What are the steps involved in a bilateral otoplasty procedure and what neurovascular structures should be preserved?

Bilateral Otoplasty Procedure: Step-by-Step Technique and Neurovascular Structures to Preserve

The bilateral otoplasty procedure requires meticulous attention to neurovascular structures, particularly the greater auricular nerve and posterior auricular vessels, to minimize complications while achieving optimal cosmetic results.

Preoperative Assessment

• Evaluate the specific ear deformities requiring correction:
  • Underdeveloped antihelical fold
  • Conchal hypertrophy/excess
  • Protruding earlobes
  • Asymmetry between ears

Surgical Steps for Bilateral Otoplasty

Step 1: Marking and Planning

• Mark the antihelical fold position while patient is awake
• Outline the planned incision in the postauricular sulcus
• Mark areas of cartilage to be addressed (antihelix, concha)

Step 2: Anesthesia and Positioning

• Local anesthesia with sedation or general anesthesia
• Position patient supine with head turned to expose the first ear
• Prep and drape to allow access to both ears

Step 3: Incision and Exposure

• Make postauricular skin incision along the marked line
• Elevate a postauricular skin flap to expose the auricular cartilage 1
• This approach provides excellent exposure while minimizing visible scarring

Step 4: Cartilage Modification

• For antihelical fold creation:
  • Option A: Anterior scoring technique - score the anterior surface of cartilage where fold is desired
  • Option B: Mattress sutures - place permanent sutures to create fold
• For conchal hypertrophy:
  • Excise excess conchal cartilage
  • Place concho-mastoid sutures to reduce auriculocephalic angle 2

Step 5: Securing the New Position

• Place non-absorbable mattress sutures between the conchal cartilage and mastoid periosteum
• Ensure symmetry with the contralateral ear throughout the procedure
• Custom silicone molds may be used to maintain the desired shape during healing 2

Step 6: Closure and Dressing

• Close the skin with absorbable sutures
• Apply light pressure dressing
• Repeat procedure on contralateral ear
• Apply protective head dressing for 1-2 days, followed by headband support

Step 7: Postoperative Care

• Maintain head dressing for first 48 hours
• Use headband at night for 3-6 weeks
• Monitor for complications: hematoma, infection, skin necrosis
• Follow-up at 1 week, 1 month, and 3 months

Critical Neurovascular Structures to Preserve

1. Greater Auricular Nerve

   • Courses superficially over the sternocleidomastoid muscle
   • Provides sensation to lower two-thirds of lateral ear and postauricular region
   • At risk during postauricular incision and flap elevation
   • Injury results in numbness or painful neuroma

2. Posterior Auricular Artery

   • Branch of external carotid artery
   • Supplies posterior ear and mastoid region
   • Located in postauricular sulcus
   • Damage can cause hematoma or skin necrosis

3. Auricular Branch of Vagus Nerve (Arnold's Nerve)

   • Provides sensation to concha and external auditory canal
   • Manipulation can trigger vasovagal response
   • Located in posterior-inferior concha

4. Superficial Temporal Vessels

   • Located anterior to the ear
   • At risk during anterior approach or helix work
   • Injury can cause bleeding or hematoma formation

Potential Complications and Prevention

• Hematoma: Most common early complication; prevent with meticulous hemostasis and pressure dressing 3
• Infection: Rare; prevent with sterile technique and perioperative antibiotics
• Skin necrosis: Can occur with excessive tension; prevent by avoiding tight dressings 4
• Suture extrusion: Prevent by burying knots and using appropriate suture material
• Recurrence: Can occur in 3% of cases; prevent with proper technique and postoperative care 4
• Asymmetry: Prevent by frequent comparison of ears during procedure

Minimally Invasive Alternatives

For select patients, newer techniques like laser-assisted cartilage reshaping (LACR) may be considered, which can be performed without anesthesia using a 1540-nm laser. However, this technique has limited evidence compared to traditional surgical approaches 5.

The surgical approach should prioritize preservation of neurovascular structures while achieving the desired cosmetic outcome, with careful attention to postoperative care to minimize complications and ensure long-term results.