What is ear surgery (otoplasty)
Ear auricles are very complicated in terms of shapes and anatomy. They have the same effect for the general face appearance as eyes, nose or mouth. Their shape is variable; however we can observe regular structures in all people. In otoplasty we try to give these structures the most natural shapes. At the same time we adjust height, width and inclination. Most often we solve abnormalities from normal position of ear auricles, their size and shape. Shape abnormalities or deformities can be either genetically predisposed or gained (result of injury, previous operation, etc). The most often requested surgery is to set prominent ears back closer to the head with possible ear shaping or modification of size. We also deal with rarer abnormalities such as for example an auricle with smooth relief or twisted.
It is most often children from age 5 to 10 who undergo the otoplasty. The ears are fully grown by age four. It is recommended to undergo the surgery in earlier age as less teasing and ridicule the child will have to endure. There is no reason for adults not to carry the surgery. The nerve endings in the auricle develop, which explains a lower tolerance to pain in adults.
The surgical procedure can help also with disproportional large ear as a whole or just some parts (e.g. very large earlobe), with stretched auricles or auricles with large creases and wrinkles. Surgeons can even build new ears for those who were born without them or who lost them through injury. In these cases either own cartilage (e.g. costicartilage) or specially shaped artificial implants are used. Auricle reconstruction is a rather complicated surgery which is performed in stages. After otoplasty, like after other surgeries, permanent scars remain, however your surgeon will make the best to conceal them as much as possible. For example after bringing the ear closer to the head the little scar is hidden behind the ear auricle.
Insertion of muscle fibres behind the ear
Types of malformations
Bat ear: is the most often malformation of the pinna. Together with this abnormality we often find less visible moon-like half curve under the helical rim (smooth antihelix). Another associated defect which is solved in otoplasty of bat ears is Darwinian tubercle. It is a projection on the back side of the protruded ear which must be removed.
Microtia (small underdeveloped auricles): The therapy for microtia and anotia consists in subsequent operations to form the auricle from rib cartilage or other artificial structures. In case of these malformations it is necessary to find out if there is a developed auditory canal, middle and inner ear, i. e. auditory function.
Anotia (there are no auricles developed)
Post-traumatic ear malformations: It is solved like microtia and anotia.
In newborn babies the protruded ears are relatively normal; it adjusts in the infantile age. In old people the cartilage structure gets softer and ear creases flatten and widen.
If the patient is going to be operated under general anesthesia, a physician or pediatrician shall confirm the health condition within the comprehensive pre-operative examination. The surgeon shall be familiar with the general health condition of the patient and his/her family. A photograph of front, side and back view is made before the operation. Sometimes even the photograph of bird’s eye view and the detail of the deformed ear are made. The angle between the head and the posterior part of the auricle is measured. The physiologic value of the angle is between 20-45 degrees; smaller in women.
Generally, it may be said the size of auricle is corresponding to the length of nose (approx. 6-6,5 cm). The helical rim is in a line with the nasal root and the end of earlobe in one line with the nasal base. The shapes and sizes of auricles depend on the sex. For example women have a much more hollowed, conch-like ear shape which means the ear is smaller. In men the ear is flatter and thus more outstretched. The differences are also apparent in the shape of earlobes. The ear axis (from the top to the earlobe) should have the same inclination as the nasal edge; however the axis is often more vertical in the population. The auricle width should not exceed half of the ear length. The surgeons use the so-called ear index = 100 x width/length to judge the ear parameters.
The patient should not take drugs containing the acetylsalicylic acid (e.g. Acylcoffin, Acylpyrin, Alnagon, Aspro, Defebrin, Harburettas, Mironal) before the operation.
The process of ear surgery (otoplasty)
Depending on the surgeon’s and your preferences, he or she will use general anesthesia (mainly for younger children) or local anesthesia that is used most often. By the general anesthesia patients are requested not to drink, eat and smoke for about 6 hours before the surgery. In this case the patient usually stays overnight in the hospital.
In most cases ear surgery is performed under local anesthesia which numbs the auricle and its vicinity area. You will be awake during the surgery, but relaxed and insensitive to pain. This method is more often used in older children or adults.
Extension of removed skin
The process of otoplasty
Usual surgery (such as bringing the auricle closer to the head) takes in average around one hour. Although complicated procedures (such as deformities solution) may take much longer. By the most performed procedure, setting the auricles back to the head, the incision is made through the fold behind the ear. The final scar is very faint and hidden from normal look. First the fat excess from the back of the ear area is removed and than the cartilage of the auricle is prepared and separated. The surgeon marks the excess skin according to the skin fold which occurs when the auricle is put closer. If the wrong position of the ear auricles is connected with shape deformities, the cartilage must be shaped.
