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Archive for the ‘ear reshaping’ Category

Techical Strategies – The Upside Down Otoplasty

Thursday, February 1st, 2018


Otoplasty is a well known ear reshaping procedure. Pinning the ears back, as it is often called, changes the shape of the ear cartilage through sutures and sometimes cartilage excisions. Done from an incision on the back of the ear it is often combined with other facial procedures due to surgical proximity and convenience. But it is always done in the supine position on the operating table and each ear is accessed by turning the head from side to side. The success and symmetry of the ear reshaping is then judged from the frontal view as the patient would see it.

There are some uncommon situations, however, when the performance of an otoplasty can be done from a different viewpoint or angle. This would be the ‘need’ to do an otoplasty in the prone or face down position. I have done this numerous times when performing simultaneous occipital skull implant and webbed neck corrective procedures. Both types of deformities have a high association with ear deformities particularly of the protruding type.

I call this type of ear reshaping an Upside Down Otoplasty. It is an interesting perspective to do the procedure because you have the best visual access to the cartilage on the back of the ear and how the auriculocephalic angle is changed. A good side view of the ear can also be seen. One does not, however, see the ear from the front view which is of course the most important one. But an experienced plastic surgeon can tell based on the side and back views how the ear may look from the front.

When performing an Upside Down Otoplasty one must be careful to not over correct or pull the ear back too far. This is fairly easy to do since closing done the angle of the ear to the side head is easily seen. But as long as the helium to mastoid skin distance is at least 15mms the ear will not become too pulled back. Another favorable sign is if the antihelical rim is not seen sticking out beyond the helical rim.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Otoplasty Surgery for Ear Reshaping

Monday, December 25th, 2017


Background: The protruding ear stands out from the side of head in an exaggerated fashion which is what makes it too visible. One of the features of a good looking ear is that it does not stand out in any conspicuous way. The increased auriculocephalic angle of the protruding ear is not due to a cartilage deficiency in volume. Rather the ear has a normal amount of cartilage but it just does not have the right shape.

Reshaping of the protruding ear through otoplasty surgery involves a variety of cartilage manipulation techniques. One of these and the one that is inherent in about every such ear surgery is the creation of a more defined antihelical fold. This is a natural fold in the ear that is the secondary cartilage fold that sits just inside the outer helical fold. Its relevance to the protruding ear is that when this fold of ear cartilage is absent or ill-defined the outer edge of the ear sticks out further.

While the results from otoplasty surgery for the protruding ear are always shown from the front or back view, it is also important to consider what the ear looks like from the side view. This has relevance during surgery as if an overcorrection occurs it can also be appreciated by an inadequate lengthening of the ear from front to back. (tragus to outer helix)

Case Study: This young female had ears that stuck out due exclusively to the absence of an antihelical fold of cartilage. Under general anesthesia an otoplasty procedure was performed from an incision on the back of the ears. Permanent horizontal mattress mattress sutures were used to create a more defined antihelical fold which pulled the ears in closer to the side of the head.

As the ear is pulled back further inward to the sides of the head by helical rim repositioning, the length of the ear from front to back (tragus to helical rim) increases. This anteroposterior ear change should look natural and not ‘scrunched’ which is a sign of over correction.


1) Traditional otoplasty surgery is about reducing the protrusion of the ear as seen in the frontal view.

2) Most reshaping procedures for the protruding ear involves creating a more defined anti helical fold.

3) The side view of the reshaped ear in otoplasty shows an increased length of the ear from front to back.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Helical Rim Lengthening in Setback Otoplasty

Monday, October 2nd, 2017


Background: The shape of the ear is complex and its affected by how its cartilage structure becomes formed during its embryologic development. With its array of folds and concavities the ear assumes a unique shape for each person. In addition to its shape,  its size and orientation to the side of the head affects how visible it is when seen in the frontal view.

The most visible part of the ear is its outer edge known as the helical rim. Formed from contributions of the embryologic Hillocks of Hiss #s 3,4 and 5, the outer rim becomes the leading edge and the most protruding level of the ear.  The length of the helical rim affects both the size and protrusion of the ear.  As an encircling anatomic feature, the smaller the helical rim is the smaller the ear may be for it may make it stick out more, depending upon how shortened it is.

