Ears that stick out from the head can be repositioned any time after the age of five or six years. The fold of skin behind the ear is cut and the excess cartilage is reduced or remodelled. The procedure takes around one hour. Bandages need to be worn for a few weeks to help manage the bruising and swelling.

Summary

• Ear correction surgery, or otoplasty, is usually done to move prominent ears closer to the head or to reduce the size of large ears.
• Similar to natural ears, the position of the ears after otoplasty will not match perfectly.
• Ear cartilage is very elastic, so there will be some forward movement of the ears after the operation.
• Talk with your surgeon about the risks and benefits of otoplasty and what results you can expect.

Otoplasty

Ear correction surgery, or otoplasty, reshapes part of the cartilage in the ears, allowing them to lie closer to the side of the head. Most people who have otoplasty are between the ages of 4 and 14. This is because, at that age, ear cartilage is softer and easier to mould. However, otoplasties can still be effective in adults.

Otoplasty can also alter large or stretched earlobes or lobes with large creases and wrinkles. Plastic surgeons can even build new ears for people who were born without them or who have lost them through injury.

Other ear problems that can be helped with otoplasty include:

• ‘lop ear’ – when the tip seems to fold down and forward
• ‘cupped ear’ – a very small ear
• ‘shell ear’ – when the curve in the outer rim, as well as the natural folds and creases, are missing.

If you are concerned about the way you or your child look, and you are thinking about surgery as a way to boost confidence, there may be other ways to achieve this. Talking to a counsellor or psychologist may help you overcome your concerns about your or your child’s appearance. Discuss possible options with your medical practitioner.

Things to consider before otoplasty

Before you choose to have otoplasty, some important issues to keep in mind include:

• Even when only one ear appears to stick out (protrude), surgery is usually performed on both ears for a better balance.
• Exact evenness (symmetry) isn’t likely. Similar to natural ears, the position of the ears after otoplasty will not match perfectly.
• Think about the financial cost. Medicare and private health insurance may cover a few costs, but you must be prepared for some out-of-pocket expenses. For more information:
• Ask your medical practitioner about any out-of-pocket costs you can expect, and if you will be eligible for a rebate.
• Smokers are at increased risk of complications. To decrease the risk of complications, and for your general health and wellbeing, try to quit smoking before having surgery.
• Consider asking another medical practitioner for a second opinion. It is important to have as much information as possible, before deciding to have otoplasty.

Finding a qualified medical practitioner

Ask your GP for advice on a suitable and reputable medical practitioner or hospital where otoplasty is performed.

At your first consultation, ask the medical practitioner about their training and experience.

This procedure should be done by a medical practitioner who is specially trained to perform otoplasty and has a lot of experience in carrying out this type of procedure. Ask to see the medical practitioner’s certificates that show them to be qualified to perform this specialised surgery.

Your current medical status and otoplasty

If you are considering having otoplasty, you need to discuss your current medical status with your medical practitioner. This includes discussing:

• your physical health – including your past medical history, such as diseases, illnesses, surgeries, immunisations and current physical status, which will include your diet and exercise regime. This would be a good time for the medical practitioner to check your blood pressure, temperature, heart rate/rhythm, oxygen saturation and respiratory rate
• your mental health – any mental illnesses or issues and their treatments
• medications you are currently on, including vitamins and supplements
• past reactions to medications
• any allergies you have.

As a result of this discussion, your medical practitioner will be able to assess the risks and possible complications of the surgery for you. They will also be able to tell you what preparations you will need to make to ensure your recovery from surgery is as smooth as possible.

Otoplasty – what happens during surgery

All surgery, including otoplasty, must be performed within licensed and accredited facilities. A registered anaesthetist must be present to treat you for any adverse reaction you may have to the anaesthetic.

Otoplasty surgery takes around one to three hours, depending on the complexity. You may have a local anaesthetic and sedation, but some people prefer a general anaesthetic. Children are usually administered general anaesthetic.

Generally, otoplasty involves several steps, including:

• The fold of skin behind the ear is cut to expose the underlying cartilage.
• The medical practitioner removes the excess cartilage. In some cases, the cartilage is remodelled. For example, the medical practitioner may reshape the cartilage by folding it back and stitching it in place
• Incisions (cuts) are closed with stitches.

Immediately after otoplasty

After the operation, you can expect:

• nausea
• mild to moderate pain or discomfort
• swelling and bruising
• numbness.

