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Year : 2020  |  Volume : 28  |  Issue : 1  |  Page : 33-37

Importance and necessity of surgical combinations in the correction of prominent ears for natural and long-lasting results

Private Aesthetic, Plastic and Reconstructive Surgery Clinic, Bursa, Turkey

Date of Submission11-Feb-2019
Date of Acceptance11-Mar-2019
Date of Web Publication31-Dec-2019

Correspondence Address:
Dr. Ayhan Okumus
Plastic Surgery Office, Ilknur Street, Bulvar 224 1/B - 10, Ihsaniye, Nilufer, Bursa
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_18_19

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Introduction: Many surgical methods are defined to correct prominent ears, with the most common being external auditory canal anomaly. Trying to treat cases where different anatomic structures coexist in the anomaly increases the risk of additional surgical intervention or causes an unnatural appearance. In this study, it was demonstrated that application of varying surgical combinations depending on the anatomic components which cause prominent ears would produce natural and long-lasting results. Materials and Methods: Seventy-one patients, with antihelix tube development defect, conchal hypertrophy, or both, were operated in our clinic between 2004 and 2018 (age range: 6–43 years, 42 females and 29 males). Four different methods were employed, consisting of postauricular skin excision of 0.5–1.5 cm, posterior abrasion of the antihelix and shaping with Mustarde sutures, semilunar excision from the large and mispositioned concha and connecting the ends before securing loosely to the mastoid fascia, and securing the dermo-perichondrial flap to the mastoid fascia. Three different surgical combinations were utilized on three patient groups with antihelix formation defect, concha hypertrophy, or both. Results: Patients were followed up for 2 years on an average, 6 months at minimum. No major complications were encountered except for one patient who had an opening of the upper pole, while another had it on both sides. All patients stated their satisfaction with the result. Conclusion: The purpose of prominent ear treatment should not only be formation of the antihelix or bringing the ear closer to head.Different problems can be solved separately with combined treatment, and more natural and lasting results can be obtained.

Keywords: Antihelix deformation, conchal excision, natural results, prominent ear, surgical combinations

How to cite this article:
Okumus A. Importance and necessity of surgical combinations in the correction of prominent ears for natural and long-lasting results. Turk J Plast Surg 2020;28:33-7

How to cite this URL:
Okumus A. Importance and necessity of surgical combinations in the correction of prominent ears for natural and long-lasting results. Turk J Plast Surg [serial online] 2020 [cited 2021 Oct 26];28:33-7. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/1/33/274436

  Introduction Top

Ears can become first realized when there is a problem, even though they are not the most outstanding parts of our faces. Prominent ears, in which the appearance of ears is outstanding and people feel the need to conceal, represent the most common external auditory canal anomaly with 5% occurrence in White race.[1] An undeveloped or underdeveloped fold of the antihelix, an extensively large or deep conchal cartilage, and differences in helical rim or lobules may form the appearance of prominent ears alone or combined. Cases where the cephalo-auricular angle is larger than 30° or where the distance between the auricle and head is more than 2.3 cm are considered prominent ears.[2]

Although many methods have been described in the treatment of prominent ears, no method appears to single-handedly suffice to correct all forms of prominent ears. Using only one surgical technique to correct all variations of prominent ear cases leads to high complication rates and unnatural results.[3]

In this study, four combined methods were employed to produce natural and long-lasting results with low complication rates in the treatment of prominent ears of varying configurations. These methods, respectively, are: (1) postauricular excision of the skin for 1.5 cm (used as desepidermization here), (2) posterior abrasion of the antihelix and shaping with Mustarde sutures, (3) semilunar excision of the large and misplaced concha, drawing up the ends and loosely fixing to the mastoid fascia, and (4) fixing the dermo-perichondrial flap to the mastoid fascia [Figure 1], [Figure 2], [Figure 3]. Surgical combinations were classified in three ways [Table 1].
Figure 1: Prominent ear characterized by conchal hypertrophy and flat antihelix

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Figure 2: Preparation of the dermo-perichondrial flap, planning of Mustarde sutures for the antihelix, and designating the conchal cartilage to be excised

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Figure 3: Shaping of the antihelix, dermo-perichondrial flap, and excision of the conchal cartilage combination

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Table 1: Classification of the method combinations and where they are included

