INTRODUCTION
Prominent ears, popularly called “flappy ears,” represent the most common congenital
deformity of the outer ear, affecting approximately 5% of the population1. Both sexes are affected in the same proportion, and in approximately 60% of cases,
this deformity can be diagnosed at birth, which is most evident in the first years
of life2,3.
People with prominent ears have facial and aesthetic harmony problems, which can lead
to psychic disorders related to social interaction, especially during childhood and
adolescence3,4,5. The outer ear reaches 85% of its final size around three years of age, reaching
adult size around 6 to 7 years6. Therefore, the ideal age for surgical correction would be between 4 and 6 years,
since it also coincides with the beginning of the individual’s school/social life4,7.
The most common cause of ear prominence is erasure or absence of the antihelix, present
in two-thirds of cases, resulting in lateral projection of the helix6. However, other changes may also be present in combination or not, namely: hypertrophy
of the shell, increase in the cephaloconcal angle (> 90°) and protrusion of the lobe1,8.
Otoplasty techniques have been developed using different antihelix treatment methods,
such as sutures, repositioning, incision and excision of cartilage3,9. In general, the antihelix treatment can be divided into two categories: incisional/abrasive
and cartilage saving10. The first aesthetic otoplasties were described by Ely, in 188111 and Luckett, in 191012, being examples of incisional techniques13,14.
After several reports of techniques published in the literature, Converse, in 196315,16, associated the incision of cartilage with sutures in order to produce a more natural
result to the antihelix and avoiding failures common to previous techniques10. In 1963, Mustardé17 was the first surgeon to describe the recreation of the antihelix fold with only
multiple horizontal sutures, thus being a technique classified as cartilage-sparing13.
Since then, several studies published in the literature have evaluated the postoperative
results obtained with different surgical techniques. However, no published studies
are comparing the results of different surgical techniques for the treatment of prominent
ears.
OBJECTIVE
This study proposes to make a comparison between two surgical techniques for antihelix
treatment used in the correction of prominent ears: The Converse and Mustardé techniques,
evaluating the surgical results, and observing if there is superiority between them.
METHODS
Primary, prospective and intervention study comparing the results of patients undergoing
the surgical procedure to correct prominent ears using the Converse technique and
that of Mustardé, performed at the Plastic Surgery Service of the Hospital das Clínicas
of the Federal University of Pernambuco (HC -UFPE).
Patients were randomly selected into two different groups of surgical techniques to
correct the antihelix, the Mustardé technique, and the Converse technique. Patients
who spontaneously sought service with the desire to correct prominent ears and who
had absence or underdevelopment of the antihelix were included. Patients who had already
undergone previous auricular surgical procedures, patients with congenital or acquired
auricular deformities, smokers, patients with chronic systemic diseases, and users
of chronic medications were excluded.
The imposed data were: sex, age, presence of erasure of anti-helix, shell hypertrophy,
lobe protrusion, increased cephalocaudal angle, laterality, auricular mastoid distance
in three sites of the ear external, complementary surgical treatment performed and
complications.
The auricular mastoid distances were measured from the mastoid region to the lateral
edge of the helix, with the head in a neutral position, measured with the aid of an
analog pachymeter in the upper, middle and lower regions, bilaterally, which correspond
respectively to the bifurcation of the antihelix in upper and lower branches, the
upper edge of the ear canal and the most caudal segment of the intertragic notch (Figure 1). The evaluation times were: preoperative, 1, 3, and 6 months postoperative, with
the necessary photographic documentation.
Figure 1 - A. Measurements made with the aid of an analog caliper; B. Auricular mastoid distances were measured from the mastoid region to the lateral
edge of the helix, in the upper, middle and lower regions.
Figure 1 - A. Measurements made with the aid of an analog caliper; B. Auricular mastoid distances were measured from the mastoid region to the lateral
edge of the helix, in the upper, middle and lower regions.
