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Archive for the ‘otoplasty’ Category

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.

Highlights:

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

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

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

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 – 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

Optimal Incision Locations for Otoplasty Surgery

Friday, June 12th, 2015

 

Otoplasty results Back view Dr Barry Eppley IndianapolisOtoplasty is a relatively simple and effective procedure for reshaping the prominent ear. Cartilage bending/repositioning through sutures is the backbone of the operation with a minor role for cartilage excision/scoring. But the ability to do these maneuvers requires an incision and this is almost always placed on the back surface of the ear. While an ear that becomes more closely positioned on the side of the head would seem like it would hide any scar placed behind it, this is not always true. Poorly placed incisions can create noticeable scars to others when seen from behind.

In the June 2015 issue of the Annals of Plastic Surgery journal, the article ‘The Discrete Scar in Prominent Ear Correction: A Digital 3-Dimensional Analysis to Determine the Ideal Incision for Otoplasty’ was published. In this paper the authors studied three incision/scar locations on the back of the ear that are typically used for otoplasty surgery.  Forty patients had the scar locations marked and then photographed across an 180 degree arc around the back of the ear. Using an assessment scale known as a ‘Visibility Arc’, in which the range of degrees where the scar is most visible is judged, the postauricular scar locations were compared. The objective was to determine the least visible incision—in other words, the scar with the shortest visibility arc. Scars located in the sulcus of the antihelical fold had the shortest average visible arc of about 70 degrees.The auriculocephalic sulcus had the largest visibility arc of a 100 degrees, A scar between these two locations had an 80 degree arc.

Otoplasty Scars Dr Barry Eppley IndianapolisWhile the success of an otoplasty is primarily about how the shape and prominence of the ear turns out, the scar does play a minor role in the success of the procedure….just like most every other plastic surgery operation. Cartilage reshaping of the ear can be done through any of the three incisions so the least visible location would be the most logical choice. This study shows that the least visible scar for otoplasty lies in the posterior antihelical groove with even a slightly more medial location as almost equally good. The most visible scar is in the junction of the ear and the head. (auriculocephalic sulcus)

Dr. Barry Eppley

Indianapolis, Indiana

Otoplasty in the Long Ear (Macrotia)

Friday, May 15th, 2015

 

Prominent ears are the most common reason for an aesthetic otoplasty correction. There are numerous reasons that one has ears that stick out too far from the absence of the antihelical fold, a large concha or combinations thereof. The surgical techniques used to treat prominent ears are based on creating a more defined antihelical fold, reducing the size of the concha and/or reducing the concha-scapha angle. Generally the size of the ear is usually not of significance as the vertical height of the ear is normal.

In the May 2015 issue of the journal Plastic and Reconstructive Surgery, an article as published entitled ‘Precision in Otoplasty: Combining Reduction Otoplasty with Traditional Otoplasty’. In this paper the authors looked at a series of otoplasty patients who also had some degree of macrotia (long ears in addition to protruding ears) Over a three year period the authors reviewed over 80 otoplasty patients of which 30 had some scaphal reduction at the same time. (36%) The scapha reduction was performed from a lateral incision inside the helical rim. The helical rim was reduced to accomodate the reduced scapha. Earlobe reduction was performed at the same time in five patients. (6%) Almost 25% of the treated patients were revisions of a prior otoplasty of which they were dissatisfied. The results from 6 to 12 months after surgery had a 100% high satisfaction rate with no significant complications. (tissue loss, infection or shape recurrence) The only visible scar was on the helical rim with some slight notching.

Otoplasty with Earlobe Reduction result left sideWhether the height or vertical length of the ear is too long is a personal judgment but there are normative numbers that can be used in this assessment. The upper limits of a normal ear length is around 65 to 70mms in adults. When an ear is too long the usual culprits of elongation are either the earlobe, the upper third of the ear or both. While a vertical earlobe reduction is easier and creates less scar, scapha reduction should be considered if that is a contributing source of the ear elongation.

