Otoplasty, from Ancient Greek οὖς (oûs), meaning "ear", and πλαστός (plastós), meaning "moulded", is a procedure for correcting the deformities and defects of the auricle (external ear), whether these defects are congenital conditions (e.g. microtia, anotia, etc.) or caused by trauma.Onions CT, editor (1996) The Oxford Dictionary of English Etymology. Oxford University Press p. 635. Otoplastic surgeons may reshape, move, or augment the cartilaginous support framework of the auricle to correct these defects.
Congenital ear deformities occasionally overlap with other medical conditions (e.g. Treacher Collins syndrome and hemifacial microsomia).
History
Antiquity Otoplasty (surgery of the ear) was developed in ancient India and is described in the medical compendium, the (Sushruta's Compendium, ). The book discussed otoplastic and other plastic surgery techniques and procedures for correcting, repairing and reconstructing ears, noses, lips, and genitalia that were amputated as criminal, religious, and military punishments. The ancient Indian medical knowledge and plastic surgery techniques of the were practiced throughout Asia until the late 18th century; the October 1794 issue of the contemporary British Gentleman's Magazine reported the practice of rhinoplasty, as described in the . Moreover, two centuries later, contemporary practices of otoplastic praxis were derived from the techniques and procedures developed and established in antiquity by Sushruta.
19th century In (Operational Surgery, 1845), Johann Friedrich Dieffenbach (1794–1847) reported the first surgical approach for the correction of prominent ears — a combination otoplasty procedure that featured the simple excision (cutting) of the problematic excess cartilage from the posterior sulcus (back groove) of the ear, and the subsequent affixing, with sutures, of the corrected auricle to the mastoid periosteum, the membrane covering the mastoid process at the underside of the mastoid portion of the temporal bone, at the back of the head. cited by
20th and 21st centuries In 1920, Harold D. Gillies (1882–1960) first reproduced the auricle by burying an external-ear support framework, made of autologous rib cartilage, under the skin of the mastoid region of the head, which reconstructed the auricle; he then separated this from the skin of the mastoid area by means of a cervical flap. In 1937, Dr. Gillies also attempted a similar pediatric ear reconstruction with an auricle support framework fabricated from maternal cartilage. This otoplasty correction technique proved inadequate, due to the problems inherent to the biochemical breakdown and elimination (resorption) of the cartilage tissue by the patient's body.
In 1964, Radford C. Tanzer (1921–2004) re-emphasized the use of autologous cartilage as the most advantageously reliable organic material for resolving microtia (abnormally small ears), because of its great histologic viability, resistance to shrinkage, and resistance to softening, and lower incidence of resorption.
The development of plastic surgery procedures, such as the refinement of J.F. Dieffenbach's ear surgery techniques, has established more than 170 otoplasty procedures for correcting prominent ears, and for correcting defects and deformities of the auricle; as such, otoplasty corrections are in three surgical-technique groups: Group I - Techniques that leave intact the cartilage support-framework of the ear, and reconfigure the distance and the angle of projection of the auricle from the head, solely by means of sutures, as in the permanent suture-insertion of the Mustardé technique the Merck stitch methodMerck, W.H. (2013). "Dr Merck's stitch method. A closed minimally invasive procedure for correction of protruding ears (Die Fadenmethode nach Dr. Merck. Ein geschlossenes, minimal-invasives Verfahren zur Anlegung abstehender Ohren)." J Aesthet Chir, 6, 209-220. and the incisionless Fritsch otoplastyFritsch, M.H. (1995). "Incisionless Otoplasty". Laryngoscope. 105, 1-11.Fritsch, M.H. (2009) "Incisionless Otoplasty". Otolaryngologic Clinics of North America |volume=42 |issue=6 |pages=1199–208,Fritsch, M.H. (2004). "Incisionless Otoplasty". Facial Plastic Surgery 20, 267–70 for creating an anti helical fold: Mustardé technique: An open invasive method, whereby the retroauricular cartilage is extensively exposed, a part of the skin is excised, and mattress sutures are inserted. Merck stitch method: a minimally invasive method, by which the ear is no longer cut open and the cartilage is left completely intact. The mattress sutures are inserted in the ear through 2 to 3 small stab incisions on the back of the ear. Incisionless Fritsch otoplasty: It is a combination of the minimally invasive technique and the Stenström technique, whereby the cartilage on the front of the ear is scored with superficial incisions. Group II — Techniques that resect (cut and remove) the pertinent excess cartilage from the support-framework of the auricle, which then render it pliable to being re-molded, reconfigured, and affixed to the head at the projection distance-and-angle characteristic of a normal ear; the relevant procedures are the cartilage-incision Converse technique and the Chongchet–Stenström technique for the anterior-correction of prominent ears. Group III — Techniques that combine the excision of cartilage portions from the support framework of the auricle, in order to reduce the degree of projection and the distance of the external ear from the head.