Your ears will be covered with dressings and bandages to protect and support them after surgery.

Potential complications of otoplasty

All surgery carries some degree of risk. Some of the possible complications of otoplasty include:

• infection – that may require treatment with antibiotics or further surgery in some cases
• allergic reaction to sutures, dressings or antiseptic solutions
• the formation of a large blood clot (haematoma) beneath an incision site, which may require drainage
• chest infection, which may develop after general anaesthesia
• a sore throat caused by the breathing tube used during general anaesthesia
• pain, bruising and swelling around the operated site(s)
• keloids and hypertrophic scars – raised, thickened scars that may form over the healed incisions. These may be itchy, annoying and unsightly but are not a threat to health
• slow healing, often related to smoking or diabetes
• short-term nausea following general anaesthesia, and other risks related to anaesthesia
• asymmetrical ears – further surgery may be necessary to correct symmetry problems or irregularities in the cartilage
• re-protrusion of one or both ears – may occur and require further surgery
• nausea and loss of balance related to fluid accumulation within the inner ear
• temporary or permanent loss of sensation in the skin around the surgical site and the surface of the ear
• small areas of skin overlying the cartilage of the ear may die, causing an ulcer that may take several weeks to heal.

This is not a complete list. For example, your medical history or lifestyle may put you at increased risk of certain complications. Speak to your medical practitioner for more information.

Self-care after otoplasty

Your medical practitioner will provide you with you with post-operative care instructions, such as:

• how to care for your surgical site(s) following surgery
• medications to apply or take orally to aid healing and reduce the risk of infection
• specific concerns to look out for – at the surgical site(s) or in your general health
• when to follow up with your medical practitioner.

General self-care suggestions may include:

• wear tight bandages, as instructed, for one or two weeks, both day and night
• expect you may experience soreness and swelling for a few weeks
• avoid any trauma to the ears – for example, do not play any contact sports until your medical practitioner says that it is okay
• report any bleeding, severe pain or unusual symptoms to your surgeon.

Long-term outlook following otoplasty

Over time, any swelling will disappear. In most cases, ear surgery will leave a faint scar on the back of the ear that will fade over 18 months or so.

Once you’ve had ear surgery, the results are permanent. However, ear cartilage is very elastic, so there is always some forward movement of the ears after the operation.

Alternatives to otoplasty

There are no medical treatment alternatives to otoplasty that can reposition or reshape the ears. You may be thinking about this surgery to boost your child’s or your own confidence. There may be other ways to achieve this. Talking to a counsellor or psychologist may help you overcome your concerns about your or your child’s appearance.

Introduction

Furnas described otoplasty in 1959 with the technique of using permanent sutures on the conchomastoid to correct the deformity of prominauris. Mustarde added an additional technique in 1962 which described using permanent conchoscaphal sutures to improve the appearance of the ear. This review focuses on the primary indication for otoplasty, prominauris.

Anatomy and Physiology

Before surgical correction of the ear, a fundamental understanding of the embryology and anatomy is necessary. Development of the ear begins with the otic placode which presents during the 3rd week of gestation. Cartilage formation is present in week 7. The hillocks of His fuse by week 12 and the antihelix then furls between weeks 12 to 16. Finally, the helix furls at 6 months. The hillocks of His are numbered one to six, and they include tragus, helical crus, helix, antihelix, antitragus, and lobule.The first three hillocks derive from the first pharyngeal arch, and the hillocks 4, 5, and 6 derive from the second pharyngeal arch.

Indications

To understand the indications for performing otoplasty, one must appreciate facial analysis. The pinna is ideally positioned approximately 15 to 20 mm from the helical rim to the scalp. Prominauris, which is the main indication for performing otoplasty, is seen when the auriculocephalic angle is greater than 30 degrees. The ideal auriculocephalic angle ranges from 20 to 30 degrees. Additionally, the vertical height of the ear should be approximately six centimeters. The width of the external ear should accordingly be about 55% of his length, averaging about 35 millimeters. The distance between the lateral helix to mastoid skin should be approximately 2 to 2.5 centimeters.[5] Upon further facial analysis, parallel lines can be drawn in the plane of the nasal dorsum and the long axis of the ear. The external ear should have about 15 degrees of posterior rotation from the vertical plane. The length of the ear should be equal to the length of the nose from the nasion to the subnasale. Also, the superior edge of the ear should lie at the level of the eyebrow, and the inferior edge should lie at the level of the nasal ala. The conchomastoid angle should be approximately 90 degrees, and the conchoscaphalic angle should be 90 degrees. The skin of the external ear is tightly adherent to the underlying cartilage anteriorly and loosely attached posteriorly.