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  Materials and Methods Top

Seventy-one patients (age range: 6–43 years; 42 females and 29 males) with flat antihelix defect, conchal hypertrophy, or both co-existing were operated on in our clinic between 2014 and 2018 [Figure 1]. Fifty of these patients were operated on under local anesthesia, 13 under sedation + local anesthesia, and eight under general anesthesia. Sixty-eight patients had bilateral prominent ears, whereas the remaining three had unilateral ears. Four different surgical methods were combined, each including at least three methods, and applied [Table 2]. Complication rates; front, back, oblique, and full lateral views of the results and their comparison to the natural appearance; and additional surgery requirements were evaluated.
Table 2: Distribution of patients according to methods employed

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Surgical technique and combinations

Once the hair had been removed from the area and the ear had been cleaned with translucent disinfectant, skin excision boundaries were marked in a way that both ends would be somewhat larger than a classic ellipse, the lower border would be 1–1.5 cm distant from the sulcus, and the final scar would remain on the posterior sulcus. The upper border was determined at where the antihelix splits into two, and the lower border was set at the ear lobule line. Operation was commenced 10 min after local anesthesia had been applied on the reverse side of the ear and the anterior conchal cartilage skin (1% mepivacaine and 1:100,000 adrenaline). After desepidermization of the marked skin, the dermis was dissected from the sulcus toward the helix, with the underlying perichondrium as a dermo-perichondrial flap. The border of the flap pedicle dissection was determined as the upper border of the antihelix. Flap size was ensured to have the same width as the excised skin, thus achieving a large exposition [Figure 2]. After the flap had been elevated, the ear was shaped with the help of the hand, and the natural fold of the antihelix was marked on the anterior and posterior. In cases where the cartilage is too strong for molding to an ideal position, cartilage weakening was performed on the posterior where the antihelix would be created. Cartilage abrasion with dermabrasion head was preferred for this purpose. In this way, the cartilage was thinned as a whole with microdermabrasion instead of making incisions which would potentially cause cartilage deformity or fracture. Abrasion was performed only on the areas where the cartilage bends and it would remain between the sutures, so that shaping would require less strength. Mustarde mattress sutures were placed with 4-0 nonabsorbable translucent polypropylene, and the antihelix was secured in a way that its natural fold would form. In cases where the conchal cavum's deepness was larger than 1.5 cm or its posterior surface was extremely strong, conchal cartilage was dissected both on the anterior and posterior until the meatus acusticus externus after forming the antihelix. Excess amount of the cartilage was removed by cartilage excision in the shape of a crescent following incision 5 mm below the lower border of the antihelix fold. The lower border of the antihelix and the remaining conchal cartilage were drawn together with 4-0 polydioxanone with no space in-between, and the same suture was secured loosely just underneath the mastoid fascia without cutting [Figure 3]. At this stage, the ear was positioned on the temporal bone by putting this suture either to the front or behind of this suture when the auricle needed drawing forward or backward. When positions of the antihelix fold and conchal cartilage were established, a previously prepared dermo-perichondrial flap was secured to the temporal fascia just underneath with 3/0 polydioxanone and single sutures in a slightly tight way to conserve the ear position. The remaining skin was closed subcuticularly and loosely with 6-0 polyglactin sutures [Figure 3]. After the procedure was over, gauze patches were placed on the anterior ear in a way that it would fill the area and the posterior sulcus, and they were wrapped so as not to apply pressure and were supported with an ear tape.

Treatment protocols to be used were determined based on the number and combination of deformities on patients. Cases where the antihelical fold deepness appeared insufficient, the conchoscaphoid angle was larger than 90° or auriculocephalic angle was larger than 35° were deemed as antihelix underdevelopment. In cases where the conchal bowl depth was larger than 1.5 cm, the distance between midhelix and mastoid was larger than 2 cm, and in those where the cartilage was distinctively stiff and pushing the antihelix toward Anterior and lateral directions were deemed as cases with conchal hypertrophy. Desepidermization was performed between 0.5 and 1.5 cm depending on the degree of auricular deformity. The purpose of this was strengthening the perichondrial flap as a dermo-perichondrial flap rather than the skin excision. Dermo-perichondrial flaps were preferred in all cases with regard to minimizing the scars by reducing the load on the skin, reducing the load on Mustarde sutures when antihelix procedures were applied, and reducing the tension of the sutures used to connect conchal cartilages where conchal excision was performed. Three combinations consisting of four different methods were utilized in 26 cases where the conchal hypertrophy and antihelical deficiency coexisted. On the other hand, only the second combination was utilized on four patients with only conchal hypertrophy, whereas it was only the first combination for 41 patients with only insufficient formation of the antihelical fold, conchoscaphoid angle of larger than 90°, and auriculocephalic angle of larger than 35° [Figure 3] and [Table 1] and [Table 2].

