Otoplasty Procedure: Incisionless Otoplasty Vs. Traditional Method

Is Incisionless Otoplasty better than Traditional Otoplasty? How do Results compare?

I completed two full surgical residency programs, one in ENT (Ear Nose Throat) surgery and one in Plastic Surgery. I started my career using primarily Incisionless Otoplasty techniques, and over the years I've adopted a hybrid of methods that combines both Traditional and Incisionless techniques.

Best of Both Worlds?  -- Combined Incisionless and Traditional methods:

My most common technique today combines traditional removal of cartilage from the deep "bowl" or "concha" area with a hybrid of weakening the "fold" area and then using Incisionless shaping sutures. The biggest difference is that I do not have to rely only on the tension of sutures for achieving a stable result. I feel this is a better option in my practice that has results that are more predictable and symmetric and have less relapse. 

Is there less risk with Incisionless? 

No, there is not less risk with Incisionless technique in my view. With Incisionless Otoplasty, all of the reshaping forces are applied by suture only, and therefore more tension and more sutures are required, and this can lead to more relapse, less control, and more likelihood of visible sutures or suture infections.

I have had to remove sutures on occasion from Incisionless Otoplasty patients that have become infected, and I've seen patients treated by other surgeons that have had chronic infection problems from Incisionless sutures and have needed reoperation. By contrast, I have not seen infection problems when I have combined techniques.

Hope this helps,

Nick Slenkovich, MD FACS

 

Most surgeons who perform otoplasty employ the more traditional techniques, amongst which toe cartilage sparing method with permanent suture fixation is  the most popular one. The most common reasons when a technique is more popular among surgeons in any type of plastic surgery include reliability and reporoducibility  and lower risk of complications. In case of the otoplasty discussion I think all apply. But, that is just one surgeon's opinion with full respect for others perspective and experiences. 

There are many different techniques to re-shape and re-position the ears. "Incisionless" Otoplasty is not truly incisionless and does require penetrating through the skin in order to get the sutures beneath the skin. Virtually all Otoplasty techniques are going to involved the same risks, including bleeding, scarring, infection, need for revision surgery, dissatisfaction with the results, etc. 
Keep in mind that these "less invasive" techniques are only reserved for certain patients, and I find that almost all patients need some element of setting the entire ear back in addition to molding and shaping the cartilage with suture in order to obtain optimal results.
Best, 

Setback otoplasty is performed
through a relatively small incision on the back of the ear.  This incision allows precise placement
of structural sutures which optimizes the contour of the ear.  These incisions heal nicely and are
well hidden behind the ear.  It’s
unusual for patients to complain about scarring once the wounds have healed.

For this reason, incisionless
otoplasty doesn’t seem to offer a major advantage over traditional
otoplasty.  In addition this
approach might compromise the final contour of the ear.  As a result, the majority of plastic
surgeons prefer a traditional technique.

Incisionless otoplasty can be useful for a small subset of patients who have minor ear prominence.  The technique involves placement of sutures through the skin to reshape the ear.  The problem with this technique is a higher risk of recurrent prominence after healing.  The traditional technique allows the placement of sutures, as well as cartilage softening, and cartilage reduction.  In skilled hands, the traditional approach allows correction of virtually any ear prominence problem, while the incisionless approach has limitations.

So in essence it is a scarless procedure.  Bad scarring can occur if the surgeon resects skin from the back of the ear in conjunction with the cartilage setback.  With the open technique there is more control and greater ability to achieve long lasting results.

There are several incisionless techniques but the most common is the use of small stab incisions in the front of the ear, which actually requires the use of an incision (small, but still potentially visible).  The problem is that the ear is much more complex and in most cases additional reshaping is required.  

 

Traditional otoplasty creates an incision in the posterior portion of the ear, hidden in the post auricular crease.  The tradeoff of having a better otoplasty result with a scar in a difficult to see location versus a result which may not address the otoplasty issue with a smaller and potentially visible scar lends the traditional scar to be the treatment of choice.

As you might suspect, so-called "incision-less" otoplasty involves multiple tiny incisions to try to accomplish what experienced plastic surgeons and facial plastic surgeons do through the usual otoplasty incision behind the ear. This "blind approach" can work in a small subset of carefully-selected otoplasty patients, but mostly incisionless otoplasty is marketing hype.

There are a lot of anatomic considerations to a properly-performed otoplasty, and all patients do NOT have the same congenital deformities. Some patients have an abnormally large concha, some have an incomplete antihelical fold, some have both, and others have more complex anatomic situations that require different reconstructive techniques. Fix THAT through a keyhole! Again, while some minor situations can be corrected or improved via small incisions, the quality of the final result is far more important than a well-placed (behind the ear) and skillfully-closed incision that is not visible even if you are bald!

The reason that more plastic surgeons do not perform this procedure is because experienced, board-certified plastic surgeons who have high ethical standards do not perform ill-advised, higher-complication, poor-result procedures. We always try to do what's best for our patients, as ultimately, our reputation and livelihood depend on that!

The incision-less technique for otoplasty is ideal for children or for adults that have soft and malleable ear cartilages. For most adults the traditional technique is better and the scar being behind the ear is of no consequence.

What do you mean by incisionless otoplasty?
I have heard of two different procedures:

The first is neonatal molding, popularized in Japan, where special splints are made for newborn infants to "mold" the ears into place. This is only effective while maternal estrogens are circulating in the fetal bloodstream and make the infant ear cartilage supple.
The other is the use of small Virutally invisible "stab" incisions in the ear in which permanent stitches are placed to bend the cartilage.

This latter technique is not very reliable and has a higher recurrence rate which makes is generally unpopular with plastic surgeons. It essentially only treats one aspect of a prominent ear which is the poorly formed anti-helical fold. There are many other features to a prominent ear that are performed during a typical ear pinning, called an "otoplasty" such as conchal excess, ear lobule rotation, postauricular cutaneous redundancy, outwardly rotated concha, etc . The incisionless otoplasty does little to correct these associated conditions and therefore its applicability is severely limited.