Surgical technique
bleeding, ®, keloids, hypertrophic scars, hematoma, skin infections, overcorrection
BLEEDING, HEMATOMA, PERIOSTEUM, SKIN INFECTION
Patients underwent otoplasty using the technique described by Maniglia et al.,A retroauricular skin ellipse was drawn about eight to ten millimeters medially to the edge of the helix and anteriorly to the retroauricular groove. The excision should not be exaggerated so that the suture can be performed without tension. Here, it was important to check the position of the lobe, as the incision should be extended through the earlobe (Surgical steps of otoplasty. (A). Mustardé tattoo points; (B) retroauricular incision; (C) dissection; (D) identification of tattoo; (E). Concha resection; (F) cartilage incision; (G) Mustardé sutures; (H) furnas sutures; (I) lobule repair.The new anti-helix is simulated with a digital maneuver, and then the markers were tattooed with a straight needle and gentian violet trough the cartilage. At least three or four points are marked to do the sutures, as described by Mustardé.The incision and removal of retroauricular skin began inferiorly so the bleeding will not affect the upper incision view. The dissection plane was between the subcutaneous tissue and the perichondrium. With an iris scissors or a scalpel, the pre-marked skin was removed. Careful hemostasis was performed. At this point it was important to highlight the preservation of the perichondrium.A lateral skin flap was made wide enough to visualize the demarcated site for Mustardé sutures. This procedure aimed to avoid threads extrusions in the postoperative period. The posterior ligaments and extrinsic muscles of the ear were sectioned, with the mastoid periosteum as the medial limit. After this step, the ear was loose, which allowed to correct, through sutures, the topography of the pavilion in a side view, as well as its retropositioning.The removal of conchal cartilage excess were established by two points: an upper and a lower one. It was important to make sure that the cartilage to be removed should not coincide with the markings of the Mustardé sutures. The extension in the smallest axis of the ellipse was proportional to the deformity to be corrected. A 15-blade scalpel was utilized to incise the cartilage, and with a freer detacher, the conchal cartilage can be easily dissected, leaving the perichondrium attached to the skin, without impairing its circulation and consequent skin vitality.The new anti-helix area was weakened through incomplete longitudinal and transverse incisions in the cartilage. The depth of the incision will depend on the thickness of the cartilage.Mustardé sutures were positioned and repaired using 4.0 colorless nylon® thread. U-shaped sutures were performed as previously marked, sliding the needle between the cartilage and the anterior skin of the auricular pavilion. Three or four sutures were performed, according to cartilaginous thickness: in the thinnest cartilages, three sutures were sufficient; in the thick ones, up to four master sutures were performed.The fixation of the remaining concha in the mastoid region allowed to reposition the auricular pavilion, providing its retropositioning with superior rotation. Four sutures with Vicryl® 3.0 thread was performed. The first suture was positioned approximately five millimeters from the upper vertex of the removed ellipse, medially. The second suture, also at 5-mm, at the lower vertex. Therefore, the third suture was placed at the upper vertex, laterally, and the fourth, at the same distance from the lower vertex (The Mustardé sutures were carefully finished, with gradual and progressive tightening. Cartilage folds should be subtle and rounded. The distance between the helix and the mastoid around 13–15 mm was respected. A slight two-millimeter overcorrection is appropriate.The last structure to be corrected was the lobule. Black nylon® 4.0 thread was used. The position of the lobe should coincide with the auricular pavilion plane. This uneven suture should be performed in the most prominent region of the lobe, simulating its retropositioning. The skin was sutured with simple, separate stitches, without tension, to avoid the appearance of hypertrophic scars, keloids and/or skin infections.The distances between the lateral edge of the helix and the surface of the mastoid were measured in its upper, middle and lower thirds before dressing. A cotton molded wrapped in antibiotic ointment was placed in the concha region, reducing the possibility of dead space and hematoma. A 12-cm wide crepe bandage should be attached around the head, taking care that there is not too much tight.