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Archive for the ‘ear reshaping’ Category

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

Vertical Ear Reduction with Setback Otoplasty

Saturday, February 11th, 2017


The vertically long ear is one that appears disproportionate to other facial features. Generally if the length of the ear is greater than that of the nose, for example, it can be judged to be too long. But no matter how it is measured of the patient thinks the ear is too long then it is.

When performing a setback otoplasty for protruding ears, it is not rare to see that the ears are also vertically long. While sometimes this can be an illusion because of the ear’s degree of outward protrusion, measurements and trial reshaping of the ear can confirm if it is really too long. If this diagnosis is missed before surgery, the setback ear may look better but still be too long. In some cases of how setback otoplasty sutures are placed, it can even make the long ear look even longer.

In the Online First edition of the February 2017 European Journal of Plastic surgery an article was published entitled ‘Upper Third Ear Reduction with a Posterior Approach’. In this paper, the authors report a specific technique for the reduction of the upper third with a posterior approach based on resection of the scapha and remodeling of the posterior skin excess. This is an ear reshaping technique that is combined with setback otoplasty.

Vertical Ear Reduction result intraop Dr Barry Eppley IndianapolisUnder normal circumstances it it virtually impossible to siginificantly reduce the vertical height of the ear without removing anterior ear skin and cartilage. The fear in doing so of course comes from concern about visible scarring. Despite these scar concerns it has not been a problem in my vertical ear reduction experience.

But when combining vertical ear reduction with a setback otoplasty, it is not wise to use the traditional anterior scaphal cartilage and skin resection technique. While it is not the cartilage resection that is the problem but the placement of incisions on both the front and backside of the ear. For this reason removing cartilage only from the posterior approach is done at the time of the setback otoplasty. Folding the ears back will allow the scaphal cartilage gap to close and shorten the height of the ear somewhat. Any skin excess can then also be removed.

Dr. Barry Eppley

Indianapolis, Indiana

The Timing of Earwell Ear Molding

Wednesday, December 7th, 2016


Ear molding is a well acknowledged method or correcting or improving various ear shape deformities. One of its basic principles is that it must be done very early in the neonatal period usually within the first few weeks after birth. Studies have indicated that the success of non-surgical ear reshaping diminished dramatically when applied after four weeks of age.

Some congenital ear deformity patients, however, do not appear until after the first few weeks of birth for a variety of reasons. The most common reason is that they simply were not aware that such non-surgical ear treatments exist. Also they often have many other important issues that take precedence over what the ear shape looks like.

earwell-ear-molding-system-dr-barry-eppley-indianapolisIn the November issue of the Archives of Plastic Surgery an article entitled ‘Correction of Congenital Auricular Deformities Using The Ear Molding Technique’ was published. In this paper the authors reported on their experience in older patients with ear molding using the Earwell system. The average age of the patients was around three weeks of age with a few out to almost two months of age. Over a one year period, twenty-eight (28) ears in eighteen (18) patients were treated. The types of congenital ear deformities included the constricted ear (64%), Stahl’s ear (21%), prominent ear (7%), and cryptotia. (7%) Average device application time was 4 weeks with some as long as two months. On a scale of 1 to 5, the average degree of improvement was 3.5. After one year the shapes of the ears were well maintained, the overall satisfaction score was 3.6. The only patients who did not have very good results were those that started treatment after three weeks of age.

While ear cartilage is flexible it has great memory. This is not true right after birth due to maternal estrogen levels. In the first week after birth material estrogen creates a large amount cartilage plasticity due to an increase in hyaluronic levels which temporarily decreases its memory. This is why neonatal ear molding can be effective. However this estrogen-related ear plasticity drops quickly as the maternal levels drop in the baby’s circulation by seven to ten days after birth. Thus the recommendation to begin ear molding in the first few weeks after birth.

But as this study has shown and in my own experience, ear molding is not a completely fruitless treatment if started after three weeks of age. Some to good improvements can still be obtained even if started at four to six weeks of age. The results as simply not as predictable or as good if done earlier. But given the non-invasive nature of the Earwell system this makes its use even in the ‘older’ patient a reasonable choice.

Dr. Barry Eppley
Indianapolis, Indiana

Case Study – Macrotia Reduction

Thursday, November 10th, 2016


Background: Any ear that is vertically longer than 65mm to 70mm would generally be perceived to be very large. Despite the numbers, however, if a patient thinks their ears are too large then they are. But in my experience patients that I see for macrotia reduction always have an ear length that is at least 65mms or greater.

Macrotia reduction is usually a ‘high and low’ procedure. This means that the top and the bottom of the ear are shortened as they offer less scar burden to do so. While one could argue that the middle of the ear is the most effective location to do a vertical ear reduction, the resultant visible scar across the middle of the ear would be considered an aesthetic drawback.

In many macrotia cases the greatest vertical ear reduction comes from shortening the earlobe. This is the only completely soft tissue component of the ear and is the most amenable to the greatest tissue removal. The upper portion of the ear is the other area for vertical eat reduction. Hiding most of the incision under the helical rim allows for a wedge of skin and cartilage to be removed and the height of the ear reduced. It is limited to how much ear cartilage can be removed and have the ear not look deformed. It is not often done alone but can be effective.

