AESTHETIC SURGERY

A New Way for Antihelixplasty in Prominent Ear Surgery Modified Postauricular Fascial Flap Su¨leyman Tas¸, MD, and Erol Benlier, MD Background: Otoplasty procedures aim to reduce the concha-mastoid angle and recreate the antihelical fold. Here, we explained the modified postauricular fascial f lap, described as a new way for recreating the antihelical fold, and reported the results of patients on whom this flap was used. Materials and Methods: The defined technique was used on 24 patients (10 females and 14 males; age, 6Y27 years; mean, 16.7 years) between June 2009 and July 2012, a total of 48 procedures in total (bilateral). Follow-up ranged from 1 to 3 years (mean, 1.5 years). At the preoperative and postoperative time points (1 and 12 months after surgery), all patients were measured for upper and middle helix-head distance and were photographed. The records were analyzed statistically using t test and analysis of variance. Results: The procedure resulted in ears that were natural in appearance without any significant visible evidence of surgery. The operations resulted in no complications except 1 patient who developed a small skin ulcer on the left ear because of band pressure. When we compared the preoperative and postoperative upper and middle helix-head distance, there was a high significance statistically. Conclusions: To introduce modified postauricular fascial f lap, we used a simple and safe procedure to recreate an antihelical fold. This procedure led to several benefits, including a natural-in-appearance antihelical fold, prevention of suture extrusion and granuloma, as well as minimized risk for recurrence due to neochondrogenesis. This method may be used as a standard procedure for treating prominent ears surgically. Key Words: antihelix, flap, otoplasty, prominent ear (Ann Plast Surg 2016;76: 615Y621)

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rominent ears are the most common congenital ear deformity, with approximately 5% incidence in whites; this population inherited an autosomal dominant pattern because of the coinciding occurrence of one or both of the following deformities: antihelix hypoplasia (more common) and concha hypertrophy. Antihelix hypoplasia, which is associated with an unformed or incomplete antihelical fold, occurs in combination with an increasing helix-mastoid angle, a flattening of the fossa triangularis and the scapha, as well as a ventral protrusion of the helix in the upper and/or middle region.1 According to the literature, several techniques may be used to recreate an antihelical fold in a prominent ear. These techniques are separated into 3 groups: cartilage invasive, cartilage sparing, and combination.1 The most widely accepted cartilage-invasive techniques include incision-suture as described by Converse and Wood-Smith2 Received April 8, 2014, and accepted for publication, after revision, June 6, 2014. From the Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Trakya University, Edirne, Turkey. Conflicts of interest and sources of funding: The authors declare that they have no conflicts of interest, commercial associations, or intent of financial gain regarding this research. Reprints: Su¨leyman Tas¸ MD, Department of Plastic, Reconstructive and Aesthetic Surgery, Trakya University Medicine Faculty, Balkan Campus, Edirne 22030, Turkey. E-mail: [email protected]. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.annalsplasticsurgery.com). Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7606-0615 DOI: 10.1097/SAP.0000000000000309

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as well as Becker,3 incision-scoring as described by Crikelair and Cosman4 as well as Chongchet,5 closed anterior scoring with a rasp as described by Stenstro¨m and Heftner,6 posterior cartilage thinning with a drill and fixation with absorbable sutures as described by Weerda,7 cartilage excision by cartilage incision as described by Walter,8 as well as cartilage island as described by Pitanguy et al.9 The main problems of this group are hematoma, shape irregularity, and necrosis.1 Thus, cartilage-sparing techniques became more popular than cartilage-invasive techniques.1,10Y12 The most popular cartilagesparing techniques are suture techniques as described by Mustarde.10 However, the recurrence rates for cartilage-sparing procedures have been reported to be higher than those for cartilage-invasive procedures.1,10Y12 Furthermore, the nonabsorbable stitches used in cartilage-sparing techniques are linked to suture extrusion, pain, and discomfort.13Y16 Recently, Horlock et al13 described the postauricular fascial flap that covers over the knots of Mustarde sutures and creates an adjunct factor for decreasing the recurrence and suture extrusion rate. However, the reported recurrence rate changes from 3.7% to 8.9% and the suture extrusion rate changes from 0% to 7.3%.13Y16 The objectives of this article were to explain the modified postauricular fascial f lap (MPFF), which was used alone for recreating the antihelical fold, to report the results of patients on whom this technique was used, and to review the literature.

