A Novel Otoplasty Technique Using Dermabrader on Prominent Ear Deformity Patients: A Retrospective Study and a Description of Technique

Background:

Approximately 5% of the population has protruding ears. An antihelix deficiency or absence is a common cause of ear protrusion. Although there are over 200 techniques to manage prominent ears, there is no evidence to support using dermabraders in this situation. To the author’s knowledge, this is one of the first articles to assess the clinical outcome of dermabrader use on patients with prominent ear deformities.

Methods:

An analysis of retrospective medical records was conducted by the senior author on patients with prominent ears treated with our novel dermabrasion technique between 2018 and 2021. The demographics, clinical assessment, and outcomes of the patients were assessed. Furthermore, the article provides a detailed description of the technique.

Results:

A total of 18 ears were operated on. Eight of the included patients had bilateral ear deformities, and two had unilateral deformities. The mean distance from the ear to the head at the superior helix was 29 mm (range, 25–35 mm). In our series, no complications were observed. During the most recent clinical evaluation, all patients had achieved acceptable ear positioning and excellent aesthetic results.

Conclusions:

Dermabrasion is a useful technique for otoplasty because no sutures are required and symmetry can be achieved in bilateral ears. Furthermore, this technology is safe, simple, reproducible, reliable, and versatile. We recommend that future studies be conducted in a prospective manner with larger sample sizes and longer follow-up periods to ensure the validity of the findings.

Takeaways

Question: In otoplasty, what is the role of dermabrasion?

Findings: In our series, no complications were observed after otoplasty using dermabrasion. During the most recent clinical evaluation, all patients had achieved acceptable ear positioning and excellent aesthetic results.

Meaning: Dermabrasion is a useful technique for otoplasty due to the fact that no sutures are required and symmetry can be achieved in bilateral ears. Furthermore, this technology is safe, simple, reproducible, reliable, and versatile.

INTRODUCTION

An ear protrusion is a physical characteristic found in around 5% of the population.¹ An enlarged concha or conchoscaphal angle, as well as aplasia or hypoplasia of the antihelix, may result in an apparent and unattractive protrusion of the ear. Over time, numerous surgical and noninvasive corrections have been discovered and published for this abnormality.^2–5 It is common to correct prominent ears in adolescents and adults with psychosocial problems or wishing to improve their appearance.⁴ A corrective otoplasty can be performed on preschool-aged children as their ears are nearing the completion of their development. It has been demonstrated that nonsurgical correction treatments are most effective in the first few weeks after birth when the cartilage is still supple and malleable enough to be shaped externally.^2,5 Several articles have discussed the need for antihelix correction in surgical otoplasties. As one of the first to address the antihelix, Stenstrom incised or abraded the ventral perichondrium to increase its ventral area.⁶ A prominent ear should be repaired according to McDowell’s fundamental objectives of otoplasty.⁷ Over 200 surgical treatments have been described,^6,8 but no single approach has been identified as the gold standard for all forms of ear protrusions. Among the different types of otoplasty, there are cartilage sculpting (cutting),⁹ cartilage-sparing (suturing),^10,11 and composite (combining sutures and sculpting).^12,13 Lemperle proposed a concealed ventral incision along the helix to gain maximum visibility of the ventral antihelical region to be abraded, thus improving Stenstrom’s approach. For thin cartilage, he advised using dermabrasion instead of rasping or incising, resulting in a smooth ventral surface, and preventing jagged and uneven cartilage appearances.⁵ Mascio et al reported their experience with an open procedure involving weakening the anterior surface of the ear cartilage by dermabrasion to obtain natural shape and acceptable symmetry. They concluded that it was a simple, quick procedure that showed immediate aesthetic improvements following the operation.¹⁴ In 1992, Pilz et al conducted a questionnaire among 267 patients who underwent otoplasty using a spherical metal head dermabrasion for retroauricular furrow and found it successful.¹⁵ Literature in regard to the use of dermabrader in managing patients with otoplasty has lacked more evidence since then. To the best of the author’s knowledge, this is one of the first articles to assess the clinical outcomes of dermabrader use on patients with prominent ear deformities.

METHODS AND MATERIALS

Selection of Patients, Study Design, and Ethical Considerations

A retrospective record review of nine patients with prominent ear deformities who had dermabrasion otoplasty performed at our institute by the senior author (A.G.) was conducted between 2018 and 2021. This study included patients with prominent ear deformities who underwent otoplasty with dermabrasion. Those with prominent ear deformities who were not corrected with the described technique were excluded. Data from the medical records were used to extract demographic information, such as the patients’ age and sex. The ear laterality, the amount of ear protrusion, any additional procedures they have had, complications (eg, infection, bleeding, wound healing issues, asymmetry, growth restriction, hypertrophic scar, keloid, and recurrence), need for revision surgery, and adverse effects are also reviewed from the medical records. Parents signed consent forms for the publication of preoperative and postoperative images. Institutional review board approval was obtained from the ethical approval committee at King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia (Ref. No. 20/2220/IRB).

