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Archive for the ‘otoplasty’ Category

Ear Pointing and Ear Elf Surgery

Sunday, January 5th, 2014


It is not rare that a patient will request to see if some face or body feature they have can be changed to look more like that possessed by a certain celebrity. Whether it be a nose, jawline, breasts or buttocks, the shape of the famous has always motivated others to seek the same. But in almost all these cases, the desire has been to achieve known shape and proportions of body features that are variations along anatomical features that can naturally occur.

Ear Pointing Dr Barry Eppley IndianapolisBut unusual face and body changes do get requested and occasionally done. One such example is the procedure known as ear pointing or elf ear surgery. The description alone tells you exactly what is being done. The desire for this procedure undoubtably has its history in Star Trek and the character Spock. But the more recent movie series of Lord of the Rings and the Hobbit movies puts only display a much larger number of characters with different ear shapes, almost all of them with ear points of various elongations.

Ear Elf Surgery Dr Barry Eppley IndianapolisThis has driven a few fans and devotees of the films to actually having their ears reshaped. One such fan who is a young model who recently underwent the procedure and chronicled her experience in an online video on YouTube which can be found under Elf Ear surgery. While many would understandably question the motivation for such an unusual ear modification, that decision and explanation is best left for the patient to answer. What is more anatomically relevant is can it really be done and, if so, how?

Ear Anatomy Dr Barry Eppley IndianapolisThe normal ear is formed by islands of cartilage (six to be exact) that come together to form a complex series of raised ridges and valleys. One of these prominent cartilage ridges is the one that rings around the upper two-thirds of the ear known as the outer helix. It essentially goes a long way in creating the recognizable ear shape of humans. The top of the outer helix forms an upper semicircle that surrounds the upper 1/3 of the ear. Inside the outer helix is the antihelix which represents a folding of the conchal cartilage and has a similar prominence to the outer helix. This is what is created in the classic ear pinning surgery for prominent ears. As the antihelical fold comes into the top of the ear it branches about two-thirds of the way along its course to form the broad fold of the superior (posterior) antihelical crus and the more sharply folded inferior (anterior) crus. Between the superior and inferior crus is the indentation known as the triangular fossa.

Ear pointing is done by taking a small wedge of skin and cartilage from the upper ear. This is like removing a slice of pie that contains the outer helix and potentially some portion of the superior crus. This triangular excision needs to be done closer to the junction of the upper and ascending outer helix so that when it is sutured together it creates a well defined point. In elf ear surgery, a much larger wedge of ear tissue is removed that effectively removes most of the superior and inferior crus so that the approximation effectively flattens the upper outer helix.

Like all ear reconstruction and reshaping surgery, it requires an understanding of how to manipulate the natural ear cartilages to obtain the desired shape. Ear pointing and ear elf surgery illustrate this point to the extreme.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery’s Did You Know? Anatomy of the Protruding Ear

Saturday, August 31st, 2013


The ears on the side of the head are relatively inconspicuous unless they stick out too far. A good looking ear is one that goes unnoticed, only bad looking ears catch our attention. But despite the small size of the ear, it has a compact anatomy that is filled with ridges and valleys. By description they comprise a dozen specific parts that collectively form what is recognized as a normal ear. When the ear sticks out too far, its most common cosmetic deformity, it is the result of a fold deformity (lack of the fold) of the antihelix or excessive development of the underlying concha. (the bowl of the ear) In some protruding ears it is a combination of both. Surgical correction involves making the antihelix fold by placing sutures on the backside of the ear to bring the outer helical rim closer to the side of the head. For the overgrown or too big concha, it may be pulled back by sutures to the mastoid bone or weakened by cartilage removal and then sutured back. Either cosmetic otoplasty is about ear reshaping by folding and bending.

Case Study: Otoplasty for Protruding Ears

Saturday, March 30th, 2013

Background: The shape of the ear, like the nose, is one of the most variable features of one’s face. While it is chocked full of hills and valleys composed of cartilage and has an array of anatomic convolutions, the human ear is nonetheless very recognizeable. Any gross abnormalities in its shape and size is easily observed.

While the ear may seem to be the least important part of one’s face because of its lateral location, it takes on great signficance when its shape is abnormal and easily seen. The most common ear abnormality is also the most visible, the protruding ear. As the ear moves from its more streamlined position on the side of the head (an ear-head angle greater than 30 degrees) to stick out, it becomes instantly more prominent.

Known by a multitude of names such as dumbo ears or elephant ears, these very names indicate that it is not viewed as a favorable facial feature. While it may provide a better eyeglass resting place or a more effective method of holding one’s ear back, the social stigma that comes with prominent ears overrides whatever functional benefit that it may provide.