Surgical anatomy of the external ear
The auricle The external ear (auricle) is a surgically challenging area in terms of anatomy, composed of a delicate and complex framework of shaped cartilage that is covered, on its visible surface, with thin, tightly adherent, hairless skin. Although of small area, the surface anatomy of the external ear is complex, consisting of the auricle and the external auditory meatus (auditory canal). The outer framework of the auricle is composed of the rim of the helix, which arises from the front and from below (anteriorly and inferiorly), from a crus (shank) that extends horizontally above the auditory canal. The helix merges downwards (inferiorly) into the cauda helices (tail of the helix), and connects to the lobule (earlobe). The region located between the crura (shanks) of the antihelix is the triangular fossa (depression), while the scapha (elongated depression) lies between the helix and antihelix. The antihelix borders in the middle (medially) to the rim of the concha (shell) and the concha proper, which is composed of the conchal cymba above (superiorly) and the conchal cavum below (inferiorly), which are separated by the helical crus, and meet the antihelix at the antihelical rim. The tragus (auditory canal lobule) and the antitragus (counterpart lobule) are separated by the intertragal notch; the auditory canal lobule does not contain cartilage, and displays varied morphologic shapes and attachments to the adjacent cheek and scalp.
Blood supply and innervation The superficial temporal and posterior auricular arteries preserve the arterial blood supply of the external ear. The sensory innervation involves the front and back (anterior and posterior) branches of the greater auricular nerve, and is reinforced by the auricular temporal and lesser occipital nerves. The auricular branch of the vagus nerves supplies a portion of the posterior wall of the external auditory canal.
Otoplastic praxis The support framework of the reconstructed auricle must be more rigid than the natural cartilage framework of a normal ear, in order for it to remain of natural size, proportion, and contour. If the reconstructed auricle framework were as structurally delicate as the cartilage framework of a natural auricle, its anatomic verisimilitude as an ear would gradually be eroded by a combination of the pressure of the tight skin-envelope in the temporal region of the head, and of the pressure of the progressive contracture of the surgical scar(s).
Prominent ears In the practice of otoplasty, the term "prominent ears" describes external ears (auricles) that, regardless of their size, protrude from the sides of the head. The abnormal appearance exceeds the normal head-to-ear measures, wherein the external ear is less than , and at an angle of less than 25 degrees, from the side of the head. Ear configurations, of distance and angle, that exceed the normal measures, appear prominent when the man or the woman is viewed from either the front or the back perspective. In the occurrence of prominent ears, the common causes of anatomic defect, deformity, and abnormality can occur individually or in combination; they are:
Underdeveloped antihelical foldThis anatomic deformity occurs consequent to the inadequate folding of the antihelix, which causes the protrusion of the scapha and the helical rim. The defect is manifested by the prominence of the scapha (the elongated depression separating the helix and the antihelix) and the upper-third of the ear; and occasionally of the middle third of the ear. Prominent conchaThis deformity is caused either by an excessively deep concha, or by an excessively wide concha-mastoid angle (<25 degrees). These two anatomic abnormalities can occur in combination, and produce a prominent concha (the largest, deepest concavity of the auricle), which then causes the prominence of the middle third of the external ear. Protruding earlobeThis defect of the earlobe causes the prominence of the lower third of the auricle.
Although most prominent ears are anatomically normal, morphologic defects, deformities, and abnormalities do occur, such as the: Constricted ear which features an abnormally small auricle, and protrudes from the head because of the inadequate development of the circumference of the helical rim, which, in turn, causes the auricle to collapse forwards, and form a 'cup ear. Cryptotic ear which is hidden in the side of the head. The condition of a hidden ear is produced when the developed helix of the auricle is contained under the skin of the scalp in the temporal region. (see Cryptotia) Macrotic ear, a prominent external ear that features an oversized auricle, but is otherwise morphologically normal. (see Macrotia) Question mark ear describes the ear that features a deformity of the supralobular region (upper area of the auricle), and has the appearance of a question mark. Stahl's ear deformity describes the presence of a third crus (shank) in the auricle, which produces a pointed elfin ear. The third crus is additional to the two crura (shanks) of the normal triangular fossa (depression), which traverses the scapha (elongated depression separating the helix and the antihelix).
Angles of the ear
Cephaloauricular and scaphoconchal angles The degrees of angle between the head and the ear, and the degrees of angle between the scapha and the concha, determine the concept of prominent ears. The study, Comparing Cephaloauricular and Scaphaconchal Angles in Prominent Ear Patients and Control Subjects (2008) reported that the comparisons of the head-to-ear angles and the scapaha-to-concha angles of a 15-patient cohort with prominent ears, with the analogous ear angles of a 15-person control group, established that the average head-to-ear angle was 47.7 degrees for the study group, and 31.1 degrees for the control group; and that the average scapha-to-concha angle was 132.6 degrees for the study cohort, and 106.7 degrees for the control group.
Antihelix