The London Centre for Ear Reconstruction
Aesthetic Surgery
- What is normal?
- Splintage with Ear Buddies™ splints
- Prominent (sticking out or bat) ears
- Large ears (Macrotia)
- Large ear lobes
- Ear piercing problems
- Ear position
- Other Ear Deformities
- Quick facts
What is normal?
Ear size, position and shape are important for facial harmony. The beauty of a face can certainly be enhanced by a perfect ear - small and neat and in the right position - a long way from the mouth, with the top of the ear level with the eyebrow and the bottom level with the base of the nose. The perfect ear also slopes backwards at the same angle as the nose.
In women, the average adult ear is 59mm tall and the average male ear 63mm tall. In boys, the ear length is 48mm at 6 months growing to 55mm at 5 years and 59mm at 10 years. The values are a little less for girls. The ear is thus almost fully-grown at 10 years and so can often look large in teenagers until the head reaches full size - we literally do grow into our ears. Thereafter, the ears remain much the same size until the age of 60 when they gradually enlarge, particularly the lower part of the ear and the lobes, and particularly in men. Large ears can run in families, but in certain people only one ear is too big, sometimes because the blood supply to one side is more plentiful, and so growth is greater on that side.
An individual’s ears are almost unique. The term “prominent” is normally used to mean ears which stick out, but the ears can also seem prominent because they are simply too large. Many sufferers develop mannerisms and hair styles to cover or compensate for their problem. Some won’t swim or go out in windy weather for fear that their ears will be revealed. Although surgery to pin back sticking-out ears is quite widely available, surgery to reduce the size of the ear is less commonplace.
A deformed ear may be apparent at birth or soon after, or may be acquired later in life through trauma, piercing, surgery or cancer, for example. In the first year or two of life, many ear deformities can be corrected by moulding using Ear Buddies™ splints, avoiding teasing and surgery later.
Splintage with Ear Buddies™ splints
The cartilage of the newborn ear is extremely soft and pliable, possibly due to the influence of mother’s oestrogen. If there is a normal amount of skin and cartilage, most abnormally shaped or prominent ears can be corrected by splintage with Ear Buddies™ splints if performed soon after birth. The technique will treat prominent ears, Stahl’s bars, lop ears, cryptotia and kinks of the rim. Some cup ears can be improved, but splintage will not help microtia.
It is several weeks before the ear cartilage begins to harden and ideally splintage should be started in the first few days of life. At this stage the cartilage is easily remoulded, the sweat and sebaceous glands are poorly developed so that the tapes which hold the splint in place stick well, and the child moves its head little, and does not reach up to the ears to dislodge or pick at the splints.
For prominent (stick-out) ears, rim kinks, Stahl’s bar, lop and cup ear, Ear Buddies™ splints are taped close to the rim of the ear and then the ear is taped back to the side of the head. The splint exerts pressure on the scaphal hollow of the ear, reforming, then emphasising the antihelical fold and the helical rim. Simply taping the ear back without the splint in situ does not effect a permanent improvement and distortion of the rim of the ear can develop later in life. To correct cryptotia, the ear should be pulled out from the side of the head, and the splint taped into position in the groove above and around the ear.
In the newborn, splintage for one to two weeks is all that is necessary, whereas in older children, the splints should be used for up to four months. Perseverance is required once the “golden” period is missed. Nevertheless, some persistent parents achieve a worthwhile correction in children as old as two years.
Early splintage may improve ear shape without the need for later surgery or anaesthetic. Splintage has the additional advantage of preventing pre-surgery teasing. It is not yet a widespread practice, despite a number of reports which show neonatal splintage of misshapen ears to be of benefit, cheap and safe. Nevertheless, it is clear that the future of treatment of such deformities lies in this direction.
Prominent (sticking out or bat) ears
The average adult ear protrudes 19mm from the side of the head. A third of ears which stick out in adulthood do not do so until the age of three months or more. Bat ears or prominent ears can be corrected at birth or soon after by moulding with Ear Buddies™ splints. After the age of 5, otoplasty or pinnaplasty can be performed under local or general anaesthetic. A suture technique is safest, minimising the risk of haematoma and infection associated with cartilage scoring techniques.
Large ears (Macrotia)
The ear splits itself into thirds vertically. The central third is known as the conchal hollow, the upper third is the scaphal hollow and the lower third is the lobe. Sometimes the ear is too large in all dimensions, and it is possible to reduce both the height and the width of the ear. If the upper third is out of balance, with a large, flat scaphal hollow, the ear can look top heavy, like an upturned pyramid. Other ears are too tall and thin, and if the lobe is too large, then the ear looks bottom heavy, or pear-shaped.
ear reduction pre-op
ear reduction post-opOccasionally one large ear becomes smaller, perhaps after an accident or because a tumour has been removed, for example, but after reconstructive surgery, it ends up looking the more attractive of the two, so the larger ear can be reduced in size to match.