  Results Top

We achieved esthetically long-lasting results with natural appearance in our patients treated with three different combinations [Table 1] of four different treatment methods [Figure 4], [Figure 5], [Figure 6], [Figure 7]. The patients were followed up for 2 years on an average (range: 6 months–5 years). None of the 71 patients developed such notable complications such as suture dehiscence, infection, hematoma, ulceration, or skin necrosis other than ecchymoses. Only one patient (1.4%) had an opening of the upper pole, while another (1.4%) had it on both sides. Both patients were revised in line with previous procedures. No recurring openings were encountered.
Figure 4: Combination 1 – Top right – preoperative, bottom right – postoperative; top left on the left – preoperative, top left on the right – postoperative; middle left – preoperative; bottom left – postoperative views

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Figure 5: Correction with combination 2 – (a) preoperative view from the front, (b) postoperative view from the front, (c) preoperative right lateral view, (d) preoperative left lateral view, (e) postoperative right lateral görünüş, (f) postoperative left lateral view, (g) preoperative view from behind, (h) postoperative view from behind

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Figure 6: Treatment with combination 3 – (a) Preoperative view from the front, (b) postoperative view from the front, (c) preoperative lateral view, (d) postoperative lateral view, (e) preoperative view from behind, (f): postoperative view from behind

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Figure 7: Treatment with combination 3 – (a) Preoperative view from the front, (b) postoperative view from the front, (c) preoperative right lateral view, (d) preoperative left lateral view, (e) postoperative right lateral view, (f) postoperative left lateral view, (g) postoperative view from behind, (h) postoperative right lateral view

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Patients were followed up for at least 6 months. At the end of the 6 months, other than patients' indication of their satisfaction, photographs were taken from four different angles. Closeup lateral photographs, which we think demonstrate the ear folds best, were compared to photographs from the same angle and distance of other people without prominent ear problems who were admitted to our clinic for other reasons. All patients stated that their ears look natural.

  Discussion Top

Ears are not of the structure to directly stand out from our faces. This is because they are consistent with other facial structures and natural folds and positions. In fact, they do not stand out in our perception of the face as a whole, but act as a harmonious part of the whole because they are shapely and natural. However, ears may quickly catch an eye when there is a visual problem, just like any part of our body standing out from the whole would cause visual disharmony. This may occur in many ways such as undersized, oversized, underdeveloped ears, or mispositioned contours or parts. What is in common of all these problems is they are all out of customary form that is deemed natural visually. Prominent ear deformity is the most frequently encountered external auditory canal visual problem.

Prominent ears are not generally observed with other congenital problems or mental problems. However, they may lead to psychological problems particularly in children and men, become a reason for making fun of in children at school age, and create chronic defects related to psychological development and character formation. It is quite interesting that a mere visual problem stands out so much in a society, is perceived as a problem, is labeled as a moniker, and used as the strongest feature to describe a person. Cleft lip or palate, nose, jaw, or eyelid disorders, which are prominent shape disorders, have never been labeled or signified as a description by the whole society. In this manner, prominent ears are an interesting disorder as they cause psychological problems many times more than the visual problem they contain.

In infancy and early childhood stages, different ear structures are viewed with positive discrimination as “cute” among family members, but things quickly turn around at school ages when the child encounters an environment outside the family. The child is described by its ears regardless of other features or abilities. After the childhood stage, girls keep their hair down to hide their ears, whereas boys start growing their hair. This reflex to hide ears continues throughout their life. In fact, the number of patients with prominent ears who never tied their hair back, showed their ears to anybody, or used a single hair style is quite high.

