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Archive for the ‘ear reshaping’ Category

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

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

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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