Cosmetic Otoplasty

Alexander L. Schneider, MD, Douglas M. Sidle, MD*

KEYWORDS Otoplasty Prominauris Prominent ear surgery Mustarde´ Furnas

KEY POINTS Otoplasty for prominent ears is unique in that it is a widely performed and accepted procedure in the pediatric population, done for cosmetic and not functional motives. A detailed knowledge of auricular anatomy and anthropometric norms is essential for the facial plastic surgeon before undertaking any otoplastic surgery. There are myriad ways to correct prominauris and the facial plastic surgeon must possess a mastery of a wide variety of techniques to provide durable and acceptable results.

INTRODUCTION EMBRYOLOGY It has been estimated that up to 5% of the popula- Before undertaking an intervention to correct tion suffers from protruding ears, otherwise known prominauris, the surgeon must first possess a as prominauris.1 Prominauris is considered to be comprehensive knowledge of the anatomy of among the most common congenital deformities the ear. As with all anatomic knowledge, this be- of the head and neck region, the most common gins with understanding the pertinent embry- congenital deformity of the external ear, and is ology. The otic placode is the precursor of the transmitted in autosomal dominant fashion with ear and develops during the third gestational variable penetrance.2 This anatomic abnormality week. The origin of the auricle (or pinna) is rooted typically causes no physiologic change with in the concept of the hillocks of His: the hillocks regards to hearing, though it has rarely in the liter- consist of 6 mesodermal swellings that encircle ature been documented to be an occupational lia- the dorsal surface of the first branchial groove. bility in a specific military population.3 The The first (mandibular) branchial arch is respon- negative psychosocial impact of prominauris is sible for the development of the 3 cranial-most often the motivating factor to seek surgical correc- hillocks, which in turn are responsible for the tion.4 In young children and adolescents, the psy- development of the (1) tragus, (2) helical crus, chological effects are often due to a combination and (3) helix. The second (hyoid) branchial arch of name-calling, bullying, and ridiculing. The is responsible for the development of the next embarrassment and anxiety associated with these most caudal hillocks: (4) antihelix, (5) antitragus, psychosocial stressors can lead to increased anx- and (6) lobule. The hillocks fuse by week 12 and iety, behavioral abnormalities, and result in lack of when this fusion occurs inappropriately a preaur- social integration.5,6 As a result, otoplasty for the icular sinus tract may result. The concha is postu- correction of prominauris is a widely accepted lated to derive from ectoderm of the first branchial cosmetic surgery in the pediatric population that groove, with the upper portion becoming the is done solely for aesthetic reasons rather than cymba concha, the middle portion becoming the for correction of an occupational or functional cavum concha, and the caudal-most portion deficit. becoming the intertragal incisura.

Disclosure Statement: The authors have nothing to disclose. Department of Otolaryngology–Head and Neck Surgery, Northwestern Memorial Hospital, Northwestern Uni- versity, 676 North Saint Clair, Suite 1325, Chicago, IL 60611, USA * Corresponding author. E-mail address: [email protected]

Facial Plast Surg Clin N Am 26 (2018) 19–29 https://doi.org/10.1016/j.fsc.2017.09.004

SURFACE ANATOMY (anterior), occipital artery (posterior), and posterior auricular artery (posterior). The superficial tempo- The ear is a complex structure composed of ral artery exits the substance of the parotid gland, elastic cartilage and skin. The 3-dimensional travels beneath the anterior auricular muscle, and topography of the external ear with its many eleva- then divides into branches that supply the anterior tions, depressions, involutions, and folds is reflec- auricle. The posterior auricular artery leaves the tive of the underlying cartilaginous structure. The external carotid artery, runs deep to the posterior auricular cartilage is a single piece of elastic fibro- auricular muscle and great auricular nerve, and cartilage, invested with perichondrium on all sur- branches to supply the posterior surface of the faces, and has a relatively uniform thickness ear. Venous drainage consists of veins of the throughout. The anterior aspect of the auricle is same name, which ultimately drain into the concave and contains the aforementioned compli- external jugular vein. The end branches of these cated topography, due in large part to the skin en- vessels form an extensive anastomotic blood sup- velope of the anterior and lateral auricle being fine, ply to the auricle, which is of great import for local thin, and firmly adherent to the underlying cartilage flap auricular reconstruction. The sensory innerva- with little intervening subcutaneous tissue be- tion of the external ear is complex. The great auric- tween skin and cartilage. The posterior aspect of ular nerve, a branch of the cervical plexus, the auricle is smooth, convex, and covered with innervates the inferior surface. The lesser occipital, a skin envelope that is considerably less adherent, also a branch of the cervical plexus, innervates the with a thin subcutaneous areolar tissue layer be- posterior superior surface. The auriculotemporal tween the skin and cartilage; these characteristics nerve, a branch of the mandibular component of are useful in flap elevation. the trigeminal nerve, innervates the anterior supe- The important surface features of the auricle are rior surface. The concha proper and tragus are seen in Fig. 1A. The helix is the peripherally innervated by the Arnold nerve, which is a small located rim of the auricle. It extends anteriorly to distal branch of the vagus nerve. form the root of the helix, or crus of the helix, ori- ented horizontally above the external acoustic meatus. Immediately inferior to the root of the helix AURICULAR MUSCULATURE is the tragus. The space between the crus of the The musculature of the auricle can be divided into helix and the tragus is the anterior incisure. The extrinsic and intrinsic muscles. The extrinsic mus- antitragus is posteroinferior to the tragus, and the cles connect the auricle with the skull and scalp, space between the tragus and antitragus is known whereas the intrinsic connect different parts of as the intertragal incisure. The antihelix begins at the auricle to each other. The superior auricular the antitragus and runs anterior and parallel to is the largest of the external muscles. It is thin, the helix, initially as a single prominence. In its fan-shaped, and has its origin on the lateral aspect superior-most extent, the antihelix splits into supe- of the galea aponeurotica, inserting onto the superior (posterior) and inferior (anterior) crura, and the rior aspect of the cranial surface of the auricle. The depression created by this division is known as the anterior auricular muscle is also thin and fan- triangular fossa. The deep concave furrow in be- shaped, arises from the anterolateral edge of the tween the helix and the antihelix is known as the galea aponeurotica, and inserts onto a projection scapha or scaphoid fossa. The concha is a cavity on the front of the helix. The posterior auricular posterior to the external auditory meatus and sur- consists of 2 to 3 fascicles. It is smaller, has its rounded by the antihelical fold. The crus of the he- origin in the mastoid portion of the temporal lix divides the conchal cavity into the cymba bone, and inserts onto the inferior aspect of the (superior) and cavum (inferior) concha, which is cranial surface of the concha. The intrinsic auric- approximately 8 mm deeper than the tragus and ular muscles are primarily composed of helicis ma- antitragus. Below the antitragus is the lobule, jor, helicis minor, tragus, and antitragicus, which which is devoid of cartilage, composed entirely surround the conchal bowl. Cranial nerve VII sup- of areolar connective tissue and fat, and marks plies the auricular musculature via its posterior an important landmark for the inferior auricle. auricular and temporal branches, though these muscles generally have very little volitional NEUROVASCULAR SUPPLY movement.

The neurovascular structures of the auricle are NORMAL ANTHROPOMETRIC FEATURES shown in Fig. 2A, B. Arterial blood supply to the ear is primarily derived from branches of the Anthropometric studies have revealed that the ver- external carotid artery, superficial temporal artery tical length of the adult auricle measures between Download English Version: https://daneshyari.com/en/article/8806060

Download Persian Version:

https://daneshyari.com/article/8806060

Daneshyari.com