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Dr. Barry Eppley

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Posts Tagged ‘otoplasty’

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

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

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

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

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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