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The Stitchless Method For Minimal Complications: Double Triangular Cartilage Excision Otoplasty

Introduction

Prominent ear deformity, affecting approximately 5% of the population, is more than just a cosmetic concern. It can profoundly impact individuals, especially children, leading to negative psychological effects and social challenges. Traditionally, corrective surgeries for prominent ears have varied in techniques and outcomes, often with significant complication rates. However, recent advancements in surgical techniques offer promising results with fewer complications and higher patient satisfaction.

Evolution of Otoplasty Techniques

Historically, otoplasty techniques have evolved from early cartilage excision and suturing methods to more sophisticated approaches aimed at minimizing complications and achieving better aesthetic outcomes.


Traditional Methods of Otoplasty

Source: ResearchGate
  • Converse Technique: Developed by Dr. Converse in the mid-20th century, this technique involves scoring and reshaping the cartilage to create an antihelical fold and reduce conchal prominence. Sutures are used to maintain the new shape.


Source: Cureus

  • Stenström Technique: Introduced in the 1960s, this method focuses on repositioning the entire ear closer to the head by suturing and scoring the cartilage.


Source: ResearchGate

  • Mustardé Technique: Developed in the 1960s, this technique corrects both the antihelical fold and conchal prominence by using deep mattress sutures.

Each traditional method aims to reshape the cartilage framework of the ear, typically involving incisions, sutures, and cartilage scoring to achieve the desired aesthetic outcome.


Double Triangular Cartilage Excision Otoplasty Surgery

Source: American Society of Plastic Surgeons

The Double Triangular Cartilage Excision Otoplasty (DTCO) is a refined surgical technique aimed at correcting prominent ears by reshaping the auricular cartilage without the use of internal sutures. This approach involves precise excisions and reshaping of the cartilage to achieve natural-looking contours and reduce ear prominence.


Introduced by Gualdi et al., DTCO represents a significant advancement in surgical precision and patient satisfaction, employing a stitchless approach to mechanically collapse the ear cartilage. This method excises specific triangular segments of cartilage, thereby reducing tension and the risk of complications such as hematoma, infection, and hypertrophic scarring.

How to Perform Double Triangular Cartilage Excision Otoplasty

  1. Patient Preparation:

    • Patients typically receive 0.5 mg/kg of diazepam orally about an hour before surgery for relaxation.

    • Antibiotic prophylaxis is administered with amoxicillin/clavulanic acid to prevent infection.

  2. Anesthesia and Incision:

    • The procedure is performed under local anesthesia with lidocaine and adrenaline to minimize bleeding and ensure patient comfort.

    • Once the area is properly anesthetized and sterilized, the surgical site is marked. A bilobed hourglass-shaped incision is made on the posterior surface of the ear, specifically between the conchal and mastoidal skin. This incision helps expose the cartilage that needs to be reshaped.


  3. Cartilage Resection:

    • Subperichondrial dissection is carefully performed to separate the cartilage from the overlying skin to preserve blood supply and minimize complications like skin necrosis.

    • Using sharp dissectors and scissors, two parallel subperichondrial dissections are made to isolate the superior and inferior insertion of the auricular cartilage from the skull.

  4. Triangular Cartilage Excision:

    • Two equilateral triangular cartilage excisions are performed at the base of the concha. These excisions are strategic to induce mechanical collapse of the ear and reduce its prominence while ensuring natural contours.

  5. Antihelix Enhancement (if needed):

    • In cases requiring antihelix enhancement, a supraperichondrial dissection of the posterior antihelix is performed.

    • Multidirectional non-transfixing incisions are made on the exposed lateral chondral structures of the antihelix to weaken and bend it into a more aesthetic shape.

  6. Bolster Dressing:

    • A bolster dressing is applied to maintain the reshaped cartilage in place and prevent hematoma formation. Non-absorbable sutures (e.g., 3-0 Prolene) secure the bolster dressing, minimizing displacement and ensuring proper healing.

  7. Closure:

    • Hemostasis is ensured, and the skin is closed with absorbable sutures (e.g., 4-0 Monocryl).

    • A head bandage dressing (e.g., Kerlix gauze) stabilizes the ears postoperatively, maintaining the position of the reshaped cartilage during initial healing.

  8. Postoperative Care:

    • Patients are instructed to wear an elastic headband during sleep for several weeks post-surgery to protect the ears and maintain the new shape.

    • Follow-up appointments monitor healing progress and address any concerns.


