Prominent ear surgery

This article covers the decision-making process in children and adults for prominent ear surgery, the choice of method, the recovery period spent in a bandage, and the possibility of the ear moving outwards again. The child's own wish, the aim of a natural appearance and what can be expected from the result are assessed together.

What is prominent ear surgery?

Prominent ear surgery, also called otoplasty, is the operation that changes the folds of the ear and its position relative to the head. The subject of this article is an ear that stands out prominently; it is not the treatment of hearing loss or the reconstruction of an underdeveloped ear.¹

The antihelix is the cartilage fold on the inner side of the outer rim of the ear. The concha is the bowl-shaped part around the ear canal. A poorly defined antihelical fold, the depth of the concha and the position of the earlobe can contribute to a prominent appearance separately or together.¹

Prominent ears alone do not mean that surgery is needed. The decision depends on the person's own wish and what they expect from the change; there is no obligation to conform to an appearance preferred by others.²

Who is it suitable for?

In children, surgery is assessed from the age of 6. This clinical threshold does not mean every child is ready at the same age. The structure of the cartilage, the child's ability to understand the operation, their compliance with care instructions and their own wish are assessed together.²

In adults too, an assessment can be made where there is a wish to change the shape or position of the ear. Where there is an active ear infection, a health problem affecting healing, or unrealistic expectations, these are addressed first.²

An appearance that troubles the family does not mean the child is troubled by it. Where a child does not want surgery, the family's wish alone or the date of starting school does not take the place of the decision.³

What does the examination assess?

The position of the ears relative to the head, the firmness of the cartilage, the antihelical fold, the depth of the concha, the earlobe and the skin are assessed. Any difference between the right and left side at the outset is recorded separately; the distance of the ear from the head is not looked at alone.¹

Previous ear surgery, infection, injury, wound healing problems or a history of raised scarring are asked about. The extent of the planned procedure and its possible risks are discussed together with this assessment.

The child is spoken to directly, in a way suited to their age. What they think about their ears, what they expect from surgery and how they view returning to school in a bandage are explored. Explaining the operation and persuading the child to have it are not the same thing.³

How is the operation planned?

How is the decision made in a child?

The family needs to take part in the assessment; the child being able to express their feelings and not objecting to the operation is also part of assessing suitability.² Where there has been experience of being teased at school, it is taken seriously, but the problem is not presented as though it lay in the child's appearance. Speaking to the school and supporting the child are addressed separately from the decision about surgery.

The threshold of 6 years does not mean that the development of the ear is definitively complete on that day. Institutional sources assess the durability of the cartilage, growth and the child's understanding together with different age frameworks.²⁴³ No promise is made that surgery will resolve all the difficulties in a child's social life.

How are cartilage sutures and cartilage incisions distinguished?

In shaping with sutures, the cartilage is folded to create a fold, or the position of the ear relative to the head is fixed. Scoring the cartilage, thinning it, or where necessary removing part of it are different procedures aimed at changing its shape. These can also be applied together with sutures.⁵³

Scoring the surface of the cartilage and cutting through its full thickness are not the same procedure. All techniques therefore cannot be divided into 2 equivalent groups labelled simply "suture" and "incision". The choice is made according to the deficiency of the fold, the structure of the concha and the characteristics of the cartilage.¹

In a 2024 meta-analysis, no significant difference was found between cartilage-sparing methods and methods that weaken the surface by scoring it, on a combined measure of recurrence and reoperation.⁶ This finding does not show that the techniques are equivalent in every person, or that recurrence will not occur with any of them. The method to be used is determined by the examination and the surgeon's assessment.

Where is the incision made, and is the same procedure applied to both ears?

The incision is usually placed in the skin crease behind the ear. The internal fixation sutures and the sutures closing the skin have different roles.⁵ The care plan in this article is for an operation with a skin incision behind the ear.

The starting shape of the two ears may not be the same. Rather than intervening to the same degree on each side, the fold and position of each ear are planned separately. The decision about a one-sided or two-sided procedure is made at the examination; the aim is not to press the ears excessively against the head.⁵

How is the anaesthetic chosen?

