Comparison of surgical techniques for prominent ear correction: Mustardé versus Converse

Introduction: prominent ears, popularly called “flappy ears,” represent the most common congenital deformity of the external ear, affecting approximately 5% of the population. Methods: Primary, prospective and intervention study comparing the results of patients undergoing the surgical procedure to correct prominent ears using the Converse and the Mustardé techniques, performed at the Plastic Surgery Service of the Hospital das Clínicas, Federal University of Pernambuco (HC) -UFPE). Results: Twenty patients were evaluated, 10 with the Converse technique, and 10 with the Mustardé technique, from June 2016 to December 2017. Both groups showed a decrease in auricular mastoid distances at the end of the observation period, ranging from 6.67 to 14.6 mm, depending on the surgical technique and the evaluation point, but without statistical significance. Regarding the average auricular mastoid distances at the end of the observation period, a difference of a maximum of 6.3 mm was observed between the evaluated groups, but without statistical significance. Regarding the symmetry of the ears within the same group, the maximum mean level of asymmetry in the Mustardé and Converse groups was 0.9 mm and 0.5 mm, respectively. However, the percentage of loss of correction of the measures obtained surgically during the observation period in both groups ranged between 15 and 19%, without statistical significance. Regarding complications, there was 1 (10%) case of hematoma in the Mustardé group. Conclusion: Converse and Mustardé techniques did not show statistical differences in the results. ■ ABSTRACT


INTRODUCTION
Prominent ears, popularly called "flappy ears," represent the most common congenital deformity of the outer ear, affecting approximately 5% of the population 1 . Both sexes are affected in the same proportion, and in approximately 60% of cases, this deformity can be diagnosed at birth, which is most evident in the first years of life 2,3 .
People with prominent ears have facial and aesthetic harmony problems, which can lead to psychic disorders related to social interaction, especially during childhood and adolescence 3,4,5 . The outer ear reaches 85% of its final size around three years of age, reaching adult size around 6 to 7 years 6 . Therefore, the ideal age for surgical correction would be between 4 and 6 years, since it also coincides with the beginning of the individual's school/social life 4,7 .

OBJECTIVE
This study proposes to make a comparison between two surgical techniques for antihelix treatment used in the correction of prominent ears: The Converse and Mustardé techniques, evaluating the surgical results, and observing if there is superiority between them.

METHODS
Primary, prospective and intervention study comparing the results of patients undergoing the surgical procedure to correct prominent ears using the Converse technique and that of Mustardé, performed at the Plastic Surgery Service of the Hospital das Clínicas of the Federal University of Pernambuco (HC -UFPE).
Patients were randomly selected into two different groups of surgical techniques to correct the antihelix, the Mustardé technique, and the Converse technique. Patients who spontaneously sought service with the desire to correct prominent ears and who had absence or underdevelopment of the antihelix were included. Patients who had already undergone previous auricular surgical procedures, patients with congenital or acquired auricular deformities, smokers, patients with chronic systemic diseases, and users of chronic medications were excluded.
The imposed data were: sex, age, presence of erasure of anti-helix, shell hypertrophy, lobe protrusion, increased cephalocaudal angle, laterality, auricular mastoid distance in three sites of the ear external, complementary surgical treatment performed and complications.
The auricular mastoid distances were measured from the mastoid region to the lateral edge of the helix, with the head in a neutral position, measured with the aid of an analog pachymeter in the upper, middle and lower regions, bilaterally, which correspond respectively to the bifurcation of the antihelix in upper and lower branches, the upper edge of the ear canal and the most caudal segment of the intertragic notch ( Figure 1). The evaluation times were: preoperative, 1, 3, and 6 months postoperative, with the necessary photographic documentation.

Surgical technique
All patients underwent the surgical procedure under local anesthesia and propofol sedation. After removal of a retroauricular skin spindle, detachment of the skin with adequate exposure of the posterior region of the auricular cartilage, one of the following procedures is followed:

Mustardé technique
It is performed the bidigital anterior maneuver of the scapha with the thumb and forefinger, transfixed in 3 places along the antihelix, which was pronounced, with the help of a 0.45x13mm needle dyed in bright green to make the "tattoo" of the posterior face of the cartilage. Suture with 4-0 mononylon, about 1 cm laterally, the previous markings for the formation of a new antihelix ( Figure 2).

Converse technique
It is performed the bidigital anterior maneuver of the scapha with the thumb and forefinger, and it is transfixed in 3 points along the antihelix, which was pronounced with the help of a 0.45x13 mm needle dyed in bright green to make the "tattoo" of the posterior cartilage. An incision is made with a scalpel blade 15, bilaterally, joining the previous markings. Subsequently, the internal/external edges are sutured with mono nylon 4-0 in 3 places to form a new antihelix ( Figure 3). spreadsheet, analyzed by SPSS software version 2.0 R version 3.4.3.
The non-parametric statistical test used was Wilcoxon's, considering a value of p <0.05.

RESULTS
Twenty patients were evaluated, 10 using the Converse technique and 10 using Mustardé, from June 2016 to December 2017. Males represented 30% of both groups, the mean age in the Converse and Mustardé group was 18.9 and 22.3 years, respectively. All patients in the study had erasure of the antihelix, increased cephaloconchal angle, and bilateral abnormalities. Conchal hypertrophy and lobe protrusion were present in 19 (95%) and 6 (30%) patients, respectively. The treatment of the concha using the Furnas technique and the treatment of the lobe was performed in all patients who presented these changes.
Both groups showed a decrease in auricular mastoid distances at the end of the observation period, ranging from 6.67 to 14.6 mm, depending on the surgical technique and the evaluation point, however, in comparison, there was no significant p-value between the group results Regarding the average auricular mastoid distances at the end of the observation period, a difference of a maximum of 6.3 mm was observed between the results obtained, but also with a negligible p-value (Table 1).
Regarding the symmetry of the ears within the same group, the maximum mean level of asymmetry in the Mustardé and Converse groups was 0.9 mm and 0.5 mm, respectively (Table 2). When evaluating the percentage of loss of correction of the measures obtained surgically during the observation period, both groups ranged between 15-19%, however, in comparison with each other, there were no significant differences between the results (Table 3). Regarding complications, there was 1 (10%) case of hematoma in the Mustardé group.

