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Archive for the ‘otoplasty’ Category

Incisional vs. Excisional Skin Otoplasty

Sunday, February 15th, 2015


Correction of prominent ears is an aesthetic surgery that has been done for over a hundred years. The anatomy of an otoplasty is relatively simple as there is just skin and cartilage associated with much of the ear. A wide variety of cartilage changing techniques have been used in otoplasty and they all can have similar success if technically well performed. But the one constant in aesthetic ear reshaping surgery has been the excision of skin on the back of the ear.

Skin Excision in Otoplasty Dr Barry Eppley IndianapolisSince otoplasty was first described and during the early years of its development, it was believed that an elliptical removal of skin on the back of the ear was important. However,  such excision of the posterior auricular skin during otoplasty has been shown more recently to provide little if any benefit to keeping the ears ‘pinned back’. Rather the workload of an otoplasty is carried by the cartilage reshaping efforts since this tissue is far stiffer and resistant to deformation than the overlying skin.

In the February issue of the Journal of Plastic Reconstructive and Aesthetic Surgery, an article was published entitled ‘Otoplasty: The Case for Skin Incision by Higher Volume Operators’. In this clinical study, the association between skin excision on the back of the ear and recurrence of ear prominence in otoplasty surgery was evaluated in about 120 otoplasties performed over a two year period at one hospital. Recurrence of prominence at the first follow-up appointment (mean follow-up 3.4 months) was 10.2%. Plastic surgeons who performed low numbers of otoplasties had significantly higher recurrence rates than high volume surgeons. There was no statistically significant association between skin excision and recurrence of prominence. Thus the authors do not advocate any skin excision on the back of the ear during otoplasty surgery.

Incisional Otoplasty Indianapolis Dr Barry EppleyMost otoplasty surgeries today approach the cartilage manipulation from the backside of the ear. This traditionally involves a vertically oriented ellipse of skin which provides wide exposure of the cartilage on the back of the ear. Usually no actual ear cartilage is removed in most cases and the desired bend in the cartilage is achieved by suture placement. Over the years I have evolved to making only an incision or just a very narrow strip of vertical skin excision whose only purpose is to provide cartilage exposure.

Besides its negligible benefit to maintaining the new ear shape, keeping as much skin as possible on the back of the ear has numerous benefits. Adequate skin cover over the placed cartilage sutures can help prevent the risk of long-term knot visibility and/or extrusion/exposure. It can also help prevent a feeling of tightness on the back of  the ear. Lastly should ever a revision for overcorrection be needed, having a normal amount of skin can be helpful in its release.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Otoplasty with Earlobe Reduction

Saturday, October 18th, 2014


Background: Otoplasty, known as ear reshaping, is a commonly performed cosmetic procedure whose intent is to make the ears less conspicuous. An aesthetically pleasing ear is one which blends into the side of the head and has no feature that makes it an ‘eye catcher’. The best looking ear is really one that is not noticed.

Otoplasty for protruding ears Dr Barry Eppley IndianapolisThe typical cosmetic otoplasty involves the classic setback or ear pinning procedure. This cartilage reshaping technique creates a more pronounced antihelical fold, reduces the prominence of the inner concha or both. This moves the protruding ear back into a less conspicuous position by changing a portion of its shape.

The earlobe is the lone non-cartilaginous structure of the ear. It is often forgotten in otoplasty because it is not part of the cartilage framework. But it can have its own unique set of deformities that if overlooked can mar an otherwise good cartilage reshaping effort. Earlobes can become conspicuous because they stick out or are too long.

Case Study: This 20 year-old female was bothered by the appearance of her ears. As a result she never wore her hair pulled back to reveal them. Her ears showed a deformity consisting of a combination of the upper 1/3  of the ear which stuck out and her earlobes which were unusually long for her age.