Protruding ears that are also enlarged are an underrecognized type of otoplasty patient. An enlarged scapha makes it difficult to set the protruding ear back properly and runs the risk of it being either under or over corrected. Scapha reduction offers a direct approach to the enlarged ear in either the primary or secondary otoplasty patient.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Otoplasty Reversal Using An Interpositional Metal Spacer

Monday, April 6th, 2015

 

Otoplasty left ear side view result Dr Barry Eppley IndianapolisBackground: Otoplasty for protruding ears is primarily done by cartilage reshaping/repositioning. Whether it is the placement of antihelical or concha-mastoid sutures, the ear is ‘pulled back or ‘pinned’ by cartilage manipulation. The use of these suture techniques is primarily an art and how many are used, placed and their degree of tightening is a matter of intraoperative judgment.

Despite the plastic surgeon’s best intent in some cases, the ears may not be pulled back far enough or may be pulled back too far. Undercorrection, whether done early or late, is an easier problem to improve by the placement of additional sutures. Overcorrection of the protruding ears, however, is a different matter. If treated early (within weeks or a month or two from the initial surgery), release of some of the sutures or replacement of them can be effective. Once scar has formed between the postauricular cartilage surfaces and/or the cartilage has lost memory, suture release will not create an otoplasty reversal. (partial)

A delayed  otoplasty reversal requires an interpositional graft to be placed between the released cartilage folds. While effective, few patients want to have a cartilage graft harvested to help the ears sit back out three to five millimeters. Ideally the cartilage graft should come from the end of one of the free floating ribs…a concept that even makes it less appealing.

Case Study: This 30 year-old female had an original otoplasty severn years ago that was undercorrected. He then had an otoplasty revision to set the ears back further. This resulted in an overcorrected problem  He had a third otoplasty procedure years later to bring the ears out further but it was not successful. To the best of his knowledge it was procedure to release the sutures.

Reversal Otoplasty Plate Dr Barry Eppley IndianapolisUnder local anesthesia, the central portion of his postauricular incisions was reopened and the scar tissue between the cartilage folds released. A small titanium mesh plate (1mm profile) was cut into a small clip-like shape and bent at 90 degrees. It was then wedged in between the released cartilage folds and sutured into placed. The skin incision was closed with small dissolveable sutures.

Reversal Otoplasty Right Ear results Dr Barry Eppley IndianaplisReversal Otoplasty Left Ear results Dr Barry Eppley IndianapolisHis immediate after surgery pictures showed a modest (3mm) increase in his ear projection which was maintained. The push of the metal plate maintained the cartilage position as new scar tissue was formed.

Partial otoplasty reversal can be successfully done using a small metal insert to hold the ear out. This effectively replaces the need for a cartilage graft as an interpositional spacer.

Case Highlights:

1) An otoplasty is said to be overcorrected when the helical rim is pulled behind the antihelix.

2) Partially reversing an otoplasty can not be done secondarily after the first few months after surgery by releasing the original cartilage sutures.

3) A delayed reversing otoplasty requires a method to hold the cartilages apart of which a small metal plate or ‘spring’ can be effective.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Young Otoplasty for Protruding Ears

Monday, March 23rd, 2015

 

Background:  The ear is made up of a complex array of ridges and depressions in a very small anatomic area. The dominant features of the ear is the external helical ridge with an internal antihelical ridge, both of which surround the bowl of the ear (concha) which surrounds the ear canal. Normally the outer helix sits just above the antihelix with an ear protrusion from the side of the head no greater than about 25 degrees or less than 2 cms from the helix to the mastoid.. When the antihelix is absent (underdeveloped antihelical fold) or the concha is very large, the ears will become protrusive or stick out.

Ear Growth Dr Barry Eppley IndianapolisWhile medical evidence now indicates that our ears do continue to slowly grow throughout life, their greatest growth occurs in the first ten years after birth. It is often stated that 80% to 85% percent of ear growth occurs by age 6. This has been the reason that corrective otoplasty surgery has not been historically recommended to be done before that age…to avoid damaging the growing ear.

