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Arch Aesthetic Plast Surg > Volume 31(1); 2025 > Article
Ahn and Park: Correcting unfolded helix in a 22-year-old male patient: a case report

Abstract

An unfolded helix is an auricular deformity that has garnered relatively little research focus. This study introduces a surgical technique designed to correct flat helix deformities. A 22-year-old male with bilateral unfolded helixes and prominent ears underwent this procedure under local anesthesia. The surgery employed a posterior auricular approach, with incisions extending from the upper pole of the ear to the concha. Along the helical rim, four radiating incisions were made, followed by oblique cuts in the cartilage and the creation of triangular flaps through advancement. The free edges of the cartilage were then overlapped and sutured together. Post-surgery, the patient experienced a successful recovery, evidenced by the curling of the helix and the absence of complications. This surgical technique is not only effective for correcting unfolded helixes but can also be efficiently performed under local anesthesia.

INTRODUCTION

Deformities of the auricle can significantly impact a patient’s quality of life. A primary objective of craniofacial surgery is to correct these deformities, aiming to restore symmetry and a normal appearance to both ears. Although the prominent ear is the most common deformity, other anomalies, such as helical deformities, are frequently observed [1].
Situated on the outer edge of the ear, the helix extends forward to form its base, known as the helix root or helix crus, which horizontally overlies the external acoustic meatus. The depression between the helix and the antihelix is termed the scapha or scaphoid fossa [2]. Some individuals exhibit a helix deformity characterized by the absence of the typical curled projection. North and Broadbent [3] were the first to identify this specific ear irregularity, which they labeled the “flat helix deformity”. This condition not only affects the helix but is also associated with the third crus of the antihelix and often correlates with other deformities such as the Stahl ear and satyr ear deformity [4].
Patients with an unfolded helix typically exhibit an underdeveloped superior crus and a prominent upper portion of the ear. Despite these distinct characteristics, reports on surgical interventions for this condition are scarce. In this case report, we present a surgical approach for a patient with an unfolded helix and a prominent ear. Enhancing our understanding of the flat helix deformity could improve treatment options and outcomes for those affected.

CASE REPORT

A 22-year-old male presented at our hospital with bilateral unfolded helixes and prominent ears (Fig. 1). The lateral overhang of the helix was deficient, and the curling in the upper third of the ear was insufficient. Under local anesthesia, we employed the posterior auricular approach. An incision was made from the upper pole of the ear to the middle of the concha, and the skin and soft tissue covering the helix were completely degloved until the antihelix was exposed. We then made four radiating incisions, each 7 mm long and spaced 10 mm apart, at the helical rim, directed toward the center of the scapha. The free edges of the cartilage were carefully overlapped to form a curl in the helix. Key sutures were used to precisely control the degree of curling, allowing for meticulous adjustment of the cartilage overlap. After marking the boundaries of the overlapped cartilage, the key sutures were removed, and any excess overlapped cartilage was trimmed. The free edges of the cartilage were then secured using horizontal mattress sutures made of polydioxanone 6-0. Any bunched-up cartilage at the edges was carefully shaved off using a no. 15 blade (Figs. 2, 3).
The patient exhibited an underdeveloped superior crus, causing the upper third of the ear to protrude prominently. Forceps were utilized to grasp the area intended to form the superior crus, allowing for precise positioning. Once the desired fold was established, its boundaries were marked by tattooing with a needle. An incision was made to expose the posterior surface of the cartilage, confirming the tattooed markings. Subsequently, a conchoscaphal suture was placed at two points using Prolene 5-0 to create the superior crus fold.
A bolster dressing composed of Furacin gauze and secured with Prolene 5-0 sutures was applied to the scapha to prevent hematoma formation. The bolsters were removed after 3 days, and the skin stitches were taken out after 2 weeks. Throughout the follow-up period, no complications were observed.

