Otoplasty

Congenitally prominent ears are a cosmetic deformity that can have a severe emotional and behavioral effect on a child. Otoplasty is a description of surgical procedures designed to give the auricle a more natural and anatomic appearance.

Problem: Prominent ears typically do not affect a child’s self-image until the child is older than 5 or 6 years, and surgery for lop ear deformity is best performed before this age. Conversely, adult patients often seek otoplasty to correct a long-standing defect. Before surgery, patients typically style their hair to camouflage their deformity. Postoperatively, patients often feel comfortable enough to wear their hair short or combed back.

Frequency: Five percent of white individuals are affected. Protruding ears are genetic; 59% of affected individuals have a family history, and transmission is in an autosomal dominant pattern with variable penetrance. Since the inner ear develops independently from the auricle, patients with prominent ears generally have normal hearing; however, other congenital deformities (especially of the genitourinary tract) may be present.

Clinical: Prominent ears can be in a myriad of forms, including cup ear, shell ear, bat ear, Machiavellian ear, and lop ear. Many patients attempt to camouflage the deformity with hairstyling.

Otoplasty is indicated for correction of ears that protrude more than 20 mm and at an angle greater than 35° from the occipital scalp. One or multiple malformed auricular subunits may be managed.

Medical therapy: Nonmedical management of lop ear deformity is generally achieved by the patient using effective hairstyling to camouflage the defect. Nonsurgical treatment of prominent ears is limited to the Far Eastern practice of applying tape or conforming bandages in early infancy to influence the growth and shape of the ear. Sustained restriction and pressure can guide the growth of the auricular cartilage during infancy. This is particularly useful for treatment of cryptotia, a condition in which the superior pole lacks lateral projection and is often covered by a fold of skin.

Surgical therapy: Otoplasty can be categorized as either cartilage splitting (cutting) or cartilage sparing. Cartilage-splitting techniques involve incisions through the cartilage and repositioning of large blocks of auricular cartilage. Cartilage-sparing techniques avoid full-thickness incisions, attempting to create more effective angles and curls in the cartilage.

Contraindications: Otoplasty is contraindicated in any patient with unrealistic expectations. Patients must receive appropriate preoperative counseling. Discuss existing facial asymmetries, and emphasize that a restoration of anatomic balance to the face is the goal of any surgery. Patients unable or unwilling to cooperate with postoperative care are not candidates for surgery. Advise patients with a history of hypertrophic scarring or keloids that these may occur after otoplasty, possibly distorting an otherwise excellent surgical result

Preoperative details: Generally, prominent ears are treated surgically. Proper preoperative management includes a detailed medical history, a psychological assessment (formal or informal), a careful physical examination, and photography.

Postoperative: The patient is seen on the first postoperative day. The dressings are removed, and the ears are inspected for any sign of hematoma. The drains are removed, and the ears are redressed, including conforming and compressive dressings. The patient is seen again on the second postoperative day; the ears are again inspected, and an elastic ski headband is placed over the head and ears. The patient wears this continuously for the next 5 days and while sleeping for the following 2 weeks. Prolene sutures are removed on the seventh postoperative day. Moderate ecchymosis and edema are expected but usually resolve within the first 2 weeks.

Incomplete correction of prominent ears is probably the most common undesirable outcome of otoplasty. Careful preoperative analysis with specific attention to each area of the auricle can prevent an incomplete reconstruction. Correction of the mid portion of the auricle greater than the superior and inferior poles leads to a “telephone ear” deformity; a reverse telephone ear deformity is a result of inadequate medialization of the central portion of the auricle.

Most patients can appreciate the results of surgery as soon as the bandages are removed. Some adult patients require a period of psychological adjustment to their new appearance. If patients are appropriately selected, they resume their lives with an improved level of self-confidence.