Surgery for the protruding ears, most commonly called ear pinning (there is no pins used in the surgery however), has been around for over 100 years. When it was originally introduced long ago, only skin was removed from the back of the ear to pull it back. This did not work well and it was eventually recognized that the actual shape of the cartilage needed to be changed to produce a better and more permanent result. Many otoplasty cartilage techniques have evolved over the years but the use of permanent sutures to make the fold remains as a main component of the operation.

Case Study: This 26 year-old female had long been bothered by her protruding ears and finally decided to have them reshaped. She had a 65 degree auriculocephalic angle and lack of an antihelical fold cartilage prominence. Her ears were also very stiff and did not fold back very easily.

Under general anesthesia, her otoplasty procedure was done from the backside of the ears. A very small strip of skin was removed from the middle portion of the back of the ear. The ear cartilage was exposed by lifting up the skin from the outer rim down to the mastoid region. Because of the stiffness of her cartilages, a small wedge of cartilage was removed from the back of the concha area to weaken it. Horizontal mattress sutures of a permanent braided variety were used to create an antihelical fold from the top of the ear down to just above the earlobe. A total of 5 sutures were placed. The skin as then closed with resorbable sutures.

She wore a small head dressing for the first night after surgery and it was removed the next day. She showered and washed her hair 48 hours after surgery. While the result initially looked good, there was some asymmetry between the right and left ears. She returned to the operating room for a left ear adjustment to bring it back further three months after the initial surgery.

Otoplasty surgery for the protruding ears is incredibly effective and produces a dramatic change in the shape of the ear. How far the ear should be respositioned back along side of the head is a matter of intraoperative judgement.Overcorrection and undercorrection is always a concern but the most likely reason for revisional otoplasty surgery is asymmetry. Getting both ears in the indentical position with the cartilage reshaping is challenging and is alspo affected by how well the sutures hold and how the ears heal.

Case Highlights:

1) Ears that stick out are because the shape of ear cartilage is not adequately folded onto itself.

2) Otoplasty or ear reshaping is done by creating a fold in the main cartilage of the ear to bring back the outer helix closer to the side of the head.

3) The most common complication with otoplasty surgery is asymmetry which may require revisional surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Bullying Due To Protruding Ears

Saturday, August 11th, 2012


As the new school year starts many teenagers begin new classes, greet old and new classmates and begin to settle in for the next nine months. But for some students the return to school brings the potential of being ridiculed and even bullied for physical traits that are seen as different. Whether it is ears that stick out, a bump on the nose, breasts that are too big or a weak chin, teenagers have long faced criticism when they don’t fit the ‘standard’ look or are not considered attractive enough. These issues can become particularly harsh when one is born with a birth defect such as cleft lip and palate.

A recent story on Good Morning America highlighted this issue with a 14 year-old girl who had multiple aesthetic facial deformities. She had her concerns addressed with an otoplasty for her protruding ears, a rhinoplasty for her nose and a chin implant augmentation. But, by far, the protruding ears are the one physical trait that is most identified with being teased or bullied. This being called numerous well known names such as elephant ears and Dumbo. Her personal story illustrates this well.

The origin of the Dumbo name is interesting and represents one of the earlier examples of child/teenage ridicule. From the 1941 Disney movie named ‘Dumbo’, it is the animated story of a baby elephant named Jumbo Jr who was born with very large ears. Not that elephants don’t naturally have large ears anyway but this baby elephant’s ears are particularly big. The baby elephant is quickly taunted for his large ears by the other elephants and is cruelly nicknamed ‘Dumbo’. In the movie Dumbo’s ears become an asset because they enable him to fly and, in the end, he becomes sort of a hero for his unique skills from his deformity.

Large protruding ears in humans, however, can not be turned into an asset. They don’t convey unto anyone any unique abilities, not even improved hearing. Because they stick out from the side of the head, they are probably more noticeable to others than other facial deformities such as those of the nose or chin. They are the most common congenital deformity of the craniofacial area occurring in roughly 5% of children and teenagers.

Ears by nature do stick out from the side of the head but how much is too much? Studies show that when the upper part of the ear sticks out more than 20mms (slightly less than an inch) from the side of the end it is viewed as protruding. Interestingly, the amount that the ear needs to stick out to be called protruding in girls is less than that of boys. All protruding ears have also been shown to be longer in vertical length than normal non-protruding ears, an anatomic feature that certainly does not help in making them look any less noticeable.