Otoplasty with Earlobe Reduction result right side Dr Barry Eppley IndianapolisOtoplasty with Earlobe Reduction result left sideUnder general anesthesia she had an initial cartilage reshaping of the upper ear. Horizontal mattress sutures were placed to make the antihelical fold more prominent and pull back the upper helix through a postauricular incision. The earlobes were then reduced using a helical rim excision technique.

Her ear results showed a much better ear shape from top to bottom. The protruding upper ear was less obvious and the reduction in the vertical length of the earlobes made a huge difference. A shorter and more proportioned earlobe even made her ears look ‘younger’.

Case Highlights:

1) Numerous changes can be made to the ear during an otoplasty procedure besides just pinning the ears back.

2) It is common that repositioning of the protruding earlobe is also done with reshaping of the ear cartilage.

3) Reduction of the long earlobe is usually best done by a helical rim excision technique. It is most commonly done in older patients who may naturally have developed longer earlobes with aging or ear ring wear.

Dr. Barry Eppley

Indianapolis, Indiana

A Study in Incisionless Otoplasty

Saturday, September 13th, 2014


Otoplasty for Protruding Ears Indianapolis Dr Barry EppleyThe surgical correction of protruding ears has been successfully done for over a century. It has long been recognized that the problem in the ear that sticks out too far lies in its cartilage framework, either lacking an adequate antihelical fold or having a too prominent concha. A postauricular open approach with the placement of horizontal mattress sutures has been the backbone of otoplasty surgery almost since its first description. While originally described with a strip of skin excision on the back of the ear, it is now recognized that skin removal is not necessary for a good result.

While highly successful, otoplasty is an open procedure requiring extensive postauricular dissection. This results in swelling, discomfort and the possibility of incisional related problems. As a result, like in many other areas of surgery, less invasive approaches have been developed. Known as the ‘incisionless otoplasty’, a technique exists for performing the procedure without making an incision to do so.

In the July/August 2014 Online First issue of the JAMA Facial Plastic Surgery journal, an article was published entitled ‘Incisionless Otoplasty – A Reliable and Replicable Technique for the Correction of Prominauris’. This study evaluated the results of 72 patients (children and adults) who underwent corrected of prominent ears by a single surgeon over a seven year period with an average follow-up of over two and a half years. Ears averaged a total of 2 to 3 sutures per ear. No infections occurred. Complications were seen in ten patients (14%) and included suture failure, suture exposure, and granuloma formation. Nine patients (13%) needed a revision to obtain an optimal aesthetic result. The authors conclude that incisionless otoplasty was well tolerated and effective with minimal complications.

Incisionless Otoplasty technique Dr Barry EppleyThe incisionless otoplasty differs from a traditional otpplasty in several ways. The technique requires good lidocaine and epinephrine solution infiltration. One basic principle of the procedure is to break the spring of the cartilage along the length of the antihelical fold using a needle. The needle acts like a small knife slicing through the anterior surface of the cartilage structurally weakening it. This is a little bit like what is done in liposuction, creating criss-crossing tunnels. Sutures are placed in a percutaneous fashion in a horizontal mattress fashion to create the desired cartilage bend. This requires that the needle re-enter the skin through exactly the same puncture site and needle tract as it exited. The horizontal mattress pattern of the suture is created by using the curve of the needle. When tied down, the knots remain on the outside of the skin on the back of the ear and become buried by pulling them through the needle hole with a skin hook.

The incisionless technique definitely has a role in otoplasty surgery. But it does require good patient selection as not every protruding ear patient’s anatomic problem lies exclusively with the antihelical fold. Despite not having an incision, it is not complication free as this paper demonstrates. If you had up the complications and the number of revisions, it has a postoperative problem rate of around 20%. This number is certainly no better than that of traditional open otoplasty surgery. But no doubt when it provides the desired aesthetic result and has no after surgery complication or need for revision, it is an improvement over an open method.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies In Plastic Surgery – Laser Assisted Otoplasty

