The postauricular fascial flap as an adjunct to Mustardé and Furnas type otoplasty.
Abstract
Anterior riberation methods of otoplasty have been criticized because of the risk of anterior hematoma that can cause anterior skin necrosis, scarring, and even cartilage destruction caused by infection. As a result, cartilage-sparing otoplasty such as the Mustardé and Furnas types has been increasingly popular. However, postauricular suture extrusion may result, and recurrence rates of up to 25 percent have been recorded. In this study, cartilage-sparing otoplasty is refined by the addition of a postauricular fascial flap to reduce suture extrusion and recurrence rates. Fifty-one patients underwent otoplasty (45 bilateral, six unilateral). This technique involves the elevation of a fascial flap from the postauricular region. A new antihelical fold is then created by Mustardé sutures, and the conchal bowl is rotated by Furnas-type concha-mastoid sutures. The fascial flap is then advanced to cover the sutures with a supplementary vascularized layer to prevent suture extrusion. In addition, the advancement of the flap acts as a postauricular support to prevent recurrence. A natural-looking antihelical fold and helical rim is created by this technique. There were no hematomas. There was recurrence in eight ears (8 percent) in six patients. Two patients requested further surgery. No patients developed suture extrusion or granuloma. This is a simple and intrinsically safe procedure and does not cause irreparable complications such as anterior scarring or skin necrosis. The postauricular fascial flap seems to prevent suture extrusion. It may also help to reduce recurrence rates to acceptable levels.
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Other noncomparative cohorts describing a cartilage-sparing technique with a postauricular flap have reported similarly low incidences of extrusion ranging from 0% to 3%, and recurrence rates ranging from 0% to 8% of ears.
“Other noncomparative cohorts describing a cartilage-sparing technique with a postauricular flap have reported similarly low incidences of extrusion ranging from 0% to 3%, as well as recurrence rates ranging from 0% to 8% of ears. 19,22-24,28”
Horlock et al highlighted that the fascial flap provided vascularized protection, reducing extrusion and recurrence rates, while preserving aesthetics.
“Horlock et al83 highlighted that the fascial flap provided vascularized protection, reducing extrusion and recurrence rates, while preserving aesthetics.”
From Otoplasty Surgical Techniques and Clinical Outcomes: A Practical Review (2026) · cites this paper as [83]
The vascularized fascia placed in this area functions as a non-epithelial buffer that separates the suture material from the overlying skin, thereby reducing the risk of extrusion and recurrence.
“Histologically, the vascularized fascia placed in this area functions as a non-epithelial buffer that separates the suture material from the overlying skin, thereby reducing the risk of extrusion and recurrence [15].”
From Comparative Analysis of Mustardé, Fascioperichondrial Flap, and Combined Otoplasty Techniques: Clinical Outcomes and Recurrence Rates in 365 Patients (2025) · cites this paper as [15]
Supportive techniques aim to reduce both recurrence and suture-related complications by providing a well-vascularized tissue barrier over the suture line.
“To address these limitations, several supportive techniques have been introduced, with particular emphasis on the postauricular fascial flap and its variations (e.g., perichondrio-adipo-dermal flap and modified bilateral fascioperichondrial flap). These methods aim to reduce both recurrence and suture-related complications by providing a well-vascularized tissue barrier over the suture line [15,16”
From Comparative Analysis of Mustardé, Fascioperichondrial Flap, and Combined Otoplasty Techniques: Clinical Outcomes and Recurrence Rates in 365 Patients (2025) · cites this paper as [15]
Scar revision or correction was of no higher frequency for the examined population compared to data found in publications of dorsal incision techniques.
“In comparison to data found in publications of dorsal incision techniques, scar revision or correction (e.g., due to hypertrophic scaring) was of no higher frequency for our examined population (Figure 3) [20].”
From Otoplasty through Ventral Skin Incision and Shaping of the Antihelix by Abrasion—A Retrospective Study (2021) · cites this paper as [20]
The literature shows palpable or protruding suture knots to be a relevant complication, even leading to the use of flap techniques for knot coverage.
“Although the literature shows palpable or protruding suture knots to be a relevant complication, even leading to respective usage of flap techniques for knot coverage [20,21]”
From Otoplasty through Ventral Skin Incision and Shaping of the Antihelix by Abrasion—A Retrospective Study (2021) · cites this paper as [20]
In the current study, both medially and laterally based postauricular dermofascial flaps provided a robust vascularized layer of tissue covering the row of cartilage sutures, with no reported suture extrusion or relapse in any case.
“In the current study, we used both medially and laterally based flaps, and found both to provide a robust vascularized layer of tissue covering the row of cartilage sutures, with no reported suture extrusion or relapse in any case.”
Several studies have modified cartilage-sparing otoplasty by including a postauricular fascial flap to cover the postauricular sutures.
“Several studies have modified cartilage-sparing otoplasty by including a postauricular fascial flap to cover the postauricular sutures. 17,19-30”
In 2001, a refined method incorporating Mustardé and Furnas sutures with a postauricular fascial flap achieved an 8% recurrence rate, with no suture extrusions or hematomas over a median follow-up of 19 months in 51 patients.
