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Background: The most common aesthetic ear surgery is a setback otoplasty. There are a wide variety of methods to pull back the protruding ear including suture techniques, cartilage removal and scoring and combinations of both. Regardless of the technique(s) used they are mainly applied to the conchal area in the middle third of the ear where the protrusion is often the greatest. When bringing back the ear how much setback is done is not an exact science. It is up the surgeon’s judgment as to what looks best although there are some basic aesthetic guidelines to follow.

The position of the ear on the side of the head does have some aesthetic norms. The relationship between the ear and the side of the head is defined as the auriculocephalic angle. This is usually in the 30 degree angle range. Since no on really takes such an angular measurement during the surgery, the most reliable and most easily observed aesthetic guideline is to appreciate that the ear when viewed from the front should look like a set of bleachers, meaning there should be three visible tiers. The conchal bowl, antihelical fold and the outer helical rim should all be visible in a step fashion. The one visible evidence of too much ear pullback is if the outer helical rim ends up hidden behind the antihelical fold.

While the immediate correction of an overdone setback otoplasty can be done by the release and removal of cartilage shaping sutures, this does not work well or at all once healing has occurred. This is particularly so when any amount of conchal cartilage resection has been done for the setback. While the ear can still be released, without any support holding it back out, it will quickly fall back to where it was.  

Case Study: This male had two prior otoplasties, an original overdone setback otoplasty and a second otoplasty that attempted to correct it. It was unclear what was done during the second otoplasty but no change occurred in the overcorrection and there was a new helical lidding deformity. 

His ear reshaping goals were an increased projection of the ears from the side of the head, elimination of the folded over helical rim and a shorter vertical ear length by earlobe reduction. 

Surgical correction consisted of an initial earlobe reduction by an inferior helical rim excision technique. Secondly a central postauricular release was done with the placement of interpositional tissue bank (cadaveric) rib grafts to hold the released ear out.

Lastly the folded over upper helical rim was repositioned by an elliptical excision of skin the back of the ear rather than excision of it. 

His immediate results showed adequate correction of the setback otoplasty and an overall better ear shape.

Case Highlights:

1) The most common otoplasty deformity is overcorrection, most evident in the middle third of the ear.

2) Successful treatment of an overcorrected otoplasty involves a combination of release and an interpositional material to prevent relapse. 

3) A postauricular approach, often through the same incision/scar from the original otoplasty, is done in the middle third of the ear where it is most constricted.

Dr. Barry Eppley

Indianapolis, Indiana

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