MATERIALS AND METHODS Between June 2009 and July 2012, a total of 24 patients (10 females and 14 males) underwent a bilateral operation, using the defined technique (48 procedures total) consecutively by the same surgeon (S.T.). At the time of surgery, patient age ranged from 6 to 27 years (mean age, 16.7 years). Two patients (6 and 7 years old) underwent operations under general anesthesia; the remaining 22 patients received local anesthesia. At the preoperative and postoperative time points (1 and 12 months after surgery), all patients were measured for upper helix-, middle helix-, and lobule-head distance and were photographed from frontal, lateral, oblique, dorsal, and base perspectives. The results were analyzed using the SPSS 11.0 (SPSS, Chicago, Ill). Continuous variables were expressed as mean (SD) and compared between the groups using t test. The differences were compared using analysis of variance, and P G 0.05 was considered significant. A prophylactic antibiotic protocol was used, which included a dose of cefazolin 30 minutes before surgery. The patients who underwent local anesthesia were discharged on the same day, and the patients who underwent general anesthesia were discharged the following day.

Surgical Techniques The key maneuvers in the use of MPFF are demonstrated in the video, Supplemental Digital Content, http://links.lww.com/SAP/A118.

Marking the New Antihelix and Flap Design The desired antihelix fold was determined by holding the pavilion in an anterior position with the fingers. To mark the distal and proximal borders of the new antihelical fold, we inserted a 27-gauge needle with the tip stained with methylene blue through the anterior surface on each side of the new fold, which enabled us to mark the www.annalsplasticsurgery.com

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posterior portion of the fold at each of the 3 levels (upper, middle, and lower parts of the antihelix). Two parallel-marked lines were derived from 6 points. Thus, while the flap was elevated, the proximal border of the flap (terminal dissection line, proximal border of the new antihelix) and the location of suture insertion in the cartilage (distal border of the new antihelix) were examined for methylene blue stain. The distal border of the flap was determined by measuring the horizontal width of the new antihelix and was established by the pinch test (representation of the new antihelix between the thumb and the indicator finger) in the 3 levels (Figs. 1AYC).

De-epithelialization, Dissection of Postauricle, and Flap Elevation The planned crescentic skin excision was performed as thinly as possible to protect f lap circulation (Fig. 2A). A scalpel was used to make the distal incision. Dissection was continued laterally on the supraperichondrial plane until the distal border of the new antihelix (Fig. 2B). The f lap was separated from the proximal skin, and scissors were used to move the postauricle skin into the mastoid fascia on the subcutaneous plane (Fig. 2C). Vessels are usually seen within the f lap, and the edges bleed, showing good vascular supply (Fig. 2D). The scalpel was used to make an incision along the distal border of the f lap, and the f lap was released on the subperichondrial plane and elevated until the proximal border of the new antihelix (Figs. 3A, B).

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If a conchal hypertrophy was detected, the elliptic conchal cartilage excision was performed (n = 3, 12.5%). If the concha-mastoid angle was greater than 30 degrees, the conchal-mastoid suture was performed between the conchal cartilage and the mastoid fascia, as described by Furnas17 (n = 8, 33.3%).