Sunday, July 27th, 2014


Mustarde Sutures in OtoplastyThe correction of prominent ears by standard otoplasty techniques has been around for decades. Using horizontal sutures of various materials, known as Mustarde sutures, the antihelix is created or made more prominent to pull the helix of the ear back into a more asesthetically acceptable position. While there are other aspects of the ear (concha, earlobe and skin on the back of the ear) that may need simultaneous reshaping, the placement of sutures into the cartilages to reshape it is the foundational maneuver in otoplasty surgery.

otoplasty markingsWhere to place these horizontal mattress sutures in the ear cartilage is the hardest part of the procedure. Accurate suture placement is key to getting the right ear cartilage shape. The traditional technique is to mark the ear prior to making the postauricular incision by using a needle and dye in a percutaneous fashion at the exact points that the sutures should bite into the cartilage. This is usually done using twelve cartilages marks so that three horizontal mattress sutures could be placed.

Laser Assisted Otoplasty Dr Barry Eppley IndianapolisSome plastic surgeons, including myself, do not mark the cartilage prior but instead use a free hand technique. In this method it is estimated where the sutures should be placed once the skin on the back of ear has been removed and the cartilages exposed. This is a trial method of suture placement which often can takes multiple tries to get all the sutures in the right place for the desired ear shape. It is effective but can sometimes be tedious to get just the right placement.

Laser Pointer in Otoplasty Dr Barry Eppley IndianapolisA non-needle method to use for marking where the sutures should be placed can be done using a laser pointer. With the ear cartilage exposed and folded forward, a laser pointer is used to point to the correct skin position. This can be done by someone holding the small hand-held laser device pointer and be told where it should be pointed or can be done with the surgeon holding it themselves in a sterile glove or wrapping. The penetrating beam of the laser pointer can be seen on the exposed cartilage on the opposite side from where it entered the skin. Hence, the term ‘laser-assisted otoplasty’. It serves the same purpose as the needle and dye but without piercing the skin with a needle.

Dr. Barry Eppley

Indianapolis, Indiana

Management of the Earlobe in Otoplasty

Wednesday, March 12th, 2014


Otoplasty is a common and extremely effective procedure for treating ears that stick out too far. (protruding ears) It is one of the most satisfying of all the facial plastic surgery procedures. It achieves its effects by reshaping the ear cartilage to give it a better shape through the creation of an antihelical fold or/reduction of an overly large concha.

Earlobes in Otoplasty Dr Barry EppleyBut ears that stick out often include the entire ear along its vertical length down to the bottom of the ear lobule. But the earlobe is the one area of the ear that has no cartilage and is really not changed significantly by ear cartilage reshaping maneuvers. In some protruding ear patients, the earlobe sticks out just as much as the larger cartilage containing portion of the ear. A separate procedure is needed directly on the earlobe if it is to lie back against the side of the head after the otoplasty is done.

In the January/February 2014 issue of JAMA Facial Plastic Surgery a paper was published entitled ‘Correcting the Lobule in Otoplasty using the Fillet Technique’. In this report human cadaver studies were performed for anatomical analysis of lobule deformities and an algorithmic approach to correction of the lobule in twelve consecutive patients using a fillet technique. The three  major anatomic components of earlobe deformities are the axial angular protrusion, the coronal angular protrusion, and the inherent shape. The fillet technique described in this paper addressed all three aspects in an effective way. The earlobe fillet technique is an efficient method to correct protruded ear lobules in otoplasty. It allows precise and predictable positioning of the earlobe.

Otoplasty Ear Pinning Dr Barry Eppley IndianapolisThe lack of any cartilage in the earlobe makes its repositioning in otoplasty, if needed, a separate ear maneuver. This has been known for decades and previous techniques to do it have been described. I have performed fishtail shaped excisions of skin on the back of earlobe to turn it back in when it sticks out too far in certain otoplasties. The upper end of the fishtail excision usually begins at the lower end of the otoplasty incision closure. The lower end of the fishtail pattern is near the bottom of the earlobe. The size of the fishtail  determines how much the earlobe is pulled inward.