The good news is that protruding ears are one of the easiest facial deformities to fix with a very minimal recovery. The results are instantaneous, complications are few, and the changes will be permanent. Through hidden incisions on the back of the ear, the cartilage is reshaped with sutures to bring back the ear into a non-protruding shape. The cost of otoplasty is also one of the least expensive of all facial plastic surgeries to undergo because of a short operative time (one hour) and minimum number of materials needed to perform it.

If your child or teenage suffers from ridicule or bullying because of their ears, consult with a plastic surgeon to get them fixed. If the cost is an issue, discuss this with the plastic surgeon and lower otoplasty fee rates may be possible. Surgery can not be done completely for free because of the fixed costs of the use of the operating room and an anesthesiologist, but most plastic surgeons have great compassion for such afflicted youth and always like to bring their expertise to someone’s lifelong benefit.

Dr. Barry Eppley

Indianapolis, Indiana

Otoplasty as Prevention for Bullying

Wednesday, June 27th, 2012

One of the historic physical features that commonly leads to teasing and ridicule is that of the ears that stick out too far. Known as ‘dumbo’. ‘elephant ears’ and other equally unflattering names, ears that project too far away from the side of the head causes a child or  an adult to look different. Undergoing an otoplasty or pinning of the ears is a well known and highly successful plastic surgery procedure that can cure that physical problem.

While teasing for protruding ears is unfortunately not rare, I recently saw a young patient whose mother told me that she was being bullied because of her ears. While I am not sure it matters whether one is being teased or bullied, it does cause me to ponder what the difference between these two undesireable behaviors are.

Teasing is a behavior that has been around since the beginning of time. Poking fun at each other to some degree is what children do. A little bit of it is natural and some may argue that it is even an important part of a child’s social development. A little bit of it can have a positive social impact as it helps develop friendships and bonding. It can have a positive impact if not carried too far.

Bullying, conversely, has a negative social impact. Bullying is teasing carried to the level of creating harm, usually with the purpose of the bully gaining increased social status. And it is almost always very personal, directed at a physical feature or a personal behavior. While at one time such behavior was limited to a smaller circle of people, today’s electronic world makes its impact much more substantial and exposed to a larger number of people. One could argue today that being teased about an obvious personal feature is no longer just teasing but constitutes bullying because of its wide reaching audience. It is always harmful and certainly does not help a child’s self-image.

Whenever possible, otoplasty surgery should be done when a child is being teased about their protruding ears. If a child reports to their parents about being teased about their ears, you can be certain that it is being done much more than the child states and is already having a negative impact. The good news is that otoplasty can be done quite early, even as young as age 4 or 5. It can be done as a pre-emptive strike on what may happen if the parents so desire before the child starts formal schooling.

Otoplasty is a fairly simple outpatient procedure that takes about one hour to perform. In children it is always best to do the procedure under general anesthesia. The procedure is tailored with children in mind so no sutures need to be removed from the back of the ear. An ear dressing is kept in place for a few days. Summertime is a common time of the year for otoplasty in children as it does not interfere with school.

Bullying for protruding ears can be remedied quickly with otoplasty and is associated with very high satisfaction rates and dramatic improvements in their self–image.  

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery’s Did You Know? The Angle of the Ear

Thursday, May 17th, 2012

The prominence of the ears is determined aesthetically by how much it sticks out from the side of the head. Known as the auriculocephalic angle, it is the angular measurement that the ear is situated from the scalp. The normal angle is somewhere between 20 and 30 degrees and is measured on the back of the ear. When the ear sticks out too far, its angle is definitely greater than 30 degrees. Otoplasty, or the pinning of the ears back, is designed to change an auriculocephalic angle that is too great and bring it back into the normal range. While these numbers provide a quantitative measurement as to what looks normal and abnormal for the ear, one can intuitively tell when the amount of ear protrusion is too much or just right.

The Role Of Plastic Surgery In Bullying Management

Monday, April 16th, 2012

Bullying for school age children and teenagers has reached unprecented awareness recently. While it is a social phenomenon that has gone on forever, many recent examples of internet intimidations and even suicides has made it newsworthy of late. The recent movie release “Bully’ has brought an awareness particularly to adults that brings back unfortunate memories for many and is perhaps why the movie has appeal to more than just those in school. Unlike days of old when bullying may have been limited to school time, there is nowhere to hide in today’s internet and smartphone age.

While bullying occurs for many reasons, physical deformities and differences are a frequent source. It is one thing when a child and teenager know that they are structurally different, but it reaches a malicious and psychosocial altering situation when it is brought to public attention. Whether it is a big nose, ears that stick out or breasts that are too large, such visually apparent features can be a source of torment and intimidation.

