Otoplasty Principles:  Learned From Reconstructive Ear Cancer Operations

Before I began my career dedicated to cosmetic otoplasty, or ear pinning procedures, I performed the full gamut of reconstructive procedures for cancers of the ear that required sophisticated flaps, tunneling, and cartilage splitting maneuvers. I learned many things that I brought with me when I perform standard cosmetic otoplasty to correct lop and cup ear deformities. What I would like to focus on here is priorities that I have learned from reconstructive otoplasty.

When there is a cancer on one ear, the ear by force must be physically reduced in size because the cancer must be removed and part of the ear lost.  Whenever I do this I have to thereby determine priorities to make this ear look as natural as possible.  What I have found is the first and foremost goal is to make the ear not stick out.  I had a colleague of mine who did not have much experience reducing cancerous ears and she asked me, “Why did the ear stick out after I reduced it?”  The answer is complex but it shows me she did not have the knowledge of how to adjust an ear size without causing it to cup outward.  The reason that priority #1 is to make the ear not protrude out is that most people view an ear from on front not from on side.  We will discuss the implications of this comment further in a moment.

The second priority is for the ear to have a normal shape and proportion, i.e., the proportion and shape of the various ear structures:  helix, antihelix, concha, lobule, etc. are in relative proportion with one another.  In other words, it is important that the ear look like a normal ear when someone is standing to the side of the individual and looking at the ear en face.  The third and least important element of reconstructive otoplasty is the actual size of the ear.  The reason for this is that first when the cancer is reduced the ear will per force be smaller.  But there is no reason to reduce the other size of the ear to match because one only truly notices the size difference between ears when one turns the head back and forth, and because one only sees one complete ear at any one time the size difference between the ears is not really noticeable.

Now that we have learned these principles, why would they be important to cosmetic, elective otoplasty?  The reason is that these principles really do hold true when I am working to make a ear look better.  My first and foremost goal is to make the ears relatively less protruding from the frontal view.  By doing this, the face looks better and like a good rhinoplasty the ears disappear from sight.  During the procedure as I shape the ear to look more natural and cosmetically appealing I am constantly looking at the patient from the front view to make sure that the ears look as symmetrical as possible and do not look over or underpinned.  In short, my #1 priority is to make the ears look good from a frontal view.  Recently, I was reviewing a photograph of a “good” before-and-after photograph on realself.com that I found to be quite terrible.  From the frontal view the upper and middle portions of the ear were plastered to the side of the face and the bottom third, the lobule, was sticking out like a sore thumb.  I am sure that as the surgeon was pinning the ear back he was only looking at the ear from the side view.  Accordingly, it is critical for a surgeon to always look at the ear creation from the front view when pinning down the ear.  That is how people see their own ears afterward and also how others view them.

The second most important principle mentioned in reconstructive otoplasty should only be met after the first priority (the degree of protrusion) is met, and the second principle again is that the ear shape look normal and proportionate from a side profile view so during a procedure I am constantly checking the ear shape from a side view as well.  The antihelical fold must look normal and not overcurved or undercurved.  The conchal shape must also look right.  The helix cannot look overbent, etc.  This principle also applies to ears that have unusual shapes like a double folded-over helix or a part of the ear missing.  I have seen and posted on my Web site a host of unusual ear conditions that I have fixed other than just lop and cup ear deformity corrections.  So creating a normal ear shape when viewed from a profile view comes as a second most important priority.

Anything after these two priorities should be considered unimportant or unachievable.  A relatively uncommon request that I receive is whether I can reduce the size of the ears.  Although this can be technically possible, I truly believe the risk of scarring and violating priority #2, which is maintaining a natural shaped ear, could occur.  In short, I do not think reduction of the ear size is possible for cosmetic purposes.

Samuel M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. For more info about Dr Lam’s otoplasty procedures, or to schedule a consultation please call 972.312.8105. If you would like to ask Dr Lam a question please visit our otoplasty forum.