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Archive for the ‘ear reshaping’ Category

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.

Highlights:

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.

Highlights:

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.

Highlights:

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

Case Study – Pediatric Reversal Otoplasty

Wednesday, June 15th, 2016

 

Background: Otoplasty is the most form of ear reshaping surgery. Even though the term otoplasty is a general one it is typically associated with treating the protruding ear. The ear that sticks out is due to excessive conchal cartilage, lack of an adequate antihelical fold or both. Changing this undesired ear shape is done by bending or folding the cartilages and then holding them into the new shape with permanent sutures.

The result from such otoplasty cartilage reshaping maneuvers has a large intraoperative artistic component. How much the cartilage is folded and setback, how many sutures to place and judging the new look are all up to the discretion of the surgeon. The outcome is made doubly challenging because there are two ears and going back and forth between them to achieve the best symmetry requires a lot of artistic judgment.

There is always the risk needing a revision from otoplasty surgery due to asymmetry or an undesired ear shape. An underdone otoplasty outcome can be satisfactorily treated by increasing the amount of the cartilage fold by placing new sutures. Correcting an overdone otoplasty, however, is not as simple as just releasing the old sutures or placing new ones. A different approach is needed to partially reverse an ear cartilage fold.

Case Study: This 6 year-old male child had an ‘incisionless otoplasty’ one year previously. The right ear shape outcome was satisfactory but the left ear looked completely different. The conchal aspect of the left ear was too protrusive and the upper ear antihelical fold was turned back too far.

Reversal Otoplasty result front view Dr Barry Eppley IndianapolisUnder general anesthesia the back of the left ear was opened and the cartilages exposed. A small conchal cartilage graft was harvested and the concha set back by concha-mastoid sutures. The antihelical fold sutures were released but that did not change its shape. An interpositional conchal cartilage graft was placed to help hold out the antihelical fold into a better ear shape. This combination of ear reshaping maneuvers achieved bette symmetry to the opposite ear.

Reversal Otoplasty Edhe Highlights Result Dr Barry Eppley IndianapolisThe difference in the cartilage shape of the ear can be seen in this edge highlighting method.

A reversal otoplasty is rarely as simple as just releasing sutures or the scar tissues between the cartilage fold. Memory of the cartilage does persist for some time and probably does so in children longer than in adults. But once a year after surgery has passed the memory of the original cartilage shape has been lost. To hold out or to partially reverse an antihelical fold an interpositional spacer graft is needed. Autologous cartilage is always the best spacer graft for a reversal otoplasty. If it is just one ear it may be possible to harvest the cartilage from the conchal area of the same ear.

Highlights:

1) Ear reshaping from an otoplasty is usually done by folding of the protruding cartilage into a new shape with suture fixation at multiple points.

2) An otoplasty can be overdone when the amount of cartilage folding is excessive and the desired three-tiered structure of the ear is disrupted.

3) A reversal otoplasty is rarely effective done by suture release after the ear is completely healed.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Macrotia Reduction

Monday, May 2nd, 2016

 

Background: The most common aesthetic ear procedure is that of ear pinning. Known technically as otoplasty, the protruding ear is reshaped and sutured (pinned) back so that it aligns better with the side of the head. This traditional aesthetic ear procedure relies on cartilage manipulation/folding rather than actual tissue removal. Its effects are created by reshaping the deformities in the existing ear cartilage.
Macrotia or the large ear is a very different surgery from that of the more common protruding ear. It is a problem caused by tissue excess having an exaggerated vertical height to the ear. The traditional vertical ear height is around 60mms with slightly more being acceptable for men and slightly less for women. When the vertical ear height exceeds 70mms it is always seen as too big or too long.
Macrotia surgery, unlike setback otoplasty, requires tissue removal. From the bottom of the ear, the earlobe can be vertically reduced by wedge excision. The top of the ear is more challenging as it is composed of cartilage and there is no place to completely hide the reduction incisions.
Case Study: This 25 year-old male had long been bothered by his large ears. They had vertical measurements of 756mm from the height of the superior helix to the bottom of the earlobe. There was also excessive protrusion of the upper ear from the side of the head.
Left Vertical Ear Reduction result (Macrotia Surgery)  Dr Barryt Eppley IndianapolisUnder general anesthesia, bilateral macrotia reduction surgery was performed. The earlobes were reduced by a vertical helical rim reduction of 5mms. The upper ear was reduced by a scaphal-conchal flap reduction with a resection across the midportion of the helical rim of 7mms. The upper ear was also set back by a suture technique.
Right Vertical Ear Reduction result Dr Barry Eppley IndianapolisMacrotia and Otoplasty Ear Reconstruction result front view Dr Barry Eppley IndianapolisHis six month after surgery results showed ears that were more normal in size and vertical length. The earlobe scars along the rim were imperceptible. The only visible scar from the scaphal-conchal reduction was across the central helical rim with a fine line scar.
Highlights:
1) Reduction of a large ear (macrotia) is quite a different surgery than that of traditional ear pinning or otoplasty.
2) Vertical ear reduction requires reduction of the ear as well as tat of the bottom of the ear.(earlobe)
3) The scars from vertical ear reduction are minor with the most visible one crossing the ear at the central helix.
Dr. Barry Eppley
Indianapolis, Indiana