In the protruding ear there is always some degree of helical rim shortening although much more minor than in the truly constricted ear. This perceived effect is caused by the lack of a well defined antihelical fold. Without an antihelical fold the outer helical rim becomes folded over or shortened.

Case Study: This teenage female was bothered by ears that stuck out  and they were a source of embarrassment for her. She had a well formed concha which was not excessive.

Under general anesthesia bilateral otoplasties were performed with the total focus on improving the shape and definition of the antihelical fold. Using permanentt horizontal mattress sutures through a postauricular incision, the creation of the antihelical fold brought back the ear into better alignment with the side of the head.

With a setback otoplasty achieved through antihelical fold creation, the length of the helical rim actually becomes longer. Such helical rim elongation allows the ear to set back further against the side of the head in a less conspicuous manner.


  1. Otoplasty surgery is most commonly done in children and teenagers to correct protruding ears.
  2. The most important principle in protruding ear correction is elongating the helical rim to move its outer portion closer to the side of the head.
  3. Antihelical fold  manipulation is the only technique for helical rim elongation.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Vertical Ear Reduction with Scaphal Resection

Saturday, September 2nd, 2017


Changing the shape of the ear is most commonly done by a traditional otoplasty or ‘ear pinning’. While the size of the ear may seem to get a bit smaller in otoplasty as it moves the ear closer to the side of the head, the actual ear size does not really change.

True ear size reduction involves a vertical change in the length of the ear from the superior helix down to the bottom of the earlobe. The most recognized ear reduction procedure is that of earlobe modification. The earlobe can be reduced by a variety of techniques but, regardless of which method is used, they all create some reduction in its vertical length as all large earlobes hang too low.

The most dramatic way to reduce a large ear is to cut out a portion off its middle, bringing the upper and lower thirds of the ear closer together. But the scar that is created by doing so would be aesthetically unacceptable and such ear reductions are only usually done in skin cancer resections.

The often overlooked or unknown ear reduction technique involves that of the upper third of the ear. Known as a scaphal flap reduction technique, skin and cartilage are removed from inside the helical rim above the antihelix and superior crus. There is a backlit across the helical rim at the middle portion of the ear which controls the amount of vertical ear height reduction. This is also the only location of a visible scar.

While often combined with ear reduction for maximal ears height reduction as in macrotia reduction surgery, the scaphal flap reduction technique can be done alone if the earlobe is already small enough. Int its use it is important to remember that its effect is in reducing the size of the upper third of the ear.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Fishtail Earlobe Reshaping in Otoplasty

Saturday, August 12th, 2017


Otoplasty or ear pinning is the most common aesthetic surgery performed on the ear and its cartilages. (technically earlobe repair would be the most common aesthetic ear surgery… but it contains no cartilage)  In repositioning the shape of the protruding ear back towards the side of the head a variety of techniques are used to reshape the underlying supporting ear cartilages. Some of these are suture plications while others involve modification or removal of sections of ill-formed cartilage.

But in ear reshaping surgery consideration must be given to the only non-cartilaginous structure of the ear…the earlobe. This small area of the ear is frequently overlooked in otoplasty and can mar the aesthetic result of an otherwise pleasing reshaped ear. In many cases if the cartilage of the ear its pulled back but the earlobe remains too far forward, the ear will still standout but to a lesser degree. A protruding earlobe disturbs an otherwise smooth helical rim line from the top of the ear downward. Such otoplasty patients with earlobes that need to be simultaneously addressed can be identified beforehand.

As part of an otoplasty I frequently reposition the earlobe as well. I use excision of a segment of skin on the back side of the earlobe in a fishtail pattern. This skin section is removed with care taken to not cut through to the other side. In closing this open area on the back of the earlobe,  the outerearlobe is pulled back but avoids becoming pinched or developing a dogear skin redundancy at its bottom edge. It is the fishtail pattern that prevents the bottom of the earlobe from becoming too pinched. This is effective whether the patient has attached or detached earlobes from the side of the face.