Case Study: This 35 year-old male felt his ears were too big. While his vertical ear height was 77mms, his earlobes were very small. He had a large conchal bowl but a middle of the ear macrotia reduction approach was not acceptable due to the potential scar.

macrotia-right-ear-scaphal-reduction-intraop-result-dr-barry-eppley-indianapolismacrotia-reduction-left-ear-scaphal-flap-intraop-result-dr-barry-eppley-indianapolisUnder local anesthesia and IV sedation, a macrotia reduction procedure was done. It was limited to just an upper ear reduction due to the small size of his earlobes.  A scaphal flap technique was with a horizontal excision across the helical rim at its middle outer portion.  A 7mm reduction of skin and cartilage was done. Vertical ear height measurements at the end of the procedure was 65mms.

The scaphal flap technique in macrotia reduction is an cartilage-skin flap that remains viable due to the attachment of the postauricular skin. When the outer ear height is shortened and closed, this creates ‘dogears’ on the back of the ear. These are removed as the final step in the procedure by removal of redundant skin folds in a vertical pattern that lies parallel to the helical rim.


1) Reduction of large ears us usually done by reducing the top and the bottom of the ear.

2) With a normal sized earlobe, macrotia reduction must be done by an upper helical scaphal flap reduction method.

3) Macrotia reduction is done under local anesthesia in most patients.

Dr. Barry Eppley

Indianapolis, Indiana

Interpositional Grafting in Otoplasty Reversal

Sunday, September 11th, 2016

otoplasty-for-protruding-ears-dr-barry-eppley-indianapolisOtoplasty is the most common total ear reshaping surgery. Its objective is to take an ear that sticks out too far and bring it in closer to the side of the head. This is typically done by changing the shape of the cartilage through sutures placed on the back of the ear. How much the ear should be set back is a matter of judgment and there is a fine line between too far and not enough.

When the ear appears set back too far it it important to realize that some relaxation of the initial ear position may relax and be just fine. One should give it a month or two to see how it heals and looks. If the ear still looks too far back at that point a surgical revision can be done to loosen or replace the cartilage plication sutures for better ear positioning.

But months or years after an otoplasty, the opportunity for simple suture release has passed. Releasing the sutures or the scar behind the ear will not work. The ear cartilage cartilage has lost its memory and has stiffened into its reshaped position. Even removing scar tissue and scoring the cartilage in an attempt to release it even a few millimeters does not usually work either.

The key to a successful otoplasty reversal is the use of an interpositional graft. Once the cartilage has been released it needs to be held out into its new position. The ideal interpositional graft would be a piece of rib cartilage. While a cartilage graft from the patient would be the ideal material to use the idea of a donor site is not usually that appealing for an elective aesthetic procedure.

tissue-bank-cartilage-in-otoplasty-reversal-dr-barry-eppley-indianapolisAnother graft option is that of tissue bank or cadaveric cartilage. Available from a variety of tissue banks in the U.S., processed pieces and sheets of cartilage are available for human implantation. A solid cartilage piece is best placed in a vertical orientation sutured into the released ear fold. It not only adds structural stability but also provides a scaffold for tissue encapsulation and adherence.

I have used a lot of different materials in otoplasty reversal procedures. These have included metal clips, autologous cartilage, and tissue bank bone and cartilage. While all of these interpositional materials have worked. cadaveric cartilage grafting seems the most biologic and avoids the need for a donor site.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Macrotia Reduction Surgery

Monday, September 5th, 2016


Background: The large ear or Macrotia deformity is marked by an increase in vertical ear height. The length of the ear has been well described by anthropometric studies and in art by a variety of measurements and proportions. The ear is supposed to be roughly the angulation and length as that of the nose. Direct measurements describe an ear that is greater than 65mm long as being large. But numbers and proportions aside if a patient feels their ear is too big…then it is.

Macrotia reduction of the large ear is done by a ‘high and low’ approach. The bottom of the ear is shortened by earlobe reduction of which the inferior helical rim excision is usually the best technique. This creates little visible scar and is the ‘easiest’ part of macrotia reduction. The top of the ear is reduced by scaphal-helical rim cartilage resection through a pedicled scaphal flap technique. This is the ‘harder’ part of macrotia surgery to execute making sure most of the suture line hides well under the inner helical rim.

Despite the extensive nature of reduction surgery on the ear, scars are very minimal. The only obvious one is the small incision that crosses the helical rim in the center of the ear. All others are hidden under the helical rim and on the bottom side of the earlobe. But even the helical rim scar heals very well.

Case Study: This 40 year-old male presented for ear reduction surgery. He had very long ears that measured from the top of the helix to the bottom of the earlobe of 80mms on the right and 79mms on the left.

Macrotia Reduction intraop right ear Dr Barry Eppley IndianapolisMacrotia Reduction intraop left ear Dr Barry Eppley IndianapolisUnder local anesthesia with IV sedation the earlobes were reduced by a helical rim resection technique removing 9mms of the lobule. Then a 6mm vertical-horizontal strip of scaphal cartilage combined with 6mms of helical rim cartilage were done through a superiorly-based helical rim flap technique. Skin was closed throughout with 5-0 plain sutures.

