Otoplasty

The usual complaint is that the ears stand away from the side of the head. That can be visible in a photograph, in a mirror from the front, or whenever the hair is worn up or short. The anatomy behind that appearance is not always the same.

When the concha is deep or rotated forward, it is the bowl of the ear that pushes the whole ear off the head. When the antihelical fold is under-formed, the outer rim does not bend back on itself and the upper and middle parts of the ear stay open. Many people have both. Treating only one of those elements leaves the other one still proud, which is why a single “pinning” manoeuvre is not a reliable description of the work.

The upper part of the ear often needs its own measures. That includes the way the cartilage is contoured towards the outer rim, so that the top of the ear sits closer to the head without producing a sharp fold or a telephone-ear shape — a tight middle with a lingering prominence above and below. The earlobe can add to the impression of prominence even when the cartilage above it has been set back, and the vertical height of the ear can be reduced when that dimension is part of the imbalance.

The target is not the smallest possible ear, and it is not a perfectly matched pair. It is an ear that sits in a quieter relationship with the side of the head and with the rest of the face.

The operation is for people whose concern is the position, the projection or, less often, the height of the ears, and who want a surgical change rather than a temporary camouflage with hair or with adhesive devices. It is suitable when the cartilage can be reduced and reshaped through the back of the ear, and when the skin of the ear will accept that new fold.

It is not a treatment for every dissatisfaction with the ear. Congenital absence or major underdevelopment of the ear is reconstructive work of a different order. Pointed or “elf” ear modification is not something we offer. A stretched or torn earlobe after jewellery is a different, smaller problem and should be planned as such. Asymmetry that comes from the way the two ears are set on the skull — they are not level, and they never are — will not be abolished by folding the cartilage.

We also need a realistic brief about symmetry. The two ears always have slightly different shapes and sizes. Perfect symmetry is not achievable. What is achievable, often, is a relatively good impression of symmetry, and that usually comes from a tailored correction on each side rather than from applying the same manoeuvre to both.

On the facial sculpting pages we return to the same idea: moderate, coordinated change usually reads better than a striking change in one place. The ears are part of that reading. They frame the width of the face. When they stand forward they can make the midface look narrower than it is, and they can pull attention away from the eyes and the jawline.

Otoplasty is often done on its own. It can also sit in the same sitting as other facial work — a rhinoplasty, a chin enhancement, or a rejuvenation procedure — when those changes are already planned and the anaesthetic choice allows it. Combining operations is a matter of the individual plan, not a package. Each element still has to earn its place.

The inverse is also true. Setting the ears back does not change a weak chin, a flat cheekbone or a heavy neck. If those are the features that bother the person in photographs, the ear operation will not carry the result on its own.

The consultation is an examination of both ears against the head and against the face, from the front, the side and the back. We look at the concha, the antihelical fold, the upper pole, the lobe and the height of the ear, and at how those parts differ from right to left. Photographs from those angles are part of the record. 3D capture of the face can help to see how the ears sit in the wider facial proportions; it is a planning tool, not a picture of the healed result, and it is less decisive here than it is for a chin or a cheekbone.

The plan is written side by side. One ear may need more reduction of the concha; the other may need more work on the rim. That difference is expected. It is also the reason a standard “degree of set-back” quoted in millimetres before the examination is not a useful brief.

The operation is carried out through an incision in the back of the ear. The scar sits in the groove between the ear and the side of the head, which is why it is not on show from the front or the side once it has settled.

Through that access, some of the skin that would become excessive when the ear is folded back is removed. Cartilage that pushes the ear forward is reduced. The remainder of the cartilage may also need to be reshaped to create the desired contours. That can require additional sutures, both to control the shape of the ear itself and to control its position against the head.

When the upper part of the ear is still proud after the central reduction, the cartilage towards the outer rim is contoured so that the fold continues into that zone rather than stopping short of it. The lobe is addressed if it would otherwise be left standing forward of the new position of the ear above it. Vertical reduction, when it is part of the plan, is built into the same sitting.

The wound is then closed and light dressings are applied over each ear.

The procedure is often carried out under local anaesthetic. That choice has a practical purpose as well as a comfort one: it allows the patient to sit up and examine the level of correction while the operation is still under way. It can also be carried out under sedation or general anaesthetic, in particular when it is combined with other interventions.

Isolated otoplasty is typically a day-case operation.

A consultation is the proper next step, not a posted price and not a decision taken from a single photograph. We need a medical history and a full list of medicines. Blood thinners raise the risk of bleeding and have to be managed around the operation. Raised blood pressure does the same. Both need to be known and planned for.

We also need to know about previous ear surgery, piercing through the cartilage, skin conditions of the ear, and any tendency to form thickened or stretched scars. Keloid and hypertrophic scars are uncommon behind the ear, but they matter more here than in many other facial sites because the skin of the ear can be unforgiving.

All surgery carries risk. For otoplasty the ones that need to be understood before the day, not after it, are these.

Bleeding and a collection of blood under the skin of the ear can distort the new shape and may need to be dealt with. Infection is uncommon but would threaten the cartilage. The correction can be incomplete, or it can be more than was wanted, or it can differ between the two sides. Some of the set-back can relax with time; that is one of the reasons we favour controlled reduction of the cartilage rather than relying only on sutures under tension. A suture used to hold shape can become palpable or work its way toward the skin and need to be removed. Numbness of the ear is common early on and usually settles; it can persist in a small area. The scar behind the ear is usually quiet, but any scar can thicken or stretch. Over-correction in the middle of the ear with residual prominence above and below is the telephone-ear contour we plan to avoid.

Perfect symmetry will not be the outcome. The honest aim is a quieter, more balanced relationship with the head, with a relatively good impression of symmetry from a tailored correction on each side.

Light dressings sit over each ear at the end of the operation. The first days are about keeping those dressings undisturbed, sleeping with some elevation, and avoiding anything that folds, knocks or pulls the ear — glasses that grip too tightly, earphones that sit inside the bowl, contact sports, and sleeping on the operated side.

Once the early dressings come off, we recommend a headband at night for the first two years after the surgery. That is a long period compared with many other facial operations. The purpose is protection of the new fold while the cartilage scar is still maturing, and protection against the ear being bent forward on a pillow. It is not a substitute for the surgical reduction; it is an adjunct to keep that reduction stable.

Most people are presentable for an office-facing role within one to two weeks, once bruising has faded and the dressings are no longer needed during the day. Exercise that risks a blow to the ear, and swimming, are left until the wounds are sound and we have agreed it. The shape continues to settle for several weeks; the scar behind the ear softens over a longer period.

Pain is usually modest and is managed with simple analgesia. A sharp increase in pain, sudden swelling of one ear, or discharge from the wound should be reported rather than waited out.

Fees are confirmed in writing once there is a plan — one ear or both, whether the upper pole or the lobe is included, whether vertical reduction is part of the work, the choice of anaesthetic, and whether anything else is being done in the same sitting. A figure offered before that plan exists is rarely a useful one.