A pleasing otoplasty result must frequently involve earlobe reshaping as well. Establishing a smooth contour from the top of the ear down to the bottom of the earlobe prevents any part of the ear from standing out..which in otoplasty surgery is the main goal. The ears needs to blend into the side of the head in a non-prominent fashion. While the ear has a complexity of hills and valleys and is artistically shaped, it still is not aesthetically pleasing to have it be more dominant than other facial features.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Macrotia Reduction Surgery

Sunday, April 30th, 2017


Background: The ear has a complex structure that is often unappreciated due to its relative obscurity on the side of the head. But when something about its structure makes it stand out, it becomes open to considerable aesthetic scrutiny. The most common aesthetic distractor is when the ear sticks out too far from the side of the head or when it has congenital deficiencies in its structure.

One very noticeable aesthetic deformity of the ear its when it is too large or vertically long. While there are numbers for normal ear sizes and relationships to other structures of the face (e.g., nose), what ultimately matters is whether the patient thinks that it is too large. Usually patients are quick to notice earlobes that are too long or hang too low.  But large conchal bowls or upper ears can also be points of aesthetic concern.

Ear reduction or macrotia surgery is much more rarely performed than of the protruding ear which can also be called large ear reduction. (even though the actual ear is not too large and no parts of the ear is being resected) Macrotia reduction surgery must remove actual portions of ear structure (skin and cartilage) to create a visible reduction in the size of the ear but also must do with the location of the scars in mind so as to not create an aesthetic distraction.

Case Study: This 35 year-old male had been bothered by the size of his ears since he was young. He had undergone a setback otoplasty and wedge earlobe reduction but this did not make his ears look any smaller.  He had a vertically long earlobe and a wide scapha between the helical rim and the superior crus in the upper third of his ear. His vertical ear length was 72mms

His macrotia reduction plan was to reduce the upper size of the ear through a scaphal flap with 5mm mid-helical rim reduction. The earlobe would be vertically reduced through an inferior rim resection technique of 7mms.

Under local anesthesia using a periauricular regional bloc technique, the scaphal flap and earlobe reductions were completed using all dissolvable sutures. His immediate post results show an ear reduction with the vertical length reduced to 64mms.

Macrotia reduction requires the removal of ear tissues and the creation of scars. With the scaphal flap and inferior rim earlobe reduction techniques, the only scar of any consequence is the one that crosses the helical rim in the middle of the ear. This small scar usually heals extremely well and has yet to be one that any patient had asked me to revise.


  1. Macrotia reduction often involves a ‘high and low’ approach to be most effective.
  2. Scaphal reduction of the upper ear and vertical reduction of the earlobe are the two principal elements of macrotia reduction.
  3. Reduction of the large ear can be done under local anesthesia using periauricular ring blocks.

Dr. Barry Eppley

Indianapolis, Indiana

Earwell Ear Molding System – Long term Clinical Results

Sunday, April 30th, 2017


Congenital ear deformities are not uncommon and are always obvious right after birth. While some would say that this is reflective of being compressed inside the womb and misshapen ears can be a self-solving issue, this is almost never the case. The concept of early ear manipulation to work with the cartilage molding capability that exists for a short time after birth is well known to offer a non-invasive and effective treatment approach. Such early efforts can help normalize the ear shape and avoid invasive and sometimes difficult surgery later.

In the March 2017 issue of the journal Plastic and Reconstructive Surgery the paper entitled ‘Classification ion Newborn Ear Malformations and their Treatment with the Earwell Infant Ear Correction System’ was published. In this paper the authors review their experience with 175 infant patients with over 300 ear deformities using the Earwell ear reshaping device. The average age treatment was begun at 12 days after birth with an average treatment period of 37 days requiring six office visits. The most common ear deformity treated was that of the constricted ear for which they developed their own classification system based on various ear features. (I through III with increasing severity) The most important feature of this classification was that of the horizontal axis which also determines how successful infant ear molding can be due to the initial severity of the ear constriction.

Treatment outcomes were determined by comparing the percentage of the deformity completely corrected vs. percentage still with appreciable residual deformity. Complete correction was achieved as follows: lidding (92%), conchal crus (90%), helical rim (86%), stahl (85%), prominence (80%) and Darwin tubercle. (50%). Overall treatment outcomes were rated as excellent to good in 88%, fair in 11% and poor. (1%) Complications were superficial excoriations which occurred in about 8% of the ears treated.

