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Dr. Barry Eppley

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Posts Tagged ‘ear reshaping’

Early Otoplasty in Children

Wednesday, October 7th, 2015


Otoplasty or pinning back of the ears is the most frequently done ear reshaping procedure. It can be done throughout life in a wide range of ages. It is most commonly done in children and teenagers where protruding ears can be a very sensitive issue in their early psychosocial. While once done in children because they were being teased or for fear of being teased, the contemporary reason is that because they are being bullied.

Being made fun of or being bullied because of prominent ears is not all that rare. While the ears may sit on the side of the head and to the side of the face, they only become conspicuous when they are abnormal. While there are measurements and angles for when the ear is most aesthetically pleasing, all that matters is when the person thinks they stick out too far. Almost always when the child or teenager thinks their ears stick out too far, the parents do also.

Early Otoplasty in Children Dr Barry Eppley IndianapolisThe age at which an otoplasty can and should be performed can be somewhat controversial. The first consideration in children is whether it will affect subsequent ear growth. Since the ear has had considerable growth by age 6 this has led to the historic recommendation that otoplasty should be done no earlier than this age. While it seems to be biologically sound that performing surgery on an ear that is largely grown is the most safe, studies have shown that it can be done much earlier without adverse effects on ear development. Otoplasty can be performed as early as age 2 without affecting ear growth. It would be prudent when doing it at this early age to resect no skin or cartilage and only use sutures for cartilage shaping.

The trickier question is a psychological one. When is it appropriate to do surgery because of an external behavior like bullying? Does the child really understand the surgery and can they cope with the process and the recovery? While these are good questions, the reality is that is one between the parents and the child. I have yet to see a child who was brought in because the parents wanted it done and the child was opposed to it. While they may not understand the actual surgery or what the recovery may be, they do understand that their ears stick out and they want it fixed.

While some may argue that having otoplasty surgery almost promotes bullying behavior, I think we all know that it is far more productive to change the physical source of the bullying than to try and change the bully. Fortunately otoplasty surgery is very safe and has few complications such as infection or ear deformity. Having performed over 100 otoplasties I have yet to see either.

Dr. Barry Eppley

Indianapolis, Indiana

The Aesthetic Role of the Antihelix in Otoplasty

Monday, March 23rd, 2015


The Antihelix in Otoplasty Dr Barry Eppley IndianapolisOtoplasty is the most common ear reshaping surgery which primarily treats the prominent or protruding ear. Treatment of the ear that sticks out has been done since Ancient India and a wide variety of techniques have been done for it. But regardless of the otoplasty technique it has been historically taught that the helix, and not the antihelix, should be seen from the front view. If the helix is pulled behind the antihelix then the otoplasty result is deemed to be overcorrected.

In the March 2015 issue of the Annals of Plastic Surgery in the Published Ahead Of Print section, a paper appeared entitled ‘The Prominent Antihelix and Helix-The Myth of the ‘Overcorrected’ Ear in Otoplasty?’  In this paper the authors set out to define the role of the antihelix in normal ears and how it is perceived from an aesthetic standpoint. Pictures of ears were used and judged to choose their favorite and their least favorite ears based on their aesthetic appeal. The two most popular ear shapes were compared. Interestingly the aesthetically preferred ear had a prominent anihelix…contradicting what is taught in otoplasty surgery. The authors also found that a prominent antihelix was common in the general population and is really normal and not abnormal. Also interesting was that the helix of the ear chosen as the most aesthetic was the one where it almost touched the side of the head.

Antihelical Fold otoplasty Dr Barry Eppley IndianapolisWhile it is still never a good idea to have the helix pulled back too far in otoplasty surgery, a prominent antihelix is not necessarily a negative ear attribute. Ultimately it is up to the patient to judge their own ear aesthetics and whether it is overcorrected should this concern arise. An interesting aside of this study was that the authors noted that most people do not know their own shape as they were unable to recognize their own ears in pictures.

