Prominent ear otoplasty — The concha first, the antihelix second

The graduated approach starting with the concha, the exact sequence of conchomastoid and Mustardé sutures with their measurements, the four families of techniques and what comparative evidence says about recurrence and complications.

Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.

Key points

Order matters: set the concha first and then adjust the antihelix to that fixed position. Doing it the other way round is the fast route to antihelical overcorrection and conchal undercorrection.
With the concha properly set, the antihelical correction needed is usually considerably less than it first appeared, and in some cases unnecessary.
All sutures are placed first and tied afterwards, in the same order they were thrown: superior, inferior and lastly the middle one. That is what prevents over-tightening the middle third and creating the telephone ear.
The suture must take anterior and posterior perichondrium with the cartilage between, but never the skin. Too superficial and it ulcerates; without the anterior perichondrium it pulls through.
No family of techniques clearly wins on satisfaction, but anterior scoring concentrates the serious complications and sutures the suture-related ones. It is a trade-off, not a hierarchy.

The graduated approach

The idea that organises modern otoplasty is simple: start with what is reversible and escalate only as needed. Suture techniques respect the integrity of the cartilaginous framework, which gives them advantages no cutting manoeuvre has. A stitch position can be trialled and changed without consequence, correction is controlled at several levels before tying, symmetry between the two ears is adjusted at the end simply by moving a suture, long-term surface irregularities are avoided and, if something goes wrong, one can go back. In a cutting manoeuvre there is no point of return. The practical consequence is that suture is the workhorse and cartilage weakening is reserved for cases where the framework will not respond to sutures alone: the adult with rigid cartilage, the cup ear with thick cartilage. Most patients up to young adulthood have cartilage plastic enough to hold correction with suture alone.

Why the concha comes first

Many authors regard the deficient antihelix as the primary abnormality and start there. It is an imprudent order: with the concha not yet fixed, one tends to over-fold the antihelix to compensate — especially at the superior crus — while the concha stays undercorrected, and the result is the reverse telephone ear: corrected poles and a standing-off middle third. Moreover, when the conchal component is large, normal auricular position simply cannot be reached without addressing the concha, however tightly the antihelix is set. The sensible order is the reverse: first fix the vertical position and angulation of the concha relative to the head, and only then decide how much antihelix is needed.

Conchal setback: the sequence

Prepare the bedExcise soft tissue deep in the postauricular sulcus. The amount excised determines how far the concha can be retropositioned, and generally more is removed superiorly than inferiorly, because more correction is needed there
First sutureA horizontal mattress from the most superior part of the floor of the triangular fossa to the mastoid periosteum. Clamp it and leave it untied. This stitch draws the concha posteriorly and superiorly, and is what stops the compressed cartilage encroaching on the ear canal
How to take the biteFull thickness: posterior perichondrium, cartilage and anterior perichondrium, no skin. Palpating the conchal skin anteriorly with the fingertip or nail helps gauge depth. Medially the mastoid periosteum must be securely engaged: the needle should feel solid
Second and thirdIn the inferior cavum and mid cymba, along identical vectors. Before tying, pull the trial sutures under some tension to check they neither slip nor pull through
TieIn the same order they were placed: superior, inferior and middle last, drawing the concha posteriorly while tightening. Tying the middle one last allows it to be aligned with the other two and avoids the telephone deformity
If it is still not enoughTangential shaving of the posterior cartilaginous eminences — ponticulus, triangular and conchal eminences — with a 10 or 11 blade, preserving the anterior perichondrium. It lets the concha retrodisplace further into the deepened sulcus

The three errors of the setback

The first is forgetting the superior vector: if traction is purely posterior, the compressed concha encroaches on the external auditory canal. The second is placing the stitch too high on the conchal wall, which displaces the bowl anteriorly and produces the same compression by another route. The third, the commonest, is over-tightening the middle suture, which is exactly the mechanism of the telephone ear. The vector matters not only for medial displacement but also for the angulation and vertical position of the auricle, so it is worth deciding it before placing the stitch, by drawing the concha back with forceps and observing the result.

Antihelicoplasty: the sequence

How many suturesTwo to four horizontal scaphaconchal mattress sutures, as many as needed for a continuous curve. There is no fixed number: symmetry is sought in the contour, not in the count
The ends firstThe superior runs from the highest scapha to the triangular fossa; the inferior from the lowest part of the antihelix to the highest part of the conchal bowl. They are the jumping-off points from which the intervening arc is built
Then the middle onesOblique and in whatever number is needed, to achieve a natural, continuous curve. Starting at the mid-antihelix risks an unnatural notch from over-tightening or poor placement
Concentric placementSutures should be concentric about the centre of the concha: the distance between the superior limbs of each mattress greater than that between the inferior ones, so the line follows the intended antihelical arc
Check and tieMeasure at the three reference points bilaterally. Target auriculocephalic distance at mid-auricle: 15-18 mm intraoperatively. Tie in the same order, the middle one last

The numbers of the Mustardé suture

Parameter	Reference	What happens if you deviate
Bite size	Around 4-6 mm	Too small and the cartilage pulls through; too large and it buckles
Spacing between sutures	The classic school proposes about 2 mm, equidistant	Too close: over-tightening, cartilage weakening and notching. Too far apart or too near the helix: bunching of the intervening cartilage and insufficient curvature
Distance between mattress limbs	Around 1 cm	This is what distributes tension. Poorly distributed, the risk of later pull-through rises sharply
Distance between outer and inner bites	Ideally 16 mm	It is the distance that allows the curve to form without notching or folding the intervening cartilage
Overcorrection	Slight, and above all at the superior crus, where correction is most often lost	In the middle third never overcorrect. And if suture number and position are right, tension distributes and overcorrection ceases to be necessary