Benefits of Double Triangular Cartilage Excision Otoplasty Compared to Traditional Methods

  1. Stitchless Technique: Unlike traditional methods that require internal sutures, DTCO eliminates the need for sutures through the cartilage itself. This reduces the risk of complications such as infection, suture extrusion, and hypertrophic scarring.

  2. Mechanical Cartilage Folding: DTCO achieves precise reshaping of the ear by mechanically collapsing targeted cartilage segments. This approach enhances natural contours and symmetry without relying on sutures to maintain shape, potentially resulting in more stable and long-lasting results.

  3. Minimal Disruption: The stitchless nature of DTCO minimizes trauma to surrounding tissues, leading to faster recovery times and reduced postoperative discomfort compared to traditional methods that involve more extensive incisions and suturing.

  4. High Patient Satisfaction: Studies have shown high rates of patient satisfaction with DTCO due to its ability to achieve natural-looking results with fewer complications. Patients report enhanced aesthetic outcomes and improved psychological well-being following surgery.

Disadvantages of Double Triangular Cartilage Excision Otoplasty

  • Specialized Training Required: Surgeons need specific training and expertise in the DTCO technique to ensure safe and effective outcomes.

  • Potential for Minor Complications: While overall complication rates are low, minor issues such as superficial skin necrosis or unsatisfactory pinna rotation may occur and require management.

  • Long-Term Durability: Further research is needed to assess the long-term stability and durability of aesthetic results achieved through this technique.

Clinical Results and Patient Satisfaction


Source: American Society of Plastic Surgeons

In a cohort of 60 patients (120 ears), the DTCO technique demonstrated a remarkable 6% overall complication rate, primarily consisting of minor issues that were easily managed. Importantly, there were no instances of infections, hematomas, or hypertrophic scars observed. Patient-reported outcomes revealed an average satisfaction score of 4.72 out of 5, highlighting the procedure's effectiveness in achieving desired aesthetic results and patient contentment.

Considerations for Performing Double Triangular Cartilage Excision Otoplasty

While the Double Triangular Cartilage Excision Otoplasty (DTCO) offers significant advantages in correcting prominent ears, several considerations must be taken into account:

  1. Patient Selection: Careful patient selection is crucial. Factors such as age, cartilage quality, and specific anatomical variations influence the suitability and outcomes of DTCO. Pediatric patients, for example, may require modified techniques due to ongoing cartilage growth.

  2. Surgical Expertise: Performing DTCO requires specialized training and expertise. Surgeons must be proficient in cartilage manipulation techniques and precise excision to achieve optimal aesthetic results while minimizing complications.

  3. Anatomical Variability: The anatomical variability of ear structures among individuals necessitates a tailored approach for each patient. Surgeons must adapt the technique to address unique ear shapes and dimensions effectively.

  4. Postoperative Care: Strict adherence to postoperative care protocols is essential for successful outcomes. Patients should follow instructions regarding headband usage, wound care, and follow-up appointments to ensure proper healing and maintenance of the reshaped cartilage.

  5. Long-term Monitoring: Long-term follow-up is crucial to assess the durability of aesthetic outcomes and detect any potential late complications, such as recurrent prominence or asymmetry. Continued research is needed to evaluate the longevity of results beyond the immediate postoperative period.

  6. Patient Expectations: Managing patient expectations is paramount. While DTCO generally achieves high patient satisfaction, clear communication regarding achievable outcomes, potential risks, and the recovery process is essential to ensure informed decision-making.

  7. Research and Advancements: Ongoing research is necessary to refine surgical techniques, improve patient outcomes, and explore innovations in otoplasty. Future advancements may further enhance the safety, efficacy, and versatility of DTCO for diverse patient populations.

Addressing these considerations ensures that Double Triangular Cartilage Excision Otoplasty is performed safely and effectively, contributing to positive aesthetic outcomes and patient satisfaction.

Conclusion

The Double Triangular Cartilage Excision Otoplasty represents a significant advancement in the field of aesthetic surgery, offering a safe and effective solution for correcting prominent ear deformities. With its low complication rates and high patient satisfaction levels, this stitchless technique has the potential to become a preferred choice among plastic surgeons worldwide. As techniques continue to evolve, the focus remains on enhancing patient outcomes and quality of life through innovative surgical interventions.

In summary, advancements such as the DTCO technique underscore the transformative impact of surgical innovation in addressing not just physical deformities but also enhancing psychological well-being and social confidence among patients.


Reference:

Double Triangular Cartilage Excision Otoplasty (2018) A new approach for the correction of prominent ear deformity (2016)



 


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