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

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

Age of Effectiveness for Neonatal Ear Molding

Saturday, March 15th, 2014


Ear deformities are not rare in newborns and there are many variations of them. Given the complexity of how the ear forms from six separate cartilage islands in utero, it is no surprise that there are going to be birth defects associated in their shape. It is well known that some neonatal ear forms can be reshaped by early modeling of the ear cartilage. The question is how early does neonatal ear reshaping need to be started to be most effective.

Ear Buddies Dr Barry Eppley IndianapolisIn the January 2012 issue of the Journal of Plastic, Reconstructive and Aesthetic Surgery, a paper was published entitled ‘A Prospective Study on Non-Surgical Correction of Protruding Ears: The importance of Early Treatment’. In this paper, a study of 209 ears in 132 babies was done using a splint in the scaphal hollow in combination with tape (Earbuddies). Treatment continued until the desired shape was obtained visually. Roughly 20% of the ears treated (27 patients) had to stop treatment due to skin irritation or device fixation problems. In those that completed treatment, results were judged as good in 1/3 fair in 1/3,  and poor in 1/3. The effectiveness of ear splinting decreased with the age of initiation with mainly poor results after six weeks of age. Older children needed to be splinted longer.

It is not uncommon to get contacted by a mother sometime in the first month or two after birth about their infant’s ear deformity. They want to know if it is too late to start ear molding therapy. While it is known that the ear cartilage becomes stiffer quickly as the infant grows, it has never been specifically determined at what age is too late to begin treatment. This study shows that when considering device molding therapy for misshapen ears, a reasonable chance of success can only be offered to parents of children up to six weeks of age.

Even when beginning ear molding at the right time, a certain percentage (about one-fifth) of patients will not be able to have a successful result due to problems with tape irritation and instability of the device. But for those infants that complete the therapy successfully, they have a significant chance of avoiding the need for otoplasty surgery later in life.

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

Case Study: A Mini-Otoplasty for Minor Ear Reshaping

Saturday, December 7th, 2013


Background: The shape of the ears is primarily influenced by the cartilage between the front and the back skin that surrounds it. In a normal ear, there are classic bends in the cartilage that create well described hills and valleys. It is these cartilage bends that give the ear its recognizeable convoluted shape.

Ear Cartilage Dr Barry Eppley IndianapolisThe prominences of the outer helix and its paralleling companion that sits just inside it (antihelix) are the cartilaginous portions that primarily influence the protrusion of the ear.  The antihelical cartilage fold controls the position of the outer helix which determines the visual impression of whether the ear sticks out or is normally shaped and more obscure.

Otoplasty or ear reshaping surgery creates bends in the ear cartilage to treat protruding or ‘dumbo’ ears. Through an incision on the back of the ear, sutures are placed so as to bend the helix backward and either make an absent antihelical fold or make it more pronounced. This simple and relatively quick procedure is well known to create an instantaneous effect for those afflicted with ears that stickout.

Case Study: This 45 year-old female was bothered by the shape of ears. She felt the upper portion of her ears stuck out and would not wear her hair back which would reveal her ears. Even when she worked out she kept her hair down to keep the ears covered.

Mini Otoplasty result Dr Barry Eppley IndianapolisIn the office, the back part of the upper ears were injected with local anesthetic. Through a one inch incision, two horizontal mattress sutures of a permanent material were placed to fold the upper ear back closer to her head. Dissolveable sutures were used to close the incisions. No dressings were used afterwards. Total operative time was 15 minutes per each ear.

This limited ear reshaping procedure, the mini-otoplasty, can help reshape minor ear deformities. It is particularly effective in the upper ear which sticks out just a little too far. It is simple and quick to perform and has no real recovery.

Case Highlights:

1) Surgical reshaping of prominent ears is done by the placement of sutures to fold the protruding ear cartilage backward.

2) Some ears that stick out have only smaller portions of the upper ear cartilage that are not well shaped and only a few sutures with a small incision can provide a quick solution to the ear shape concern.

3) The ‘mini-otoplasty’ is a minor ear reshaping procedure done under local anesthesia in an office setting.

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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