DISCUSSION
The Mustardé and Converse techniques described, respectively, in 1955 and 1963, have their uses spread throughout the world; however, like all surgical tactics, they present their positive and negative points. The Converse technique, considered incisional, has as a positive point the fact that the cartilaginous incision provides a loss of local resistance for the manufacture of the new antihelix, decreasing the tension in the suture, supposedly decreasing recurrence rates, however as a negative point, this

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After performing the surgical technique of each group, it is then followed for the other treatments: Furnas stitches and lobe repositioning, if necessary, and the skin is closed with 4-0 mono nylon.  On the contrary, the Mustardé technique, considered cartilage-sparing, has the advantage of providing a smooth contour for the antihelix, on the other hand, due to the lack of weakening of the cartilage, there is supposed to be a tendency for the cartilage returns to its abnormal position, which can cause an increase in recurrence rates 6,18 .
In general, in order to achieve the best results, the following aspects described by McDowell, in 1968 19 , must be observed and fulfilled: 1) the helix must be seen entirely behind the antihelix in the frontal view; 2) smooth and regular helix; 3) final scar must be located in the retroauricular groove and without distortion; 4) difference in measurements between the operated sides of a maximum of 3mm; and, 5) the distance from the helix to the mastoid, at the upper, middle and lower points, should vary between 10-12mm, 16-18mm and 20-22mm 18 respectively.
It was observed that both groups reached all the above criteria during the observation period, except for the proposed distances, however, McDowell does not describe in his article how such measurements were determined, which hinders a reliable comparison 9 . However, the final measurements of the present study comply with that established by Adamson et al., in 1991 20 , which determines an auricular mastoid distance from the upper-middle segment of the ear between 15 and 20 mm as aesthetically desirable 20 (Table 4). When comparing the final averages of the auricular mastoid distances, between the two surgical techniques evaluated, there was a difference of 6.3 mm maximum between the results obtained, but with an unimportant p-value, that is, both techniques provided similar auricular positions (Table 1).
Both groups showed a decrease in auricular mastoid distances at the end of the observation period ranging from 6.67 to 14.6 mm, very similar to that found in the literature, as the studies by Adamson et al., in 1991 20 , Schneider andSide, in 2018 21 and Foda, in 1999 22 , obtained average rates of auricular medialization, respectively, of 5.9 mm, 14 mm and 17 mm, depending on the place and time of the evaluation. As for the symmetry between the ears within the same surgical technique, the asymmetry varied from 0 to 0.9 mm, that  that the difference between the groups was a maximum of 1%, but with an unimportant p-value compared to each other, which suggests an equivalence of the rates of correction loss between the surgical techniques ( Table 3). As for complications, Elliott divides complications into early and late. The precocious ones would be a hematoma, infection, chondritis, pain, bleeding, itching, and skin necrosis. Late ones would be visible scarring, patient dissatisfaction, suture-related problems, and dysesthesias 6 . We observed only one case of hematoma in the Mustardé group; however, the literature shows is, both groups remained within the maximum of 3 mm recommended in the literature 18,21 (Table 2). Despite being a subjective criterion, the surgical team and all patients were satisfied with the results obtained at the end of the observation period 20 (Figures 4 and 5).
Regarding the percentages of loss of correction, these would vary from 15 to 19% in both groups, depending on the follow-up evaluated. These values are lower than those found in the literature, such as that of Foda, in 1999 22 , in which the average was 32%; however, this one had a follow-up of 28.4 months, that is, we could observe a higher percentage in more extended monitoring period. Another point to highlight would be

PM
Conception and design study, methodology, project administration, supervision, writing -review & editing.

KK
Analysis and/or data interpretation, data curation, final manuscript approval, formal analysis, methodology, project administration.

PSL
Analysis and/or data interpretation, data curation, project administration, writingreview & editing.

ALF
Analysis and/or data interpretation, data curation, final manuscript approval, project administration.

Supervision.
complication rates ranging from 0% to 47.3%, that is, the index found in this research remained within the expected range 23,24 . The treatment was performed with simple outpatient drainage and a compressive dressing with adequate resolution of the case. It is noteworthy that no studies were found in the literature comparing surgical techniques to reposition the antihelix using a standardized and objective measurement protocol. Another positive point, Tables 1 and 3, which show, respectively, the means of the final measurements of the points evaluated between the groups and the percentages of the means of recurrence, did not obtain the p-value at the 5% level with the test. Wilcoxon. In other words, the sample size did not influence the comparison of results between the Mustardé and Converse techniques. Furthermore, therefore, the sample size used in the research was sufficient to conclude that the lack of difference in the results between the treatments evaluated was not due to the number of participants, but to the similarity of the results of the techniques.
On the other hand, a possible bias in this study was the 6-month follow-up period, as there are studies with periods of up to 6.25 years 9 . That is, we could then experience higher rates of correction loss, complications, and even recurrence of prominent ears.

CONCLUSION
The Converse and Mustardé techniques showed no statistical difference in the results, when compared to each other.