The London Centre for Ear Reconstruction
Prominent ( stick-out ) Ears
Introduction
The overall frequency of prominent ears in North America (defined as those which stick out from the side of the head at an angle greater than 40 degrees) is 4.5% but many more people are concerned about smaller degrees of prominence. About two thirds (61%) of prominent ears are noticeable soon after birth. The remaining third become obvious around three months of age, as baby’s head shape changes and as the cartilage framework of the ear hardens during early life.
pre-splint
post-splintParents are often falsely reassured by Health Professionals that their child’s ears will look more normal with age, but this is rarely the case. An ear which is easily pushed forward when baby sleeps, feeds or turns its head is likely to become more prominent until, at least, the age of six months. The condition is not viewed as a deformity in all cultures; in some Eastern cultures, ears which stick out are thought to catch good luck.
pre-splint
post-splintEar Buddies
To avoid teasing and otoplasty in later years, splintage using Ear Buddies™ is now recognised as the treatment of choice for stick-out or deformed ears. Babies move their heads very little in the first few weeks of life, the skin hardly sweats and once the birth coating has been cleaned off, the tapes used to fix the splints in place usually stick for long enough - about two weeks - to ensure a good correction. Sticking back the ears with tape alone, without first splinting them, is unlikely to work and can cause notching of the rim to develop at a later date.
before
splint taped earEar Buddies™ are best used at birth, or as soon as the ears start to stick out. A third of prominent ears don’t begin to stick out until about three months of age but by then, splintage takes longer. Unsplinted, at least one in twenty people will have prominent ears by the age of 5. With persistence, splintage with Ear Buddies’ can still be effective up to the age of two years, but the process is much more difficult as the infant is by then able to reach up to the ears and potentially interfere with the splints.
Surgery (also called otoplasty or pinnaplasty)
If the opportunity to splint the ears is missed, surgery to set back ears is best delayed until after the age of 5 years. Prior to this, the cartilage is especially soft and efforts to reshape it may instead cause irregularity. There is no upper age limit for surgery. It is quite common for women to request set back of ears so that they can wear their hair up to marry, for example, or in the case of men, as they start to lose their hair.
Sometimes parents [quite understandably] request that their child’s prominent ears are corrected when the child [equally understandably] is reluctant to have the operation. It is safest in such a situation to put the wishes of the child first. Children who are teased are usually willing to have otoplasty. Sometimes the need to wear hair up in a ballet class, for example, will prompt a request for pinnaplasty surgery. It is essential before surgery to discuss the desired position of the ears. Some patients want only a gentle change whilst, for others, only ears which are flat to the side of the head are acceptable.
pre-op
post-opNo two prominent ears are the same. The commonest problem is an inadequate antihelical fold. This can cause the ear to protrude at right angles to the mastoid skin. In other ears the bowl of the ear (the conchal bowl) is excessively deep but the antihelical fold is normal. A grading scale for prominent ears has been put forward by Graham and Gault, which also includes factors such as elasticity and memory of the cartilage. Some ears will need additional attention to a protruding lobe or an isolated protrusion of the upper pole alone. Some ears are pinned back specifically so that a hearing aid can be worn, and in these, space must be left for the device - too tight a set-back should be avoided.
pre-op
post-opHistorically, a variety of otoplasty techniques have been used to attempt to remould the cartilage. Excision techniques to set back the ear are rarely used now, and so the main alternatives are cartilage scoring (in which the framework of the ear is scored to weaken it) and cartilage sparing (in which the curves and folds are reshaped using sutures (stitches) without damaging the cartilage). It is unwise to rely on skin excision alone to hold back the ear, since this may increase the risk of hypertrophic scarring.
pre-op
post-opThe safest technique for correction of prominent ears uses sutures (cartilage sparing). Although cartilage scoring surgery can be successful in most cases, complications are unpredictable. The cartilage can continue to bleed post-operatively, encouraging infection, and in a small but significant number of cases, the ear becomes severely deformed. Other complications of scoring surgery include tethering of the ear (telephone ear) and buckling of the rim. Total ear reconstruction is sometimes necessary because of extensive loss of ear tissue.
pre-op
post-opGault Technique (cartilage sparing with posterior fascial flap)
A suture technique alone can allow the ears to become prominent again if the stitches “cheesewire” through the cartilage, but a modification using a posterior fascial flap (known as the Gault technique) solves this problem.
Sutures inserted
Sutures tighteningA 2005 independent review of the three techniques concludes “cartilage sparing otoplasty refined with the posterior fascial flap results in significantly improved aesthetic and functional outcomes” (From Comparison of Cartilage Scoring and Cartilage Sparing Otoplasty - a Study of 203 Cases. Abstract , British Journal of Plastic Surgery (2005) 58, 127-144 Mandal, Bahia and Stewart).
pre-op
post-opOptions
Pinnaplasty can be performed under general, twilight or local anaesthesia. Local anaesthetic is especially good if you are very particular about how much the ears are pinned back, since you can sit up before the stitches are finally tied and look at the results. It avoids the very small but real risk of general anaesthesia and the recovery time is much shorter - you can decide to stay in hospital just for the day, or to have Out-Patient surgery, also called walk-in, walk-out surgery. The local anaesthetic option is also the cheapest; the hospital fee is less and there is no anaesthetist’s fee.
pre-op
post-opQuick Facts
Length of surgery:
Anaesthetic:
Hospital stay:
Recovery:
Risks of otoplasty:
45 mins to 1 hour per ear
Local, twilight or general
Out-Patient, Day Case or 1 night
A head bandage recommended for seven days (to prevent the ears being pushed forwards by the pillow) A head band can be worn in its place for those unable to wear a head bandage (available from Mr Gault’s office)
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
Ridings P, Gault DT and Khan L. (l994)
Reduction in post operative vomiting after surgical correction of prominent ears
British Journal of Anaesthesia - 72 : 592 - 593.
Tan ST and Gault DT. (1994)
When Do Ears Become Prominent?
British Journal of Plastic Surgery 47: 573 - 574.
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. (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.
Laing H and Gault DT. (1995)
Bat Ears - A European Perspective
Christmas Edition of the British Medical Journal 311: 1715.
Graham KE and Gault DT. (1997)
Endoscopic Assisted Otoplasty: a preliminary report
British Journal of Plastic Surgery 50: 47-55.
Graham KE and Gault DT. (1998)
Clinical Experience of Endoscopic Otoplasty (Letter)
Plastic and Reconstructive Surgery 102:2275.
Gault DT. (1998)
Ear Splintage
Face 5: 211-212.
Sylaidis P and Gault D.
Antihelical folding for pinnaplasty using one posterior cartilage score and horizontal mattress sutures.
Annals of Plastic Surgery Vol 45 (no 3) Sept 2000 341-342.
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.
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