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The protruding ears are the congenital deformity and can be hereditary or unhereditary conditioned. Sometimes parents accuse themselves because of the child’s protruding ears because they allegedly were overlapped during the sleep so they were putting various types of plasters in the attempt to get the ears closer to the head. Of course, such attempts always end unsuccessfully because the protruding ears are the congenital deformity and can not become neither worse nor better by positioning a little child’s ears during the sleep. It is considered that 90% of the growth and development of the ear is completed in the first 6 years of life, and the remaining 10% of the ear growth happens in the later period of life. Therefore, the protruding ears correction or otoplasty can be done at 6 years of life. In older people often the disproportionately large ears can be noticed that have arisen during the process of aging (weakening and lengthening of the ear cartilage, loss of the earlobe skin elasticity). The best period for the correction of the protruding ears is the preschool age (between 6 and 7 years of life), because in that age a child is not yet subjected to teasing from peers at school and can not develop lasting psychological trauma, or the inferiority complex. In our population, adolescents and young adults are most often subjected to the aesthetic correction of the protruding ears. The causes of otapostasis may be multiple. The normal value of the angle between the head and the ear (the auriculomastoid angle) varies from 10 to 25 degrees. Otapostasis may occur due to the less developed or completely undeveloped inner fold of the ear (the antehelix). The second possible reason is the “dangling appearance” of the earlobes, and the most common cause is the too high posterior wall of the concha of the auricle. Besides the most common deformities of the ears, there are several congenital ear anomalies which are necessary to be specified.

Small or wrinkled ear (microtia) – the hearing is normal or reduced, or there is the complete deafness; the external ear canal can be normally developed or fully undeveloped. Microtia may manifest differently, where a slightly expressed microtia is much easier to be corrected surgically. The extreme cases of microtia (the extremely small part of the ear is developed) represent a big surgical problem and often the results are not satisfactory.

Cup ear defomity – small ears with completely undeveloped inner fold; the auriculomastoid angle is about 60-90 degrees, and the appearance is associated to the cup. Such ears can be very successfully corrected with the standard ear correction which includes several additional surgical maneuvers.

Lop ear defomity – normally big ears where the upper pole of the ear is overlapped over the lower parts of the ear. The surgery successfully corrects this natural deformity, and the aesthetic results are excellent and permanent.

Otoplasty is done under general anesthesia for the children from 6 to 12 years, and under local anesthesia for the rest of the population of patients. The elastic bandage has to be worn over the forehead and ears for the first 2-3 postoperative days. The patients must wear the ear brace during the night in the next month so as not to ruin the result achieved during the sleep.

Procedure

The first step is preoperative examination of a patient during which it is necessary to establish a type of deformity. The approach to each patient is strictly individual. A thorough family and personal history has to be taken. Wishes and expectations of a patient from the procedure are carefully observed. After the consultation follows the examination (palpation, inspection). Any preoperative asymmetries of the ears must be carefully noted and demonstrated to the patient. The angle between the ear and the head (the auriculomastoid angle) must be accurately measured by the protractor (the normal value of the angle is up to 25-30 degrees). In addition, the ear anatomy must be considered in detail and ascertained whether there are any anomalies of the helical or external, the internal or antehelical, rim of the auricle. The important part of the examination is palpation of the ear cartilage, and the ear cartilage can be of soft, medium or hard consistency. After a comprehensive examination a precise surgical plan of the surgery is made, which always consists of a combination of several surgical techniques. In the “Polyclinic Ostojić” we never use only one surgical technique, because there are significant deformities variations of the protruding ears, and just one surgical technique can not satisfactorily solve all kinds of deformations. On the basis of long experience and many successfully performed procedures on the protruding ears, we have concluded that the best results are achieved by a combination of different surgical techniques, taken from the multiple surgical methods. Therefore, the approach to each patient is strictly individual, and a detailed preoperative ear analysis gives the answer to which surgical maneuvers will be used to obtain the optimal and lasting aesthetic result to the satisfaction of both physicians and patients.

Surgical procedure

As outlined several times, the approach to each patient must be strictly individual. There is a large number of different ear deformities, and as a result numerous surgical techniques have appeared, of which none can solve every type of deformation or anomaly of the protruding ears. It is certain that there is no ideal surgical technique that successfully solves each ear deformity. It is wrong to apply only one method which a surgeon applies with assurance in the treatment of the different deformations. In the “Polyclinic Ostojić” we have a completely different approach that includes the simultaneous application of the multiple operating techniques depending on each patient, or her/his ear deformity. So far more than a hundred different methods of the protruding ears operations have been described in the medical literature during the past 150 years. The optimal surgical technique is determined after the thorough preoperative examination, and it always includes a combination of numerous surgical maneuvers taken from a variety of techniques, all with the aim of achieving the perfect aesthetic result for each patient. The experience of over 1200 protruding ear corrections  gives us the right to express our own expert opinion. As a contribution to the specified statements, there are many pictures of excellent results in the gallery which show that the ears are perfectly adherent with the head, and that their natural shape is still kept. The main objective of the cosmetic surgery is to achieve a normal position of the ears, which have to look natural, unoperated.