While the Earwell molding system for congenital ear deformities has been around for awhile, this is the largest series reported of its long-term results. While it has been known for a long time that very early efforts at reshaping a deformed ear can be helpful, having a effective and consistent method to to do so has been lacking until the Earwell system became clinically available.

Several important points about the Earwell system is that its use must be initiated as soon as possible after birth. In this paper their average age of beginning treatment was less than two weeks after birth which is ideal. I get many a parent who calls a month or six weeks after birth to begin treatment. The success at this delayed time of treatment initiation drops precipitously as the cartilage pliability changes. The other very important point is that the Earwell device does more than just fold the ear cartilages back into a more favorable position. The genthe and sustained forces on the helical rim causes actual cartilage expansion and lengthening.  This explains its success in improvement of even the more significant constricted ear deformities who have a true lack of cartilage volume.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Stahl’s Ear Correction with Rib Cartilage Graft

Saturday, April 22nd, 2017


Background:  There are a wide variety of congenital ears deformities that involves either deformed or missing natural cartilage structures of the ear. One such well known deformity is that of the Stahl’s ear. This consists of an ear that has a pointy shape due to an extra fold or third crus in the scapula. It is often referred to as a Spock part in reference to the Star Trek TV character.

Stahls’ ear is primarily caused by the ear cartilage being misshapen. The upper ear usually has two distinct folds known as a superior and inferior crus. But in Stahl’s ear a third crus or fold occurs. This causes the outer rim of the upper ear to fold inward giving it a pointed shape.

If recognized very early after birth, external ear molding devices (e.g., Earwell) can correct the misshapen ear as the young ear cartilage is very flexible and moldable. But once one passes six to weeks after birth the ear loses its responsive to external molding forces and surgery becomes the only treatment option.

Case Study: This 12 year-old male had misshapen ears that he disliked. The upper outer helical rim was bent over or folded in. This created a pointed shape to his upper ears. He had been given the diagnosis of Stahls’ ear although it was not a classic presentation of it.

Under a general anesthesia an incision was made on the back surface of the ears. This allowed the helical rim skin to be dissected off the cartilage and expose the upper ear cartilage shape over the deformed area. Radial cuts were made in the cartilage to allow it to unfurl and create a more defined outer helical rim. To support this new shape a cartilage graft from a small piece of rib #9 was used by suturing it on the inside of the newly formed helical rim. On the right ear  a small wedge of cartilage and skin was removed to bring down the height of the helix.The skin was then pulled back over the reconstruction and closed with dissolvable sutures.

His immediate intraoperative result showed improvement in the shape of ear through recreation of a more defined outer helical rim. While many techniques for Stahl’s ear correction have been described they all rely on innate cartilage reshaping alone. Add a small cartilage graft can help support these cartilage reshaping efforts.


  1. Stahl’s ear is a congenital deformity marked by an abnormal fold in the upper ear which makes it pointy.
  2. Reconstruction they deformed upper ear requires cartilage reshaping which often requires the use of a cartilage graft for support.
  3. A small piece of rib #9 can be used for a strong and curved cartilage graft.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Asian Otoplasty

Sunday, March 5th, 2017


Background: The most common congenital malformation of the external ears is that of excessive protrusion. Technically defined as the auriculo-cephalic angle, how open this angle is defines creates the appearance of ears that stick out too far. While the normal angle is up to 30 degrees, what really counts is the patient perception of their ear position.  If the patient thinks their ears stick out too far, then they do.

Ear deformities are common with all ethnicities and genders. I have performed otoplasty correction on many different types of ethnic patients from Hispanic to Burmese. It does appear to be more common in Asians, presumably due to the increased bitemporal skull widths and less projecting occiputs. This may force the conchal position of the ear more outward.

While the fundamental components of an otoplasty to decrease the auriculo-cephalic angle are the same for all patients, the Asian otoplasty has a few anatomic issues to consider. Their thicker skin that is more prone to hypertrophic scarring makes the location and length of the incision important. Also their ear cartilages can be thicker with greater stiffness which may make them less easily moldable to a simple suture or two. Cartilage softening manuevers may be needed.