“In 2001, a refined method incorporating Mustardé14 and Furnas15 sutures with a postauricular fascial flap achieved an 8% recurrence rate, with no suture extrusions or hematomas over a median follow-up of 19 months in 51 patients.83”
From Otoplasty Surgical Techniques and Clinical Outcomes: A Practical Review (2026) · cites this paper as [83]
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Commentary on: Prominent Ear Correction: A Comprehensive Review of Fascial Flaps in Otoplasty
Shokrollahi, K. (2018) · Aesthetic Surgery Journal · doi:10.1093/asj/sjy043 · Cited by 1 · see citing works
Lloyd, M. S. (2025) · Journal of Craniofacial Surgery · doi:10.1097/scs.0000000000011923
Otoplasty Surgical Techniques and Clinical Outcomes: A Practical Review
Kaleeny, J. D., & Janis, J. E. (2026) · Plastic and Reconstructive Surgery - Global Open · doi:10.1097/gox.0000000000007404
“Velcro headband worn at night for a month Foda 82 Penrose drain, light-pressure dressing applied with vaselinized ribbon Not specified Horlock 83 Not specified Head bandage applied for 1 wk Schaverien 84 Standard head bandage applied and is replaced Headband worn at night for 6 wk Schlegel-Wagner 85 Soft dressing remo…”
Otoplasty for prominent ear: A systematic review of surgical techniques
Thomson, H., Gosden, J., & Mandal, A. (2026) · JPRAS Open · doi:10.1016/j.jpra.2026.02.013
“10 • The suture-postauricular fascial flap hybrid is a method piloted by Horlock et al. 11 that introduces a postauricular flap to provide a vascularised layer over the sutures, thereby theoretically reducing the risk of extrusion and recurrence, a notorious limitation of using sutures exclusively.”
Diamond Burr Drill Use in Otoplasty
Bajaj, Y., & Choudhury, N. (2013) · Springer eBooks · doi:10.1007/978-3-642-35431-1_30
Posterior Suturing with Postauricular Fascial Flap Otoplasty
Schaverien, M. V., & Stewart, K. J. (2013) · Springer eBooks · doi:10.1007/978-3-642-35431-1_34
Schreiber, N. T. N., & Mobley, S. R. (2013) · Springer eBooks · doi:10.1007/978-3-642-35431-1_10
Evaluation of a new suture otoplasty technique
Gilleard, O., Walsh, K. C., King, I. C. C., Tsang, C., Rahman, S. M., & Dheansa, B. S. (2015) · JPRAS Open · doi:10.1016/j.jpra.2015.03.004
Cartilage Folding Technique in Otoplasty
Isac, C., & Isac, A. (2013) · Springer eBooks · doi:10.1007/978-3-642-35431-1_32
Ear Reconstruction and Pinaplasty
Quereshy, F. A., & Burton, B. (2017) · Elsevier eBooks · doi:10.1016/b978-0-7020-6056-4.00084-8
Combined Technique in Aesthetic Otoplasty
Salgarello, M., & Visconti, G. (2013) · Springer eBooks · doi:10.1007/978-3-642-35431-1_21
Isac, C., Isac, A., Bratu, T. I., & Antohi, N. (2012) · Springer eBooks · doi:10.1007/978-3-642-21837-8_18
Vlahovic, A. M., & Haxhija, E. Q. (2017) · Springer eBooks · doi:10.1007/978-3-319-56004-5_2
Shokrollahi, K. (2022) · Aesthetic Surgery Journal · doi:10.1093/asj/sjac152
Benefits of medially based perichondrio-adipo-dermal flap in cartilage sparing prominent ear surgery
Mandour, Y. M. H., & Abdelmofeed, A. M. (2023) · Acta Otorrinolaringologica (English Edition) · doi:10.1016/j.otoeng.2021.09.005
Combined Mustardé and Furnas type otoplasty with minimal conchal cartilage excision
Kökten, N. (2023) · Marmara medical journal · doi:10.5472/marumj.1378429
Brito, K., & Zacharia, M. (2024) · The American Journal of Cosmetic Surgery · doi:10.1177/07488068231225058
Cartilage-Sparing Otoplasty: An Overview of the Mustardé and Furnas Suture Techniques
Levin, M., Ziai, H., Gantous, A. M., & Adamson, P. A. (2024) · Facial Plastic Surgery · doi:10.1055/s-0044-1782539
Bat Ear Correction Steps and Outcomes for Better Life Support
Shawky, M. A., Shawky, M. A., Zaghloul, A. I., & Zakaria, N. Z. (2024) · Indian Journal of Otolaryngology and Head & Neck Surgery · doi:10.1007/s12070-024-04872-9
Vlahovic, A. M., & Haxhija, E. Q. (2026) · Springer eBooks · doi:10.1007/978-3-032-16616-6_2
- Authors
- Horlock, N., Misra, A., & Gault, D. T.
- Affiliations
- Mount Vernon Hospital (GB)
- ORCID
- Misra, Alok
- Venue
- Plastic and Reconstructive Surgery
- Published
- 2001-11
- Volume
- 108
- Issue
- 6
- Pages
- 1487-1490
- ISSN
- 0032-1052 (ISSN-L)
- OpenAlex
- W2005444244
- Cited by
- 102
- References
- 14
- Citations by year
- 2026: 4 · 2025: 2 · 2024: 7 · 2023: 3 · 2022: 6 · 2021: 3 · 2020: 6 · 2019: 7 · 2018: 11 · 2017: 4 · 2016: 6 · 2015: 2 · 2014: 4 · 2013: 13 · 2012: 7
- FWCI
- 0.99
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Plastic & Reconstructive Surgery (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Surgery › Reconstructive Facial Surgery Techniques
- Health Sciences › Medicine › Surgery › Nasal Surgery and Airway Studies
- Health Sciences › Medicine › Genetics › Congenital Ear and Nasal Anomalies
- Keywords
- otoplasty, suture extrusion, recurrence, antihelical fold
- MeSH terms
- Adolescent, Adult, Aged, Child, Child, Preschool, Ear Cartilage, Ear, External, Female, Humans, Male, Middle Aged, Postoperative Complications, Surgical Flaps, Plastic Surgery Procedures
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