Surgical technique
All patients underwent the surgical procedure under local anesthesia and propofol
sedation. After removal of a retroauricular skin spindle, detachment of the skin with
adequate exposure of the posterior region of the auricular cartilage, one of the following
procedures is followed:
Mustardé technique
It is performed the bidigital anterior maneuver of the scapha with the thumb and forefinger,
transfixed in 3 places along the antihelix, which was pronounced, with the help of
a 0.45x13mm needle dyed in bright green to make the “tattoo” of the posterior face
of the cartilage. Suture with 4-0 mononylon, about 1 cm laterally, the previous markings
for the formation of a new antihelix (Figure 2).
Figure 2 - A. Previous marking; B. Complete subcutaneous detachment, exceeding the guide points; C. Suture with 4-0 mononylon, about 1 cm laterally to previous markings; D. Immediate postoperative with the formation of a new anti-helix.
Figure 2 - A. Previous marking; B. Complete subcutaneous detachment, exceeding the guide points; C. Suture with 4-0 mononylon, about 1 cm laterally to previous markings; D. Immediate postoperative with the formation of a new anti-helix.
Converse technique
It is performed the bidigital anterior maneuver of the scapha with the thumb and forefinger,
and it is transfixed in 3 points along the antihelix, which was pronounced with the
help of a 0.45x13 mm needle dyed in bright green to make the “tattoo” of the posterior
cartilage. An incision is made with a scalpel blade 15, bilaterally, joining the previous
markings. Subsequently, the internal/external edges are sutured with mono nylon 4-0
in 3 places to form a new antihelix (Figure 3).
Figure 3 - A. Previous Marking; B. Marking of the posterior face of the cartilage in the projection of the anti-helix;
C. Incision with a scalpel blade 15, bilaterally associated with suture with 4-0 mononylon
in 3 locations; D. Immediate postoperative.
Figure 3 - A. Previous Marking; B. Marking of the posterior face of the cartilage in the projection of the anti-helix;
C. Incision with a scalpel blade 15, bilaterally associated with suture with 4-0 mononylon
in 3 locations; D. Immediate postoperative.
After performing the surgical technique of each group, it is then followed for the
other treatments: Furnas stitches and lobe repositioning, if necessary, and the skin
is closed with 4-0 mono nylon.
The research followed the principles of the Declaration of Helsinki, revised in 2000,
and Resolution 196/96 of the National Health Council. It was also submitted to the
institution’s Ethics and Research Committee (CEP), being approved with CAAE 64223417.9.0000.5208
and Opinion 2,019,499. The data were grouped in a Microsoft Office Excel 2015 spreadsheet,
analyzed by SPSS software version 2.0 R version 3.4.3.
The non-parametric statistical test used was Wilcoxon’s, considering a value of p
<0.05.
RESULTS
Twenty patients were evaluated, 10 using the Converse technique and 10 using Mustardé,
from June 2016 to December 2017. Males represented 30% of both groups, the mean age
in the Converse and Mustardé group was 18.9 and 22.3 years, respectively. All patients
in the study had erasure of the antihelix, increased cephaloconchal angle, and bilateral
abnormalities. Conchal hypertrophy and lobe protrusion were present in 19 (95%) and
6 (30%) patients, respectively. The treatment of the concha using the Furnas technique
and the treatment of the lobe was performed in all patients who presented these changes.
Both groups showed a decrease in auricular mastoid distances at the end of the observation
period, ranging from 6.67 to 14.6 mm, depending on the surgical technique and the
evaluation point, however, in comparison, there was no significant p-value between
the group results Regarding the average auricular mastoid distances at the end of
the observation period, a difference of a maximum of 6.3 mm was observed between the
results obtained, but also with a negligible p-value (Table 1).
Table 1 - Auricular mastoid distance during the observation period and mean decrease.
Measurement
locations
|
Means |
Significance |
| Mustardé |
Decrease |
Converse |
Decrease |
p-valor
|
| Evaluation time |
Preoperative |
6 Months |
Preoperative |
6 Months |
| Upper/right third |
29.60 |
15 |
14.60 |
29.10 |
15.27 |
13.83 |
0.726 |
| Upper/left third |
29.60 |
15.50 |
14.10 |
28.80 |
15.77 |
13.03 |
0.9523 |
| Middle/right third |
28.60 |
15.60 |
13 |
27.30 |
15.13 |
12.17 |
0.7648 |
| Middle/left third |
27.10 |
15.50 |
11.60 |
26.40 |
15.50 |
10.90 |
0.6232 |
| Lower/right third |
19.90 |
12.10 |
7.80 |
20.10 |
12.73 |
7.37 |
0.2931 |
| Lower/left third |
21.70 |
13 |
8.70 |
19.40 |
12.73 |
6.67 |
0.6808 |
Table 1 - Auricular mastoid distance during the observation period and mean decrease.