Innervation of the external ear is elaborate and involves multiple cranial nerves which include: auriculotemporal nerve from the trigeminal nerve, facial nerve, glossopharyngeal nerve, Arnold’s nerve from the vagus nerve, and nerves from the second and third cervical plexus. As a result, adequate local anesthesia can be difficult to achieve. The external ear receives vascular supply by the superficial temporal artery, the posterior auricular artery, and the lesser occipital arteries. Prominauris is the primary indication for otoplasty, and as such is seen in approximately 5% of Caucasians. This auricular condition can be inherited in an autosomal dominant fashion, and many patients report a family history. The etiology of prominauris is related to two main factors which are a poorly developed antihelical fold and excessive conchal cartilage. The most common cause is the poorly developed antihelical fold with excessive conchal cartilage being the second most common cause. The surgery should be performed at 5 to 6 years old when the ear has reached 90% of its adult size, and the cartilage has increased in stiffness.

Technique or Treatment

The Mustarde technique treats the underdeveloped antihelical fold. When examining the ear the surgeon should apply gentle pressure to form the planned antihelical fold. Then mattress suture points should be marked 8 mm on each side of the new antihelical fold. Hydrodissection with local anesthetic is critical to promote anesthesia and hemostasis; 1% local lidocaine with epinephrine 1 to 100,000 is typically an acceptable local anesthetic. Cartilage tattoo can be performed with methylene blue to mark the cartilage site of suturing. A postauricular incision is made to provide access for the sutures. There is an option to score the cartilage which can help weaken it to ensure that the cartilage loses its elasticity. The horizontal mattress sutures should include three separate sutures from superior to inferior about 10 mm apart. The Furnas technique focuses on correcting excessive conchal cartilage. This technique involves using roughly four permanent conchomastoid sutures. These sutures need to go through the lateral perichondrium to the mastoid periosteum while avoiding the anterior conchal skin.The Davis technique, which involves removing conchal cartilage to treat excessive cartilage, may also be a surgical option. The postoperative dressing should include a xeroform gauze which is tightly packed around the external ear followed by padding with fluffs and a mastoid dressing which does not cover the eyes. Most dressings should be removed on postoperative day one to ensure that there is no hematoma.

Complications

Complications largely divide into early and late complications. Early complications involve hematoma, bleeding, postoperative infections including perichondritis, dehiscence, and necrosis of the skin. The most worrisome postoperative complication is a hematoma. Hematoma formation can lead to cartilage and skin necrosis. If not addressed immediately, the hematoma can progress to infection which could worsen cartilage necrosis and lead to cauliflower deformity. Cartilage necrosis can also result from over tightening of the sutures and sometimes excessive pressure from the dressing. Postoperative hematomas are usually seen between one to three days after surgery. Pain is one of the main symptoms and should prompt a timely examination.

Other late complications include excessive scarring suture extrusion, hypersensitivity, and most importantly poor aesthetic outcomes. Unsatisfactory aesthetic outcomes are the most common complication of otoplasty. The aesthetic complications are notable. The telephone ear deformity is related to the overcorrection of the middle mattress suture relative to the superior and inferior sutures. The reverse telephone ear results from over tightening the inferior and superior Mustarde sutures. The vertical post deformity is a result of improperly placed sutures which leaves a sharp vertical fold in the antihelix. The hidden helix complication is another result of overtightening the Mustarde sutures so that the antihelix is not visible from an anterior facial view.

Clinical Significance

A proper understanding of the diagnosis, indications, and surgical techniques will lead to positive outcomes in otoplasty.

Enhancing Healthcare Team Outcomes

The correction of prominauris has traditionally been under the specialties of plastic surgery and otolaryngology. Although otoplasty is typically an outpatient procedure, it still requires a team approach. The child’s pediatrician most often refers these patients to the surgeon, which requires an understanding of the diagnosis and direct communication with the surgical practice, as well as knowledge of the appropriate timing of referral and repair. If a wound infection and subsequent perichondritis were to develop, consulting with an infectious disease pharmacist may also be warranted to help guide antibiotic selection. The earlier a complication is recognized, the better the prognosis and subsequent cosmetic outcome (Level V).