Prominent Ear Correction: A Comprehensive Review of Fascial Flaps in Otoplasty

Dr. Süleyman Taş reviews the evolution of fascial flap techniques in prominent-ear correction, comparing cartilage-invasive and cartilage-sparing approaches and the role of postauricular fascia and perichondrium.

Scope of the Review

More than 200 techniques have been described for prominent-ear correction over the last century. These methods use different combinations of postauricular incisions, cartilage scoring, excision and suturing to recreate the antihelical fold and normalize ear-to-head angles. This review focuses on the growing role of fascial flaps and compares their design, anatomy, reported outcomes and limitations.

Cartilage-Invasive and Cartilage-Sparing Concepts

Cartilage-invasive techniques may use cartilage incision, scoring, thinning or excision. They can overcome strong cartilage memory but may create irregularity, cartilage injury, hematoma or skin complications. Cartilage-sparing approaches rely more heavily on sutures, such as Mustardé and Furnas techniques, and generally avoid direct cartilage destruction but may have recurrence, suture extrusion or buried-suture discomfort.

The review presents fascial flaps as an attempt to combine structural correction with living-tissue coverage, reduce suture-related problems and potentially improve long-term stability.

Postauricular Anatomy

The posterior ear soft tissue is described in layers: skin, subcutaneous fat, postauricular fascia and perichondrium. Intrinsic postauricular fascia covers the posterior auricular surface, while extrinsic fascia is associated with the mastoid region. The review emphasizes that understanding these layers is essential because flap viability, strength and cartilage healing depend on where dissection occurs and whether perichondrium is included.

Proximally Based Postauricular Fascial Flap

The postauricular fascial flap described by Horlock and colleagues is elevated proximally and used as an adjunct to Mustardé and Furnas sutures. The flap covers the permanent suture layer and adds posterior support. In the reported 51-patient series, recurrence occurred in approximately 8.3% and suture extrusion in approximately 4% over a median follow-up of 11 months.

A later comparative study of 203 patients found that the fascial-flap group had lower overall complication, recurrence and reoperation rates and higher satisfaction and symmetry scores than the compared techniques, although it required more operative time. Subsequent pediatric series also reported low but nonzero recurrence and suture-related complications.

Distally Based Fascial Flap

The distally based postauricular flap was developed to improve exposure and reduce some limitations of proximally based designs. It can be used as a cover over Mustardé and Furnas sutures, as reinforcement, or in selected cases as a principal corrective structure anchored to an appropriate mastoid point.

The review stresses that the flap must be sufficiently robust and that identifying the mastoid “sweet spot” is technically important. Small pediatric series showed encouraging short-term results, but long-term performance as a stand-alone procedure requires further clarification.

Triangular Fascioperichondrial Flap

A triangular distally based flap includes perichondrium and is used to recreate the antihelical fold and medialize the upper pole. In an 82-patient series with a mean 3.4-year follow-up, reported late complications included recurrence, suture extrusion and hypertrophic scarring, with a cumulative reoperation risk of roughly 10.85% over nine years.

The technique can provide precise traction and tissue-to-tissue fixation but may still require scoring or permanent sutures. The review identifies these as potential disadvantages, particularly when cartilage injury or suture extrusion is a concern.

Distally Based Perichondrio-Adipo-Dermal Flap

This technique extends a robust flap along the helical rim and anchors it to the mastoid fascia, simultaneously influencing the antihelix and conchamastoid relationship. A reported 20-patient series found no early hematoma, necrosis or suture extrusion and one recurrence.

Including perichondrium can strengthen the flap but also makes dissection more delicate because perichondrium becomes thin in some auricular regions. Cartilage rupture and unexpected changes in the scapha-mastoid or postauricular sulcus are discussed as possible concerns.

Bilateral Fascioperichondrial Flap

A bilateral technique combines proximally and distally based fascial flaps. In the reviewed 100-patient series, the method was used with anterior scoring, Mustardé sutures and Furnas sutures. No early complications were reported; two patients required reoperation to improve symmetry.

The proposed advantage is distribution of tension and separate coverage of sutures, although the review critically notes that joining the flaps at the midline may reduce some of the theoretical mechanical benefit.

Proximally Based Dermo-Fascio-Perichondrial Flap

Taş and colleagues described a proximally based dermo-fascio-perichondrial flap intended to recreate the antihelix without permanent Mustardé sutures or routine cartilage scoring. The flap includes perichondrium and is strategically anchored so that living perichondrial surfaces can meet.

In the reported 24-patient series, mean follow-up was 18 months. No early or late complication such as hematoma, wound dehiscence, infection, suture extrusion, granuloma, skin necrosis or recurrence was reported. One temporary anterior skin ulcer was attributed to a tight headband. Auriculocephalic distances improved significantly from preoperative measurements.

Role of the Perichondrium

Perichondrium has vascular and cellular importance for auricular cartilage. The review discusses the theoretical advantages of including it in a fascial flap: greater strength, vascularity and potential regenerative support. At the same time, elevating perichondrium may leave cartilage more fragile during placement of sutures, so technique and suture location require care.

No Single Otoplasty Technique Fits Every Ear

The review concludes that prominent-ear deformity is heterogeneous. Conchamastoid, scapha-conchal and scapha-mastoid angles can each contribute differently. Conchal hypertrophy, antihelical deficiency, prominent lobule, macrotia and cartilage stiffness may require separate maneuvers.

Rather than trying to solve every deformity with a single technique, the surgeon should diagnose each component and combine flap, suture, cartilage and soft-tissue procedures as needed.

Conclusion

Prominent-ear repair remains technically diverse and lacks one universal standard. Fascial flap reconstruction has become an important cartilage-sparing or cartilage-supporting strategy. Detailed auricular anatomy and thoughtful selection of flap design are central to reducing recurrence and achieving a natural antihelical contour.

Official Publication and External Source

DOI: https://doi.org/10.1093/asj/sjx254

Journal: Aesthetic Surgery Journal. This page is a comprehensive educational presentation derived from the supplied scientific publication and does not replace individualized medical evaluation.