Cartilage incision technique: The incision in skin is almost identical in all ear surgeries. The excess skin marked before the operation is removed. The following process however differs. The surgeon removes part of the cartilage from the posterior part of the ear. The skin in the front is not damaged at all. The disadvantage is the loss of smooth auricle structure. The effort is made to perform the incisions in the cartilage as straight as possible. The ear may be slightly shaped by suture. The direction of stitches helps to extend or shorten the ear length.
Cartilage saving technique: The incision in cartilage is not necessary or is only on surface. The cartilage grinding is used to soften the cartilage structure which then shapes much better. The cartilage is modeled using sutures. The stitches are used in 3 basic places. One stitch fixes the ear in the upper third, then 3 U-shape stitches are used in the middle of the ear and another stitch in the lower third. Thus the soft cartilage should form a natural fold (antihelix). There are also alternatives of skin incisions behind the ear which are not made in the crease behind the ear but above and then in parallel on both the sides. They form a skin cover from which the skin is resected as needed at the end of the operation. The possibility to remove the skin after the adjustment of cartilage is an advantage of this approach. The better overview of the operation field for the surgeon is another one.
Unfortunately, as in all cosmetic surgeries the 100% satisfaction is never guaranteed and therefore re-operations are performed. They may be done from the same incisions but it is necessary to count with more complications. The effect of the surgery is permanent and if you are satisfied with your operation results, there is no danger of re-operation. The ear should not be re-operated before 6, or rather 12 months.
Even if only one ear appears to protrude, surgery is very often performed on both ears for a better balance.
Are you the best candidate for ear surgery - otoplasty?
Before the surgery
In the initial meeting, your surgeon will evaluate your child's condition, or yours if you are considering surgery for yourself, and he/she will recommend the most effective technique. He or she will also give you specific instructions on how to prepare for surgery. The most suitable time for the operation is the spring before school attendance starts. Even for adults the better season is spring or autumn; however the surgery may be performed anytime.
Discuss your goals and expectations with your surgeon. Your surgeon will explain you the process of the surgery, anesthesia that he or she will use and the risks and costs involved. Don't hesitate to ask your surgeon any questions you may have, especially those regarding your expectations and results. Most surgeons recommend that parents stay alert to their child's feelings about protruding ears. Don't insist on the surgery until your child wants the change. Children who feel uncomfortable about their ears and want the surgery are generally more cooperative during the process and happier with the outcome.
After your surgery
If the surgery is made under local anesthesia, the patient goes directly after the procedure home for home care. The surgery under general anesthesia requests usually to stay overnight in the hospital.
The patient's head will be wrapped in a bulky bandage immediately after the surgery. Sometimes also special elastic bandage is used.
The ears may ache a lot for a few days after the surgery (especially adults), this can be relieved by medication that your doctor will prescribe you. They are also often swollen. The swelling may appear only on one side. It should gradually disappear within two weeks. Within a few days, the bulky bandages will be replaced by a lighter head dressing similar to a headband or by already mentioned elastic bandage. Be sure to follow your surgeon's directions for wearing this dressing, especially at night. In the first week after the operation it is better to sleep on back.
If the non-absorbable stitches are used, they are removed mostly after ten to fourteen days. After the bandage removal any activity in which the ear might be bent should be avoided. Most adults can go back to work about one week after the surgery. Also children can go back to school after seven days or so, if they're freed from physical training. If you plan an appointment at hairdresser you are advised to make so before the surgery or 2 weeks after the scars are healed because the products used for colouring or perms may disturb the healing process. You shall survive without washing hairs for two weeks or you have it washed at the clinics during re-dressing. It is important not to take the bandage off on your own or soak it; it could cause an infection.
Children tolerate better the pain in the operated place and therefore the surgery is preferably performed in children. In adults the ear has a better nerve supply and the pain is worse. The pain is relieved by drugs. The risk of bleeding complication is higher in modeling operations than in surgeries reducing the ear protrusion, and also is higher in re-operations. Post-operative infections are less often than in other surgeries. Mostly, it has a local character in the area of the suture. If the infection is present in the cartilage the general treatment by antibiotics is necessary. More serious complications include the skin necrosis above the cartilage (it is more often in smokers with vasoconstriction). The surgeons encounter hypertrophic or keloid scars in the posterior part of the ear. This complications show as lumps behind ears. Nowadays, these complications are encountered less often because more non-irritating materials are used. The condition is treated by local application of corticoids followed by resection and skin grafted behind the ear. Not even this therapy guarantees the 100% result because the overgrowth of tissue in the scars may repeat. Sometimes post-operative deformities occur which are indicated for re-operations.
The ear surgery (protruded ears) is refunded by health insurance in children up to 10 years. It is generally performed at ENT departments. If you have a congenital auricle abnormality, your treatment is also refunded.
How long will the effect of ear surgery last?
Results of otoplasty are usually permanent. If you are realistic in your expectations, so you are looking for improvement not ideal, you will be pleased with your surgery results. Therefore discuss with your surgeon frankly the surgery possibilities and results that can be achieved by this operation.
This text has been created with kind assistance of Tomas Dolezal, M.D.