All these problems result from the fact that ears become noticeable even though they should not. Therefore, the purpose of the treatment should be achieving the most natural result and ensuring that the ears are not noticed. The transition from appearance of prominent ears to an appearance of operated-on ears solves the problem because it theoretically removes the appearance of prominent ears; however, it brings along yet another visual problem; intelligibly operated-on ear with visual problems. This sensibility is characterized by the poor appearance of distance of the posterior ear and position and folds of the ear. However, every result bringing the ear closer to the cranium is considered as successful at first, and hair is quickly kept down or even cut short. Shape disorders in the ear after the operation are noticed with time and causes discomfort to the patient. Later on, the ears are hidden behind the hair once again. Even though prominent ear problems are more noticeable in our day and age because hats and scarves are worn less often and hairstyles are shorter in both men and women, this very same visual problem has actually discomforted people throughout the history.

Since the first treatment of prominent ears by Edward Ely in 1881[3] until the modern endoscopy-supported prominent ear corrections,[4] more than 200 treatment methods have been defined,[5] most of them as a modification of the former. Most authors state that the technique they define produces successful results in all types of prominent ears and share their results with the argument that it is the best technique. A considerable part of these techniques is reshaping the antihelix and creating a new tube technique.[6],[7],[8] However, trying to solve the problem by only shaping the antihelix especially when the conchal cartilage is large and stiff either increases the risk of complication or leaves the ear in a shape with sharper contours and artificial appearance, which reveals that it was intervened.[9],[10] In addition, results are beter in people with antihelix problems, whilw the visual outcome is quite artificial and unnatural in complex cases.

Use of combined methods in breaking or weakening a force which pushes ear outward means that the force imposed on the operated area is to be shared between sutures and tissues.[10] In cases where the conchal cartilage is large, conchal excision shares the burden on sutures used at antihelix formation and the cartilage on which sutures are placed and the dermo-perichondrial flap shares the burden on skin sutures.[11] In this manner, risks of suture dehiscence or break, hypertrophic scar, or noticeable scar are reduced. Bending the antihelix excessively and making it seems deformed will not be required to correct auricle's outward position. Use of loose sutures and refraining from overcorrection while shaping the antihelix helps forming natural folds.

  Conclusion Top

The purpose of prominent ear treatment should not only be formation of the antihelix but also bringing the ear closer to the head. Maintaining the posterior ear distance and depth, delivering natural state to ear folds, and adjusting the angle and positions of the conchal distance and the ear on the temporal bone should be ensured as a whole. Achieving all of these with a single surgical treatment method does not seem possible. In other respects, different problems can be solved separately with combined treatment, and more natural and long-lasting results can be obtained.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Bardach J. Surgery for congenital acquired malformation of the auricle. Otolaryngology-Head and Neck Surgery., St. Louis 1986. p. 2861.  Back to cited text no. 1
Schneider AL, Sidle DM. Cosmetic otoplasty. Facial Plast Surg Clin North Am 2018;26:19-29.  Back to cited text no. 2
Ely ET. An operation for prominence of the auricles (with two wood-cuts). Arch Otol 1881; 10: 97-8.  Back to cited text no. 3
Graham KE, Gault DT. Endoscopic assisted otoplasty: A preliminary report. Br J Plast Surg 1997;50:47-57.  Back to cited text no. 4
Bogetti P, Boltri M, Spagnoli G, Balocco P. Otoplasty for prominent ears with combined techniques. Eur J Plast Surg 2003;26:144-8.  Back to cited text no. 5
Mustarde JC. The correction of prominent ears using simple mattress sutures. Br J Plast Surg 1963;16:170-8.  Back to cited text no. 6
Mustardé JC. The treatment of prominent ears by buried mattress sutures: A ten-year survey. Plast Reconstr Surg 1967;39:382-6.  Back to cited text no. 7
Stenstroem SJ. A “natural” technıque for correctıon of congenıtally promınent ears. Plast Reconstr Surg 1963;32:509-18.  Back to cited text no. 8
Salgarelli AC, Bellini P, Multinu A, Landini B, Broccaioli E, Consolo U. Combined technique for the correction of prominent ears: Results in 140 patients. Br J Oral Maxillofac Surg 2009;47:545-9.  Back to cited text no. 9
Stewart KJ, Lancerotto L. Surgical otoplasty: An evidence-based approach to prominent ears correction. Facial Plast Surg Clin North Am 2018;26:9-18.  Back to cited text no. 10
Furnas DW. Otoplasty for prominent ears. Clin Plast Surg 2002;29:273-88, viii.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

  [Table 1], [Table 2]


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