Background: Protruding ears are a frequent source of embarrassment and ridicule. Whether it is a young school-age child or an adult, ears that stick out too far can make one very self-conscious. There is an established angle number between the side of the head and the ear. (auriculo-cephalic angle, 20 to 30 degrees) However, how one feels about the position of the ear is more important than any number.

Otoplasty, corrective ear reshaping, can be done at almost any age. In my Indianapolis plastic surgery practice, I have performed otoplasty on patients from age two to seventy-four. Otoplasty is a simple cartilage manipulation of the ear that is not affected by the age of the patient.   

Case Study:This is a classic case of pediatric or school-age otoplasty. An eight year-old male was seen with very prominent ears. Often called cupped ears when they are very prominent, the ear angle is close to 90 degrees. The cup description comes from the large concha (bowl or cup) that is responsible for driving the ear away from the side of the head. Interestingly, his mother had her ears done when she was a child and his younger sister also had prominent ears, demonstrating that ear shape and position has a familial influence. In some families, there must be a gene loci for this condition when it affects so many members of the same family.  

There has been some debate about the timing of otoplasty surgery. It was historic teaching that otoplasty should not be done until at least age six, when the ear is near fully grown. The concern was that early cartilage manipulation would affect its growth. This has not been borne out by both experimental research and clinical experience. Otoplasties done as early as age two have failed to show any subsequent growth problems. Conversely, there is no upper age limit when it can be done either. The cartilage never becomes too stiff to be folded and bent. Feel the ear in a senior citizen as you will find it is still quite pliable.

While there are a variety of otoplasty techniques, the most reliable methods use an open approach. Incisionless and minimally-invasive methods can be effective when the ear cartilage is not stiff or too severely deformed. While they are theoretically appealing because they are ‘less-invasive, open otoplasty is not that much more of an operation. The difference between open vs closed otoplasty is not as vastly different, for example, as between open vs closed gall bladder removal.  

This boy’s otoplasty was performed as an office-based procedure under general anesthesia. Through incisions on the back of the ear (postauricular incision), the cartilage was exposed.  Some plastic surgeons prefer to take a strip of skin from the back of the ear, others do not. The original methods of otoplasty believed that skin removal was a necessary part of the procedure to ensure setback. That is no longer believed to be true.  A combination of  horizontal mattress sutures for antihelical fold creation and simple sutures for conchal setback were done. Placing these sutures is a  bit of an art form and there is no precise science as to how many sutures should be used. Nor what type of sutures should be used. I prefer braided non-resorbable (mersilene) sutures but slow resorbing sutures can be used as well. The incision is closed with dissolveable sutures.

A circumferential head dressing is placed at the end of surgery. In teenagers and adults, it is removed the next day. In children, it will stay in place for up to a week if tolerated. The ears will be sore for a few weeks and little swollen for seven to ten days. One can shower and get the ears wet as soon as the dressing is removed. One only needs to be careful about inadvertent bending or pulling on the ears so the sutures are not dislodged. Ultimately, it is scar tissue which keeps the ears in their new position but the sutures do this task in the short-term.

The effects of otoplasty are immediate and dramatic. They may initially look a little pulled back too far in the beginning but that relaxes into a more natural position in the first few months after surgery.  

Case Highlights:

1)      Otoplasty can be performed at almost any age. The timing of surgery is based purely on the psychological motivation of the patient or parents in the young child.

2)      Ear reshaping in otoplasty is done primarily by either folding the cartilage to create more of an antihelical fold or suturing the conchal cartilage back to the mastoid fascia. Sometimes a wedge of conchal cartilage is removed to break the recoil of the cartilage and prevent some relapse of ear position.

3)      Otoplasty is a reliable and proven method of ear repositioning that has few complications with a quick recovery.

Dr. Barry Eppley

Indianapolis, Indiana

1.   1. Why do my ears stick out?

The shape of our ears is a direct reflection of the cartilage that makes it up. Other than the ear lobe, our ears are composed of just cartilage and the skin that covers it. While one can ponder why normal ears look the way they do, the cartilage framework which is responsible has a complex shape comprised of numerous hills and valleys which comes together in a three-tiered structure. The upper outer tier or rim is the helix. The next tier inside the helix, separated by a small valley, is the antihelix. The antihelix is a fold in the cartilage. Ears generally stick out because the antihelix is not folded properly. When this fold is missing or diminished, the outer helix sticks out further creating the protruding ear. In some cases, the size of the conchal cartilage (around the ear hole) is too big and also makes the ear stick out as well.

