Operative Strategies

The Importance of Conchal Resection in

Correcting the Prominent Ear

The authors believe that conchal hypertrophy plays a sharp, irregular, and
more significant role in ear prominence than has been unsightly antihelical fold
indicated in the literature. Instead of focusing on the with buried helical rims. 13
antihelical fold, this otoplasty technique emphasizes The initial procedure in such
chondrocutaneous resection. With even limited resec- patients has frequently
tion and resuturing of the cut concha, the antihelix ignored or ineffectively
yields to posterior suture placement with a soft, treated the conchal hyper-
smooth, rounded shape unmarred by any sharp, irreg- trophy. Secondary correc-
tion is usually achieved with Bruce S. Bauer, MD, Chicago,
ular surfaces. (Aesthetic Surg J 2005;25:72-79.) IL, is a board-certified plastic sur-
conchal reduction alone or geon. Co-authors: Alexander
combined with ancillary Margulis, MD, Jerusalem,
Israel; David H. Song, MD,
procedures.14,15 Chicago, IL.

S
urgery to correct a prominent ear can profoundly An important test of any
improve self-image, provided that the otoplasty tech- technique is that it is easily
nique is appropriate for the specific deformity and learned and that the results are reproducible in the hands
yields a normal-appearing ear that is proportionate to of other surgeons. Equally important in an otoplasty
other facial features. Minor ear deformities, before or after technique is the ability to apply it to a wide variety of
otoplasty, can significantly impact the quality of results prominent ear deformities. (Deformities may frequently
and patient satisfaction. Failure to correctly analyze the vary from side-to-side in the same patient). The ability to
complex deformity that comprises the prominent ear is the obtain consistently good results with this technique has
most common cause of an undesirable otoplasty result. been universal. In the rare patient in whom the deformity
The technique I describe here has evolved over the is under-corrected, secondary correction is always easy,
past 24 years of practice and factors in the great varia- such as slight correction of superior pole or lobule promi-
tion in ear deformities that we classify as “prominent.” nence, compared with the difficulty of correcting an
Underpinning this technique is the realization that too excessively sharpened and folded antihelix with exces-
much emphasis has been placed on creation of the anti- sively resected skin.
helical fold1-5 and not enough on appreciating the role of
conchal hypertrophy in creating ear prominence.6-8 Preoperative Issues and Operative Planning
The ideal surgical procedure for correction of promi- Even minor ear deformities can be the source of signif-
nent ears should accomplish the following: (1) correct the icant peer ridicule, shaping the way a child relates to
protrusion, (2) correct the prominently visible helix and classmates and performs in class. The psychological
antihelix, (3) create a smooth antihelical fold, (4) leave impact of this deformity may last well into adulthood if
the postauricular sulcus intact, (5) avoid a “plastered the ears are not corrected. Otoplasty should be timed to
back” postoperative appearance, and (6) avoid creation minimize this trauma but it should not be performed
of a sharp antihelical fold.9 before the child is old enough to cooperate with the post-
Unfortunately, most otoplasty techniques reported in operative regimen or before the child is old enough to
the literature address correction of the antihelical efface- understand the reason for the surgery. My preference is
ment alone. The sheer number of different methods avail- to wait until the child is 5, but in a particularly sensitive
able is testament to the difficulty in achieving child already suffering from classmate teasing, I may
reproducible results and patient satisfaction.10-12 choose to perform the procedure a little earlier. However,
Patients who are dissatisfied with the result of an oto- such cases are typically associated with an inordinate
plasty will typically present with an overemphasized, number of early postoperative visits to replace bandages,