Case Study – Macrotia Ear Reduction

Sunday, December 6th, 2015

 

Background: The embryology and development of the human ear is a marvel in not only its complexity but how well it works most of the time. It is created by the merging of six separate tissue segments (hillocks) in utero that create the recognizable ear that is a collection of various ridges and valleys. But due to its complex shape the ear is prone to a wide variety of congenital anomalies of which microtia is the most severe.

macrotiaThe opposite of microtia is macrotia where the ear is abnormally large. Unlike microtia where various parts of the ear are either missing or deformed, in macrotia the ear components are normal but bigger than desired. The ear is usually felt to be large primarily because it is vertically long. Various parts of the ear may be bigger than normal but usually the upper and lower thirds of the ear are what is too long.

The average height of the ear, as measured from the bottom of the lobule to the top of the upper helix, is in the range of 60 to 65mms. (average of 63mms) While they are some slight differences in these measurements between men and women, they are not all that different. (around 5% or less) The average length of the earlobe is around 18mms or about 1/3 of the total ear height.The average height of the pinna or cartilaginous portion of the ear, calculated by subtracting the earlobe height from the total ear height, was around 45mms.

Case Study: This 27 year male had ears that he felt were too big (long) as well as stuck out. He had seen other plastic surgeons but they only wanted to fix the protruding aspect of them. His total ear height was 76mms with an earlobe length of 24mms.

Vertical Ear Reduction result intraop Dr Barry Eppley IndianapolisUnder local anesthesia with infiltration around the base of his ear, three specific ear reshaping procedures were done. The earlobe was vertically reduced by 6mms with a helical rim excision technique. The upper third of the ear was reduced by 7mms using  scaphal excision of cartilage and outer skin with a helical rim reduction. (scapha-helical rim flap) Lastly ear was set back with concha-mastoid sutures from a postauricular incision. At the end of the procedure the total ear height was 65mms.

Macrotia ear reduction is done by reducing the height of the ear from the top (scapha-helical reduction) and bottom (earlobe reduction) simultaneously. Correction of any ear protrusion can be safely done during macrotia reduction surgery.

Highlights:

  1. Macrotia is an aesthetically abnormal enlargement of the ear that is most manifest in the vertical dimension.
  2. Macrotia ears usually have a combined increased height of the upper ear and longer earlobe.

3) Macrotia ear reduction surgery is done by an upper ear scapha-helical reduction flap and a helical rim earlobe reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Otoplasty Reversal with Irradiated Rib Graft

Thursday, October 15th, 2015

 

Background: Otoplasty is a well known cosmetic ear surgery that treats ears that stick out too far. It is done by either creating an increased cartilage fold, removing or scoring (weakening) of the cartilage or a combination of both techniques. The goal is to change an auriculocephalic angle to a more acceptable one, bringing the ear closer to the side of the head.

In doing an otoplasty and setting the ear back, there is no precise formula in creating the new ear angle. It is done by the surgeon’s artistic eye and experience in knowing what is an acceptable ear position. This makes doing an otoplasty as much an art as it is a science. This also leads to the most common ear problem after otoplasty…over-or undercorrection of the ear position.

Undercorrection of an otoplasty is the easiest problem to fix. The ear can be pulled back further through additional suture placement. The more difficult problem is when the ear is  over corrected. If seen early after surgery before considerable scar contracture has occurred and cartilage memory has been changed, sutures can be released and a scar release performed. But if done long after healing has occurred, scar and suture release is not going to work.

Case Study: This 30 year old male had an otoplasty ten years ago that left him with a telephone ear deformity. The central outer rim of the ear (helical rim) cold not be seen. It was located behind the antihelical fold. The upper and lower helical rim was more visible.

Otoplasty Reversal with Irradiated Rib Graft intraop Dr Barry Eppley IndianapolisUnder local anesthesia his previous incisions were opened on the central part of his ear on the back side. Scar tissue and old sutures were excised. The outer ear cartilage was scored and released so that it could be elevated. Using an irradiated piece of cadaver bone, a vertical strut was fashioned and placed on the back of the ear to hold it out. It was  sutured onto the cartilage on the back of the ear.

Otoplasty Reversal result right ear Dr Barry Eppley IndianapolisOtoplasty Reversal result left ear bDr Barry Eppley IndianapolisThe use of an interpositional graft is the key to a successful otoplasty reversal. A strong support is needed to push and hold the ear back out. Scar release and suture release/removal is not going to make the ear jump out and increase its auriculocephalic angle. There may be other types of grafts that can work but homologous or cadaveric bone grafts not only avoids a donor harvest site but offers long-term stability.

Highlights:

1) Overcorrection of an otoplasty often presents as the center portion of the rim of the ear being pulled back too far, creating the classic telephone ear deformity.

2) Correction of the over done otoplasty requires cartilage release and an interpositional graft to hold it back out and prevent relapse.

3) Numerous interpositional grafts can be used but homologous cartilage or bone grafts avoid a donor site harvest.

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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