2.      How are the ears reshaped and what makes them stay that way?

Since the protruding ear problem is because the cartilage is not folded properly, otoplasty surgery is directed towards folding or bending the ear back into a better shape. (remaking the antihelix fold) This is done through an incision on the back of the ear. From the backside, permanent sutures are placed to recreate a better fold. Placing these sutures is an art form and how many sutures are placed and where will differ for each patient. Other cartilage manipulations are often done as well including conchal reduction and sutures between the concha and the mastoid bone. Once the desired shape is obtained the skin incision is closed with small dissolveable sutures. While the sutures are responsible for the new ear shape in the short-term, scar tissue that forms between the cartilage folds keeps it that way permanently.

3.      At what age can otoplasty surgery be done?

That question is best answered by addressing how young and how old can one have otoplasty surgery? Historically, otoplasty surgery was not done until a child was at least six years of age. The belief was that one had to wait until the ear was nearly fully grown so that its development was not affected by scar formation. That belief has now been discarded and I have performed ear surgery as young as two years of age without any adverse effects. For children, therefore, the timing of surgery is largely psychological and not chronological. When the parents or the child feel that it is a problem, then surgery should be done.

Conversely, there is no upper age limit. The cartilage can be reshaped at any age.  I have done otoplasty surgery in an 82 year-old. It bothered her all her life and she was finally determined to do something about it.

4.      Is ear surgery painful and is there a lot of swelling after?

Our ears are definitely sensitive and if you even bump your ears you know how uncomfortable that can be. While otoplasty surgery is not acutely painful, the ears will most certainly be sore and will remain tender for weeks after surgery. The ears do swell but most of that goes away in a few weeks. Despite the tenderness and swelling, the new look to the ears is immediately evident and often a dramatic improvement.

5.      My ears look different, can surgery make them look more symmetric?

Rarely are our ears exactly symmetric but, because they are not close together and seen as a matched set, these asymmetries are usually not bothersome. When the ears are very visibly different, it is likely due to some significant differences in the shape of the cartilage. Protruding ears are often different with one side sticking out further than the other Such cartilage deformities can be improved by using different suturing and reshaping techniques on each side. While perfect asymmetry is usually not possible, enough improvement can be obtained so that whatever differences may remain, they are no longer obvious to the casual observer.

6.      Will insurance pay for my ear surgery?

Even though one could argue that protruding ears is a developmental anomaly ( a form of a birth defect), insurance will not pay for otoplasty surgery. Because it only changes ear shape (cosmetic effect) and does not improve the ear’s function (hearing), there is no medical or functional benefit.

7.      My earlobe has split from heavy ear rings, how easy is it to repair?

Unlike the rest of the ear, the earlobe is only skin and a little bit of fat. Heavy ear ring use or accidental pulling on an ear ring can cause it to pull through or split this fragile and thin skin. Repairing a split ear lobe is a simple office procedure done under local anesthesia. The edges of the split must be cut open and sutured back together. The ear can be re-pierced again six weeks after repair.

Dr. Barry Eppley

Indianapolis, Indiana 

The ears make up a small and often unnoticed part of the face. Since they sit way to the side of the face and are often obscured by hair, they make little impact on one’s facial appearance. Unless they have a congenital alteration of its complex cartilage structure which causes them to become visibly prominent. The most common cartilage deformity is that which causes the protruding ear.

There is a certain amount of distance between the ear and the side of the head which makes it either indiscriminate or very noticeable. Known as the auriculocephalic (ear to head) angle, it should generally be no greater than 30 degrees. When the ear sticks out more than that, it becomes a facial focal point. Known by a lot of unflattering names, dumbo ears and elephant ears to name a few, protruding ears can be a source of poor self-image and ridicule.