But as children enter school environments earlier then ever before, some parents are interested in having protruding ears corrected before six years of age. Since otoplasty surgery is not an excisional or destructive procedure, such intervention is deemed as safe and does not disturb subsequent ear growth. Some plastic surgery studies have shown that otoplasty can be safely performed as young as two years old.

Case Study: This 4 year-old male child was seen with a parental request to have ears corrected. He had large protruding ears with the complete absence of antihelical folds and large conchal bowls. The felt it would be best to correct his protruding ears now as opposed to waiting until he was older.

Under general anesthesia, he underwent an otoplasty correction using two different suture techniques. The antihelical folds were created using multiple horizontal mattress sutures of 4-0 monocryl. The concha was set back using a single 4-0 monocryl suture between the conchal cartilage and the mastoid fascia. Only a thin strip of skin was removed from the back of the ear for the incisional access.

Child Otoplasty result front viewChild Otoplasty result back viewHis otoplasty results shows a tremendous improvement in the shape of his ears in both the front and back views. He had no significant pain after surgery although his ears will remain sensitive for a few months after surgery. No ear growth problems would be expected to occur as the ear cartilage was simply folded and sutured. In young children it is best to use dissolveable sutures as opposed to permanent ones to avoid any risk of long-term suture reactions/extrusions.

Case Highlights:

1) Otoplasty is an effective procedure for reshaping the protruding ear.

2) Otoplasty can be done at a very early age using suture techniques without harming future ear growth.

3) Dissolveable or permanent sutures can be used in early age otoplasties.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Case Study – Webbed Neck Correction with Otoplasties

Sunday, March 8th, 2015

 

Webbed Neck in Turner's SyndromeBackground: The webbed neck deformity is a congenital skin fold disorder that runs along the sides of the neck to the shoulders. Known technically as the pterygium colli deformity, it is known to occur in a large number of medical conditions but the most common are the genetic conditions of Turner’s and Noonan syndrome as well as Klippel-Feil syndrome. At birth there are smaller loose folds of skin on the sides of the neck but with growth the webs expand outward ultimately making it look like there is little to no neck.

Surgical correction of the webbed neck deformity is a very different form of a neck lift. It is challenging because of the thickened fascia that comprises the band and a low hairline that extends down along the webs. The most common surgical techniques are the use of modified Z-plasties. A Z-plasty is placed with the midline arm down the length of the web. The subcutaneous fibrous band is excised, the shortened trapezius muscle is released, and the hair-bearingskin flap is cut out. The anterior skin flap is rotated and advanced to join its mirror image flap from the opposite side of the neck at the posterior midline. Any remaining skin dog-ears near the shoulder are corrected with additional small Z-plasties.

An alternative technique is a purely posterior neck approach using a Butterfly correction technique. In this method, a butterfly-shaped portion of redundant skin is excised posteriorly and the lateral, superior and inferior flaps joined in a double Y midline suture line or even that of an X pattern closure. The Butterfly technique avoids the unnatural hairline and noticeable scars characteristic of a lateral Z-plasty method but does so with often a less than complete correction of the webs.

Case Study: This 9 year-old female who had Turner’s syndrome had large neck webs that completely obscured any visible neck. They extended from behind her ears out to her shoulders She also had protruding ears due to a lack of antihelical folds.

Webbed Neck and Otoplasty Correction resultUnder general anesthesia she underwent an initial Butterfly correction technique for her webbed neck in the prone position. At the same time, otoplasties were performed through postauricular incisions using permanent horizontal mattress sutures to create antihelical folds. Four months later she underwent a second stage webbed neck correction where a large posterior Z-plasty was performed using the previous scars from her first procedure to gain further reduction in the webs and to relocate the low hairline.

She had substantial improvement in her webbed neck and ear deformities. There remained some slight medial neck bands but there were no visible scars. All scars were in the occipital hairline and on the posterior neck.

Case Highlights:

1) Webbed neck deormities are most commonly seen in congenital conditions such as Turner’s syndrome.

2) Traditional webbed neck surgeries use z-plasties along the sides of the neck which can result in visible scarring.

3) A two-stage approach to correction of the webbed neck results in no visible scars along the sides of the neck or shoulders.

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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