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Journal Information
Vol. 62. Issue 3.
Pages 181-187 (May - June 2011)
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5808
Vol. 62. Issue 3.
Pages 181-187 (May - June 2011)
Original article
DOI: 10.1016/j.otoeng.2010.11.004
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Otoplasty Without Cartilage Section Using the Mustardé Technique. Presentation of Our Experience
Otoplastia sin sección cartilaginosa mediante la técnica de Mustardé. Presentación de nuestros resultados
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5808
Luis Mompó??
Corresponding author
mompo_lui@gva.es

Corresponding author.
, Gracia Pastor, Marina Carrasco, M.a Teresa Cuesta, José Dalmau
Servicio de Otorrinolaringología, Hospital Universitario Doctor Peset, Valencia, Spain
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Abstract
Background

Some loop ear surgical procedures include cartilage section or abrasion, while others involve antihelix folding by simple suture.

Methods

Our results with the Mustardé technique are presented. This procedure avoids an aggressive action on the ear cartilage and makes antihelix folding easier.

Results

Good aesthetic results were obtained in all our patients, with a low complication rate.

Conclusions

We conclude this cartilage technical procedure has an advantage over the aggressive ones, with a low complication rate.

Keywords:
Otoplasty
Loop ears
Antihelix reconstruction
Resumen
Introducción

Entre las técnicas quirúrgicas para el tratamiento de las orejas en asa podemos distinguir entre las que conllevan una sección ó abrasión del cartílago y las que únicamente se basan en la sutura del mismo.

Métodos

Presentamos nuestros resultados mediante la técnica de Mustardé, con la que evitamos realizar una acción agresiva sobre el cartílago, facilitando la formación del pliegue del antehélix.

Resultados

En nuestra serie hemos obtenido un buen resultado estético, con bajo porcentaje de complicaciones.

Conclusiones

Pensamos que esta técnica aporta una ventaja sobre las que son agresivas con el cartílago, presentando un bajo porcentaje de complicaciones.

Palabras clave:
Otoplastia
Orejas en asa
Reconstrucción del antehélix
Full Text
Introduction

The auricular pavilion is formed by a thin sheet of elastic cartilage lined by epithelium, forming a series of anatomical contours. The lobe is formed by fibrous-fatty tissue (Fig. 1).

Figure 1.

Diagram of the ear.

(0.16MB).

The ears are at the sides of the head, in front of the mastoid process and behind the temporomandibular joint, roughly equidistant between the outer angle of the eye and the external occipital protuberance. They are generally located between 2 horizontal lines, the top one marked by the edge of the eyebrows and the bottom one passing just below the subseptum. Their average height is 60–65mm and their width, 25–35mm.

The angle that they form with the head (known as the auriculocephalic angle) measures 20–30° on average. However, there are some amplitude variations, which range up to 90°.

In the post-auricular region, there are 2 important angles, one between the skull and the concha (cephaloconchal angle) and one between the scapha and the concha (scaphoconchal angle); both have an average value of 90°.

The antihelix fold and adequate conchal development give the ear its characteristic shape.

The arterial supply to the ear stems from the temporal and superficial branches of the external carotid artery in its anterior section, whereas for the posterior section, it is the occipital branch joined to the post-auricular branches of the external carotid.

Innervation originates from the auricular branch of the cervical plexus and the auriculotemporal branch of the inferior maxillary nerve.

The auricular pavilion deformity known as loop ears or protruding ears is due to one or both of the following deformities: a lack of antihelix fold or a hypertrophy of the concha cartilage. In many cases, both deformities coincide to a greater or lesser degree.

There are several techniques to help create an antihelix fold. Some of them involve conducting various types of sections in the ear cartilage, some by an anterior approach (such as that by Stenström1,2) or by a posterior approach (such as those by Becker3,4 or Converse5), while others are more conservative with the cartilage, such as the technique by Mustardé.6

Surgical Technique

Once the patient is intubated, we carry out anaesthetic infiltration on the posterior side of the ear pavilion using 2% mepivacaine with adrenaline. A prophylactic antibiotic protocol is used, which includes a dose of cefazolin 30min prior to surgery and a second dose 4–6h after surgery.

Cutaneous excision is performed using a posterior approach, in a spindle shape. We form the antihelix fold by holding the pavilion with the fingers in an anterior position. Meanwhile, the posterior side should show the prominences formed by the cartilage located between the helix and the antihelix, as well as that between the antihelix and the chocha, which should be sutured. In this way, we can easily determine the location of the points where the stitches are to be placed; this avoids the use of needles that pierce the cartilage and consequently avoids trauma to it (Fig. 2).

Figure 2.

Otoplasty. Marking “U” suture points with a marker pen.

(0.11MB).

A sterile marker should be used to mark the 4 points through which the suture will pass to create a “U” suture. This should be done with non-absorbable material. In our series, we used Gore Tex® thread or nylon suture.

We start at the top of the pavilion, then descend and take 2 or 3 stitches as necessary.

The needle must pass through the width of the cartilage without penetrating to the anterior side. Once both prominences have been sutured, we gradually tighten it until the fold acquires the desired shape. Next, we suture downwards, adding 1 or 2 more as needed (Figs. 3–5).

Figure 3.

Schematic of cartilage suture to create the new fold.

(0.15MB).
Figure 4.

Schematic of cartilage suture to create the new fold.

(0.21MB).
Figure 5.

Otoplasty. Cartilage suture in “U” shape.

(0.15MB).

The remaining skin is sutured and the usual dressing in this type of surgery is then applied.