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as well as a great deal of parental concern about whether of the lower pole of the ear and lobe. Then approximate
the final results of the surgery have been compromised. In the edges of the conchal cartilage with 4 or 5 interrupted
children who are integrating well and not having early 5-0 clear nylon sutures (Figure 1C). Close the anterior
problems, it may be prudent to wait until the child skin incision with 3 or 4 interrupted 5-0 chromic gut hor-
requests the surgery. izontal mattress sutures, followed by a running 6-0 fast-
I use general anesthesia for virtually all the primary oto- absorbing chromic gut (Figure 1D).
plasty procedures that I perform; however, adults may To reconstruct the effaced antihelix and correct the
undergo this procedure under local anesthesia with moni- lobule prominence, begin with a retroauricular squid-
tored intravenous sedation. To date, none of my secondary shaped skin excision and carry it down to the perichon-
procedures has required general anesthesia and all have been drium. This “dumbbell”-shaped ellipse (with
performed in my clinic setting. All patients are given prophy- diamond-shaped inferior end) is designed to allow access
lactic coverage with a broad spectrum antibiotic started to the posterior surface of the scapha and helical sulcus
intraoperatively and continued for 3–4 days after surgery. for further suture placement (Figure 2A). It also assists in
correcting the lower pole prominence. Design the maxi-
Surgical Technique mal width of the diamond-shaped inferior “squid” exten-
Sterile preparation of the face and ears is done using a sion to rest at the point of maximal lobule prominence.
green soap solution and a standard head drape secured Dissect the posterior surface of the conchal bowl and
with staples. Secure stray hairs with clear adhesive tape. scapha in the supraperichondral plane. Preserving peri-
Infiltrate 0.5% lidocaine with 1:200,000 epinephrine chondrium is particularly important because it decreases
solution into the anterior and posterior surfaces of both the possibility of sutures pulling through the cartilage.
ears. For postoperative analgesia, block the bilateral After exposing the posterior surface of the cartilage,
great auricular nerves with 0.25% bupivacaine. identify and dissect free the helical tail. In essence, the
Typically, I begin the procedure on the side with the helical tail is a duplication of cartilage extending down
more prominent ear, starting with an incision on the from the mid-to-lower third of the helical rim. The helical
anterior surface of the concha. Place the incision at the tail must not be freed from the skin overlying its anterior
junction of the posterior conchal wall and “floor” of the surface because this maneuver will diminish the effective-
concha, beginning in the cymba concha and continuing ness of correction of the lobule prominence. The last part
to a point below the antitragus, but not as far as the of the dissection frees the soft tissues above the mastoid
external auditory meatus (Figure 1A). This is deeper in surface, exposing the white mastoid fascia for later suture
the concha than the incision described by Elliott.6 Placing placement. Use bipolar cautery throughout the procedure
the incision too high in the concha will decrease control to assure hemostasis.
of the antihelical fold, allowing the cut edge adjacent to Before placing the sutures that will further correct the
the antihelix to spring forward. ear prominence, place pressure on the helical rim and
Carry the incision through both the anterior skin and antihelix to immediately demonstrate that the spring, or
conchal cartilage, stopping shy of the posterior conchal resistance of the cartilage to further shaping of the anti-
skin. Sharp dissection in the loose areolar plane behind helix, has been decreased to what is required before ante-
the concha (not in the subperichondrial plane) frees soft rior resection and that reshaping can be accomplished
tissue and skin from the posterior surface of the conchal without any sharpening of the antihelix. This is a key
bowl. Gently set back the antihelix with finger pressure point of the technique because even a limited amount of
to accurately estimate the severity of conchal hypertro- conchal resection will result in decreased spring and
phy and the amount of cartilage and skin resection need- increased ease of antihelix shaping. In addition, the
ed to create an aesthetically pleasing ear position (Figure extension of the conchal incision to the cartilage below
1B). the antitragus softens the spring of cartilage in this area,
Next, excise a crescent moon-shaped chondrocuta- allowing the lobule to be more easily recessed.
neous portion (Figure 1 inset). Typically, more cartilage Place 2 or 3 sutures of 4-0 clear nylon from the
than skin is resected to assure a tension-free closure. Be scaphal cartilage and helical sulcus cartilage to the mas-
cautious not to excise too much cartilage deep to the toid fascia to correct prominence of the upper- and mid-
antitragus because excessive resection in this area will third of the ear. Determine the proper placement of these
pull the antitragus upward and increase the prominence permanent sutures by applying pressure to the desired

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Correcting the Prominent Ear
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C D
Figure 1. A, Carefully place the anterior incision at the interface of the lateral conchal floor and the posterior conchal wall. B, Gently depress the
helix with your finger to reveal the exact amount of conchal hypertrophy to be excised. Usually a crescent-shaped chondrocutaneous segment is
removed with more cartilage than skin excised (Inset). C, D, Close the anterior incision by approximating the cartilage with 5-0 clear nylon and
approximating the skin with 5-0 chromic gut in a horizontal mattress followed by a running 6-0 fast-absorbing gut.