The fillet technique described in this paper is conceptually similar to that of the fishtail technique that I have used for some time. It can also be done separately later under local anesthesia in those otoplasties where the protruding earlobe was not treated initially.

Dr. Barry Eppley

Indianapolis, Indiana

Ear Reduction Surgery for Macrotia

Tuesday, February 18th, 2014


The most common aesthetic ear problem is that of the protruding ears. Caused by either the lack of a well defined ear fold or too big of an inner concha, a good ear shape can be obtained by a variety of traditional otoplasty techniques. While the protruding ear often appears to be too big, it only appears so because they stick out too far from the side of the head. Once brought back into a more pleasing relationship to the side of the head, the once protruding ear now appears normal in size.

Ear Height Measurements Dr Barry Eppley IndianapolisBut there are ears that are occasionally too big or oversized known as macrotia. In essence they are disproportionately large in height compared to the size of the head. Anthropometric measurements have shown that the normal vertical length of the ears are around 60mms in women (58 to 62mms) and somewhat larger in men, averaging closer to 65mm. (range of 62 to 66ms) The height of the ear has also been historically stated to be equal to the length of the nose although this is a far less reliable measure of an acceptable size. Ultimately, however, what appears is whether the patient thinks their ears are too big or not.

Just like for the protruding ear, there is an otoplasty surgery to make big ears smaller. (less tall) Unlike protruding ear surgery, however, skin and cartilage must be removed to reduce its vertical height. While one method is to take out a large central wedge from the middle of the ear, this produces more of a visible scar that crosses two two ear ridges as it goes from the concha to the outer helix. This is more of an ear reconstruction technique commonly used in skin cancer.

Vertical Ear Reduction Technique (Scapha Reduction) Dr Barry Eppley IndianapolisA more aesthetic ear reduction technique for macrotia is the ‘high’ and ‘low’ method. Taking some tissue from the top and the bottom of the ear creates a noticeable height reduction while placing scars in more inconspicuous locations. This ear reduction surgery is done by a ‘high’ excision by the taking of a crescent-shaped segment of skin and cartilage from the scapha fossa. Depending upon how much height needs to be reduced, this may or may not cross the helical rim at its lower end. The ‘low’ excision involves a helical rim wedge excision along the bottom part of the ear lobule. As much as 10 to 12mms of ear height can be reduced with this ear reduction method.

Unlike setback otoplasty, ear reduction otoplasty surgery actually involves less recovery and swelling of the ear as the actual extent of surface area of the ear traumatized is less.

Dr. Barry Eppley

Dr. Cris Ueno

Indianapolis, Indiana

Case Study: Vertical Ear Reduction (Macrotia Surgery)

Tuesday, February 11th, 2014


Background: Otoplasty is a common aesthetic surgery for ear reshaping which very successfully corrects a protruding ear problem. From incisions behind the ear,  a cartilage fold is created by sutures that pulls the helical rim backward reducing its outer prominence and lessening the aurioculomastoid angle. While ears that stick out often look big, they usually only appear that way due to their protrusion.

While protruding ears are very common, a truly large ear or macrotia is very rare. Macrotia would be defined by an ear height that exceeds the normative height of which numerous studies show a mean height of around 60 to 63mms from the apex of the superior helix down to the inferior extension of the lobule. These same studies show that the lobule comprises under 2 cms or less than 1/3 of the total ear height. Morphometric measurements aside, there is also the patient’s perception of whether they think their ear is too long regardless of the actual measurement.

Macrotia reduction surgery is quite different than a traditional setback otoplasty. True vertical ear reduction requires a shortening or removal of skin and cartilage to create that effect. While there are many wedge resection techniques that will create substantial vertical reduction, which are borrowed from skin cancer resection and ear reconstruction technique, they result in a substantial risk of a prominent scar across the central aspect of the ear. While staggering the incisions across the concave and convex surfaces of the ear can help with the scarring substantially, it is still a high risk manuever in the aesthetic ear patient.