Regarding the symmetry of the ears within the same group, the maximum mean level of
asymmetry in the Mustardé and Converse groups was 0.9 mm and 0.5 mm, respectively
(Table 2). When evaluating the percentage of loss of correction of the measures obtained surgically
during the observation period, both groups ranged between 15-19%, however, in comparison
with each other, there were no significant differences between the results (Table 3). Regarding complications, there was 1 (10%) case of hematoma in the Mustardé group.
Table 2 - Mean asymmetry (in mm) between the ears.
| Measurement locations |
Mustardé |
Converse |
| Right |
Left |
Asymmetry |
Left |
Left |
Asymmetry |
| Upper third |
15 |
15.50 |
0.50 |
15.27 |
15.77 |
0.50 |
| Middle third |
15.60 |
15.50 |
0.10 |
15.13 |
15.50 |
0.37 |
| Lower third |
12.10 |
13 |
0.90 |
12.73 |
12.73 |
0 |
Table 2 - Mean asymmetry (in mm) between the ears.
Table 3 - Rate of loss of measures surgically reached at the end of the evaluation period.
| Measurement locations |
Means |
Significance |
| Mustardé |
Converse |
p-value
|
| Upper/right third |
18% |
19% |
0.726 |
| Upper/left third |
19% |
18% |
0.9523 |
| Middle/right third |
16% |
17% |
0.7648 |
| Middle/left third |
17% |
17% |
0.6232 |
| Lower/right third |
15% |
15% |
0.2931 |
| Lower/left third |
16% |
15% |
0.6808 |
Table 3 - Rate of loss of measures surgically reached at the end of the evaluation period.
DISCUSSION
The Mustardé and Converse techniques described, respectively, in 1955 and 1963, have
their uses spread throughout the world; however, like all surgical tactics, they present
their positive and negative points. The Converse technique, considered incisional,
has as a positive point the fact that the cartilaginous incision provides a loss of
local resistance for the manufacture of the new antihelix, decreasing the tension
in the suture, supposedly decreasing recurrence rates, however as a negative point,
this incision can provide visible contour irregularities to the anti-helix6,18.
On the contrary, the Mustardé technique, considered cartilage-sparing, has the advantage
of providing a smooth contour for the antihelix, on the other hand, due to the lack
of weakening of the cartilage, there is supposed to be a tendency for the cartilage
returns to its abnormal position, which can cause an increase in recurrence rates6,18.
In general, in order to achieve the best results, the following aspects described
by McDowell, in 196819, must be observed and fulfilled: 1) the helix must be seen entirely behind the antihelix
in the frontal view; 2) smooth and regular helix; 3) final scar must be located in
the retroauricular groove and without distortion; 4) difference in measurements between
the operated sides of a maximum of 3mm; and, 5) the distance from the helix to the
mastoid, at the upper, middle and lower points, should vary between 10-12mm, 16-18mm
and 20-22mm18 respectively.
It was observed that both groups reached all the above criteria during the observation
period, except for the proposed distances, however, McDowell does not describe in
his article how such measurements were determined, which hinders a reliable comparison9. However, the final measurements of the present study comply with that established
by Adamson et al., in 199120, which determines an auricular mastoid distance from the upper-middle segment of
the ear between 15 and 20 mm as aesthetically desirable20 (Table 4). When comparing the final averages of the auricular mastoid distances, between the
two surgical techniques evaluated, there was a difference of 6.3 mm maximum between
the results obtained, but with an unimportant p-value, that is, both techniques provided
similar auricular positions (Table 1).