The patient can be discharged the day after surgery, after a review of the surgical wound to rule out the presence of complications (mainly haematomas and chondritis).

The bandage should be removed 7 days after surgery. At this point, the patient should be advised to sleep with a rubber band holding both pavilions for 1 month.

We took pictures of patients during the reviews, which took place 1 month and 9 months after surgery.

Results

We present 14 patients intervened at our hospital with this technique, between June 2003 and October 2008. In total, 3 patients were male and 11 female, with a mean age of 16.5 years (range, 6–35 years). All patients were operated on under general anaesthesia.

The result of the surgery was satisfactory in 12 of the 14 cases to date. One patient required a further operation due to recurrence of the deformity, caused by a release of the suture. In another patient, the suture protruded through the skin, so we proceeded to resect that stitch, with a satisfactory cosmetic result.

Figs. 6–9 show some examples of patients before and after surgery.

Figure 6.

Case 1. Frontal view at 6 months after surgery.

(0.18MB).
Figure 7.

Case 1. Lateral view.

(0.21MB).
Figure 8.

Case 2. Frontal view at 6 months after surgery.

(0.25MB).
Figure 9.

Case 2. Lateral view.

(0.24MB).
Discussion

Surgical resolution of prominent or loop ears can be accomplished by numerous techniques. The majority are divided between those that carry out an invasive procedure on the cartilage7 (scraping, section and repositioning) and those attempting to be more conservative to avoid most complications.8

Techniques such as that by Converse, which weakens the cartilage by abrasion through milling, or that by Chongchet,9 which creates incisions in the cartilage to facilitate folding, or that by Pitanguy,10 with a cartilage island, are widely distributed and accepted.

Other more conservative techniques are derived from the technique devised by Mustardé, which creates a new antihelix fold using non-absorbable suture material after piercing the cartilage with insulin needles to mark suture fold zones or using provisional transfixing stitches that give shape to the cartilage before carrying out the final suture. These procedures involve less traumatism for the cartilage.

Both techniques have supporters and there are numerous studies that show the results with both techniques and that provide combinations and modifications thereof, obtaining acceptable results in most cases.

In our experience, the cartilaginous section involves more traumatism to the ear cartilage. In addition, the sectioned cartilage edge may be left marked on the anterior side of the pavilion, giving a worse cosmetic result.

The reason for using the Mustardé technique without using insulin needles to mark the stitches is based on an intention to avoid trauma to the cartilage as far as possible, to minimise complications and facilitate the location of the points where the suture must be placed to form the antihelix fold, while shortening the operating time. It is consequently not necessary to section or weaken or cross the cartilage previously, because cartilage suture is sufficient to obtain very acceptable results, as in our series.

Using a division method, Balogh11 reported a recurrence rate of 3.95%. However, Mahler12 reported a recurrence rate of 20% with a combined approach, and Tan13 compared both techniques and obtained a much lower recurrence rate using the technique of anterior striation.

Using the Mustardé technique in 127 patients, Aguilar et al.14 reported a recurrence rate of 4.72%. Colpaert and Missoten15 used a personal technique derived from a Chongchet modification and reported a recurrence rate of 0%.

Schlegel-Wagner et al.16 conducted a retrospective study of 420 patients who underwent otoplasty with a technique including anterior weakening of the cartilage combined with post-auricular fixation sutures. They found satisfactory, long-lasting results in 91% of cases, with a recurrence of the defect in 2.3% of cases and partial in 8.6%.

Schaverien et al.17 published the results of a study including 112 prominent ears intervened using posterior sutures and covered with post-auricular facial flap. The clinical recurrence was 4.5%.

Olivier et al.18 published a review of long-term results and complication rate of otoplasties performed in 104 patients with a cartilage-conserving technique (a modification of the Mustardé technique), which obtained a satisfaction rate of 95%, with a rate of early complications of 6% (bleeding, asymmetry). Late complications (9%) included extrusion of stitches as well as keloid and hypertrophic scarring. Only 3 cases of the total required a second operation.

Mandal et al. conducted a study comparing 3 otoplasty techniques (Group A, anterior cartilage weakening technique; Group B, cartilage-conserving technique; and Group C, cartilage sutures with posterior facial reinforcement technique) in 203 patients. They concluded that cartilage-conserving techniques with posterior facial reinforcement had the lowest number of complications, obtaining a better cosmetic result.19

Richards et al.20 (in their published article “Otoplasty a review of surgical techniques”) and Panettiere et al.21 (in their article titled “Otoplasty: a comparison of techniques for the treatment of antihelix defects”) found no statistically-significant differences between the results of the techniques, although the latter noted that the techniques aimed at preserving the cartilage produced a more natural and aesthetic curvature of the ear.

Conclusions

Numerous techniques have been described for the resolution of prominent ears and all have advantages and disadvantages. In our experience, minimising trauma to the cartilage structure leads to good cosmetic results and fewer complications.

Even without using insulin needles, we can locate the suture points, minimising trauma to the cartilage, reducing the number of complications and shortening the surgical time.

The theoretical drawback of the techniques that do not carry out cartilage sectioning is a higher percentage of recurrence of the deformity. The low percentage (7%) of recurrences in our series suggests that this technique is valid for the treatment of lack of antihelix fold.

Conflict of Interests

The authors have no conflicts of interest to declare.

References
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Please cite this article as: Mompó L, et al. Otoplastia sin sección cartilaginosa mediante la técnica de Mustardé. Presentación de nuestros resultados. Acta Otorrinolaringol Esp. 2011;62:181–7.

Copyright © 2010. Elsevier España, S.L.. All rights reserved
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