Case Study: This 25 year-old young male wanted to decrease the size of his ears. He felt they were too long and disproportionate to the rest of his face. The vertical length of his  ears were 71mms. Most of the excessive ear height was in the upper 1/3 of the ear with a large scaphal fossa.

Vertical Ear Reduction Technique (Scapha Reduction) Dr Barry Eppley IndianapolisUnder a field block of local anesthesia at the base of the ear and then directly into the ear, a  bidirectional reduction approach was done. A 5mm helical rim reduction was done on the lobule. Then a 7mm resection of skin and cartilage was done of the scapha fossa, placing the closure just inside the helical rim. To get the reduction, a transverse full thickness incision was needed across the helical rim so that the top of the ear would rotate downward. Dissolveable sutures were used throughout all incisions.

Vertical Ear Reduction Dr Barry Eppley IndianapolisThis superior and inferior vertical reduction reduced the ear height down to 60mms. (reduction of 11mms). The scarring was very minmal and the only long-tern concern with healing would be a potential small notch deformity at the helical rim. This could be created by a small scar revision if necessary.

Vertical ear reduction (macrotia reduction) can be successfully done with judicious excisional locations and meticulous surgical technique. Macrotia surgery can be done under local anesthesia with no real recovery other than some ear swelling and mild ear discomfort.

Case Highlights:

1) The large ear, known as macrotia, is most commonly one of increased vertical height.

2) In macrotia reduction surgery, the goal is to place scars at inconspicuous locations as possible. The central wedge reduction method usually results in prominent scarring.

3) Superior scaphal and inferior helical rim reductions can create up to a cm. of vertical height ear shortening with very acceptable scarring.

Dr. Barry Eppley

Indianapolis, Indiana

Preventing Suture Extrusion In Otoplasty Ear Reshaping

Monday, January 20th, 2014


The most common congenital ear deformity treated is that of protruding ears. It is very successfully treated by an ear reshaping surgery known as otoplasty. Often referred to an pinning the ears back, it is a procedure that has been around for over 100 years. While originally described as the simple removal of skin on the back of the ear to fold it back, the real success of the procedure is based on the folding of the cartilage and the holding of its new shape with sutures.

Otoplasty Sutures Dr Barry Eppley IndianapolisWhile highly successful, one of the common complications of an otoplasty is suture extrusion. This occurs because the knots of the sutures used to fold the cartilage are right under the incisional closure on the back of the ear. Since most plastic surgeons use a permanent suture for long-term retention, the knot has a lifetime to work its way through the skin. Thus, suture extrusion can occur months to years after the surgery. While not usually causing a major problem, it can cause both irritation or even local infection.

In the January 2014 issue of Aesthetic Plastic Surgery, an article was published entitled ‘New Otoplasty Approach: ‘A Laterally Based Postauricular Dermal Flap as an Addition to Mustarde and Furnas to Prevent Suture Extrusion and Recurrence’. In this paper a technique to prevent suture extrusion is described using a dermal flap to cover the cartilage sutures and their knots when the skin is closed on the back of the ear. Rather than just cutting out a traditional ellipse of skin on the back of the ear, the anterior skin flap is de-epithelialized and preserved. It is then used to cover the sutures as it is sewn down to the postauricular fascia or the underside of the medial skin flap. This otoplasty technique modification was in 17 consecutive otoplasty patients. After a follow-up period of 6 to 36 months (mean follow-up of 16 months), the patients were evaluated for ear shape recurrence and/or suture line problems.  None were observed which substantiates their conclusion that the posterior auricular dermal flap both prevents suture extrusion and decreases recurrent ear shape deformities.

Indianapolis Otoplasty Dr Barry EppleyThis postauricular de-epithelialized flap in otoplasty is one I have used for years. After having had a few otoplasty suture extrusions early in my practice, I quickly sought a method to provide thicker soft tissue coverage over the suture knots on the back of the ear. Since the utility of the soft tissue excision has long been proven to be an irrevelant part of what holds the ear back in its new position, it seemed a waste to merely throw it away. Doing so leaves just a thin layer of skin over the sutures. This is a simple and effective method to ‘thicken’ the postauricular  incisional line closure.