The operation can be carried out under general or local anaesthesia.⁵ Age, the extent of the procedure and the person's ability to cooperate throughout are assessed in the choice. In children general anaesthesia comes into question; in adults local anaesthesia can be chosen under suitable conditions.³ The wording "general/local" in the fact box summarises these separate options; it does not mean the same anaesthetic will be used for everyone.

How do you prepare for surgery?

Smoking and nicotine: Smoking is a risk factor for wound healing problems after surgery. Direct surgical data on nicotine products other than cigarettes are scarcer. The practice reference of the American Society of Plastic Surgeons notes a lack of clinical data on e-cigarette use and surgical risk, but states that because nicotine is known to reduce blood flow, e-cigarettes and other nicotine products are regarded as a potential risk factor.⁷ Stopping smoking, vaping and other nicotine-containing products at least 1 month before the operation, and not using them after surgery until healing is complete, is therefore advised. The studies below concern smoking cessation; their results do not establish the same reduction in risk for every nicotine product. A review pooling 6 randomised and 15 observational studies showed that every week of abstinence added benefit, and that studies with at least 4 weeks of abstinence produced markedly better results than shorter ones.⁸ A study appraising systematic reviews together reported that cessation interventions beginning at least 4 weeks before surgery and combining multiple behavioural support sessions with pharmacotherapy reduced complications. The same study notes that interventions with only one component, even when started more than 4 weeks before surgery, raise quit rates without reducing complications.⁹ Shorter intervals are not useless either: in a meta-analysis of 55 studies covering adults undergoing a range of operations, the risk of pulmonary complications was 27 per cent lower in relative terms among those who stopped at least 2 weeks before surgery, and 29 per cent lower among those who stopped at least 4 weeks before, compared with those who continued smoking.¹⁰ The benefit therefore grows as the interval lengthens; being late does not make stopping pointless. The interval applied and the nicotine policy can vary from surgeon to surgeon.

Coexisting illness: Diabetes and blood pressure are expected to be under control before surgery. Where there is an active infection in the body, surgery is postponed.

Medication: Blood thinners and some herbal products can increase bleeding. Every medicine and supplement you take needs to be declared. Prescribed medication should not be stopped on your own decision.

Tests and anaesthetic assessment: The tests required are determined by general health and by the anaesthetic assessment.¹¹ Any previous problem with anaesthesia or drug allergy should be declared. The instructions given about fasting and about how to take medication on the day of surgery are followed.

Home and transport: Someone is arranged to accompany you home on discharge.¹¹ The timing of check-ups, the help you may need in the first days and the plan for time off work are organised beforehand. Follow the surgical team's guidance on preparing the operation area; do not shave or prepare the incision area at home on your own initiative.

In a child, care in the first days, transport to check-ups and protecting the ear from knocks at school are planned together with the family. Because the date of returning to school and the date the band is no longer used will not be the same, this is discussed beforehand. The advice about nicotine is for people who use such products; the adult results in the research are not a risk percentage specific to children.

What is recovery like?

1-2 hours are planned for the operation and 1 night for the hospital stay. The type of anaesthetic is assessed beforehand; whether it is general or local depends on the person's circumstances.

The first check-up is within the first week. 1 week is planned for removal of the skin sutures; the incision is checked and suitability assessed. This check-up does not mean that all the fixation sutures shaping the ear from within are removed.⁵

7-10 days are expected for bruising to settle and 1 week for marked oedema to subside. This timetable does not mean all the swelling will end on the same day. The shape of the ear becomes assessable within 2-3 months.

Being able to return to school or work does not mean the ears no longer need protecting from knocks. The first assessment of the shape and the preservation of the position in the long term are also different matters; the possibility of the ear moving outwards again is explained separately in the long-term section.¹²

What to pay attention to after surgery

The following is a general framework. Where the instructions you were given differ, your surgeon's instructions apply. In a child, care is carried out together with the family; the headings on driving and sexual activity are for adults.