In patients with neurofibromatosis, the ear is often enlarged and in the wrong place on the side of the head. Some lymph tissue growths can involve the ear and sometimes block the ear canal.
A number of techniques for reducing the size of the ear have been developed over recent years. Some of these work well, but at the risk of notching the rim of the ear.
The most successful technique uses an incision hidden in the folds of ear, usually just inside the rim. A crescent shaped piece of tissue is removed from the over-large area of the ear, exactly tailored to rebalance the relative sizes of the scaphal and conchal areas of the ear. Reductions of a centimetre in height are not uncommon. Large ears which also stick out too much from the side of the head should not be corrected in one go, because the cartilage of the ear can twist and deform. The goals are best achieved in two separate operations, the first to make the ears smaller and the second to set them back, separated by at least six months.
Large Ear Lobes
Reduction of the size of large ear lobes is a common request. Normal ear lobes do not contain cartilage, and it is possible to excise a simple skin wedge to make them significantly smaller. Normal sized ear lobes which stick out from the rest of the ear can also be addressed with this type of wedge-excision technique, and unlike the main part of the ear, the size and the position of the lobes can be corrected in one procedure. This is relatively minor surgery, taking about half an hour per lobe, so it would be unusual to use a general anaesthetic unless the patient was particularly apprehensive of local anaesthesia or unless the main part of the ear was being tackled at the same time - combined ear and lobe reductions are perfectly feasible. An over-large lobe is common in patients in whom a giant naevus involves the ear.
Combined lobe and ear reduction pre-op
Combined lobe and ear reduction post-opEar piercing problems
Piercing holes can elongate, particularly when heavy earrings are worn, and eventually the ear lobe splits. An unattractive piercing can be eliminated by incorporating the hole in the incision for an ear lobe reduction.
ear piercing repair pre-op
ear piercing repair immediately post-opPiercing of the upper ear can lead to infection and even ear loss, requiring reconstruction.
Ear position
Problems of ear position can also be remedied by surgery. The most attractive ears begin about one ear length behind the outer corner of the eye, and slope backwards in the same line as the nose. A change in this “angle” of the ear can confer unusual character - a very vertical ear appears abnormally formal, whereas one which slopes back too much can appear “drunk” or wayward. An ear which is too low or too close to the face can make its owner appear less intelligent. An injudicious face-lift can cause the ear to be pulled forwards and downwards, sometimes almost onto the cheek. This means that the scarring which can result is also brought into full view. Sometimes the ear lobes only are affected, either being pulled forwards, or made to stick out after a face-lift. All of these problems are correctable, but best avoided in the first place.
A procedure called auropexy can change the position of the ear in the same way as a mastopexy corrects drooping breasts. The misplaced ear is literally lifted back and re-sited in the correct position. For post face-lift patients, this has the additional benefit of improving the original lift.
Other Ear Deformities
Tags
Pre-auricular skin tags are very common. Sometimes the tags are of skin only, but usually the tag contains a long tail of cartilage extending into the cheek.
It is commonplace to ligate pre-auricular skin tags soon after birth. A new technique is to apply a Liga clip. This is quick and easy to do, requiring no anaesthetic, and a few days later the tag drops off.
pre-auricular tag
after Liga clip appliedTags with a substantial cartilage core are best treated by excision of the skin tag and cartilage spindle under general anaesthetic.
Mirror ear or polyotia
Rarely, persistent pre-auricular tissues are so large that they resemble an extra ear and the term polyotia is used. The “second” ear can appear as a mirror image folded forward and lying on the posterior cheek, and the term mirror ear is also applied.
mirror ear or polyotia
mirror ear or polyotia correctedPits and sinuses
Pre-auricular sinuses can be difficult to excise and may recur after treatment. Very occasionally the sinuses track deeply near to the facial nerve. They often occur on both sides and frequently cause no trouble. However, if recurrent infections occur which fail to settle with antibiotics, surgical excision is appropriate.
Abnormal folds (Stahl’s bar)
Abnormal folding of the ear is common. A Stahl’s bar or third crus is a frequent finding. In a small number of cases the upper pole of the ear flops over and here the term lop ear is used. In some ears, there is a kink of the ear (helical) rim or abnormal fusion of the ear (helical) rim to the antihelical fold. In some patients the whole ear appears collapsed vertically to give an ear of reduced height. A Stahl’s bar is easily and temporarily corrected by finger pressure but surgical correction can be difficult and this deformity is best corrected at birth with Ear Buddies™ splints.
If the golden period for splintage is missed, then a direct wedge excision of the Stahl’s bar [skin and cartilage] is the most reliable technique.
Collapsed ears
In a number of patients the ear helical rim is adequate but the scaphal hollow is folded backwards to rest on the conchal hollow. The height and shape of the ear can be improved by undoing the soft tissue tethering between the scaphal and conchal cartilages and splinting these structures apart with a cartilage graft from another part of the ear. Surgery can be avoided if the ear is splinted soon after birth with Ear Buddies™ splints.