Protruding ears are caused by a variety of cartilage malformations. The most common reason that an ear sticks out is that the antihelical fold is either absent or underdeveloped. (weak fold) The antihelical fold is the inner fold just inside the outer rim. (helix) It is the fold that turns the helical rim back in, preventing the ear from angling far outward. The other structure that can cause ear protrusion is the size of the concha. Known as the bowl of the ear, it is the cartilage structure that wraps around the ear hole and extends outward to meet the outer ear folds. If the concha gets too big, it can drive the outer rim of the ear to stick out.

Correction of the protruding ear  (otoplasty) has been around for nearly a hundred years. Many different plastic surgery techniques have been used but all are based on some manipulation of the cartilage problem. Most use suture creation of a more visible antihelical fold, reduction of the large concha,  suture setback of the prominent concha to the mastoid area, or some combination of two or more of them. While all of these methods are well known, it takes an artistic sense to mix and match them for each individual ear setback.

A good otoplasty result is one that does not trade-off one ear deformity for another. Overcorrection (setback too far) is known as the telephone ear deformity and looks like an ear plastered to the side of the head. Symmetry of the ear correction is relatively important even though both ears are not usually viewed at the same time. But patients will pay much more attention to their ears after surgery so intraoperative matching and attention to detail is important.

 One aspect of otoplasty that is often overlooked is the earlobe. While it does not have any cartilage in it, it often will stick out too far with the rest of the ear as well. I frequently will set it back with the cartilage of the ear through a fishtail pattern skin excision on its back surface. This simple otoplasty maneuver can make a good ear result look even better. The helical rim of the ear should be seen as flowing from the top down to the bottom of the earlobe without outward deviation.

Otoplasty surgery requires an appreciation of the cartilage problem and matching it with the correct cartilage manipulation techniques. Done through an incision on the back of the ear, it is a simple but eloquent outpatient procedure that produces immediate and dramatic results. In some protruding ear problems that are not severe, the surgery can be performed in the office under local anesthesia.   

Dr. Barry Eppley

Indianapolis, Indiana

Cauliflower deformation of the ear has been known for over a thousand years since the Greeks in paintings and sculptures imaged pugilists and wrestlers. Its cause, however, has only become more recently known as the result of auricular trauma and subsequent hematoma. Once a bleed and hematoma occur under the perichondrium (from shearing trauma to the ear), if it is not removed in a timely manner, will result in new cartilage formation. The delicate framework of the ear with its many concavities and ridges does not have more than a few millimeters of thickness. Cartilage thickening can easily deform how the ear looks.

Ear trauma and hematoma is a common injury occurring among high school and collegiate wrestlers in particular. Incision and drainage followed by the immediate application of a pressure dressing sutured to the ear is the treatment approach. In my Indianapolis plastic surgery practice, I prefer to shape a xeroform bolster, like that used for securing a skin graft, over the evacuated hematoma area and use through and through ear sutures to hold it into place. This precisely adapts the overlying skin back down to the cartilage, eliminating any chance of recurrence and preventing neocartilage formation.This stays in place for about seven to ten days and is easily removed. It also allows a rapid return to athletic competition.

Once a cauliflower ear is established, successful treatment is more difficult. I have found one treatment approach that is successful. Skin flaps are initially raised over the deformed part of the ear. The easiest method is to place an incision along the antihelix and raise it towards the face. Most of the ear skin can be degloved without vascular compromise if needed by using an incision on the backside of the helical rim. Cartilage must next be removed. Since the goal is usually to recreate an obscured concavity, the deformed cartilage can be thinned down on its outer surface or a new concavity can be made by removing full-thickness cartilage. Like making an ear cartilage framework, structure is only needed for the tiers or prominent ridges. Once the ear shape is recreated, the skin is put back and bolsters applied over the new concave areas.

Both the primary and secondary treatment of the cauliflower ear deformity is based on removal of the underlying cause (blood and cartilage growth) and eliminating any space afterwards between the cartilage and the overlying skin. Custom-shaped bolster dressings are critical to the success of this form of ear reconstruction.

Dr. Barry Eppley

Indianapolis, Indiana

Microtia is a well known congenital ear deformity that has a broad spectrum of presentations. From a small residual bump to a crumpled shortened ear, no two cases of microtia are exactly alike. But they all similar in that they are an incompletely formed ear that is much smaller than a normal one. The underlying cartilage framework and ear canal are malformed and it is easy to see why such a complex structure can go developmentally awry.