points on the anterior ear surface with a straight Keith the sutures through the mastoid fascia and tie them at the
needle, then passing the needlepoint through the selected proper tension to create a smooth antihelical fold (Figure
spot so it can be visualized on the posterior surface of the 3). Before cutting the suture, grasp the knot with a for-
cartilage (Figure 2B). Then place a suture at each specific ceps and slide it down against the mastoid surface (mini-
point; it is not necessary to tattoo the cartilage. With- mizing risk of later suture extrusion). As you tie these
draw the Keith needle as you place the suture. Then pass sutures, take care to observe the relationship of the

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A B

Figure 2. A, Design the squid-shaped excision (essentially the typical “dumbbell”-shaped ellipse with the inferior end widened to a diamond shape)
to allow access for suture placement for correction of the upper- and mid-ear prominence and for fine adjustment of the lower pole projection.
Position the diamond-shaped “squid” extension with its maximal width at the point of maximal lobule prominence. B, Initially place scaphal cartilage
to mastoid fascia and subsequent helical sulcus cartilage sutures by marking the point with a straight Keith needle. After placing the nylon suture,
withdraw the straight needle.

Figure 3. Place additional scaphal and helical sulcus to mastoid sutures using 4-0 clear nylon, effectively recreating a smooth antihelical fold.
Generally, only 2–3 sutures are required. Place all sutures before tying the first.

reshaped antihelix and the helical rim to make sure that terior squid-shaped defect using 5-0 chromic gut. With
the helical rim remains visible from the frontal view. the diamond-shaped inferior portion of the “squid”
Once you correct the upper- and mid-auricular promi- designed as I described, create the appropriate lobule
nence, address the lobule prominence by closing the pos- contour, shape, and projection by varying the initial

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Figure 4. After you tie all of the deep sutures, close the posterior “squid”-shaped defect with 5-0 chromic sutures (inset). Create the appropriate
contour and shape of the lobule by varying the initial suture position with Av sutured to either A, B, or C (most frequently Av to A rather than Av to B).
The remaining incision is then closed with running 5-0 chromic suture.

Figure 5. The inset is illustrated with the initial closing suture now placed between point Av and point B and the corrected shape and prominence of
the lobule demonstrated after closure.

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 Operative Strategies

A B

C D

E F

Figure 6. A, C, Preoperative views demonstrate bilateral ear prominence in a 6-year-old boy with asymmetric conchal hypertrophy with effacement of
the superior antihelix. B, D, Postoperative views 1 year after otoplasty demonstrate correction of asymmetry and conchal hypertrophy. Frontal view
shows the ear’s natural appearance with helical rim readily visible in appropriate relation to antihelix. E, F, Bilateral lateral views show natural curve
to antihelix without sharpness or irregularity.

The Importance of Conchal Resection in AESTHETIC SURGERY JOURNAL ~ January/February 2005 77

Correcting the Prominent Ear
 Operative Strategies

A B

C D

E F

G H
Figure 7. A, C, E, G, Preoperative views of a 15-year-old girl with bilateral ear prominence (greater on the right side than on the left) due to combined
conchal hypertrophy and effacement of the antihelical folds (particularly on the right). B, D, F, H, Postoperative views 6 months after otoplasty.
Lateral views demonstrate antihelical folds without sharpness or irregularity.