The ear and the surrounding areas of the face and neck must be thoroughly preoperatively anesthesied. In the adult age otoplasty is almost always done under local or reinforced local anesthesia, and with children aged 6 to 12 the surgery is performed under general anesthesia. The picture shows the application of the local anesthetic into the back surface of the ear.

A scalpel is used to make the lateral, so-called “dummbell”, incision, which must be at least 1 cm away from the outer or helical edge of the ear. The incision cuts the skin and subcutaneous tissue.

The “dummbell” incision is complete. A piece of skin of the back part of the ear between the two incisions will be removed, because this is a surplus skin which is made when the angle between the ear and the head is normalized (the auriculomastoid angle up to 25° degrees) to avoid the formation of the unaesthetical skin fold.

Cutting out the surplus skin. In the background the ear cartilage covered with the perihondrium or cartilage envelope can be seen. The surgery is done in bloodless conditions which is visible in both pictures.

The surgical scissors for preparing are used to partly undermine the remaining skin of the back ear surface to enable the access to the cartilage tail of the external ear fold that most often causes the protruding position of the earlobes. Undermining is important to facilitate the sewing of the skin edges in the end of the operation.

In the picture the removal of a piece of the hypertrophic muscle-connective tissue located behind the ear (the so-called retroauricular area) is shown. The top of the surgical scissors is pointed to the posterior auricular muscle. That muscle has no function because the majority of people can not move ears in different directions. As such, this rudimentary muscle will be removed along with the surrounding tissue to create a new space to be used to rotate the ear and normalize the angle between the ear and the head.

The hypertrophic piece of the muscle-connective tissue can sometimes be up to 12 mm thick. Applying the most modern radiowave scalpel allows the quick, precise and bloodless removal of  the specified tissue. The radiowave knife at the same time cuts the tissue and coagulates the small blood vessels and thus stops the bleeding during the cutting.

On the left picture the end of the process of tissue removal with the radiowave knife is visible. On the right picture the removed thick piece of the muscle-connective tissue is shown.

The radiowave knife, which a surgeon used for performing the surgery. By using the precise radiowave knife the bloodless operations are achieved, which means a minimal duration of the postoperative swelling and bruises and a quick recovery and return to the normal life activities.

After the specified tissue is removed, a new space is formed to be used to accommodate the ear. In the bottom of the operating field the envelope or periost of the part of the temporal bone is located.

Removing a part of the ear cartilage (the helix tail), which is mostly responsible for the protruding earlobe. With this surgical maneuver more beautiful and more natural relation of the ear to the head is achieved. If this surgical maneuver is not performed, there is a high possibility of the postoperative ear deformity in the form of the “telephone headsets”, which means that the upper and lower part of the ear would be bulged, while the central part of the ear would collapse to the head.

A needle pierced through the ear indicates the place where the suture will be placed, which will get the ear close to the head, and which is clearly shown in the picture right. The suture passes only through a part of the cartilage, so it would not be visible from the front ear plane. The suture can be resorptive or unresorptive. After the long experimenting with the different highest quality sutures, in the “Polyclinic Ostojić” we most often use the resorptive suture Coated Vicryl 3-0, which resorbes after a few months. The lasting or permanent suture can cause the granuloma or be extruded from the area behind the ear even several years after the procedure, so we prefer to use the resorptive sutures with which there is no such possibility.

Another leg of the suture passes through the envelope or periost of the bone behind the ear (the fixed point), after which the suture is maximally tightened  while estimating a new position of the ear. In the right picture it is visible that the ear in the new position looks natural and unoperated, which is the ultimate goal of the operation.

Sewing the edges of the skin incisions on the posterior surface of the auricle with the running Prolene (4-0) suture, with the special attention devoted to the precise adherence of the edges of the incision so that the scar would be almost invisible.

The local application of antibiotic ointment on the ear in order to prevent infection. After that the sterile vaseline gauze (visible in the picture right) is put in order to facilitate removing the elastic bandage.

Then the sterile cotton packing, sterile gauze and sterile elastic bandage that fixates the ears in the new position in the next two days are set.

Postoperative period

In the early postoperative period, no patient suffers from pain because the intramuscular injections of analgetics are being applied, and in the following days it is enough to take 1 or 2 tablets of analgetics. The patient must sleep on her/his back with a slightly hightened pillow. Bruises under the ears and/or mild eyelid swelling, which occured because of the elastic bandage, can be most visible 2-4 days after the procedure, and they usually last for 7-10 days. In the first two postoperative days a slightly raised temperature can occur that is not necessary to cure. The complete elastic bandage is removed after two days and thereafter the ears are fully uncovered. After removing the bandage, it is recommended to wash the ears with the children’s baths and to locally apply antibiotic spray. The stitches are removed the seventh postoperative day. The patient must wear the elastic brace over the forehead and the ears during the sleep in the next month. It is not advisable to wear heavy glasses or to jump headlong into the water. Sports with a ball and/or rough physical manipulation of the ears must be avoided for at least 4 weeks. The majority of the patients feel temporary numbness or hypoesthesia in the area of the upper half of the ear and retroauricular area, which passes within a few months.