Recreation of the Antihelical Fold Starting at the top points marked with methylene blue previously, the sutures of polydioxanone 3/0 were inserted at the corresponding markings via retroauricular access through the auricular cartilage and the perichondrium without penetrating the ventral skin. Next, the sutures were passed from the distal part of the f lap, which was used as a mattress, and left untied. After the sutures were inserted at the other corresponding set of markings, the thread was tied (Fig. 4). The knots of the mattress sutures were fastened below the f lap to prevent suture extrusion afterward. The distal portion of the f lap was stitched with a running suture of Monocryl 5/0 to cover the knots safely, and other final adjustments were performed. The incision was closed with a running suture of Prolene 5/0. A saline-soaked piece of cotton was placed in all anterior cervices of the ear, and a dressing was applied with mild pressure and drained for 24 hours. Next, the dressings were removed, and an athletic headband was worn continuously for 2 weeks. The skin sutures were removed 10 days after the operation.

FIGURE 1. A, While the new antihelix was positioned between the thumb and indicator fingers, the horizontal width of the new antihelix was measured on the 3 levels. Distal border of the new antihelix (A), proximal border of the new antihelix (B), and width of the new antihelix on the sagittal plane (a). B, The methylene blue stains on the cephalic plane were used to identify the proximal border of the f lap. The width of the new antihelix identified the distal border of the f lap. The point where the suture was passed from the cartilage (A), the f lap dissection termination point (B), and the point where the suture was passed from the f lap (C). C, The image was obtained after the f lap was drawn. 616

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Modified Postauricular Fascial Flap

FIGURE 2. A, The image was obtained after de-epithelialization. B, Distal dissection was completed by exposure of the distal antihelix borderline, which was stained as 3 points with methylene blue. C, Dissection was continued cephalically with scissors on the subdermal plane until the mastoid fascia was reached. D, The image reveals the vascular network that supplies blood to the f lap.

Summary of Modification 1. Incisions and f lap are set on the posterior of the new antihelix, whereas in the original description, the incisions and f lap are set near the postauricular sulcus. 2. The planned crescentic skin excision is performed as de-epithelialization, whereas in the original description, epidermis and dermis are excised. Thus, a thicker flap is gained. 3. The flap is elevated until the proximal border of the new antihelix instead of the mastoid fascia. Exposure of the mastoid area is done through the subcutaneous plane. Thus, an antihelical fold can be created without Mustarde sutures (Figs. 5A, B).

RESULTS Follow-up ranged from 1 to 3 years (mean, 1.5 years). The procedure resulted in ears that were natural in appearance without any

significant visible evidence of surgery. By using the MPFF, a naturallooking antihelical fold with a rounded profile that lacked sharp edges was achieved, and the intraoperative ear position was maintained at a desirable distance (Figs. 6Y9). Complications, such as bleeding, hematoma, skin necrosis, wound dehiscence or infection, suture extrusion or granuloma, recurrence of deformity, asymmetry, or unsatisfactory results, did not occur, with the exception of 1 patient. Seven days after surgery, a small skin ulcer was observed on this patient’s left ear due to band pressure. The ulcer healed within 2 to 3 days (Fig. 10). No scarring was observed; the posterior scar was inconspicuous (Fig. 11). All patients and the surgeon were satisfied with the results. Measurements for upper and middle helix-head distance were summarized in Table 1. The mean (SD) upper helix-head distance was 25.38 (3.923) mm (range, 18Y34 mm) preoperatively, 10.63 (0.866) mm (range, 10Y13 mm) 1 month postoperatively (P G 0.0001),

FIGURE 3. The f lap was released on the subperichondrial plane by elevation until the border of the proximal antihelix, stained as 3 points with methylene blue, was exposed. The image was obtained after f lap elevation from the anterior aspect (A) and from the posterior aspect (B). * 2014 Wolters Kluwer Health, Inc. All rights reserved.

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FIGURE 4. After the sutures were inserted in the other set of corresponding markings, the knots of the mattress sutures were fastened below the f lap to prevent suture extrusion afterward.

and 11.42 (1.007) mm (range, 10Y14 mm) 12 months postoperatively (P G 0.0001). The mean (SD) middle helix-head distance was 29.71 (3.307) mm preoperatively, 16.04 (0.898) mm 1 month postoperatively (P G 0.0001), and 17.33 (0.996) mm 12 months postoperatively

FIGURE 6. Preoperative views are shown from front (A) and lateral (B) perspectives. Postoperative views are shown at 18 months from front (C) and lateral (D) perspectives.