 One of the marvels of modern plastic surgery is the reconstruction of the microtia ear deformity, the most complex form of an otoplasty. While it is not a life-threatening or life-changing deformity, its reconstruction is a complex array of operative steps that call upon a variety of basic plastic surgery techniques and an artistic ability. While it is not as technically precise as the vascular anastomosis of a free flap, it is similarly unforgiving in its execution. You have one good opportunity to work with the skin over the deformed cartilage remnant. Your first effort is your best chance for the best result. Salvages of failed ear reconstructions are extremely difficult and almost always far from satisfying.

While there are different methods for putting the initial cartilage framework together, and it is a learned skill to masterfully assemble one, the more critical step is in how the overlying skin is handled. What is the correct location and angulation of the framework, is the skin adequate or does it need tissue expanded,  how much of the deformed cartilage should be removed, and what about the typical low lying hairline? All of these issues can compromise an otherwise well-crafted cartilage framework by obscuring its exquisitely carved detail.

Beyond the most critical step of first-stage cartilage framework fabrication and insertion is the creation of smaller but aesthetically important ear details. The lobule, ear to head separation, and the concha-tragus unit all make important contributions to what we see as a more normal ear. While different microtia surgeons may stage these subsequent creations at different times or in differing combinations, all will attest to their value in the pursuit of what nature failed to create.

Even with all the current and future innovations of plastic surgery, microtia reconstruction remains a marvel and is a collage of plastic surgery techniques focused one relatively small area. The sheer rarity of microtia makes its reconstructive mastery limited to just a handful of plastic surgeons.

Dr. Barry Eppley
Indianapolis, Indiana

Otoplasty, often referred to as ear pinning, remains as one of the most satisfying of all plastic surgery procedures above the shoulders. In a very short operative time, the ears can be dramatically reshaped to assume a less noticeable and more aesthetically pleasing appearance. Through an incision on the back of the ear, the otoplasty procedure is performed without visible scars.

The key to a successful otoplasty is identifying the cartilage deformity that makes the ear stick out too far. In most cases, the lack of an antihelical fold is the crux of the problem and this is the reason for the use of permanent horizontal mattress sutures known as Mustarde suturing. Bringing back the helical rim, particularly if it is largely absent, really pulls the protruding ear back. But in some cases, the lack of an antihelical fold is not the problem.

Some cases of protruding ears are the result of a large concha or bowl, not the antihelix. The inner tier, or third level, of the ear is shaped like a bowl and  helps capture sound to direct it into the ear canal to the ear drum. The concha forms the under support for the outer antilhelix and helix. When it is too large, it can be the primary source of a cosmetic deformity. When this is present, one will often have a good antihelical fold but the ear still sticks out too far. Without reduction of the large concha, other suturing methods will be unsuccessful. Removing a wedge of conchal cartilage and using sutures that pull back the concha towards the mastoid are needed to make the ear sit closer to the side of the head.

Many otoplasty procedures require a combination of antihelical and conchal manipulations to create a new ear position that does not look deformed or ‘crimped’. I have seen several cases of ears pulled back too far that had unusual or unnatural folds in them. This is the result of not identifying the total cartilage problem and trying to make one cartilage reshaping method (usually antihelical fold suturing) do too much. As a general rule, the helical rim should always stick out just beyond the antihelical trim in a frontal view. And there should always be a small vertical curve or slope from the antihelical rim to the base of the concha without a sharp transition or indent in the skin. Such deformities can be seen intraoperatively and one should not expect much relaxation of the ear shape after surgery. In short, don’t overcorrect counting on it ‘evening out’ after surgery.

The complex cartilage shapes of the ear usually defy a simple suture or two to adequately reshape them. Appreciating what cartilage abnormalities makes the ears stick out too much will enable the right combination of cartilage bending and resection to give the ear a better profile without deforming it. The repositioning of the cartilage through sutures allows scar tissue to form which is ultimately responsible for the long-term retention of their altered shape.