Bandage and night band: 4-6 weeks of use are planned for the bandage and 4-6 weeks for the night band. Which band is used in which period, the pattern of daytime use and how it is changed are explained by your surgeon. No day of transition is derived from these periods on your own initiative. The bandage is used to protect the operated area and to support the new position of the ear during early healing.¹³ It should not be removed without your surgeon's knowledge because it itches or its appearance is troubling. The ASPS care information states that removing it early can lead to the loss of part of the correction and to a need for further surgery.¹³ This possibility does not mean that recurrence will not occur in anyone who uses the band.

Incision care: The dressing instructions given for the incision behind the ear are followed. Crusts are not picked off and the ends of sutures are not pulled. Where there is steadily increasing pain or pressure under the bandage, do not try to solve it by wrapping the band more tightly; inform the surgical team.

Sleeping: Rest with the head elevated. Your surgeon decides how long that position and the avoidance of physical strain are continued. A sleeping position that puts no pressure on the incision is preferred. Returning to sleeping on the side or front is assessed according to the state of the incision and the swelling.

Cold application: Cold is applied to the operated area without pressing on it. The form and duration of the application are determined by your surgeon's instructions.

Showering, wound and dressings: When you may shower depends on the dressing used. If there is a skin incision, once allowed you can shower without rubbing the wound and pat the area dry gently. Baths, swimming pools and the sea wait until the wound has closed completely.

Washing the hair: The hair is first washed after 1 week, in the manner your surgeon describes and according to the state of the incision and the bandage. How the bandage is protected or changed during washing is determined by the care plan given. Being able to wash the hair does not mean the bandage treatment has ended. The ear is not pulled and the incision is not rubbed; the bandage is not left wet.

Movement: Strain such as bending the head down, straining and heavy lifting is limited in the early period. Movements that stretch or rub the incision area are avoided. Even if you feel well, do not return to strenuous activity suddenly. Activity and rest through the day are organised according to the plan given on discharge.

Pain: There can be tenderness and pain in the ear, and itching under the bandage.¹³ The painkillers given are used as instructed. Pain that begins suddenly or steadily increases, particularly in one ear, is reported without waiting for the check-up day.¹

Returning to work, school and sport: 1-2 weeks are set aside for a return to work or school. On returning to school, suitability is assessed separately for physical education, contact play and activities carrying a risk of a knock to the ear. A return to sport is planned in stages within 2-4 weeks; sports in which the ear could be bent or struck are not begun merely because the timetable has run its course. 2-4 weeks are expected for a full return to daily life. That the bandage and night band continue for longer does not conflict with this timetable; returning to everyday function and ceasing to protect the ear are different decisions.

Driving: A return to driving can be assessed after 1-3 days. The effects of the anaesthetic on attention must have passed; there must be no dizziness, no use of a medicine causing drowsiness and no pain preventing you from turning your head. Where these conditions are not met, driving is not undertaken even if the timetable has run its course. Someone accompanies you home on discharge.

Sexual activity: A return can be assessed once everyday movements no longer cause marked pain and you feel comfortable. Pressure on the head and ear area, movements that stretch the incision line, and marked straining are avoided. Rather than a fixed day, the course of healing and the surgeon's advice are taken as the guide.

Smoking: Smoking impairs wound healing after surgery as well; cigarettes and nicotine products should be avoided until healing is complete.

Findings that are normal: Bruising, swelling, tenderness, numbness or tingling can occur around the ear.⁴ What matters is less the presence of a mild finding than how it changes. Pain and swelling that increase instead of decreasing, fever or discharge should not be waited out as ordinary healing.

How do the scars change?

The incision behind the ear leaves a scar. Placing it in the natural crease can reduce its visibility; this does not mean there will be no scar at all.⁵ 6 months to 1 year is expected for the scar to mature. The appearance in the early period is not taken as the final state of the scar.

Silicone gel and massage are advised for the skin scar behind the ear. When they are started and how they are applied are determined by your surgeon according to the healing of the incision; no product is applied to an open wound on your own initiative. Where there is a raised scar or one that steadily enlarges, it is checked. No promise is made that silicone and massage will prevent all scar problems.