Surgical Technique Description

The patient’s prominent ear was diagnosed based on a full medical history and a comprehensive physical examination. Preoperative blood tests were performed on all patients to determine their complete blood count, creatinine levels, electrolytes, and blood crossmatch. As a baseline, all patients had preoperative blood tests. Additionally, before surgery, as part of a routine checkup in our institute. The senior plastic surgeon (A.G.) performed all prominent ear otoplasty procedures. Dermabrader otoplasty is indicated in patients with prominent ear deformities. The following describes the main elements of our novel technique; however, patient-specific adjustments were made for each individual patient. The technique does not adhere to the historic norms of Gibson principles, which state that cartilage deforms along the opposite direction of abrasion based on scoring cartilage using blades and needles. We mainly use a dermabrader in our approach. Hence, we use the Gibson principle, but in a different way in order to change forces and allow cartilage to rotate in the opposite direction.

The dermabrader used was a 50/60 Hz per cycle model, registered 23BZ0075 of OSADA electric company. After explaining the benefits, risks, and complications to the parents and the patient, consent was obtained. Anesthesia and endotracheal intubation were administered to all patients, except two adult patients whose procedures were performed under local anesthesia. At the time of anesthesia induction, a prophylactic intravenous antibiotic was administered. The patients were all positioned supine. Typical prep and drape were followed. The postauricular area and mastoid area of the ear were exposed. The antihelix is shaped manually with forceps. We marked the lateral and medial edges of the antihelix and reinforced them with 25 gauge needles soaked in methylene blue. We subcutaneously injected tumescent lidocaine into the anterior and posterior aspects of the ear. The site of the skin incision was made by drawing a line between the medial and lateral antihelix margins from the posterior side of the ear. Incisions would be made along this line eventually. A full thickness of skin was excised by making an elliptical incision, and hemostasis was achieved. A posterior skin dissection was performed, the marked methylene blue was applied, and the marking was reinforced with a marking pin. An incision along the lateral outer edge of the antihelix down to the perichondrium was performed. Blade and sweeping maneuver or tenotomy scissors were used to dissect the anterior surface of the skin until the inner aspect of the antihelix was identified and marked. The anterior surface of the antihelix was dermbraded using a hand-held dermabrader with a 50-Hz speed, resulting in the rotation and recreation of antihelix. After the ideal shape was achieved, the dermabrasion was stopped, and the skin was redraped. After that, we measured the distance from the angle mastoid to the concha, and if the measurement was greater than 18 mm, whenever there is conchal excess, we add either a conchomastoid suture or an elliptical excision of some of the concha if suturing is insufficient. After hemostasis was established, the skin was sutured with horizontal mattress sutures using 5.0 vicryl rapide sutures. For symmetry, the same steps were performed on the other ear. The basic steps of the procedure are illustrated in Figure 1. The dressing was then applied. The patients were discharged the same day or the next day.

Fig. 1.

A brief overview of dermabrasion as an otoplasty technique for correcting prominent ears. A, Preoperative image of a prominent ear of an 8-year-old female child. B, Using 25-gauge needles soaked in methylene blue, the medial and lateral edges of the antihelix were reinforced. C, The skin was excised in an elliptical fashion, and hemostasis was achieved. D, A hand-held dermabrader with a 50-Hz speed was used to dermbrade the anterior surface of the antihelix, resulting in its rotation and recreation. E-F, After achieving the ideal shape, the dermabrasion was stopped, and the skin was redraped.

Postoperative Protocol

The patients were discharged with oral antibiotics and analgesia. The patients were advised to maintain head elevation, avoid bending, avoid swimming, and not sleep on the ear. Initial head wrap was worn for 7–10 days postoperatively, then reassessed, and the wound was assessed. For another 5 days, a crepe bandage was applied. In order to maintain ear position appropriately towards the side of the head, patients were advised to use a headband. A headband was applied for 6 weeks; then, patients were discharged. A few of the patients included in the study are shown in Figures 2 and 3.

Fig. 2.

A 16-year-old female patient with bilateral prominent ear deformities. A, Preoperative oblique right view. B, Preoperative frontal view. C, Preoperative oblique left view. D, Four months postoperative oblique right view. E, Four months postoperative frontal view. F, Four months postoperative oblique left view.

Fig. 3.

A 4-year-old male child with bilateral prominent ear deformities. A, Preoperative oblique right view. B, Preoperative frontal view. C, Preoperative oblique left view. D, Four months postoperative oblique right view. E, Four months postoperative frontal view. F, Four months postoperative oblique left view.