Tabela 4 - Comparação das medidas observadas no presente estudo com as encontradas na literatura.
| Locais de mensuração |
Médias |
| Grupo Mustardé |
Grupo Converse |
Adamson, 1991 |
McDowell, 1968 |
| Terço superior/direito |
15 |
15.27 |
15-20 |
10/dez |
| Terço superior/esquerdo |
15.50 |
15.77 |
| Terço médio/direito |
15.60 |
15.13 |
16-18 |
| Terço médio/esquerdo |
15.50 |
15.50 |
| Terço inferior/direito |
12.10 |
12.73 |
Não definido |
20-22 |
| Terço inferior/esquerdo |
13 |
12.73 |
Tabela 4 - Comparação das medidas observadas no presente estudo com as encontradas na literatura.
Both groups showed a decrease in auricular mastoid distances at the end of the observation
period ranging from 6.67 to 14.6 mm, very similar to that found in the literature,
as the studies by Adamson et al., in 199120, Schneider and Side, in 201821 and Foda, in 199922, obtained average rates of auricular medialization, respectively, of 5.9 mm, 14 mm
and 17 mm, depending on the place and time of the evaluation. As for the symmetry
between the ears within the same surgical technique, the asymmetry varied from 0 to
0.9 mm, that is, both groups remained within the maximum of 3 mm recommended in the
literature18,21 (Table 2). Despite being a subjective criterion, the surgical team and all patients were satisfied
with the results obtained at the end of the observation period20 (Figures 4 and 5).
Figure 4 - A e C: Aspecto pré-operatório; B e D: Aspecto pós-operatório.
Figure 4 - A e C: Aspecto pré-operatório; B e D: Aspecto pós-operatório.
Figure 5 - A e C: Aspecto pré-operatório; B e D: Aspecto pós-operatório.
Figure 5 - A e C: Aspecto pré-operatório; B e D: Aspecto pós-operatório.
Regarding the percentages of loss of correction, these would vary from 15 to 19% in
both groups, depending on the follow-up evaluated. These values are lower than those
found in the literature, such as that of Foda, in 199922, in which the average was 32%; however, this one had a follow-up of 28.4 months,
that is, we could observe a higher percentage in more extended monitoring period.
Another point to highlight would be that the difference between the groups was a maximum
of 1%, but with an unimportant p-value compared to each other, which suggests an equivalence
of the rates of correction loss between the surgical techniques (Table 3).
As for complications, Elliott divides complications into early and late. The precocious
ones would be a hematoma, infection, chondritis, pain, bleeding, itching, and skin
necrosis. Late ones would be visible scarring, patient dissatisfaction, suture-related
problems, and dysesthesias6. We observed only one case of hematoma in the Mustardé group; however, the literature
shows complication rates ranging from 0% to 47.3%, that is, the index found in this
research remained within the expected range23,24. The treatment was performed with simple outpatient drainage and a compressive dressing
with adequate resolution of the case.
It is noteworthy that no studies were found in the literature comparing surgical techniques
to reposition the antihelix using a standardized and objective measurement protocol.
Another positive point, Tables 1 and 3, which show, respectively, the means of the final measurements of the points evaluated
between the groups and the percentages of the means of recurrence, did not obtain
the p-value at the 5% level with the test. Wilcoxon. In other words, the sample size
did not influence the comparison of results between the Mustardé and Converse techniques.
Furthermore, therefore, the sample size used in the research was sufficient to conclude
that the lack of difference in the results between the treatments evaluated was not
due to the number of participants, but to the similarity of the results of the techniques.
On the other hand, a possible bias in this study was the 6-month follow-up period,
as there are studies with periods of up to 6.25 years9. That is, we could then experience higher rates of correction loss, complications,
and even recurrence of prominent ears.
CONCLUSION
The Converse and Mustardé techniques showed no statistical difference in the results,
when compared to each other.
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1. Hospital das Clínicas da Universidade Federal de Pernambuco, Recife, PE, Brasil.
Corresponding author: Marcel Fernando Miranda Batista Lima, Rua Barão de Itamaracá, nº78 - apto 1203 - Espinheiro, Recife, PE, Brazil. Zip Code:
52020-070 E-mail: marcelflima@hotmail.com
Article received: September 30, 2019.
Article accepted: February 22, 2020.
Conflicts of interest: none.
