially be an essential part of future prominent ear repair techniques. Disclosures The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The author received no financial support for the research, authorship, and publication of this article. Acknowledgements The author thanks Dr Salih Colakoglu and Dr. Lindsey Gade for their valuable contributions in drawings and language editing. REFERENCES 1. Naumann A . Otoplasty - techniques, characteristics and risks . GMS Curr Top Otorhinolaryngol Head Neck Surg . 2007 ; 6 : Doc04 . Google Scholar PubMed 2. Converse JM , Wood-Smith D . Technical details in the surgical correction of the lop ear deformity . Plast Reconstr Surg . 1963 ; 31 : 118 - 128 . Google Scholar CrossRef Search ADS PubMed 3. Becker OJ . Surgical correction of the abnormally protruding ear . Arch Otolaryngol . 1949 ; 50 ( 5 ): 541 - 560 , illust. 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Aesthetic Surgery Journal – Oxford University Press
Published: Feb 27, 2018
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