RESULTS

A total of 18 ears [nine patients (five female and four male patients with prominent ear deformities)] were operated on in our institute, using this novel otoplasty technique (Table 1). All patients were medically free and did not have any syndromic conditions. The mean age of the patients was 11 years (range, 6-29 years old). Eight of the included patients had bilateral ear deformities, and two had unilateral deformities. In terms of the cause of ear protrusion, nine patients had ill-defined antihelical folds (100%), four had obtuse choncomastoid angles (44.4%), for which they underwent conchomastoid sutures, and one patient had conchal cartilage hypertrophy (11.1%), where conchal resection was done in addition. Except for two patients, all patients underwent primary otoplasty. In these two patients, Mustardé technique otoplasty had failed. The mean preoperative distance from the ear to the head at the superior helix was 29 mm (range, 25–35 mm). Additional procedures included conchomastoid sutures in four patients (50%), and concharesection in one patient (12%). The mean operative time was 61 minutes (ranging from 50 to 101 minutes). In our series, no complications such as infection, bleeding, wound healing issues, asymmetry, growth restriction, hypertrophic scar, keloid, or recurrence were observed. During the most recent clinical evaluation, all patients achieved excellent aesthetic results and high patient satisfaction. Revision procedures were not performed on any of the patients. The mean postoperative follow-up was 6 months (range, 4–12 months).

Table 1.

Distribution of Categorical Variables

Variables	Frequency	Percentage (%)
Gender
Male	4	44
Laterality
Unilateral	2	22
Etiology of ear protrusion
Ill-defined antihelical folds	9	100
Obtuse choncomstoid angles	4	44
Chonchal cartilage hypertrophy	1	11
Additional procedure
Conchomastoid sutures	4	44
Conchal resection	1	11
No additional procedure	4	44

DISCUSSION

There are around 5% of people with an ear protrusion.¹ There have been over 200 surgical treatments described,^6,8 but no one method has been found to be the gold standard for all types of ear protrusions. We have operated on 18 ears using a novel technique, in which dermabraders were used to correct prominent ear deformities in this retrospective review study. We observed no complications in our series, with overall acceptable ear positioning and excellent cosmetic results. There has been little evidence since then regarding the use of dermabraders in the management of patients with otoplasty. As far as the authors are aware, this is the first study to evaluate dermabrader use on patients with prominent ear deformities. As the projection of the ear remains constant from an anterior view throughout life, the auricular width remains constant from maximum projection from an anterior view at the age of 6 years.¹⁶ Among the patients, the average age was 11 years (range, 6–29 years old). Correction of prominent ears is common among adolescents and adults with psychosocial problems or who wish to approve their appearance.⁴ Auricular projection is constant throughout life, reaching a maximum of 12 to 28 mm, with an average width of 20.4 mm.^5,16 Based on our findings, the distance from the ear to the head at the superior helix was 29 mm on average, with a range of 25 to 35 mm. As a hereditary trait, the protruding ear affects 5% of children.¹ Several advantages have been demonstrated in our technique, including avoiding any internal suture, reducing the risk of complications from sutures (eg, extrusion, suture failure), and decreasing the risk of recurrence. Furthermore, our technique works well on hard and firm cartilage, and it is easy to achieve bilateral ear symmetry. Additionally, this technique is useful for patients whose previous suture-based otoplasty procedures failed. However, it has the major disadvantage of requiring a learning curve. Skin avulsion can also occur from the dermabrader, or cartilage damage with overabrasion, resulting in asymmetrical and irregular results. The decision must be adjusted according to the patient’s age and cartilage thickness when performing otoplasty using this technique. Compared with older patients, younger patients’ cartilage is softer, which can make such procedures more challenging. On the other hand, dermabrasion works better on hard, firm cartilage. In light of the aforementioned reasons, the Mustardé suture technique is more suitable for young children than adults.

Limitations and Future Recommendations

Although the study aims were accomplished and it was considered the first in the Middle East, there were several limitations. The first is its retrospective nature and the fact that improper documentation was observed, whether it was a preoperative or postoperative assessment, including the postoperative superior helix to mastoid distance. There is also a limitation in terms of the number of patients. In most prior studies, few patients were involved, which might explain this. Moreover, younger patients require a longer time period of study due to the short average follow-up. Lastly, postoperative posterior views of the ears were not obtained. Our recommendation is that future studies compare the current technique used in managing prominent ears with other known techniques in the literature.

CONCLUSIONS

The purpose of this article is to present an overview of our experiences managing prominent ears using our novel otoplasty technique utilizing dermabrasion. In our opinion, no single technique is ideal for otoplasty. Dermabrasion is a useful technique for otoplasty because no sutures are required and symmetry can be achieved in bilateral ears. Furthermore, this technology is safe, simple, reproducible, reliable, and versatile. However, it has a disadvantage that it requires a learning curve to master. We recommend that this technique be used as the gold standard approach for managing prominent ear deformities. In addition, we recommend that future studies be conducted in a prospective manner with larger sample sizes and longer follow-up periods to ensure the validity of the findings.

PATIENT CONSENT

The parents or guardians provided written consent for the use of the patients’ images.