Goals/Purpose: The current techniques to treat prominent ear could be classified as “open” approaches. In these strategies a variable amount of retro-auricular skin is resected and the cartilaginous frame is molded. However, the drawback of these techniques is the complications, such as pathologic scar, hypertophic or even keloid, and high rates of recurrence.
The aim of this study is to demonstrate an alternative closed approach to treat prominent ear without skin resection, mostly in ethnic-skin patients. The entire procedure was performed through a small incision located at the external border of the helix at the junction of the superior crus of the antihelix (Fig.1).
Methods/Technique: The surgery was performed on 695 patients, 452 females and 243 males, included 689 bilateral and 6 unilateral cases (n=1,384 ears), mean age 18 years. The follow-up period ranged from six months to 12 years. Of the 76 patients had ethnic skin: 11 had black skin, 35 were mestizo skin, 9 asian oriental skin and 21 indian complexion.
The data were classified according the Egloff grading; Type 1- absence of antihelix and hypertrophic concha; Type 2: hypertrophic concha and normal anti-helix; Type 3: absence of anti-helix and normal concha; and Type 4: one of the above-mentioned types along with a divergent lobule. Type 1 was observed in almost 550 patients(79%).
TECHNIQUE- The ear was infiltrated with 0,5% xylocaine 1/800,000 epinephrine proportioning tumescence. The surgical access is a single 6 to 8mm incision located on the external border of the helix at the junction of the superior crura of the antihelix. The strategy was performed by anterior and posterior global undermining of the auricular skin over the antihelix and concha, associated with controlled anterior antihelix scratching. The anti-helical row framework was molded using trans-cutaneous buried Kayexs stitches. Reduction of the hypertrophic concha was achieved according the “conchal show” principles. An accessory small aperture was made at the posteroinferio part of the auricula, at the intertraginea incisure, to easy conchal trimming (Fig 2).
Results/Complications: A balanced external ear configuration was present in majority of the cases. A smooth antihelix surface was consistently achieved with few complications. COMPLICATIONS:The main abnormal event was sinus formation with stitches extrusion present in 21 patients (2,8%). Asymmetry in 26 patients (3,6%), hematoma in eight patients, and infection in one patient. No pathologic scar was recorded. The Follow-up period ranged from six months to 12 years (Figs. 3, 4, 5).
Conclusion: The closed approach performed through a small incision without skin resection can correct effectively prominent ear types I, II and III of the Egloff grading. This strategy requires tumescent infiltration with anterior and posterior undermining of the auricula over the anti-helix and concha, and controlled anterior scratching over the anti-helix, which is molded and stabilized using trans-cutaneous stitches. The hypertrophic concha is removed according the “conchal show” principles. The mini-invasive approach is indicated mostly indicated in ethnic –skin patients.
Level of evidence: IV
Fig.1 - View of the minimal surgical access to the closed approach. The site is located at the external border of the helix at the junction of the superior crus of the antihelix.
Fig.2 – Surgical steps. (Above,left ): The surgical access and the anterior undermining of the skin above the antihelix and concha are demarked with dotted lines, and the anterior rasping and scratching of the anti-helix ; (Above right): The undermining of the skin over the concha at the retroauricular topography, using a Metzembaum demarked with dotted lines; (Below, Left): The Metzembaum scissors trespass the cartilage under the inferior curs of the antihelix and preserves at a minimum 10mm from the external border of the anti-helix to the auditory canal according the “conchal show”, cutting and biting the excess; (Below, right): The crescent piece of cartilage is produced and the cartilage is molded internally using 5-0 monofilament buried stitches.
Fig. 3 – (Above): A 10 year-old black-skin patient before and one week after the closed procedure. The scar is under the white paper at the superior pole. (Below): Close view of the same patient. No scar and good skin retraction.
Fig. 4 – (Above, front view): A 9 year-old black-skin patient before and 12 years after the closed approach. (Below) Back view of the same patient show satisfactory medianization of the ear, and no scar at the posterior aspect of the pina.
Fig. 5 – A 7 year-old patient before and after the closed approach. A close view of the back aspect of the ear shows satisfactory medianization of the pinna and no scar.
Fig, 6 – A 14 year-old black-skin patient before and six months after the closed approach.
Fig. 7- A 13 year-old ethnic skin patient eight month before and after the closed approach demonstrated in this study.