British Journal o/ Plmtk- Surgq (I 986) 39. 27C-273 ( 19X6 The Trustees of British Association of Plastic Surgeons

Long-term survey of prominent ear surgery: a comparison of two methods

K. H. TAN

Plastic Surgery Unit, Canniesburn Hospital, Bearsden. Glasgow

Summary-A retrospective study was undertaken of 191 patients under the age of 16, who underwent surgery during the period 1974 to 1978. Using questionnaires, acceptance of the 2 most used methods, the Mustard& technique (45 cases) and the anterior scoring (101 cases), was assessed and the case sheets of the involved patients were collected. Though there was no difference in the final acceptance of both methods, a significantly larger number of cases treated with the Mustard6 technique needed re-operation. The use of non-absorbable material (white silk) was the cause of stitch complications in this method.

Correction of prominent ears has always been an underrated aspect of plastic surgery. Yet the defor- mity may be the source of intense shame and anguish in the child. and can cause subsequent emotional problems.

Strong feelings about this deformity are culture bound and this might explain why in the far East, where it often means a sign of good fortune, its cor- rection is an unpopular procedure, while in this part of the world prominent ears often seem to be considered a sign of idiocy.

Successful treatment can mean, therefore, a great deal to the patient and this was the reason that a long term survey was started in 198 1 to analyse dif- ferent aspects of prominent ear surgery.

Methods

To evaluate the results, questionnaires (Fig. 1) were sent to the parents of all patients under the age of 16. the youngest being 3, who underwent surgery during the period 19741978. The minimum time lapse between the start of the survey and the last operation was 3 years. Three-hundred-and-eighty- nine letters were sent and 191 returned. The follow- ing aspects received particular attention:

(9

(ii)

(iii)

the judgement of the final result; patients and parents were asked to grade the final cosmetic result as “excellent”. “the same” or “worse”. the problems encountered in the postoperative period whether a subsequent operation was per- formed to obtain the final result

(iv) whether a particular group could be defined who obtained the best final result

The case notes were received of the 191 patients who returned their forms. One hundred and forty- six cases were treated with either the Mustarde technique or the anterior scoring and 45 by differ- ent methods.

It was decided to do a comparison of the two most used methods, the anterior scoring (101 cases) and the Mustarde technique (45 cases). In the Mus- tarde type of operation white silk was used. Both types of operation were performed by registrars or senior registrars and sometimes by consultant (8 cases). They were done under general anaesthesia, but in 5 cases local anaesthesia was used, 3 of which were treated with the anterior scoring and 2 with the Mustard6 type of operation.

For evaluation of the results assistance was received from the Department of Community Medicine of Glasgow University.

Results

Table 1 shows the outcome of the assessment of the Mustard& technique and the anterior scoring. Using the chi-square test no significant difference could be found.

Table 2 shows complications of both methods. A specific problem confined to the Mustarde tech- nique (extracted from the case notes) was due to the presence of stitches (Fig. 2) resulting in sinuses and wound infection in 7 cases (I 5%). Looking at the number of cases which required re-operation, a

LONG-TERM SURVEY OF PROMINENT EAR SURGERY: A COMPARISON OF TWO METHODS 271

PLEASE COMPLETE:

NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................................................................................

ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .........................................................................

TELEPHONE NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..............................................................

DATE OF BIRTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...............................................................

1.

2.

Were both ears affected?

What is your opinion about the result of the operation at this moment?

Excellent Better than before the operation The same as before Worse than before

YES NO

3.

4.

5.

Is the result now different from shortly after the operation?

Is your child happy with the result?

The major reason for the operation was:-

Being teased Cosmetic Both

YES NO

YES NO

6 Have there been problems following surgery? If so, please indicate.

Bad shape of the ear Pain after operation An ugly scar Itching or bleeding after the operation

7 Would you consider a second operation to correct any problems? YES NO

8. Was a second operation performed? YES NO

9 Would you be prepared to come to one of the Clinics for a short examination and photograph? YES NO

10. Could you bring a photograph from before the operation?

Fig. 1

YES NO

Table 1 Comparison of parental assessment and method used

Assessment Mustard6 technique Anterior scoring

Excellent 27 (60%) 57 (56%) Better 14 (31%) 39 (39%) The same 3 (7%) 3 (3%) Worse 1 (2%) 2 (2%)

Total 45 (100%) 101(100%)

Table 2 Complications of prominent ear surgery

Complication Mustard6 technique Anterior scoring

Bad shape 3 (7%) 6 (6%) Pain 9 (20%) 5 (5%) Ugly scar 2 (2%) Itching 2 (4%) 5 (5%) Bleeding 15 ( 33%) 8 (8%)

Total 45 (100%) 101 (100%)

significantly smaller proportion was found in the anterior scoring group (Table 3).

Table 4 shows the number of cases which in fact underwent re-operation and the method used.

The Mustard6 technique was more often used as a salvage procedure though the numbers are too small for statistical analysis.

To investigate if age could be a determining fac- tor in the assessment of the final result, a compari- son was made between the groups of children aged 5 or below and aged 6-15 (Table 5). No significant difference could be found.

Discussion

In Western culture abnormalities of the ear tend to be stimuli for undue attention and jokes, and pro- minent ears may be the source of intense shame and anguish in the child (MacGregor, 1978).