Complications

The ear aesthetic correction complications are very rare. Possible complications include

• infection
• hematoma or bleeding
• hypertrophic scars or keloids
• recidive or recurrence of the ear deformity (1-2% of cases), or the visible ear asymmetry

APPENDIX

Congenital anomalies and traumatic ear deformities

The congenital anomalies of the ears are rare. There is a variety of the congenital ear anomalies: the microtia (the undeveloped or poorly developed ear), the overlapped upper part of the ear (the “lop ear deformity”), the deformed cup-shaped ears (the “ear cup defomity”). In our long surgical practice, in the “Polyclinic Ostojić”  we have met with all sorts of ear anomalies that we have successfully corrected. As outlined earlier, the surgical approach must be adapted to the type of the ear anomalies and it must always consist of several surgical maneuvers taken from the various operational methods. In the operating treatment of the ear deformities and anomalies, we have successfully used transplanting of free, full thickness skin and cartilaginous transplants from one ear to another, and sometimes also the local skin flaps in one or more operational stages. Such an approach, strictly individual to each patient, ensures the lasting and excellent aesthetic result, which fundamentally changes the quality of life of a patient. The traumatic ear deformities are also rare. Most often they arise from the traffic accidents or fights. In the “Polyclinic Ostojić” we had the opportunity to meet the traumatic ear deformities. The selection of the operational methods is also very individual because such deformities are significantly different, and enviable skills of a surgeon are required to achieve the excellent aesthetic result. In the “Polyclinic Ostojić” we have performed a considerable number of very successful operations, with a great pleasure of our patients and ourselves. It is important to mention that some patients are not aware that the numerous ear anomalies and deformities can be successfully corrected. We will show an example of the demanding correction of the congenital ear anomaly of the right ear.

Surgical procedure (the microtia or reduced and constricted ear)

In the pictures a rare case of the congenital anomaly of the upper half of the right ear is shown. It is evident that the external cartilage or helical edge of the ear lies completely outside the skin helical edge, located in the subcutaneous tissue of the fold between the upper part of the ear and the head, in anatomically completely inappropriate place. It specifically means that the outer edge of the ear consists solely of the skin duplicature, without the cartilage basis as usual. In addition, the cartilage part of the upper half of the ear is wrinkled. In the right picture it is visible that there is no normal anatomical groove or sulcus between the upper half of the ear and the temporal area of the head (a patient shown could not wear glasses because they were constantly falling down). The angle between the ear and the head is  90 degrees (the normal value of the specified angle is 25-30 degrees). The scapha (the plane between the outer or helical edge and the inner or antehelical edge of the ear) is not developed at all.

The incision begins in the upper part of the ear, which is completely accreted to the head and descends down towards the lower half of the ear where it is at least 1 cm away from the outer edge of the ear. The incision extends through the skin and subcutaneous tissue of the back ear surface.

A piece of skin is removed from the lower two thirds of the ear, which will later be used as an autologous, full thickness skin graft. The skin is not removed from the upper third of the ear because in that area there already is a lack of skin.

The images show complete separating of the skin from the underlying cartilage of the ear. The overlapped and wrinkled cartilage of the outer edge of the ear or helix can be seen.

The scalpel is used to completely separate the external from the internal cartilage fold of the ear, so the cartilage of the outer edge could slip into the skin duplicature of the outer edge, in its normal anatomic position.

A piece of the muscle-connective tissue behind the ear is being removed with the radiowave knife to create a space to be used to rotate the reconstructed ear, in order to normalize the angle between the ear and the head.

The cartilage of the outer edge of the ear is being connected to the skin edge of the outer fold of the ear with the resorptive sutures to be fixated in its normal anatomic position.

Now the cartilage is completely located in the skin duplicature of the outer fold of the ear or  the helix.

A free transplant of the skin taken from the back surface of the ear, which will be inserted on the front surface of the ear, is shown.

The free transplant of full thickness skin is sewn with the resorptive 5-0 sutures into the front surface of the ear to form the scapha or the plane between the outer and the inner fold of the ear, which is congenitally undeveloped in the given patient. The resorptive thread was used that does not have to be removed because removing the sutures might mechanically damage the new vascularization and cause the consequent slough of the transplant. Although the incisions are located on the front surface of the ear, they will be completely invisible after a few months. The skin transplant will take the normal color of the skin after being fully accepted in the new position.

Another free skin transplant, also taken from the back ear surface, is embedded with the aim to create the normal, anatomical groove between the upper half of the ear and the head, and which did not exist before the operation.

The picture shows the vitality of the free skin transplant on the seventh postoperative day. This means that the color of the transplant completely matches the surrounding skin color, which undoubtedly proves that the transplant is fully accepted in the new location.

The picture shows the right ear before and after the specified procedures. The difference is evident. The ear has taken a completely natural form. The free skin transplant is perfectly incorporated in the projection of the scapha and is almost invisible. The pictures prove that we are able to successfully correct the great majority of the anomalies and deformations of the ear. It should be taken into consideration that the right image is taken 3 weeks after the procedure, so we can expect the final result in this case to be even better.