1. Lidocaine 2% with 1:100,000 epinephrine is injected using a tuberculin syringe and 30 gauge needle. Care is taken to avoid hitting small vessels and causing ecchymosis. After pronounced blanching is achieved, the procedure may start. General anesthesia is usually required in children. Peri-operative antibiotics (usually cephalosporin) are used as a precaution against perichondritis.
2. A 20 gauge phlebotomy needle is used to produce multiple scores along the anterior surface of the cartilage for the length of the newly created antihelical fold. The needle is placed through the skin in only 2 or 3 places and used as a subcutaneous mini-knife. Care is taken not to create a large, confluent pocket that could result in a hematoma. Rather, narrow tracts allow the needle to thoroughly score the cartilage (Figure 1). Observers have remarked that this technique in some ways resembles the tunnels created by liposuction surgeons. The purpose is to break the intrinsic cartilage “spring”.
3. A bilateral series of percutaneous retention sutures is placed using incisionless technique. If necessary, ink dots may be drawn on the skin to aid with suture placement. Each suture loop is pulled tight to achieve the desired cartilage bend.
4. A measuring ruler is used to assure symmetry. Then, the final knots are placed. A surgeon’s hitch is followed by 3 further half hitches.
5. After all knots are tied, a single pronged skin hook is used to help pull the skin over each individual knot. If a retracted, buried knot appears to re-exit the needle hole, a 6-0 mild chromic suture is placed through the needle hole (Figure 2). Transparent antibiotic ointment is placed on the puncture sites.