‘Bumps’ and Clefts
A bump on the helical rim is a common finding, often referred to as a Darwin’s tubercle. Clefts of the ear and ear lobe occur when two or more of the hillocks which form the ear during development fail to join together normally.
Lop and Cup ear
Surgery for a lop ear can be avoided if the ear is splinted soon after birth with Ear Buddies™ splints. Moulding using Ear Buddies™ splints may improve a cup ear, but when the tissues are severely constricted, they must be surgically released.
Cup ears
In a cup ear the helical rim is constricted to give a prominent, cone-shaped ear. This is particularly difficult to correct. The constricted rim of a cup ear must be expanded in order to allow it to flatten. There are a number of techniques depending on the severity of the constriction. Sometimes, a formal ear reconstruction using a carved costal cartilage framework is advised.
Cup ear pre-op
Cup ear immediately post-opLop ears
To support a lop ear, sutures can be used to create a “U” shaped cartilage prop at the site of the missing upper antihelical fold, and the ear hitched to the mastoid fascia.
Lop ear
Lop ear correctedCryptotia (“the hidden ear”)
Sometimes only the lower two-thirds of an ear is visible and the groove above the ear seems lost. When the ear is gently pulled away from the side of the head, the upper pole cartilage becomes evident, having been hidden beneath scalp skin. The upper pole is excessively tethered and the lower pole is prominent. Moulding using Ear Buddies™ splints can correct cryptotia if started early enough. Surgical release is possible later in life.
Cryptotia pre-op
Cryptotia post-opFolded-over helical rim
If uncorrected by moulding using Ear Buddies™ splints at birth, a folded-over helical rim can be corrected by surgery later.
Folded over helical rim pre-op
Folded over helical rim post-opRim augmentation
The rim can be notched or deformed by taping a baby’s ear without first fitting an Ear Buddies™ splint at birth. The rim of the ear can be augmented using a dermis graft.
Rim augmentation pre-op
Rim augmentation post-opQuick facts
Ear reduction
| Length of surgery | 45 mins to 1 hour per ear |
| Anaesthetic | Local, twilight or general |
| Hospital stay | Out-Patient, Day Case or 1 night |
Recover |
Head bandage recommended for seven days (to prevent the ears being forwards by the pillow) A head band can be worn in its place for those unable to wear head bandage |
Risks of surgery |
Haematoma (bleeding and bruising) Keloid and hypertrophic scars Infection Necrosis (loss of tissue) Prolonged redness of scars Recurrence |
| All these complications can be minimised by sticking to pre and post-operative guidelines |
Ear Lobe reduction
| Length of surgery | 30 mins per ear |
| Anaesthetic | Usually local, but twilight or general if requested |
| Hospital stay | Usually Out-Patient, but Day Case or 1 night |
Recover |
|
Risks of surgery |
Haematoma (bleeding and bruising) Keloid and hypertrophic scars Infection Necrosis (loss of tissue) Prolonged redness of scars Recurrence |
All these complications can be minimised by sticking to pre and post-operative guidelines |
Relevant Publications
Books
Gault DT and Rothera M
Management of Congenital Deformities of the External and Middle Ear - a chapter for Scott Brown's Otorhinolaryngology, Head and Neck Surgery, 7th Edition Arnold
Academic Papers
Tan ST, Shibu MM and Gault DT. (1994)
A Splint for Correction of Congenital Ear Deformities
British Journal of Plastic Surgery 47 : 575 - 578.
Gault DT, Grippaudo FR & Tyler M. (1995)
Ear Reduction
British Journal of Plastic Surgery 48: 30 - 34
Gault DT. (1995)
Invited commentary on:
Congenital anomalies of the auricle: correction through external splints
European Journal of Plastic Surgery 18: 291 - 292.
Gault DT. (1995)
Can I Bend Your Ear?
You and Your Baby Magazine page 72.
Vogelin E, Grobbelaar AO, Chana JS & Gault DT. (1998)
Cauliflower Ears
British Journal of Plastic Surgery 51: 359-362
Horlock N, Grobbelaar AO & Gault DT. (1998)
5-year Series of Constricted (lop & cup) Ear Corrections: Development of the mastoid hitch as an adjunctive technique
Plastic and Reconstructive Surgery 102: 2325-2332.
Gault DT. (1998)
Ear Splintage
Face 5: 211-212
Horlock N, Misra A, Gault D.
The postauricular fascial flap as an adjunct to Mustarde and Furnas type otoplasty.
Plastic and Reconstructive Surgery 108: 6 1487 – 1490, 2001.
Gore S, Myers S, Gault D
Mirror ear: a reconstructive technique for substantial tragal anomalies or polyotia
Journal of Plastic, Reconstructive and Aesthetic Surgery 59, 499-504 2006
Beckett KS and Gault D
Operating in an eczematous surgical field; Don’t be rash, delay surgery to avoid infective complications
Accepted by the British Journal of Plastic Surgery 2006