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 Operative Strategies

suture position with Av (the point of the diamond at the used for ear reconstruction.
point of maximal lobule prominence) sutured to either A, While no single otoplasty technique can be applied to
B, or C (most frequently Av to A rather than Av to B) all prominent ear deformities, the technique I describe —
(Figures 4 and 5). Once you place this initial suture, com- which, with experience, can be enhanced with added
plete the closure with a running 5-0 chromic suture. nuances — is as versatile as any I have ever seen or tried
Correcting the more prominent side first allows for a and provides a proven, reproducible, and effective
symmetrical “setback” by providing a guide for suture method for correcting virtually all prominent ears.
placement that will define the antihelix and lobule promi-
nence. References
1. Ely ET. An operation for prominence of the auricles. Arch Otolaryngol
Dressing and Postoperative Care 1881;10:97.
2. Luckett WH. A new operation for prominent ears based on the anatomy
Dress the ears with Bacitracin ointment (Clay-Park of the deformity. Surg Gynecol Obstet 1910;10:635.
Lab Inc, Bronx, NY); Xeroform gauze (Baxter 3. Stenstrom SJ. A “natural” technique for correction of congenitally promi-
Healthcare Corp, Deerfield, IL); and fluff dressings nent ears. Plast Reconstr Surg 1963;32:509.
secured with a stretch net head wrap. Leave the dressing 4. Stark RB, Saunders DE. Natural appearance restored to the unduly
undisturbed for 6–7 days after surgery and then remove prominent ear. Br J Plast Surg 1962;15:385.

it. Following its removal, advise patients to use a stretch 5. Mustardé JC. The correction of prominent ears using simple mattress
sutures. Br J Plast Surg 1963;16:170.
terry sport headband for an additional 2–3 weeks at
6. Elliott RA. Otoplasty: A combined approach. Clin Plast Surg
night only. 1990;17:373-381.
I ask patients to minimize physical activity for a total 7. Bauer BS. Aesthetic surgery of the ear. In: Marchac D, Granick M,
of 3 weeks following surgery. After the dressing is Solomon M, eds. Aesthetic Surgery of the Male. Boston, Mass:
removed, I instruct patients to wash their hair daily with Butterworth-Heinemann; 1997:255-286.

mild shampoo and cleanse the ears gently. This is contin- 8. Erol OO. New modification in otoplasty: anterior approach. Plast
Reconstr Surg 2001;107:193-202.
ued until the sutures have dissolved. I typically reevaluate
9. McDowell AJ. Goals in otoplasty for protruding ears. Plast Reconstr Surg
patients at 6 and 12 months after surgery (Figures 6 and
1968;41:17-27.
7).
10. Spira M. Otoplasty: what I do now—a 30-year perspective. Plast
Reconstr Surg 1999;104:834-840.
Conclusion
11. Stal S, Klebuc M, Spira M. An algorithm for otoplasty. Oper Tech in
Despite many techniques that discuss accentuating the Plast and Reconst Surg 1997;4:88.

antihelical fold as the key component in correcting the 12. Spira M, Stal S. The conchal flap: an adjunct in otoplasty. Ann Plast
Surg 1983;11:291-298.
prominent ear, my experience has taught me that the
13. Elliott RA. Complications in treatment of prominent ears. Clin Plast Surg
prominent ear has many and varied causes, but the com-
1978;5:479-490.
mon denominator is hypertrophy of the concha. The
14. Bauer BS. Combined otoplasty technique: analysis and treatment of the
degree of conchal hypertrophy does not need to be great prominent ear. Oper Tech in Plast Reconst Surg 1997;4:109.
for a patient to reap the benefits of chondrocutaneous 15. Bauer BS, Song DH, Aitken ME. Combined Otoplasty Technique: chon-
resection as the cornerstone of the otoplasty technique. drocutaneous conchal resection as the cornerstone to correction of the
Recognizing this fact is imperative but, to date, it is a fact prominent ear. Plast Reconstr Surg 2002;110:1033-1040.

that is under-appreciated. With even limited resection 16. Furnas DW. Discussion. Erol OO. New modification in otoplasty: anterior
approach. Plast Reconstr Surg 2001;107:203-205.
and resuturing of the cut concha, the antihelix yields to
the posterior placement of sutures with a soft, smooth, Reprint requests: Bruce S. Bauer, MD, Children’s Pediatric Plastic and
Reconstructive Surgery, 2300 Children’s Plaza, Box 93 Chicago, Illinois
rounded shape, unmarred by any sharp irregular sur- 60614.
faces. Despite concerns expressed by some authors, and Copyright © 2005 by The American Society for Aesthetic Plastic Surgery, Inc.
criticism of the anterior approach to the concha as a 1090-820X/$30.00
potential source of keloid scarring, 16 I have not seen doi:10.1016/j.asj.2004.10.004
unsightly scarring in any of these cases, nor in a much
larger series of conchal donor sites for composite grafts

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Correcting the Prominent Ear