Risks and complications

Although most people are reported to be satisfied with the result after otoplasty, there remains a possibility of infection, bleeding, asymmetry and the ear becoming prominent again.⁴ Because the research covers different methods, ages and periods of follow-up, no single complication percentage can be applied to all patients.⁶

Recurrence, asymmetry and irregularity of shape

The ear can move outwards again, part of the original prominence can remain, or a difference can be seen between the two ears.⁴ The new fold can look sharp, or the parts of the ear can sit out of keeping with one another; deformities described as "telephone ear" and "reverse telephone ear", related to over- or under-correction, have also been reported.¹

Not all of these problems require further surgery. Remaining prominence, prominence that returns over time, and intervention directed only at a suture are assessed separately.¹⁴¹² The numerical data on recurrence and its limits are in the long-term section.

A suture becoming palpable or extruding

The internal sutures can become prominent under the skin, cause tenderness or extrude through the skin.⁴¹ A visible thread is not pulled out on your own initiative. Whether removing the suture is sufficient, and its effect on the support of the ear, are assessed at the examination. In one series of children and adolescents, some extruded sutures were dealt with in the clinic, and not all of these situations were counted as a repeat otoplasty.¹⁴

Bleeding, haematoma and infection

A haematoma is a collection of blood under the skin. Pain that is marked, persistent or suddenly increasing, particularly on one side, may call for early assessment for this problem.¹ Infection and problems with wound healing can also arise.¹⁵

Chondritis, an infection of the cartilage, is not of the same seriousness as ordinary redness of an incision. Because it can lead to loss of cartilage and lasting deformity of the ear, it is described as a complication requiring urgent assessment.¹ Increasing pain, redness, swelling or discharge is not a reason to delay a check-up.

Raised scarring and changes in sensation

Hypertrophic scarring or a keloid can develop; a keloid is a raised scar that can grow beyond the boundary of the incision.¹ Although hidden behind the ear, the scar can still become prominent. Any similar problem with previous wounds should be reported at the examination.

Numbness, tingling or a change in sensitivity can occur; it cannot be said that these sensations will settle within the same period in every person.⁴ Persistent pain and changes in the sensation of the skin are also among the reported risks.¹⁵

Anaesthetic and general surgical risks

General surgical risks such as a reaction to the anaesthetic or to the materials used, bleeding, infection and clots are also assessed.¹⁵ That local anaesthesia can be chosen does not mean the procedure is without risk. Precautions are arranged according to the person's age, health and anaesthetic plan.

Blood clots: A clot forming in the leg veins and travelling to the lungs is serious. One-sided leg pain and swelling, sudden shortness of breath or chest pain need urgent assessment.

The approach to preventing clots is decided according to the person's risk and the operation planned. The measures to be used are explained in the discharge and care plan. No blood thinner is started without being prescribed, and existing treatment is not altered on the person's own decision.

Does the result change over time?

The corrected ear moving outwards again is possible. It cannot be established from the appearance in the first days after surgery alone, nor can it be said that after a particular period of follow-up it will never occur.¹² Recurrence and repeat surgery are not the same figure; not every repeat operation is carried out because the ear has moved out again.¹⁴ The following results concern different methods, follow-up periods and outcomes; they cannot be added together to calculate personal risk.

Combined recurrence and reoperation: In a 2024 meta-analysis of cartilage-sparing otoplasty, 14 studies covering a total of 2,008 ears were examined; the combined rate of recurrence and reoperation was reported as 4.27 per cent, with a 95 per cent confidence interval of 2.93-6.22.⁶ The rates reported by the individual publications range from 0 to 9.01 per cent, and the variation between studies is significant.⁶ This range is not the rate of recurrence alone; it brings together different definitions and periods of follow-up. Nor does the lower end being 0 per cent mean that recurrence is impossible in an individual. In the same review, a statistical adjustment assessing the possible effect of publication bias produced an estimate of 5.72 per cent, with a confidence interval of 3.90-8.40.⁶ This is an estimate from a model applied to the same data, not an observed rate in a new patient group or a definitive value for the true risk.