(P G 0.0001). In addition, the difference between measurements 1 month postoperatively and 12 months postoperatively was statistically significant (P G 0.0001).

DISCUSSION Several f laps from the posterior surface of the ear were described for auricle reconstruction. Shokrollahi et al11 used the distally based fascial f lap without perichondrium adjunctively to reinforce suture-based techniques in a series of 15 patients. However, the fascia

FIGURE 5. A schematic of the f lap dissection plane is shown. A, The original description of postauricular fascial f lap by Horlock et al. B, The MPFF. 618

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FIGURE 7. Preoperative views are shown from front (A) and lateral (B) perspectives. Postoperative views are shown at 12 months from front (C) and lateral (D) perspectives. * 2014 Wolters Kluwer Health, Inc. All rights reserved.

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Modified Postauricular Fascial Flap

FIGURE 10. Seven days after the operation, a small skin ulcer was visible on the left ear because of band pressure. The ulcer healed within 2 to 3 days.

FIGURE 8. Preoperative views are shown from front (A) and lateral (B) perspectives. Postoperative views are shown at 15 months from front (C) and lateral (D) perspectives.

is a loose connective tissue, with a distally based fascial f lap alone, and the recurrence rates in suture-based techniques could not be reduced. Concurrently correcting the upper pole is harder in this technique, and it has a potential risk to obliterate the postauricular sulcus. Frascino18 demonstrated in 82 patients that replacing Mustarde sutures and using a triangular fascioperichondrial flap from the posterior auricular surface would prove to be an effective fixation method

FIGURE 9. Preoperative views are shown from front (A) and lateral (B) perspectives. Postoperative views are shown at 13 months from front (C) and lateral (D) perspectives. * 2014 Wolters Kluwer Health, Inc. All rights reserved.

recreating the antihelix. In this study, medialization of the upper pole of the f lap was possible, but the Mustarde mattress sutures were required for the middle and lower poles. Moreover, the described f lap could not be used in combination with anterior or closed approach techniques or in cases that required treatment in which the base was fixed. The leading cause of reoperation reportedly was the excessive loss of medialization of the upper pole, with a rate of 7.5% and a hypertrophy scar rate of 1.8%.18 Furthermore, despite the use of nonabsorbable suture materials, the author did not report any suture extrusion. After postauricular fascial flap was described by Horlock et al,13 it was progressively popularized because of the decrease in complications of the Mustarde technique such as pain, extrusion, and recurrence. This study of 51 patients (101 ears) reported that the suture extrusion rate decreased (0%) but the recurrence rate did not change significantly (8.9%). In the following reports, with the same technique, Mandal et al14 reported a 7.3% suture extrusion rate and a 4.9% recurrence rate in their study of 41 patients (82 ears); Sinha and Richard15 reported a 2.64% suture extrusion rate and a 3.7% recurrence rate in 227 patients (435 ears); and Schaverien et al16 reported a 4.5% recurrence rate and a 5.4% rate of suture complications in 60 patients (112 ears). However,

FIGURE 11. The posterior scar was inconspicuous. www.annalsplasticsurgery.com

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TABLE 1. Measurements for Upper and Middle Helix-Head Distance Upper helix-head distance Middle helix-head distance

Before Surgery

1 mo After Surgery

12 mo After Surgery

P

25.38 (3.923) 29.71 (3.307)

10.63 (0.866) 16.04 (0.898)

11.42 (1.007) 17.33 (0.996)