The primary goal of otoplasty must always be to

272 BRITISH JOURNAL OF PLASTIC SURGERY

Fig. 2

Table 3 Outcome of cases requiring operation

1st Refused Redo Chance to operalion 2nd operation Mustard; anterior scoring

Mustard6 II 3 I I

Anterior Redo anterior Change to scoring scoring Mustard&

10 3 1 6

Table 4 The number of cases requiring reoperation for each method

Mustard6 technique Anterior scoring

Total number 45 101

Requiring operation 1 I (24%) 10 (9.9%)

p<o.o5

Table 5 Comparison of the final result in two age groups

Excellent Better The same Worse

Children aged 5 or helon

15 (62%) 8 (33%) I (5%)

Children aged 615

99 (59%) 59 (35%)

6 (4%) 3 (2%)

Total 24(100%) 167 (100%)

hold the mirror up to nature, consistently produc- ing normal appearance and aesthetically pleasing results, which are not recognisable as operated ears either on short-term or long-term follow-up (Wright, 1970). However, the patients’ require- ments are often less rigorous since they are often more concerned about the gross outline and the position of the ear as a whole (McDowell, 1968). This might explain why some of our patients refused a secondary procedure in cases judged by the surgeon as not satisfactory.

Numerous methods of correction have been de- scribed, all claiming to be excellent and to give ex- cellent results. In our survey the two most popular methods, the anterior scoring as described by Chongchet (1963) and Tolhurst (1972) and the method using buried mattress sutures as described by Mustard6 in 1963, were compared.

The fact that there was no statistical significant difference in the patients’ assessment of the final outcome might support the view of McDowell, that, for many patients today, good results are pos- sible from any of several procedures. The use of buried sutures, which could, as also shown in our series, lead to serious problems, was condemned by Davis in 1978.

The importance of preoperative appraisal of anatomical abnormalities like absence of folding, enlarged concha or a combination of the two, was stressed by Tardy et al. in 1969. In this respect sur- face measurements as proposed by Farkas in 1978 could be useful.

On reviewing the literature only a few long term surveys were found.

Minderjahn et al. (1980) performed a 5-year re- view of 135 otoplasties using MustardC’s technique and achieved a good result in 53%, an improve- ment in 12%, a partial relapse in 7.5% and a total relapse in 5.7%. These results are comparable with our results as shown in Table 1.

Mustard& found 17 of his 391 cases in a IO-year

LONG-TERM SURVEY OF PROMINENT EAR SURGERY: A COMPARISON OF TWO METHODS 273

survey (1967) not satisfactory. These faulty results were due to kinks in the antihelix, stitches which were cutting out, recurrence of prominence by put- ting the sutures too close to the summit of the fold and operation at too young an age, since it may take several years for prominence to develop fully.

This last point was later underlined by Wright (1979) and it raises the question whether an opera- tion at an early age, though probably desirable for social and psychological reasons, is still the best choice.

In conclusion, though in this retrospective study no difference could be found in the final assessment of both methods, the fact that in a significantly larger number of cases of the Mustard6 group a re- operation was required would favour the anterior scoring technique.

Acknowledgements

The author wishes to thank Mr M. H. C. Webster for his advice and encouragement, Miss L. Amosso for her secretarial work, the Department of Photography of Canniesburn Hospital, and Mr W. Harper Gilmour from the Department of Community Medicine, Glasgow University.

References

Chongchet, V. (1963). A method of antihelix reconstruction. British Journal of Plastic Surgery, 16,268.

Davies, J. (1978). Prominent ears. Clinics in Plastic Surgery, 5, 471.

Farkas, L. G. (1978). Anthropometry of normal and anomalous ears. Clinics in Plastic Surgery, 5,401.

MacGregor, F. C. (1978). Ear deformities: social and psycho- logical implications. Clinics in Plastic Surgery, 5, 347.

McDowell, A. J. (1968). Goals in otoplasty for protruding ears. Plastic and Reconstructive Surgery, 41, 17.

Minderjahn, A., Huttl, W. R. and Hildmann, H. (1980). Mus- tardt’s otoplasty. Evaluation of correlation between clinical and statistical findings. Journal of Maxillofacial Surgery, 8, 241.

Mustard& J. C. (1963). The correction of prominent ears using simple mattress sutures. British Journal of Plastic Surgery, 16, 170.

Mustard& J. C. (1967). The treatment of prominent ears by bur- ied mattress sutures: a ten-year survey. Plastic and Recon- structive Surgery, 39,382.

Tardy, M. E. Jr, Tenta, L. T. and Pastorek, N. J. (1969). Mat- tress suture otoplasty: indications and limitations. Laryn- goscope, 79,961.

Tolhurst, D. E. (1972). The correction of prominent ears. British Journal of Plastic Surgery, 25.26 1.

Wright, W. K. (1970). Otoplasty goals and principles. Archives of Otolaryngology, 92, 568.

The Author

K. H. Tan, MD, Locum Registrar, Plastic Surgery Unit, Free University Amsterdam (Academic Hospital). Formerly Senior House Officer, Plastic Surgery Unit, Canniesburn Hos- pital, Bearsden. Glasgow.

Requests for reprints to: Dr K. H. Tan, Grotiuslaan IS,2353 BP Leiderdorp, The Netherlands.