DISCUSSION

The helix is the outermost edge of the ear, extending from its attachment point on the scalp (the root) to the end of the cartilage at the earlobe. Typically, it has a curved, rolled shape, although its form can vary significantly. An unfolded helix is characterized by a flattened edge or a lack of the usual curvature [5]. North and Broadbent [3] first introduced the term “flat helix deformity” to describe an ear with a spatulate shape, marked by the absence of a helical curl. The flat helix deformity has often been underestimated, leading to scarce reports on its correction. An unfolded helix and a prominent ear may occur independently or concurrently, depending on the individual’s ear structure.
While the helix plays a crucial role in forming the normal shape of the ear, treatment for its morphological abnormalities has been relatively overlooked. Ducourtioux [6] first proposed a treatment method in 1971, which involved performing three cartilaginous wedge resections on the helix, followed by plication and suturing. Maurice and Eisbach [7] later refined this approach by performing small composite wedge resections, confining the cuts to the helix itself, and then proceeding with the repair. However, this method has limitations in controlling the extent of inward curling of the helix. When the helix curls more than expected, there is no straightforward method to reverse this.
Lykoudis et al. [4] also developed cartilaginous flaps and introduced an overlapping technique that simplifies the adjustment of the helix shape compared to earlier methods. However, regions with overlapping cartilage tend to be thicker, which can lead to irregular deformities along the rim of the helix. Olivas-Menayo and Gomez-Martinez de Lecea [8] employed a large single-wedge resection approach. While this operation is relatively straightforward, it may result in a notch deformity where the repaired margin of the helix sinks inward.
This surgical method introduces a novel approach by reducing the size of the excised areas while increasing their number. Instead of excising and suturing wedges, this technique involves creating slits, overlapping the cartilage, suturing them together, and then performing trimming. By overlapping and suturing the cartilage, the method enhances stability and allows for better control over the amount of curl. Additionally, trimming the overlapped areas helps minimize irregular deformities. In this case, the patient initially presented with a flat helix at the superior posterior border of the ear and successfully achieved curling of the helix in both ears following the operation (Fig. 4). Four 7-mm-long radiating incisions were made, spaced 10 mm apart. Our surgical method employs the incision and temporary key suture technique, which facilitates easier adjustment of the helix shape. Additionally, in bilateral cases, achieving symmetry between both sides becomes more straightforward. Moreover, by removing the overlapping cartilage, we were able to prevent irregularities along the helix rim.
A prominent ear, often accompanied by an unfolded helix, typically features a well-developed antihelix, while the superior crus remains underdeveloped. Although various methods exist for correcting prominent ears, in such cases, the correction can be effectively achieved using only a concho-scapha suture [9,10]. This technique enables adequate correction through a single incision, eliminating the need for additional cuts. Furthermore, the thin skin and soft tissue in this area can lead to noticeable postoperative cartilage irregularities. Therefore, it is crucial to meticulously trim the cartilage margin during the final stages of the procedure, paying close attention to skin thickness and ensuring sufficient undermining.
The surgical technique described is relatively straightforward, capable of creating the curve of the helix, and can be performed under local anesthesia, thereby reducing the burden on patients. It has proven to be an effective method for helix correction, exhibiting promising outcomes in previous cases.

NOTES

Conflicts of Interest

No potential conflict of interest relevant to this article was reported.

Ethical approval

The report was approved by the Institutional Review Board of Korea University Anam Hospital (IRB No. 2024AN0230).

Patient consent

The patient provided written informed consent for the publication and use of his images.

Fig. 1.
Preoperative photographs. (A, B) Bilateral unfolded helixes and prominent ears.
aaps-2024-01242f1.jpg
Fig. 2.
Intraoperative photographs. (A) Degloving of the skin and soft tissue covering the helix. (B) Four radiating incisions were made at the helical rim; the cartilages were advanced, and triangular cartilaginous flaps were sutured using horizontal mattress sutures.
aaps-2024-01242f2.jpg
Fig. 3.
Surgical procedure. Four radiating incisions were made, and the cartilages were carefully overlapped to shape the helix into a curl using key sutures. The overlapped cartilage was marked and removed, after which the cartilage forming the helix curl was securely sutured. Excess cartilage at the edges was shaved off.
aaps-2024-01242f3.jpg
Fig. 4.
Postoperative photographs. (A, B) Three weeks and 4 days after surgery.
aaps-2024-01242f4.jpg

REFERENCES

1. Porter CJ, Tan ST. Congenital auricular anomalies: topographic anatomy, embryology, classification, and treatment strategies. Plast Reconstr Surg 2005;115:1701-12.
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3. North JF, Broadbent RG. Correcting the flat helix. Br J Plast Surg 1977;30:310-2.
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4. Lykoudis EG, Seretis K, Spyropoulou GA. A 6-year experience in flat helix correction with a simple procedure. Arch Facial Plast Surg 2011;13:168-72.
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5. Hunter A, Frias JL, Gillessen-Kaesbach G, et al. Elements of morphology: standard terminology for the ear. Am J Med Genet A 2009;149A:40-60.
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6. Ducourtioux JL. A simple procedure for surgical correction of a congenitally absent helix. Ann Chir Plast 1971;16:60-2.

7. Maurice PF, Eisbach KJ. Aesthetic otoplasty: wedge excision of a flattened helix to create a helical curl. Arch Facial Plast Surg 2005;7:195-7.
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8. Olivas-Menayo J, Gomez-Martinez de Lecea C. A pinch test to correct an unfolded helix: an innovative and predictable technique. Aesthetic Plast Surg 2021;45:2768-71.
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9. Mustarde JC. The correction of prominent ears using simple mattress sutures. Br J Plast Surg 1963;16:170-8.
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10. Furnas DW. Correction of prominent ears by conchamastoid sutures. Plast Reconstr Surg 1968;42:189-93.
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