Loss of correction: In the abstract of a recent retrospective series in which a suture-based method was used, 4 losses of correction were reported in 288 ears of 147 people. Mean follow-up was 24.3 months and the shortest follow-up 6 months; alongside prominent ears, constricted ear shapes were also included in this single surgeon's series.¹⁶ The abstract does not explain the measurement threshold for loss of correction, and the mention of an option of further surgery is not presented as a number of revisions carried out. This result is not a rate of recurrence applying to everyone.

Complete and partial recurrence at long follow-up: In the abstract of a series with longer follow-up, in which scoring of the anterior surface of the cartilage was combined with fixation sutures behind the ear, complete recurrence was reported in 7 of 301 ears followed for a mean of 6.25 years, that is 2.3 per cent, and partial recurrence in the upper part in 26 ears, that is 8.6 per cent. 72 per cent of the people included at the outset attended the long-term check-up.¹² These are results per ear; they do not show that the same proportion of people underwent further surgery. No comparison of the superiority of methods can be made with the other, more briefly followed series.

Repeat surgery: This distinction is also seen in the number of repeat operations. In a series of 119 ears in 68 children and adolescents in whom Mustardé sutures were used, 2 repeat operations, that is 1.7 per cent, were reported at a median follow-up of 72 weeks. 1 of these was for an extruded suture and 1 for remaining prominence of the ear due to suture failure.¹⁴ Reading the 1.7 per cent as a rate of recurrence erases these different reasons.

Using the protective band matters in early healing; the possibility of recurrence is not reduced to whether or not a person used the band.¹³⁶ Where the ear opens out later, the cause, the state of the folds and how far the person is troubled by it are assessed first. Not every opening out is automatically a decision for a new operation.

What can be expected from the result?

The aim is a natural position that preserves the folds of the ear and is in keeping with the person's face; it is not to make the two ears exactly alike or to bring them excessively close to the head.⁵ Not all of the differences present at the outset may be removable, and further correction may be needed.¹⁵

In a child, the change expected should be discussed with the child's own view in mind. In an adult too, the decision is not based on someone else's wish or on an effort to conform to a single measure of appearance.² No promise is made that surgery will definitively end teasing, or change everything a person thinks about themselves.

Returning to school, leaving off the band, assessing the shape and the maturing of the scar are different stages. The result is not settled by the appearance when the first bandage is opened.

When should you contact a doctor?

Do not wait for the scheduled check-up in the following situations.

• Rapidly increasing swelling and tightness, particularly in one ear
• Pain that increases rather than settling, or becomes marked despite the pain treatment given
• Fever, spreading redness or discharge from the incision line
• The wound opening or bleeding that does not stop
• Steadily increasing pain or pressure under the bandage, or a marked change in the colour of the skin

Haematoma and infection of the cartilage may call for early assessment; the presence of a bandage is not a reason to wait out increasing complaints in the ear.¹¹³ An extruded suture or a slowly developing change in shape is also reported to your doctor; where these are accompanied by increasing pain, redness or discharge, the check-up is not delayed.

One-sided leg pain and swelling, sudden shortness of breath or chest pain are also emergencies. Where there is a sudden breathing problem in particular, urgent assessment should not be delayed while trying to reach your doctor.

About the numbers in this article

The periods in the fact box, the threshold of 6 years, and the timetable for check-ups, the bandage, the night band, washing the hair, bruising, oedema, shape and the scar are the approved framework of clinical practice. They are not research results showing that everyone reaches the same state on the same day. Returning to school or work is not the same date as leaving off the protective band.

The research figures belong to separate groups. The number of ears is not the number of people. Recurrence, remaining prominence and repeat surgery are not the same outcome. The estimates and ranges given for combined recurrence and reoperation should not be read as a personal percentage of recurrence. The duration of follow-up is not a guarantee of durability given to an individual.

The smoking cessation data cover a range of operations; they have not been transferred as a complication rate specific to otoplasty or to children. A relative reduction in risk does not mean the same number of percentage points is subtracted from everyone's risk.

References

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