Is plastic surgery a solution for bullying when these physical conditions exist? Before bullying reached its current awareness, such plastic surgery procedures have been done for a long time for those children and teenagers whose self-images were affected by them. There is no question that such operations as rhinoplasty, otoplasty, congenital facial deformity surgery (e.g., cleft lip and palate) and breast reduction have psychologically helped many young patients. I have seen and been told by parents of patients that they have become less introverted and shy after their plastic surgery. I can often see it in their eyes and facial expressions that they are feeling better about themselves.

But that does not make plastic surgery a solution for bullying? You can change the physical deformity but you can’t change their social circumstances. Plastic surgery is but one tool, one aspect of the therapy so to speak, in bullying management for the physically affected. In the properly selected patient who has parental support and permission, plastic surgery correction can make an invaluable contribubtion.

This should not be confused with other plastic surgery procedures that do not correct a physical deformity but are done in an effort to alter one’s natural, albeit not desired, body shape. These would be so-called efforts to make one look more thin or shapely. Or to help one have a body that is more like that of some celebrity or model. Breast augmentation and liposuction, while a personal decision for adults, are not what I would consider important self-image surgeries for younger patients to help them escape bullying or criticisms from their peers.

Dr. Barry Eppley

Indianapolis, Indiana

Earology and Plastic Surgery of The Ear

Wednesday, February 1st, 2012

Despite their small size, the ears have a very complex morphology. The ear may well be the most topographically diverse structure of the whole external body. With numerous convexities and concavities of which each has a name, the ear is a marvel of human development. What is even more remarkable about its shape is appreciating how it develops embryologically from six separate tissue islands to coalesce into what we recognize as an ear. As a plastic surgeon, changing the shape of the ear or reconstructing any missing parts brings the appreciation of its anatomy to a whole new level.

The complexity of ear shape has apparently been appreciated by more than just plastic surgeons. I had no idea until I recently an article on the use of ears for establishing human identification, known as Earology. In  two books written on this subject by Alfred Iannarelli, it has been proposed and used as a method of forensic science. What it is not widely accepted and highly controversial, it is postulated that each human ear is uniquely different and no two are exactly alike. As such, one’s ear print is purportedly as unique as one’s fingerprint. This has lead to the use of ear print identification as a potential method in forensic science.

A few clinical studies done long ago on a limited number of adults and babies concluded that no two ears are alike. But it was the work of Iannarelli, author of the book “Ear Identification’ published in 1964, who is said to have studied thousands of ears that lays the foundation for the pseudoscience of Earology. Using a self-devised method of anthropometric measurements which would baffle a high school geometry student, the ear is extensively measured and analyzed and one’s uniqueness established. In a revised edition published twenty-five years later, the use of latent ear prints, much like taking fingerprints, has also been proposed for use in crime scenes.


Despite forty years of research, Iannarelli has failed to provide sufficient evidence to convince scientists of his theory, as with fingerprints, that no two ears are exactly identical. As a plastic surgeons who has seen and worked on many hundreds of ears from cosmetic otoplasty, microtia reconstruction and earlobe repairs, many quite frankly look more similar than dissimilar. I am certain that linear measurements between many of the ear components of different patients will show some differences. But overall ear shapes are most certainly not as distinct as fingerprints from a two-dimensional standpoint.  Furthermore, the ear is a very elastic and deformable structure which would make getting an earprint, unlike a fingerprint, subject to a lot of three-dimensional distortion and variability based on the technique used.

Plastic surgery of the ear is challenging due to its complex three-dimensional shape. Reshaping the ear through otoplasty by suture manipulation of the helical fold and the angle of the concha is less difficult than creating part or all of an ear from scratch. (microtia) But both spectrums of external ear surgery require an appreciation of the anatomy of the affected ear and its opposite member on the other side of the head. Unlike earology, earplasty is a precise surgical science that takes into consideration the uniqueness of each patient’s ears…no matter how subtle they may be.


Dr. Barry Eppley

Indianapolis, Indiana

Revision of the Overcorrected Otoplasty

Wednesday, August 10th, 2011

Otoplasty correction of the protruding ear can be one of most satisfying plastic surgery procedures one can undergo. The immediate change of prominent ears that stick out to an instantaneous normal appearance is often nothing short of dramatic. While the cartilaginous cause of the prominent ear can be easily determined, its correction involves a lot of artistic technique in its reshaping. As a result, undesireable otoplasty results can occasionally happen as the surgery is not an exact science.

In the August 2011 issue of Plastic and Reconstructive surgery, a good article on the secondary correction of the unfavorable result after otoplasty was published. The article covers both the secondary treatment of undercorrection and overcorrection. The section on undoing overcorrection of an otoplasty (ears pinned back too far) interested me the most as this is by far the more difficult problem.