The vertical post and the bowstring effect

Two shape defects entirely dependent on how the sutures are placed. The vertical post appears when the antihelix ends up as a straight, conspicuous ridge instead of a curve tapering smoothly anteroinferiorly; it comes from sutures placed too far apart or too near the helical margin. And one rule that admits no exception: antihelical sutures must not be tightened so far that the helical margin lies medial to the fold; the helix must always be visible lateral to the antihelix on frontal view. The second defect is technical and silent: if the suture lies tense over the postauricular skin at the incision line, a bowstring effect results that compromises healing and opens the door to dehiscence, granuloma, latent infection and late suture extrusion. When tying, return the ear to its anatomical position and look at how the soft tissues sit.

The four families of techniques

Family	Principle	Strength and weakness
Suture only	Scaphaconchal mattresses for the antihelix and conchomastoid for the concha, without breaching cartilage integrity	Versatile, adjustable and reversible. In exchange it concentrates granuloma, suture extrusion and prominent scarring, and in the adult the spring of mature cartilage may stretch the scar and re-protrude
Anterior scoring	Weakening the anterior cartilage surface so it folds towards the side with intact perichondrium	It creates a stable fold without depending on suture. It is the family that concentrates the serious complications: anterior skin necrosis, residual pain, notching and cartilage irregularity
Scoring + suture	Weakening just enough to increase flexibility, ease furling and reduce tension on the mattress sutures	It is the reasonable compromise in the rigid adult ear. In animal models the fold holds better when the anterior perichondrium has been rasped, thanks to the fibrocartilaginous cap that forms over the surface
Cartilage cutting	Dividing the cartilage along the desired antihelical line and resuturing the edges	Vigorous and definitive correction. No way back, and in direct comparisons recurrence was higher than with cartilage-sparing techniques

What the comparative evidence says

There are no randomised trials in otoplasty and probably never will be, given its elective nature. What exists are non-randomised comparisons and reviews, and they should be read knowing that.
In a series of 203 patients comparing anterior scoring, posterior suture and suture with a postauricular fascial flap, recurrence was 11 %, 8 % and 4.8 % and reoperation 8.8 %, 6 % and 3.6 %: the fascial flap came out ahead on all three.
In a systematic review of the literature published between 1977 and 2002, only 12 of 149 papers met minimum criteria. Dissatisfaction was 7.1 % with suture alone, 4.8 % with rasping alone, 4 % with rasping and suture and 5.2 % with cutting, with no statistically significant differences.
The reasonable reading is not that one technique is superior but that the complication profile shifts: choosing scoring means accepting skin and contour risk, choosing suture means accepting suture problems. And mandatory revision runs at around 2 % of otoplasties, a good figure compared with other aesthetic facial procedures.

Adjunctive manoeuvres, at the end

Persistently cupped superior pole: a suture from the triangular fossa to the temporalis fascia. In a review of 62 consecutive otoplasties it was needed in 13 % of cases.
Prominent inferior pole: a suture from the cauda helicis to the mastoid, needed in 9.7 % in the same series. And lobular protrusion sometimes improves with a single cauda-conchal mattress suture.
Darwin’s tubercle: direct excision through an incision camouflaged in the lateral helical curl, with a small ellipse of redundant skin. A long rather than a short incision is preferable, to close without a standing cone.
An unfurled helix with a high scapha gives the characteristic angulated rim. With sufficient cartilage stock, scoring suffices; with weak cartilage, radial scapha-helical mattress sutures are needed to avoid instability, and in extreme cases full-thickness wedges or a graft.

The Gibson effect, applied to the helix

The same principle that explains why a costal graft warps works in our favour here: cartilage bends towards the side where the perichondrium remains intact. Hence partial-thickness incisions on the posterior surface of the helical rim encourage anterior furling, without sutures or resections. The correction is secured with a temporary through-and-through bolster for seven days. It is a small but representative example of how auricular cartilage is worked: not by forcing it, but by controlled unbalancing of the forces that keep it flat.

Choosing the technique

Is the cartilage pliable enough to hold correction with suture alone?

Yes, a child or young adultSuture only, with a graduated approach: conchomastoid first, scaphaconchal second, adjunctive sutures only if needed. This resolves the great majority.

No, it is rigidMove to the next point.

Where is the stiffness preventing the fold?

In the antihelixTunnel scoring of the anterior antihelical surface, just enough to ease folding and unload tension from the mattress sutures. Do not score the scapha: it predisposes to further antihelical unfurling.

In the concha, still deepShaving the posterior cartilage islands with a cold blade, preserving the anterior perichondrium. In a series of 62 cases it was needed in only 3.

In the whole frameworkThe cartilage-cutting family, accepting that there is no way back and that reported recurrence is higher. Also consider the postauricular fascial flap, which in direct comparison reduced recurrence and both early and late complications.

Conchomastoid sutures: the mattress takes lateral and medial perichondrium with the cartilage between, never the anterior skin, and the vector of pull is posterior and superior.

Mustardé scaphaconchal mattress sutures seen from behind, with the concentric placement about the centre of the concha that produces the natural antihelical arc.

References

Related specialty: Facial Aesthetic Surgery

All surgical notes