Dr. Barry Eppley

Indianapolis, Indiana

The correction of protruding ears has been done by a variety of procedures over the years, from cutting out skin on the bck of the ear, removing cartilage, and cartilage suturing techniques. Over the years, it has been learned that the removal of skin and cartilage is unnecessary as the problem is not tissue excess, but the shape of the cartilage. Specifically, the shape or absence of shape of the antihelical fold is the problem. Creating the antihelical fold through the use of cartilage sutures on the backside of the ear creates a very natural-looking ear result and should match what one can achieve by folding the ears back with one’s fingers.

This relatively simple procedure is done as an outpatient procedure that generally takes one hour or less to perform on both ears. By making an incision on the back the ear, the cartilage  can be reshaped by a suture technique. Sometimes it is necessary to take some skin from the back of the earlobe to get it to fall in line with the shape of the rest of the ear. But this is not always necessary. The ear effect created is immediate and dramatic. In adults, I have them wear a headband to protect the ear for a few days but they can shower the next day and have no fear about gettiing it wet. In children, I ‘childproof’ the ears by a bigger head dressing that stays on for around five days and then they wear a headband after for protection.

The key to a good-looking otoplasty result is that the new ear position must be natural-looking. Overdone ears which are pulled back too far are unnatural and are known as the ‘telephone-ear’ deformity. This problem is difficult to correct unless the patient returns to the oeprating room within a few weeks after surgery.

Otoplasty is a very gratifying operation that has few complications. Beyond the immediate risks of infection or poor correction (which I have not yet seen), the only long-term issue is that the permanent sutures used may eventually come through on the back of the ear. This is a minor problem that is solved in the office. It is very pleasing to see such a simple operation that has such dramatic lifelong self-image benefits.

Dr. Barry Eppley

Indianapolis, Indiana

The correction of protruding ears, also known as otoplasty or ear pinning surgery, is a simple plastic surgery procedure that has a dramatic visual effect and an equally significant improvement in one’s self-image. By repositioning the cartilage of the ear with sutures through an incision on the back of the ear, the angle of the ear as it protrudes from the side of the head can be altered to a more favorable setback position. The effect is instantaneous, both on the operative table as well as when the ear dressings come off. Here are my after surgery instructions that I provide to my otoplasty patients.
1. A circumferential head dressing will be placed on at the end of the surgery
to protect the ears in their new position. In adults and teenagers, this dressing
can be removed the next day. In children, the head dressing will stay in place for 1 week.
(if they can stand it for that long!)
2. Dissolvable sutures are used behind the ears so suture removal is not necessary.
3. Once the head dressing is removed, the ears still need to be protected. In
children, a ‘ski band’ or head band is to be worn as much as possible for
the next 2 weeks. In adults, this form of protection should be worn only at night
for several weeks after surgery. If one should accidentally twist an ear or roll over
on it during the night, it is possible to loosen or break the sutures with the ear
returning to its appearance prior to surgery.
4. Eyeglasses should not be worn for the first week after surgery so they do not
rub on the incisions behind the ears.
5. The ears will remain somewhat swollen for up to a month after surgery. Be patient
before judging the final result as it takes time for the ears to settle and be less
sensitive to the touch.
6. Swimming and other underwater activities should be avoided for two weeks after
the surgery.
7. Sports activities that pose a risk for direct ear trauma (e.g., basketball) should be
avoided for one month after surgery.
8. Make sure to take and complete your antibiotic prescription. While ear infections are
rare, should they occur around cartilage (known as chondritis), they can pose a
big problem. Cartilage infections are difficult to eliminate.
9. The need for pain medication is usually quite short-lived in otoplasty surgery. The ears
are sore but not acutely painful.
10. The sutures used to reshape the cartilage are permanent. It is uncommon, but possible,
for these sutures years later to extrude on the back of the ear. This usually appears
as a white knot which is easily removed in the office.
Dr. Barry Eppley

Indianapolis, Indiana

Having spent a long time in plastic surgery at Riley Hospital in Indianapolis, I have performed a lot of cosmetic otoplasty procedures for protrudung ears as well as ear reconstructions in children both with missing or partially missing ears. Parents frequently have a lot of questions about otoplasty in their child and many of these questions are fairly common. Here are the most typical ones.

AT WHAT AGE CAN AN OTOPLASTY BE DONE IN A CHILD?