While often lumped into the name, ‘telephone ear deformity’, ear overcorrections are apparent as the outer aspect of the ear touches or nearly touches the side of the head. This makes the outer edge of the concha being the visible outer edge of the ear rather than the helical rim. This could happen because the sutures used to create the antihelical fold are pulled too tight or back too far, the conchal hypertrophy cause of the prominence is left untreated, or too much skin has been removed from the back of the ear.

Ear overcorrections essentially take an ear, which has too much tissue or cartilage that is abnormally shaped, and turns it into a situation of relative tissue deficiency. As the authors point out in their revision description, the ear needs to be released from a postauricular approach and can often reveal a skin deficiency and a need for cartilage grafts. These two issues must be taken into consideration before surgery. If skin on the back of the ear is deficient, either a sliding skin flap from a sulcus incision or ‘finger flaps’ from the mastoid must be used to replace the missing skin. The donor site will require a small skin graft.

Once the ear cartilage is released, cartilage grafts will be needed to stent open a collapsed antihelical fold or to reinforce areas of cartilage fracture that have occurred from the release. Such cartilage grafts can only come from two sources, the ear concha itself or a small rib graft. The choice will be based on how much cartilage reinforcement is needed.

Reconstructing an overcorrected otoplasty can be difficult but almost always needs tissue grafts. If an overcorrection is treated very early after the initial otoplasty, suture release alone may be sufficient. But once scar and tissue adhesions is established, months to years later, the issue becomes of one of cartilage release and reinforcement and skin flaps or grafts.

Dr. Barry Eppley

Indianapolis, Indiana

Otoplasty For Protruding Ears: Matching The Cartilage Problem With The Surgical Technique

Monday, July 18th, 2011

Even though the ears are located off to the side of the face, they can have an influence on one’s facial appearance. Being made up of a collection of ridges and grooves with a dangling earlobe hanging off of a cartilage framework, the ear is often not appreciated for its complex shape…until it is abnormal. The most common ear shape anomaly is when it sticks out too far.

The ear should not be a dominant structure on one’s head. With a geometry that is as individual as one’s fingerprint, it remains obscure as long as it sits at an angle of less than 30 degrees from the side of the head. Once going beyond this angle, the ear becomes too prominent.This prominence is caused by an alteration in the shape of the ear cartilage. The two most common causes of the protruding ear are absence of the antihelical fold and a large concha.

The two primary folds of the ear are the helix and the antihelix. The second inward fold of the ear is the antihelix. Situated inside of the outer rim (helix) of the ear, this fold brings back the entire outer edge of the ear. When it is absent, the ear protrudes much like the inside of a cup. Complete absence of the antihelical fold accounts for the most dramatic of protruding ears…ears that stick out dramatically. This is the classic type of otoplasty correction in which horizontal mattress (Mustarde) sutures are placed from the back of the ear to create this ear fold. The result is easy to see before by folding back the outer helix and manually creating this ear fold.

The most inner component of the ear is the concha. It has a bowl shape that surrounds the ear hole or external auditory meatus. The size of this bowl can also be a source of ear protrusion. If it is very large, it pushes out the the antihelical and helical ear folds away from the size of the head. A large concha usually causes a less dramatic protrusion than an absent antihelical fold. A large concha makes the ear stiff when pushed against as it is a thicker cartilage and has more surface area than the outer ear folds. Correction of the conchal hypertrophy protruding ear involves pulling back the concha through sutures between it and the mastoid fascia. Often the stiffer concha needs to be weakened by thinning it or removing some cartilage.

Many protruding ear problems are a combination of both a large concha and the lack of an antihelical fold. Often there may be a weak antihelical fold and a slightly large concha. The use of combined antihelical fold sutures and a conchal reduction/setback is often needed. These are the hardest protruding ear problems to treat and require a careful eye beforehand to make the diagnosis and intraoperative artistry and persistence to get the best ear shape.

One of the most overlooked problems in the protruding ear is the earlobe. Since it is not part of the cartilage structure of the ear, it will not lay back when the cartilage is reshaped if it is also protrusive. Often the earlobe must also be folded back by skin removal on the back of the earlobe as part of the otoplasty procedure.

In reshaping of the protruding ear, it is important to match the corrective technique with the cartilage shape problem. Failure to do so results in many of the postoperative otoplasty problems which consist of unnatural shapes and bends of the ear’s cartilages. Once the ear cartilages are resected, unnatural bends created, or set back too far, secondary correction can be difficult.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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