Prominent ears

Surgery to correct protruding ears is referred to as otoplasty. Ears protrude out from the head because of abnormalities in ear cartilage development. The degree of deformity varies from very mild to severe. Such deformities can attract unwanted attention and children with these deformities may be subject to ridicule.

Prominent Ears

Figure 1: This diagram was shown to me by parents after I had performed surgery. It indicates how some children are teased about their ears.

 

Prominent Ears

Figure 2: Of all the surgery I do, patients who have had their prominent ears corrected are often the most grateful.

 

Body image awareness with regard to facial features is usually apparent by age 5. Children usually begin school around this time and other school children may call attention to ear deformities. The ear has completed 85% of its growth by age 3. There is very little ear growth after age 10. Prominent ears may be corrected from age 4 onward depending on when the patient or their parents request surgery.

Prominent Ears

Figure 3: External Ear Anatomy

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Figure 4: Surgical techniques to make the ear less prominent

There are a number of factors in the development of the ear cartilage that affect the shape of the ear. In the majority of cases there is a combination of too much cartilage in the central bowl shaped portion of the ear called the concha, and a failure of the natural folds to develop in the portion of the ear known as the antihelix (crura antihelicis in this Figure 3).

The specific surgical manoeuvres needed for correction of the more common protruding ears will depend on the degree to which excess conchal cartilage or failure of anti-helical fold development predominate in the production of the defect. The specific surgical techniques used will depend on the underlying deformity. There are three aspects that usually need to be considered.

  1. The amount of excessive conchal cartilage
  2. The degree of antihelical fold development
  3. The amount the lobule protrudes

Figure 4 illustrates two techniques. Techniques are also used on the anti-helix to fold it backwards. In Figure 4 a sttich is being used to create the antihelical fold. Soft tissue excision and shaving of the cartilage can be used to reduce the prominence of the ear (illustrated in Figure 4). Most otoplasty procedures can be done on an outpatient basis. Younger patients require a general anaesthetic; in some adults this procedure can be performed under local anaesthesia. The surgical incisions can usually be hidden behind the ear or in the ear folds. The procedure is concerned with alteration of the cartilage framework.

Prominent Ears

Figure 5: Asymmetrical ears before surgery

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Figure 6: Surgica result in patient in Figure 5

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Figure 7: Asymmetrical ears in a model

The goal is to get two ears corrected to be exactly the same however many ears are asymmetric before surgery and small asymmetries may persist after surgery. This lady had asymmetrical ears before surgery (Figure 5).  Whereas before surgery she grew her hair long to hide her ears, she now feels confident to wear her hair high on her head (Figure 6). If one studies faces closely you will observe most people have asymmetric ears and faces.  This model (Figure 7) appearing on the cover of a prominent fashion magazine had asymmetric ears as well as an asymmetric face (Note differences in the size of her cheeks). It is important to be aware of these asymmetries prior to surgery.

Surgery

Anaesthesia
Most otoplasty procedures can be done on an outpatient basis. Younger patients require a general anaesthetic; in some adults this procedure can be performed under local anaesthesia. I normally do this in adults by giving them an oral sedating agent first. I then inject the local anaesthetic.

Creation of an antihelical fold
A variety of techniques have been described to create the antihelical fold. All techniques have a degree of unpredictability and failure. I use an anterior tunnel technique. Here I am creating a tunnel on the anterior surface of the concha beneath the skin (Figure 8). I then score the cartilage in order to weaken it. I place semipermanent stitches to hold the newly created fold in the desired position.

Prominent Ears

Figure 8: Creating an anterior tunnel

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Figure 9: Shaving the conchal bowel

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Figure 10: A firm head dressing is applied after the procedure

Removal of Conchal Cartilage
Ears often protrude because of a large conchal bowl. Here I have excised soft tissue and shaved down the cartilage to set the ear back (Figure 9).

Postoperative Care
In children, I use a dissolvable suture to close the skin incisions. In adults I use a continuous Nylon suture which I remove at a week. A firm head dressing is then placed over the ears (Figure 10). I leave this in place for 24-36 hours. Post operative care involves the need to wear a headband at night for up to six weeks.

Complications
The risks and complications associated with otoplasty include those risks associated with any operation involving general anaesthesia. Wound infection is extremely rare. A haematoma (collection of blood) between the skin and cartilage can cause loss of skin or disturb the cartilage repair. It is possible for the sutures holding the new cartilage shape to pull through the cartilage or to break. A common problem is slight protrusion of the upper part of the ear postoperatively. Either event might lead to a need for revision of the reconstruction. 

Results of Surgery

All these pictures are of patients whom I have operated on. The postoperative results are usually at three months or later.

 

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Cost of surgery

The cost of surgery will depend on the extent of the surgery.  The surgery usually takes about 90 minutes.  When one includes theatre and anaesthetic time the total cost of surgery is approximately $6,000

Publications

Bartley J. Conchal setback in otoplasty. Aust J Otolaryngol 1997; 2: 605-8.

Bartley J, Connolly A. Pitfalls and pinnoplasty. CME Bulletin - Otolarygology, Head and Neck Surgery 1998; 2: 102-104.

Connolly A, Bartley J. "External" Mustarde suture and otoplasty. Clin Otolaryngol 1998 23: 97-9.

Bartley J. How long should ears be bandaged after otoplasty. Journal of Laryngology and Otology 1998; 112:431-2.

Book Chapter
Bartley J. Controversies in Otoplasty. In: Controversies in Otolaryngology. Malhotra A, Kirtane M (Editors) Jaypee Bros, New Delhi, 2005.

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