Pre-operative
The consultation
During the consultation for otoplasty, I carefully assess three fundamental elements and explain each of them to the patient: the absence of the anti-helix, the projection of the conchas, and the presence or absence of asymmetries.
The anti-helix is a fold in the cartilage that gives curvature to the outer part of the ear, especially in the upper segment. In patients with protruding ears, one or both anti-helices are "flattened," which projects the ears forward, creating the protruding appearance. In otoplasty, I delicately redesign the anti-helices, following the technique in Professor Ivo Pitanguy's Island. In some cases — particularly in small children, whose cartilage is more pliable — it is possible to simply scrape the cartilage to recreate the anti-helices, without the need for a full-thickness incision.
Excess cartilage in the concha projects the ears forward, potentially reaching an angle close to 90 degrees with the head. In surgery, I rotate the conchas backwards without removing cartilage, maintaining the natural projection. I consider an ear without any projection, flat against the head, to be artificial. In my technique, I perform a calculated hypercorrection, as the ears gradually open over the first three weeks until they achieve a balanced and attractive result. To control this opening, the patient wears a compressive band 24 hours a day during this period.
Asymmetries between the ears are quite common — often, one ear projects more than the other. In the vast majority of cases, otoplasty minimises these differences so efficiently that they become imperceptible in daily life. In rare situations, when the asymmetry involves a significant deformity, the surgery may include partial or total reconstruction of the auricle.
Anatomical details I assess during the otoplasty consultation
Helix
The helix of the ear is the outermost fold, starting at the root of the ear and ending at the lobe. Most of the time, its curvature is normal, but in cases of otoplasty for lop ear or cup ear, the curvature is very pronounced, sometimes caused by a horizontal fold in the cartilage that crosses the anti-helix, requiring, in these cases, reshaping of the helix and supporting it with a spring made from the cartilage of the concha.
Anti-helix
In most cases of protruding ears, the anti-helix, which should be a curved "Y" shaped fold, located just anterior to the helix, is absent. Otoplasty involves reshaping the cartilage, recreating the anti-helix and thereby reducing the projection, especially of the upper pole of the protruding ear.
Darwin's tubercle
This fold or projection on the helix, at its superior-external point, is evident in most people but may be just a barely perceptible thickening in others, and is called Darwin's tubercle. In some cases, when it is very prominent and accentuates the projection of protruding ears, I may surgically reduce it during otoplasty.
Lobe
The lobe of the ear is the lower part, without cartilage, where earrings are placed. The lobe can be attached or free. In some cases, especially in the elderly, it can be excessively large, and plastic surgery for ears can reduce its size by removing a wedge in the shape of a slice of pizza close to its insertion on the face. In other cases, otoplasty can close torn holes from earrings (due to allergy or trauma), through an anterior zetaplasty and simple suture at the back, to break the scar, interposing healthy skin in it, preventing future tears.
Tragus
This cartilage protuberance in front of the ear, at the height of the external auditory canal, is called the tragus. The tragus may be flattened, mainly due to a stigma from facial plastic surgery, the facelift, when the surgeon tries to hide the scar behind the tragus. In these cases, it is enough to release the cartilage by removing the scar tissue that holds it, restoring its projection. The cartilage protuberance above the lobe is called the antitragus.
Root
The uppermost insertion of the ear, consisting of the beginning of the helix and located just above the tragus, is called the root of the ear. It rarely needs to be operated on with otoplasty, but it is very useful in cases of helix flap (Antia flap), where a V-Y flap is performed at the root, allowing lateral and inferior advancement of the helix to repair substance loss in the middle or upper thirds of the helix. Most of the time, it serves as an anatomical parameter during facial lifting surgery as the maximum limit where the hairline can reach, in order to avoid a stigma of facial plastic surgery.
Concha
This smooth, concave part, adhered to the mastoid, posterior to the external acoustic meatus, is called the concha and contains cartilage that is ideal for performing grafts of hyaline cartilage, in the nose, for example. The concha may be very prominently projected in patients with protruding ears and can be detached at its posterior part and properly fixed to the mastoid, reducing its projection. Normally, I perform this manoeuvre in conjunction with reshaping the anti-helix.
Examinations
I request the following pre-operative examinations to perform otoplasty safely:
- Complete blood count;
- PAT with INR + APTT;
- Creatinine;
- Urea;
- Fasting blood glucose;
- Total proteins and fractions;
- Urine I;
- Electrocardiogram;
- Surgical risk, which consists of evaluation with the cardiologist.
The anaesthesia
I perform otoplasty under general anaesthesia, which provides total comfort to the patient during the procedure, which lasts between sixty and ninety minutes. In selected cases of cooperative adults, local anaesthesia with sedation may be a viable alternative, but general anaesthesia remains my preference for the tranquillity it provides — especially in children.