Classic plastic surgery teaching is that an otoplasty should wait until the ears are nearly fully formed at around age 6. The theory is that scarring on the ear may not cause it to develop properly if done before that age. While this may be classic teaching, it has now been shown that otoplasty done as early age 2 does not result in any problems of ear growth. Therefore, I think age 2 and beyond is a safe time to do otoplasty from an ear development standpoint.
The more relevant question(s) in my mind in terms of otoplasty surgery timing is….when will the child be reasonably cooperative (they need to allow a head dressing to be on for a week after surgery) and when does it bother the child (from a social teasing standpoint). These are practical surgical issues and when these two question are put together, I find age 4 is reasonable. The child at age 4 is more cooperative than age 2 and I think you want to otoplasty surgery BEFORE they are teased to prevent any self-image issues. (i.e., before they formally go to school and are around a lot of other children)

IS RECOVERY AFTER AN OTOPLASTY DIFFICULT?

In general, no. The ears are somewhat tender but not acutely painful. Most bothersome (after 3 or 4 days) is the head dressings which gets itchy and does impede their hearing somewhat (they may have selective hearing anyway!) The head dressing is only there to prevent the ears being bent, twisted, or traumatized which may cause the sutures holding them back to come loose…with the ear ending up sticking out again.

HOW PERMANENT ARE THE RESULTS OF OTOPLASTY?

Once healed, an otoplasty result is fairly permament. Some studieds have shown that very long-term results of otoplasty shown some mild degree of relaxation but the improvememnt is so substantial thaty this minor ‘relapse’ is not even noticed.
Until an otoplasty heals, however, the ear is at risk of coming ‘undone’. For the first month or so, the new ear position is held there by the internal sutures. After that, the scar that forms takes over for the sutures which are no longer needed. Therefore, one must be careful during the first month to not disrupt the internal sutures which are temporarily playing a critical role.

As an Indianapolis otoplasty surgeon, this procedure remains one of the most satisfying of all cosmetic procedures…and its immediate improvement in a child or teenagers self-image is a joy to watch and hear about.

Dr. Barry Eppley

Indianapolis, Indiana

Protruding ears, or ears that stick out, are a frequent source of embarrassment for patients. This is most common in children who can undergo a lot of ridicule during the early school years which can lead to psychological damage and negative self-image development. However, I have seen similar issues in much older patients as well. I most recently did a 72 year-old patient’s ear correction and when asked why now…she stated it had bothered her her entire life and now she was able to do it!
The good thing about the correction of protruding ears, known as otoplasty, is that it is a very simple and easy procedure to go through that creates an instantaneous change. Otoplasty is done through an incision on the back of the ears. (actually some skin is removed from the back of the ears as well) Through this approach, permanent sutures are placed to reshape the outer cartilage of the ear, specifically to create the ear fold that is missing known as the antihelix. Sometimes the size of inner cartilage known as the concha or bowl of the ear may be reduced as well. Permanent sutures may also be placed from the concha to the skull bone behind the ear (mastoid) to help further pull back the position of the ear. Both suture manuevers help change the angle of the ear from the side of the head so that the entire ear lays back further. Dissolvable sutures ares used to close the wound and a wrap around head dressing is then applied at the end of surgery.
The results of otoplasty surgery are immediate. While there will be some mild swelling and soreness to the ears, the change is dramatic as the dressings are removed. In children, the ear dressing is worn up to one week to prevent inadvertent bending of the ears which could pop the sutures. In teenagers and adults, the ear dressing is worn for just one day. The only precaution is not bend or twist the ears as the sutures are all that is holding the ears back in the first few weeks after surgery. After several months, the ears are held in their new shape permanenetly by the development of scar tissue. The sutures no longer play a critical role at that point.
Complications are few with otoplasty. Cosmetically, the goal is to get as much symmetry between the ears as possible, although exact perfect symmetry is rarely achieveable. The only long-term complication I have seen has been an occasional suture extrusion over time through the skin on the back of the ear. This could occur after months or years. I have even seen one lady who had a suture come through 35 years later!
Otoplasty is a wonderfully gratifying procedure that can dramatically change a patients self-image. If one has a concern about protruding ears, one should not put it off out of fear of pain or a long recovery. It will be a life-changing 1 hour of surgery!

Dr. Barry Eppley

Indianapolis, Indiana