The effects of macrotia reduction are immediate and often dramatic. The ears do swell a bit and are mildly uncomfortable for a week to ten days. No dressings are used other than antibiotic ointment. Full healing can be expected in about 3 to 4 weeks.


1) Macrotia is almost always marked by both a large upper ear framework and a long earlobe.

2) The combination of a scaphal-helical rim reduction combined with earlobe shortening can make the ear 10 to 15mms vertically shorter.

3) Vertical earlobe reduction/reshaping can be performed under local anesthesia with or without IV sedation.

Dr. Barry Eppley

Indianapolis, Indiana

Suture Extrusion in Otoplasty

Monday, July 4th, 2016


Otoplasty suture technique Dr Barry Eppley IndianapolisOtoplasty is the most common ear reshaping procedure for prominent ears. Known as ear pinning, it achieves its result by bending the ear cartilage back into a better position and stabilizing them with sutures. In the short term it is the sutures that maintain the new ear position and a loss of their tension or knot stability would be detrimental for the desired aesthetic result. In the long term (may months) it is the scar tissue that holds the reshaped cartilage and eventually the cartilage will lose its memory.

mersilene suture in otoplasty dr barry eppley indianapolisBecause of the importance of early suture stability in otoplasty, many plastic surgeons prefer the use of mersilene sutures. Mersilene is a synthetic polyester fiber that is completely non-resorbable. Because it is a braided suture it has great handling and knot tying features. It allows for precise and consistent suture tension which is of paramount importance when adjusting the amount cartilage bending at various points along the back of the ear.

Otoplasty Suture Extrusion Dr Barry Eppley IndianapolisOnce an otoplasty has satisfactorily healed and the patient is happy with the result in both shape and symmetry, there is only one potential long-term complication. Since the mersilene sutures are permanent and are right under the skin on the back of the ear, there is a lifelong risk of a suture reaction or extrusion. Like all suture knots that are right under the skin they may eventually work themselves through the original incison/scar line or surrounding skin. This presents as new onset ear pain with either a suture extrusion or a draining suture abscess.

Fortunately such otoplasty suture issues can be easily solved. The exposed suture must be removed. In some cases it can be simply pulled out. In other cases the knot must extracted under local anesthesia. Removal of the suture does not affect the otoplasty result.

The occurrence of long-term suture extrusion in otoplasty surgery is very low. But it can occur at any time over a patient’s lifetime. Given that many otoplasties are done in very young patients, it may not occur for decades. Just to prove that point I removed an extruding suture from an 82 year-old that had an otoplasty done in 1947!

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Small Vertical Ear Reduction

Thursday, June 30th, 2016


Background: Vertical reduction of the ear is an uncommon otoplasty procedure as it is infrequently requested. It is best known and used in the treatment of macrotia where the entire ear is very large and vertically long. Macrotia reduction most commonly uses a ‘high and low’ technique where the upper helix (high) and the earlobe (low) are reduced. Put together a substantial reduction in ear height of 10 to 15mms can be achieved.

But not every vertical ear reduction has to be dramatic or requires a two level approach to it. In smaller vertical ear reductions the procedure can be limited to either the upper ear or just the earlobe. But when the patient has a concern about the shape of their upper ear (along with any height concerns) then an isolated upper ear reduction may be useful.

externak ear anatomyThe reduction of the upper ear comes from removal of a portion of the scapha. The scapha is the depression or groove between the helix and the anthelix. It is composed of cartilage with skin on both of its sides. While it can be reduced on its own that will result in only a few millimeters of vertical height reduction. And if too much is removed will cause a distortion in the natural curvature of the upper helix. Adequate scaphal reduction requires removal of a portion of the helical rim as well.

Case Study: This patient wanted to have one ear lowered at its upper third to match better to the shape of the opposite ear. Even though the ear that was asked to be lower was the more normal shape, the patient correctly surmised that it was easier t lower the height of the upper helix than it was to raise it.

Scaphal Vertical Ear Reduction intraop Dr Barry Eppley IndianapolisSmall Vertical Ear Reduction result Dr Barry Eppley IndianapolisDuring surgery a scaphal reduction was done with a pedicled helical flap based on the outer helix. This means that the back cut across the helix was done at its helical root attachment. This brought down the height of the ear through excision of the scapha and removal of a piece of the helical rim at its backcut area.

Vertical ear reduction of the upper ear is done by excision of a portion of the scapha. It can only cause a visible reduction of height by a corresponding helical rim excision whose length matches the amount of vertical reduction desired. It can be based either anteriorly by a mid-helical rim excision or posteriorly by a superior helical rim excision. How one wants the shape of the top of the ear to look determines how to base the scaphal reduction flap.


1) Vertical reduction of the upper ear is done through a scaphal removal technique

2) A scaphal reduction is a pedicled ear flap that can be based off the superior root of the helix or off the midportion of the helical rim.

3) The choice of which scaphal reduction method depends on the desired shape of the upper ear after reduction and the location of the scar.

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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