Dr. Barry Eppley

Indianapolis, Indiana

Ear Pointing and Ear Elf Surgery

Sunday, January 5th, 2014


It is not rare that a patient will request to see if some face or body feature they have can be changed to look more like that possessed by a certain celebrity. Whether it be a nose, jawline, breasts or buttocks, the shape of the famous has always motivated others to seek the same. But in almost all these cases, the desire has been to achieve known shape and proportions of body features that are variations along anatomical features that can naturally occur.

Ear Pointing Dr Barry Eppley IndianapolisBut unusual face and body changes do get requested and occasionally done. One such example is the procedure known as ear pointing or elf ear surgery. The description alone tells you exactly what is being done. The desire for this procedure undoubtably has its history in Star Trek and the character Spock. But the more recent movie series of Lord of the Rings and the Hobbit movies puts only display a much larger number of characters with different ear shapes, almost all of them with ear points of various elongations.

Ear Elf Surgery Dr Barry Eppley IndianapolisThis has driven a few fans and devotees of the films to actually having their ears reshaped. One such fan who is a young model who recently underwent the procedure and chronicled her experience in an online video on YouTube which can be found under Elf Ear surgery. While many would understandably question the motivation for such an unusual ear modification, that decision and explanation is best left for the patient to answer. What is more anatomically relevant is can it really be done and, if so, how?

Ear Anatomy Dr Barry Eppley IndianapolisThe normal ear is formed by islands of cartilage (six to be exact) that come together to form a complex series of raised ridges and valleys. One of these prominent cartilage ridges is the one that rings around the upper two-thirds of the ear known as the outer helix. It essentially goes a long way in creating the recognizable ear shape of humans. The top of the outer helix forms an upper semicircle that surrounds the upper 1/3 of the ear. Inside the outer helix is the antihelix which represents a folding of the conchal cartilage and has a similar prominence to the outer helix. This is what is created in the classic ear pinning surgery for prominent ears. As the antihelical fold comes into the top of the ear it branches about two-thirds of the way along its course to form the broad fold of the superior (posterior) antihelical crus and the more sharply folded inferior (anterior) crus. Between the superior and inferior crus is the indentation known as the triangular fossa.

Ear pointing is done by taking a small wedge of skin and cartilage from the upper ear. This is like removing a slice of pie that contains the outer helix and potentially some portion of the superior crus. This triangular excision needs to be done closer to the junction of the upper and ascending outer helix so that when it is sutured together it creates a well defined point. In elf ear surgery, a much larger wedge of ear tissue is removed that effectively removes most of the superior and inferior crus so that the approximation effectively flattens the upper outer helix.

Like all ear reconstruction and reshaping surgery, it requires an understanding of how to manipulate the natural ear cartilages to obtain the desired shape. Ear pointing and ear elf surgery illustrate this point to the extreme.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery’s Did You Know? Anatomy of the Protruding Ear

Saturday, August 31st, 2013


The ears on the side of the head are relatively inconspicuous unless they stick out too far. A good looking ear is one that goes unnoticed, only bad looking ears catch our attention. But despite the small size of the ear, it has a compact anatomy that is filled with ridges and valleys. By description they comprise a dozen specific parts that collectively form what is recognized as a normal ear. When the ear sticks out too far, its most common cosmetic deformity, it is the result of a fold deformity (lack of the fold) of the antihelix or excessive development of the underlying concha. (the bowl of the ear) In some protruding ears it is a combination of both. Surgical correction involves making the antihelix fold by placing sutures on the backside of the ear to bring the outer helical rim closer to the side of the head. For the overgrown or too big concha, it may be pulled back by sutures to the mastoid bone or weakened by cartilage removal and then sutured back. Either cosmetic otoplasty is about ear reshaping by folding and bending.

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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