G0.0001 G0.0001

it is an additional step to the Mustarde technique, and until today, it was used always as an adjunct method to the Mustarde technique. Second, the recurrence rate for this flap is variable because, after postauricular f lap elevation, inserting Mustarde sutures is hard and may cause tearing of cartilage due to postauricular perichondrium elevation. All these problems highlight the need for improving this technique to achieve perfection. The posterior skin of the ear differs from the adherent anterior skin and can be conveniently moved by adjusting the loose connective tissue between the skin and the perichondrium. In isolation, the posterior skin of the ear exists as a fascial layer; it contains blood vessels, nerves, perichondrium, and fibrofatty tissue.19 Thus, the described f lap can be considered a dermofascial f lap. Histological examination of that region has revealed a rich vascular network.19 This flap is feasible because of the anatomical basis of the vascular network. In the normal mature ear, upper helix-head distance is 10 to 12 mm and middle helix-head distance is 16 to 18 mm.20 In our study, the procedures resulted in ears that were natural and goodlooking in appearance. There was a significant difference between the measurement of preoperative and postoperative helix-head distance for both upper and middle. In addition, the difference between measurements 1 month postoperatively and 12 months postoperatively was significant, but at 12 months postoperatively, the upper and middle helix-head distances were in the range of 10 to 14 mm and 16 to 20 mm, respectively. Although the ears were desirable and natural-looking in appearance, the statistical analyses show us that an overcorrection is needed, as in all otoplasty techniques. In addition, this technique has a learning curve, as in all new procedures, and Schaverien et al16 reported a 46% loss of medialization of 1 mm or more in their series of 60 cases of posterior suturing with postauricular fascial flap. This modified technique is based on wound healing and scar formation concepts. The cartilaginous frame memory is a key point for the successful correction of prominent ears.21 One advantage of this technique is the tension that occurs when the auricle setback dissolves along the entire flap instead of the 3 sutures as in the Mustarde technique. Thus, the mechanical force applied to the flap by the cartilage frame is minimized, and optimal immobilization and adequate balance are achieved. Cagici et al22 studied the effects of different suture materials on the reshaping of cartilage in rabbits and reported that the effectiveness of long-lasting absorbable suture materials is as effective as that of nonabsorbable sutures. The MPFF technique prevents the suture extrusion, pain, and discomfort associated with buried stitches by using long absorbable suture materials and tying the knots below the f lap. Bending of the f lap is prevented because the f lap includes the perichondrium, and the perichondrium is an inelastic tissue. In addition, the authors consider that scar formation between different tissue layers could prevent recurrence. Scar formation occurred at 3 different levels: (a) between cartilage and the dermofascial f lap, (b) between the f lap and the perichondrium of the distal antihelix, as well as (c) between the f lap and associated subcutaneous tissue. Another adjunct factor for reparation is neochondrogenesis, which occurred after the dissection of the perichondrium, which generated a new and definitive state with natural tension that lasted until the injured surface was regenerated completely. In the elevation seen 620

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in the result of cranial magnetic resonance imaging due to another medical reason of 1 patient, who underwent bilateral otoplasty with MPFF technique 4 months before (Fig. 12), we observed that the elevated perichondrium fully coaptated to the new place in cartilaginous surface, thickening perichondrium is seen in the same density of cartilage, and connective tissue support is demonstrated under the perichondrium. The mattress sutures in the Mustarde technique do not promote true coaptation of the cartilaginous surfaces but instead brought the surfaces closer to one another.17 In the MPFF technique, 2 raw surfaces are accreted definitively and provide greater efficacy for long-term fixation. The MPFF, which is used to recreate a new antihelical fold, is not disrupted to correct the other deformities in the ear, and, if necessary, it can be combined with conchal setback procedures, conchal excision, and lobuloplasty. Here, we introduced the MPFFVa simple and safe procedure for recreating the antihelical fold. The benefits of this procedure include a resultant antihelical fold that appears natural, the prevention of suture extrusion and granuloma, as well as less tissue trauma due to the use of absorbable suture materials and making it possible to use it alone for creation of new antihelix. This technique both minimizes the risk for recurrence due to neochondrogenesis, which is stimulated by the elevated perichondrium, and can be used in combination with other techniques. This may become the standard procedure for surgically treating prominent ears. However, much larger case series are needed for further elevation.

