 Hi everyone, Dr. Saul here in Beverly Hills today. It's all above the neck. So we did a couple of blepharoplasty. The next we're doing a autoplasy. Remember, autoplasies, the ears are set after age 12. So, you know, just for people that have ears, pronounced ears, and they want to set back, you could do it in the teenage years. Today we have our teenagers, one of the only procedures I do on the teenage years because the ears are set after 12 and you can maneuver the cartilage and it's a very simple procedure done under local and it helps patients that come in look for it. We don't go out there, but people that are looking for it, the teenage years, you can do it. Usually around 14, 15 are good years to do that. So let's look at our patient today. So you can see his ears. He has beautiful hair, but his ears are prominent. So what we are going to do is we're going to make a small incision. We're going to go in to the conca, set the conca back and he has good folds here. He has very good folds. I'll put probably one or two stitches to show the fold just a little bit more and then set the conca back against it. Usually this is about 17 millimeters. People have a tendency to want it to be stuck back. It's never stuck back. Remember we slide our eyeglasses and everything to the back of the ear. So about 17 millimeters would be such. I do overcorrect a little because there is a little bounce to the cartilage. So the same thing on this side. This side is a little bit more pronounced. You could see right here. We're going to make an incision. We're going to set that back and then the fold. You could see how more mark the fold and we're going to go over it and boom. It's going to be a very nice beautiful case. Very simple. Just like going to the dentist after I numb him up. There should be no pain or discomfort. Stay tuned. It's going to be an exciting day. The elevator. Then I'm going to use this small instrument to go in and just elevate the skin from the cartilage right here because what I'm going to do is I want this to bend here. So the way you bend the cartilage is that you rough it up a little bit so it becomes more flexible. So right now I'm just separating the cartilage from the skin. See I'm down here right here. So I'm just freeing it up right there freed up freed up the skin. How you doing? Okay. Just a little tugging right? Yeah. Not sharp. It's just like a little bit tugging and pushing. Yeah. Good. Perfect. So now I'm just going in with the rough surface of my instrument and just bring it down so it'll fold the way I want it to fold. So here it is. That'll help with the with the flexibility of the cartilage. There. Okay. So you see our incision. I'm going to go down here. Make a nice little incision. How you doing? Fine. Are you feeling anything? It's like a little like I feel something but it's not painful. Okay. Just feel a little pressure. Yeah. Okay. Pressure is good. So once we've made that incision then we're going to remove this piece of skin. Remember we have a lot of local in here. So what we're doing is we're lifting the tissue off the cartilage. You can see the cartilage there. There's the conca. We're just elevating. We want to go about to right there. So we need to do some elevation of this. So that's what we're doing. We could do it either with a blade or cotterie. We're staying with the cotterie, less bleeding, less cleaner case. We're staying right on the cartilage. Right above the fascia of the cartilage. Just go. We're just going in. You can see how nicely it opens up even with the scissors. There it is where you could see how far we are. We want to go a little bit further when we see a little blood vessel right there. We're going to just cotterize and look at less oozing. Still got the oozing. You could see with our dissection we're just almost at the edge of the ear. We dissected everything. Now the next thing to dissect is the other side. We've dissected the ear. Now we need to dissect the mastoid fascia. That's where we're going to pin the ear back to. So here we are. This is called the mastoid fascia. It's very strong. That's why we're clearing it up because we're going to pin the ear from here to this fascia. The white stuff is the fascia. So when we're going to put our permanent sutures, we're going to put it against the fascia. So it's going to stay back and it's going to cause the ear cartilage to bend backwards. So in order for me to know from the other side where the fold of the ear is, I've just put some placement sutures here. So in the back I realize where I want to create that fold. And now by doing suturing and different methods of stitching, we're going to perform that and get the fold more defined. By carefully putting a suture on the ear cartilage without going through the skin, we put it from one side and then we come in. And then we're going to put one. This you want about a centimeter or less. And you want to make sure that it's not coming through the skin, right? So there it is. Here's our suture. And we're going to put a couple of these on each side because he has a nice, this is already nice. It's not like he doesn't have any fold to it, but we'll create a better fold. And then we're going to do one more. There's our suture. So we're going to go above it. We're not through the skin, right? Okay, then we're going to go on this side. And then we are going to go about a centimeter and get a nice bite. So here's our other suture. So we're going to go above it, get a nice piece, make sure it's not coming through the skin. And then we'll go a little bit lower, about a centimeter, get a good bite, and out. Now we have a lot of sutures here. So we'll be diligent. This is our suture with this one. What we're going to do is, so here's our suture. See how it folds in nicely? We get a nice fold to it. And then we're going to, so we've defined a helical fold. You could see how much more brisk it is. And now I'm going to put my sutures from the conca back to the mastoid fascia. And it's going to give us this look. Look at how nice that's going to look. So this is the fascia I'm talking about. This is very strong. Here we are. Look at that. I could almost lift his head off the table with this suture because it's so strong. So there it is. We go through the mastoid fascia. And then we're going to go through the conca, which is right. This is called the conca to pull it back. So we're going to go take a big, nice piece of it without coming through. We're not through. Let's see how this is going to look. So we're going to put one there. Put one up here. Put one there. It's going to give him a nice, very nice look. What do you guys think? So there's our fourth suture right there. Let go now. So look at how nice and nice and clean it looks. It looks very normal. You don't want it to be overdone, but look at that perfect. If we measure that, that's perfect measurement with the caliper right from the base of the skull. Here's the caliper. We're going to put it at about, let's see, 10 millimeters. Look at that. It's like 10 millimeters from the base. It's even overcorrected because as I told you, you want a little spring. Look at that. This is at 12. Look at that. Beautiful. Very natural looking. It looks great. So again, we make a little incision because we want to bend the cartilage, the helical fold. So I'm just going to elevate the skin off the cartilage. There we are. You can see my markings. I'm trying to follow my markings, of course, there and there. So there we are. We have a nice little plane between the skin and the helical fold. Then we use the rasp one to create a little bend in the cartilage. The cartilage works interestingly. If I go at it from the top, it'll bend backwards. If I go from the back, it'll bend upwards. So if we want it to bend down, so we're going on top and making it flex backward. There we are. We clean that. So we're going to make then ellipse incision again, just like the other side. All the way and go down here. Remove the tiny bit of skin. That'll give us access to the mastoid fascia and the conca. So you can see I'm just elevating just the skin. I don't need to remove the fascia or anything else. Just the skin, almost kind of like the blepharoplasty we do. So you can see how nicely this plane elevates after you've had numbing in there. Again, we want to go as far up towards the edge of the ear. And you can see this is all my two mests. And look at that beautiful plane. You can either dissect this, as I said, using the scissors, the knife, the cottery, whichever one you feel comfortable with. So in order to create the helical fold, we're going to go above our suture. This is where our helical fold is. We go above it and we're going to go below it. It's not through, right? So you can see the lower one when we tighten it gives it a more of a fold. Here is, look at the fold created. Look at that. Look how nice that fold looks. Okay, so we're just going to tie the knot on that fold. Fold back to the skin. And here's our last suture for the helical fold. Look at that beautiful creation of that helical fold.