Rhinoplasty Dr Bashar Bizrah Article on: Related Facial Surgery Part 2: Prominent Ear Correction

In March 1881, a twelve year old boy was brought to Edward Talbot Ely (1850-1885), a young Otolaryngologist at the Manhattan Eye and Ear Hospital. The boy complained that his peers pulled his prominent ears. Using Ether as an anaesthetic, Ely excised a strip of cartilage and skin to permit the ear to lie close to the skull. The result pleased the boy and his mother, so a month later, Ely operated on the left ear. Although, many new techniques have emerged over the years, the author believes that Ely’s clever procedure, still offers the best long term results.

Prominent ears are present when the angle between the head and the auricle is greater than thirty five degrees. The malformations include the absence of the antihelix and an overdeveloped concha. It may be unilateral or bilateral. Prominent ears are best corrected in the year before starting school to minimize the psychological problems. (Fig. 18 – 5)

Surgical technique:

1. Premedication – general anaesthesia or local anesthesia.
2. Infiltration with posterior auricular surface with 1 % Xylocaine, adrenaline 1-200,000.
3. The auricle is pushed backward with the finger to aid contouring of the antihelix fold.
4. The outlined antihelix is marked by a pen. (Figs. 18 -1,22)
5. The ellipse of extra redundant skin is excised from the posterior surface of the auricle, with preservation of as much fat and connective tissue as possible, in order to hold the sutures which are applied later.
6. The shape and position of the antihelix is transferred to the posterior surface of the auricle with needles dipped in methyline blue. The dipped needle is pushed through the ear cartilage from the anterior surface of the auricle, at several points, along the marked antihelix, transferring the shape of the new antihelix to the posterior cartilage and connective tissue. (Fig. 18 – 2)
7. Using blade 11, the cartilage is now incised along the methyline blue points that have been marked out. A second incision is made parallel and one to two mm proximal to the first one.
8. The island of cartilage that has just been created along and proximal to the methyline blue points is now excised. (Cartilage Island Excision Technique – C.I.E.T. as described Ely’s). (Fig. 18 – 22)
9. The mattress 4/0 Dexon sutures are now applied, through the subcutaneous tissue that remains attached to the edge of the artilage, in order to approximate the excised edges of the cartilage. The mattress sutures will close the gap and create an antihelix.
   (Fig. 18 – 4)
10. The skin is closed using absorbable 4/0 Dexon mattress sutures.
11. Pressure bandage (not too tight) is applied for five days. Prophylactic oral antibiotics are given for one week, (Amoxycilline, Fucloxacilline).
12. Another modification of the Ely’s technique is the Cartilage Island preservation technique. The cartilage strip is not excised, it remains overlapping the cartilage suture line. The edges of the excised conchal cartilage around the island are undermined for one to two millimeters, in order to allow the overlapping of the cartilage strip when the mattress sutures are applied. The overlapped strip offers more natural appearance and minimizes the visible sharp edges, but it has a higher recurrence rate due to the stretching tension caused by the volume of the cartilage strip on the suture line. (Fig. 18 – 3)

Fig. 18 - 1. The auricle is pushed backward with the finger to aid contouring the antihelix. The outlined anthelix is marked.

Fig. 18 - 2. The shape and position of the antihelix is transferred to the posterior surface of the auricle with a needle dipped in methyline blue.

In the author’s experience of over 130 prominent ears corrections, he has found that the strip excision (Ely’s technique) offers the most satisfying results for both the patient and the surgeon. Other techniques of scoring, island of cartilage preservation and suture technique unfortunately, had a high recurrence rate, which the author later revised for the strip excision technique. Although the strip excision technique may leave a sharp antihelix, in the author’s experience, he has had no patients complain about sharp antihelix, but he has had many patients who asked to have their ears pinned back. The patients are more concerned with the approximation rather than the sharp edges which are not visible to them.

Technique applied	Total: 130	Success	Recurrence	Revision
Strip excision Ely’s	77	75	2	1
Scoring technique	15	8	7	5
Suture technique	17	9	8	6
Cartilage island preservation technique	21	15	6	4

Complications:

• Haematoma: Pain may indicate haematoma, infection or pressure necrosis. If pain persists, the dressing is removed and the ear is inspected. Haematoma is evacuated by removing one or two sutures, this is why a continuous subcuticular suture should not be used. Pressure dressing is re-applied.
• Infection: This may lead to perichondritis and later cauliflower deformity. Prophylactic antibiotics are recommended. If infection is present, intravenous antibiotics should be started immediately and swabs sent for culture and sensitivity. An abscess must be drained.
• Pressure necrosis: If the pressure bandage is applied too tightly, it may cause pressure necrosis ulcers or loss of cartilage. Pain is the warning sign, whenever the patient is complaining of pain, the dressing is removed and the auricle inspected for bluish discolouration (necr_osis), hematoma or infection.
• Unsatisfactory results will need to be revised.

Fig. 18 - 3. The Cartilage Island PreseNation technique: The cartilage strip is not excised. It remains to overlapping the suture line.

References

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