FIGURE 12. At 4 months, cranial axial T1 magnetic resonance imaging shows a thickening perichondrium fully coaptated to the new place in the cartilage surface (yellow arrow) and connective tissue support under the perichondrium (red arrow). * 2014 Wolters Kluwer Health, Inc. All rights reserved.

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REFERENCES 1. Naumann A. OtoplastyVtechniques, characteristics and risks. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2007;6:Doc04. 2. Converse JM, Wood-Smith D. Technical details in the surgical correction of the lop ear deformity. Plast Reconstr Surg1963;31:118Y128. 3. Becker OJ. Surgical correction of the abnormally protruding ear. Arch Otolaryngol. 1949;50:541Y560. 4. Crikelair GF, Cosman B. Another solution for the problem of the prominent ear. Ann Surg. 1964;160:314Y324. 5. Chongchet V. A method of antihelix reconstruction. Br J PlastSurg. 1963;16: 268Y272. 6. Stenstrom SJ, Heftner J. The Stenstrom otoplasty. Clin Plast Surg. 1978;5:465Y470. 7. Weerda H. Remarks about otoplasty and avulsion of the auricle. Laryngorhinootologie. 1979;58:242Y251. 8. Walter C. Plastic surgery of protruding ears. HNO. 1998;46:193Y194. 9. Pitanguy I, Mu¨ller P, Piccolo N, et al.The treatment of prominent ears: a 25-year survey of the island technique. Aesthetic Plast Surg. 1987;11:87Y93. 10. Mustarde JC. The correction of prominent ears using simple mattress sutures. Br J Plast Surg. 1963;16:170Y178. 11. Shokrollahi K, Cooper MA, Hiew LY. A new strategy for otoplasty. J Plast Reconstr Aesthet Surg. 2009;62:774Y781. 12. Yugueros P, Friedland JA. Otoplasty: the experience of 100 consecutive patients. Plast Reconstr Surg. 2001;108:1045Y1051.

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Modified Postauricular Fascial Flap

13. Horlock N, Misra A, Gault DT. The postauricular fascial flap as an adjunct to Mustarde´ and Furnas type otoplasty. Plast Reconstr Surg. 2001;108: 1487Y1490. 14. Mandal A, Bahia H, Ahmad T, et al. Comparison of cartilage scoring and cartilage sparing otoplastyVa study of 203 cases. J Plast Reconstr Aesthet Surg. 2006;59:1170Y1176. 15. Sinha M, Richard B. Postauricular fascial flap and suture otoplasty: a prospective outcome study of 227 patients. J Plast Reconstr Aesthet Surg. 2012;65:367Y371. 16. Schaverien MV, Al-Busaidi S, Stewart KJ. Long-term results of posterior suturing with postauricular fascial flap otoplasty. J Plast Reconstr Aesthet Surg. 2010;63:1447Y1451. 17. Furnas DW. Otoplasty for prominent ears. Clin Plast Surg. 2002;29:273Y288. 18. Frascino LF. The use of a retroauricular fascioperichondrial flap in the recreation of the antihelical fold in prominent ear surgery. Ann Plast Surg. 2009;63: 536Y540. 19. Shokrollahi K, Taylor JP, Le Roux CM, et al. The postauricular fascia: classification, anatomy, and potential surgical applications. Ann Plast Surg. 2014;73:92Y97 20. Adamson JE, Horton CE, Crawford HH. The growth pattern of the external ear. Plast Reconstr Surg. 1965;36:466Y470. 21. Park C, Roh TS. Anatomy and embryology of the external ear and their clinical correlation. Clin Plast Surg. 2002;29:155Y174. 22. Cagici CA, Cakmak O, Bal N, et al. Effects of different suture materials on cartilage reshaping. Arch Facial Plast Surg. 2008;10:124Y129.

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A New Way for Antihelixplasty in Prominent Ear Surgery: Modified Postauricular Fascial Flap.

Otoplasty procedures aim to reduce the concha-mastoid angle and recreate the antihelical fold. Here, we explained the modified postauricular fascial f...
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