Otoplasty: Pros & Cons of Two Approaches

If you want your ears to be really close to your head then conchal cartilage resection is the way to go.  However, sometimes cartilage resection can lead to an un-natural appearing and 'overdone' appearing ear.  If you just need the anti-helix setback then no cartilage resection is necessary and permanent sutures can be used to create the anti-helical fold.  Usually after three months the cartilage is secure enough that any pull on the ears (sports) would not risk recurrence of the original ear form.  Most importantly, you should go to a surgeon that performs this surgery often and is familiar with all techniques.  

The question is what is better partial conchal bowl resection/shaving  versus suture placement.  The answer depends on your anatomy.  Conchal bowl resection/shaving and suture placement can be used independently of each other and also can be used at the same time.  Each case is individual and depends on factors such as:


size of conchal bowl

stiffness of conchal cartilage

desired aesthetics


As with any procedure, the technique is only as good as the surgeon using it.  

 

 

In my opinion, I think it is best to resect a small about of cartilage to help the ears rest in a natural position.  By just pinning them back but not resecting the cartilage, there is potential for the cartilage to snap back toward the original position.

 

Good Luck.

I am not sure if anyone can provide you with definitive numbers regarding the recurrence of the prominence "redrift" as you call it. I have performed both and generally prefer the setback sutures over conchal reduction/resection.

The ear setback techniques your surgeon's described are valid methods depending on the situation and surgeon preference. Re-drift and or asymmetry are real risks with otoplasty done by any method. Most surgeons will over correct the ears slightly to account for this.

I feel that the long term stability of the new ear position is due to the scar that develops in the area and fixes the ear in place. I often shave the conchal cartilage to thin it out and weaken it. As others have mentioned, removing soft tissue from mastoid area is often quite helpful as well. This creates further space for the ear to  scar into and allows for larger setbacks (if indicated).

As you mentioned, sutures can pull through the cartilage, especially if subjected to trauma. That is one reason why one should rely more on scarring to give long term results. After several months of healing it would be much harder to see re-drift.

The suture setback approach (without cartilage work) can be indicated if less significant setback is desired or if the conchal cartilage itself isn't too prominent.

There are many techniques used during otoplasty and the question of which technique is best depends on the individual anatomy. In general sutures alone are not strong enough to hold cartilage back long-term without other measures to alter the anatomy.

There are two main issues when considering an Otoplasty. 1) Is there an absent anti helical fold? 2) Is there an overly protruding conchal bowl? Either problem can be addressed with cartilage incision or suture techniques.
I generally use incisional techniques and actual cartilage removal if the patient's cartilages are firm and have lots of recoil. This is less likely to have recoil or spring back. In patients with fairly soft cartilages and less intrinsic spring to the cartilages the suture setback is excellent and should give a good long term result.

Most of us who do otoplasty will combine a variety of techniques and maneuvers to address the specific anatomy of each patients' ears.
Cartilage cutting techniques can sometimes lead to very unnatural curves and edges over time, so I tend to avoid much cartilage cutting.
A deep conchal bowl can often be set back nicely and naturally by resecting the soft tissue behind the ear, creating a so-called conchal nest. This does not create the telephone ear deformity when done correctly. And the angle of the ear with respect to the head is indeed customizable by adjusting where on the conchal bowl the sutures are placed, so it's wrong to say that it always results in ears that are positioned flat back against the head. That would be an error in technique, not a flaw in the method itself.
Many prominent ears also demonstrate antihelical unfurling...incomplete formation of some of the natural folds in the cartilage. This is a separate issue that is also addressed during surgery, typically with carefully placed Mustarde sutures to recreate those folds. This does need to be done with permanent suture, IMO.
Modification of the earlobe is also commonly addressed if needed. This is a situation where I may resect some cartilage, but only at the cauda helicis (the tail end of the outer edge of cartilage just above the lobe).
Rather than getting bogged down in the technical details (which is an issue more for your surgeon than for you), critically review both surgeons' work in their before and after photos, verify the surgeons' credentials through your state medical board and even do a little Googling of both surgeons'. Do your homework, and then hope for the best.
Hope this helps,
--DCP

Which otoplasty is better?  Conchal cartilage excision, or permanent suturing ?

The answer depends upon what your anatomy is like and upon the preference of your board certified plastic  surgeon.  either one can give good results, and sometimes both otoplasty techniques can be used together.

I prefer to excise a portion of the conchal cartilage as it is less likely to spring back if a permanent suture breaks or tears through the mastoid fascia.  

 

In my experience, cutting cartilage in the antihelical fold can lead to visible ridging so i almost never cut in this area.  In the concha, it is seamless and difficult to detect that anything was removed. That being said, I see a slight drift back on occasion with my lop deformities and see almost none with my cup deformities.  Removing cartilage in the concha to me is a much more assured method of keeping the ear where I want it without any sizable risk.  I think that the cup deformity (if it is present and worth treating) needs to have excess cartilage removed for the best results.

best wishes,

Dr. Sam Lam