Case Study: This 30 year-old female had protruding ears all of her lift. She usually wore her hair down because of being self-conscious about their appearance.

Asian Otoplasty results front view Dr Barry Eppley IndianapolisUnder local anesthesia and through a limited postauricular incision (no skin as removed), the posterior surface of the ear cartilage was exposed. The stiffness of the conchal cartilage was reduced using a grid-pattern (checkerboard) full-thickness cartilage cuts with a scalpel. Using a combination of horizontal mattress cartilage sutures and concha-mastoid cartilage-fascia sutures, the ears were reshaped and pulled back into a less protrusive position along the sides of the head.

Asianj Otoplasty results back view Dr Barry Eppley IndianapolisHer result could be be critiqued as being slightly overdone with the ears pulled back too far. She, however, was satisfied with the outcome. What is most interesting about her result is how her face became much more prominent. Her well structured and strong skeletal facial shape seems much more apparent after the otoplasty surgery. It is clear that her face was there all along. But when the focus of the eyes turns away form the prominent ears to just that of her face. its beauty becomes much more apparent.


1) Ear malformations are common amongst all ethnic groups although it may be more prominent in Asians due to their natural skull shape.

2) Otoplasty surgery for prominent ears in Asians must factor in their thicker skin and often stronger ear cartilages.

3) Asian otoplasty allows an increased emphasis on the face where angular and stronger skeletal features are more evident.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Pediatric Otoplasty

Monday, February 20th, 2017


Background: The formation of the ear is an amazingly complex embryonic process. That is evident in just looking at the ear with its spiral array of convexities and concavities of cartilage around the ear canal. It is remarkable that it forms properly and does so twice in most people due to its bilateral presence.

But because of its complexity the ear is one of the most commonly misshapen of all facial features. From minor deformities like earlobe clefts and Stahl’s ear to major malformations like microtia there is a wide array of congenital ear malformations that can occur. One of the most common ear anomalies, and it is questionable whether it should be called an anomaly, is that of the protruding ear. All of the ear is present but its sticks out too far from the side of head due to the lack of an antihelical fold, overgrowth of the concha or some combination of both.

Setback otoplasty, also called ear pinning, is the well recognized surgery for the correction of the excessively protruding ear. It is done in both adults and children. The common question in children is at what age is the proper time to perform the surgery. The underlying premise of this question is when can the surgery be done so that it will not adversely affect growth of the ear cartilage.

Case Study: This 6 year-old male child has very prominent ears due primarily to a lack of antihelical fold development. Where the fold was completely absent the ear stuck out the most. Down near the earlobe some sembence of an antihelical fold was present and the ear stuck out less.

Male Child Otoplasty result front view Dr. Batrry Eppley IndianapolisUnder general anesthesia an otoplasty procedure was performed through an incision on the back of his ears. Minimal skin was removed from the back of the ear and the correction was done principally through multiple horizontal mattress sutures (to create the fold) and some concha-mastoid sutures. (to decrease the auriculo-cephalic angle)

Pediatric Otoplasty result back view Dr Barry Eppley IndianapolisPediatric Otoplasty result side view Dr Barry Eppley IndianapolisHis one month results show a good and reasonable symmetric ear reshaping result. A close-up side view of before and after pictures show that the effect was largely achieved by creating an antihelical fold and a more defined superior crus in the upper helix.

Clinical studies have shown that suture cartilage manipulation of the ear can be done as early as age 2 without any negative growth effects on the ear cartilage. While it can be technically done at such as early age (and I have done so numerous times) there is the important question of postoperative compliance and avoidance of unintentional ear trauma. (which could cause suture disruption and partial ear shape relapse) Between lack of any psychosocial developmental issues in children and performing elective surgery at such a young age, it is far more common to have pediatric otoplasty done closer to age 5 or 6.


1) Congenital ear deformities are amongst the most frequently occurring of all facial deformities of which the protuding ear is the most common one seen.

2) Setback otoplasty (ear pinning) achieves its effect primarily by cartilage bending.

3) The age to perform an otoplasty is largely parent driven in children and be effectively done anytime after age 2.

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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