The surgical site is prepared to ensure that no hairs enter the incision. The outer ear is then anaesthetised using 1% lidocaine combined with 1,200,000 units of adrenaline, which is injected into the posterior aspect using the tumescent technique, ensuring perfect diffusion to the anterior aspect, which therefore does not require infiltration. The anaesthesia for otoplasty lasts around 3 hours, and the total duration of the procedure is between one and a half and two hours. We then proceed to cover the surgical site with a clear chlorhexidine solution, immediately followed by the placement of sterile drapes.
Although there are some surgeons who perform an anterior approach, the posterior approach is preferred, from behind, so that the scar is completely concealed.
The shape of the incision may be spindle-shaped, although this may lead to a deformity known as “telephone ears”, since with this type of incision only removes a small amount of skin tissue from the lobe and from the tip of the ear.
For this reason it is preferred to use the incision proposed by McDowell, in the shape of an hourglass, to achieve avoid this problem. When the lobe is excessively prominent the incision is a24> proposed by Wood-Smith in the year 1980” fish tail”, in order to be able to bring the lobe closer to the mastoid process.
Schematic drawing of the incision by McDowell
The excess skin from the posterior region is then removed. Next one proceeds to reduce the protrusion of the conchal cartilage. Furnas proposed the introduction of a procedure for suturing the cartilage conchal to the tissue periosteum which is is found covering the mastoid process of the skull.
Schematic diagram of the technique of Davis
Although this technique is minimally invasive, it has the drawback that the results may be less stable in the long term, and it is possible that, over time, the auricles may protrude outwards again; therefore, it can be used in patients with mild or moderate protrusion.
The technique that provides the most stable results is the Davis technique, which involves the removal of kidney-shaped auricular tissue, whilst always leaving approximately 8 mm of the antihelix intact.
When the projection of the conchal cartilage has subsided, we proceed to folding of the antihelix and to give it a shape that is more aesthetic. Many techniques have been proposed in which bones a23> extract bones from cartilage; however these procedures may lead to long-term problems of an aesthetic nature, with the antihelix exhibiting shapes that are excessively angular and “skeletalised”.
So then, the procedure which gives the best results is the one proposed by Mustardé, with which the folding of the antihelix is achieved thanks to the application of padding sutures using PTFE suture thread a23> of 5/0 of gauge.
Before making the incisions, the cartilage in the area where the fold is to be created must be thinned. This can be done using a manual file accessed from the front, although this can cause significant inflammation in the area, lead to blisters and, in some cases, result in loss of tissue after surgery.
The most correct approach is to access via the posterior side, weakening the cartilaginous cartilaginous tissue by means of small incisions made with a cold scalpel, although the technique proposed by Bajaj in 2007 is preferable, by means of the use of a rotary instrument, with milling of the area that is intended to be weakened.
Placement of the stitches made of polytetrafluoroethylene also known as “mustard sutures or “otoplasty with sutures”
Schematic drawing of the procedure for Bajaj which weakens the cartilaginous cartilage without the need for making incisions or manual scraping.
When the cartilage in the crease area has weakened, the area to be sutured is marked out. To do this, three needles are inserted from the front to mark the area with methylene blue. When the sutures are tied, the cartilage folds. It is of the utmost importance that each stitch is tied with a different tension to avoid an aesthetically poor result. The part of the auricular pole requires a looser suture, in order to achieve a more natural appearance.
The closure of the wound is carried out in stages. First one must suture the SMAS (the aponeurotic tissue between the cartilage and the cutaneouscutaneous tissue) which has previously been preserved by means of sutures made of polyglycolide; thus preventing the extrusion of the the sutures made of PTFE in the post-operative period. The plane of skin is closed with a continuous suture of Nylon of gauge 5/0, which will be removed fifteen days after the surgery.
