Mr David T Gault
Consultant Plastic Surgeon
- Pinnaplasty or Otoplasty for prominent (stick-out or bat) ears
- Ear reduction for big ears
- Ear Lobe reduction for big lobes
- Split ear lobes after piercing problems
- Lop ear and cup ear
- Cryptotia
- Folded over helical rim
- Rim augmentation
- Correction of failed surgery for stick-out ears
- For Microtia (partial or total absence of an ear at birth)
- For Acquired ear loss (accidents, bites, burns, failed surgery, for example)
- Simple autogenous ear reconstruction
- Complex autogenous ear reconstruction (for significant tissue loss or failed simple autogenous ear reconstruction)
Aesthetic Ear Surgery:
Ear Reconstruction:
Aesthetic Ear Surgery:
A deformed ear may be apparent at birth or soon after, or may be acquired later in life through trauma, piercing, surgery or cancer, for example. In the first year or two of life, many ear deformities can be corrected by moulding using Ear Ear Buddies™ splints, avoiding teasing and surgery later.
Prominent (sticking out or bat) ears
Bat ears can be corrected at birth and even within the first year by moulding with Ear Buddies™ splints. Unfortunately, this chance if sometimes missed if parents are falsely reassured that their baby will “grow into” their ears. Otoplasty or pinnaplasty is best performed after the age of 5, although if teasing is severe, or the child needs to wear a behind-the-ear hearing aid, it can be done earlier. The surgery can take place under local or general anaesthetic, or local anaesthetic with sedation. A suture technique is safest, minimising the risk of haematoma and infection associated with anterior scoring.
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Ear reduction (for big ears) etc
Sometimes the ear is too large in all dimensions. Other ears are too tall and thin, and in some only the upper third is out of balance, so that it looks like an upturned pyramid. Using an incision hidden in the folds of ear, usually just inside the rim, the ear can be re-modelled into a more attractive shape. On the post-op picture below, one of the possible incision lines can be seen marked by the sutures which have not yet been removed.
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Lobe reduction
It is possible to make large ear lobes smaller. By incorporating an ill-placed or unwanted piercing hole, this patient had a combined ear and ear lobe reduction with elimination of an unattractive piercing.
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Ear piercing problems (Split ear lobes)
Piercing holes can elongate, particularly when heavy earrings are worn, and eventually the ear lobe splits. Piercing of the upper ear can lead to infection and even ear loss, requiring reconstruction.
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Lop ear and Cup ear
If uncorrected by moulding using Ear Buddies™ splints at birth, a lop ear can be corrected by surgery later. Moulding using Ear Buddies™ splints may improve a cup ear, but when the tissues are severely constricted, they must be surgically released.
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Cryptotia (the hidden ear)
Moulding using Ear Buddies™ splints can correct cryptotia if started early enough. Surgical release is possible later in life.
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Folded-over helical rim
If uncorrected by moulding using Ear Buddies™ splints at birth, a folded-over helical rim can be corrected by surgery later.
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Rim augmentation
The rim of the ear can be augmented using a dermis graft.
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Correction of deformity due to anterior scoring surgery for bat ears
The safest technique for correction of prominent ears employs sutures (above). Although anterior scoring surgery can be successful in most cases, haematoma formation is unpredictable, and in a small but significant number of cases, the ear becomes severely deformed. Other complications of anterior scoring surgery include tethering of the ear (telephone ear) and buckling of the rim.
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Total ear reconstruction is sometimes necessary (see here).
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Ear Reconstruction
The lack of an ear, or part of it, is a significant deformity, and the psychological effects should not be underestimated. In some, particularly teenagers, concern over a deformed ear lies at the root of serious behaviour problems. Lack of an ear is also a disability - the ear supports glasses, sunglasses, blue-tooth headsets and headphones.
Some are born without one or both ears, a condition known as microtia (link to microtia section below). Others lose their ear, or part of it, in later life. 73% of this group result from bites, road traffic accidents, shootings and burns. Most of the rest come from failed surgery to set back prominent ears, and from infected piercings.
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Microtia
Microtia, the absence at birth, of an ear, affects about 1 in 6000 children. In one in ten microtia cases, both baby’s ears will be affected. The problem that results in microtia occurs in the womb about 8 weeks after the baby is conceived. The most likely cause is an interruption of the blood supply to the area which will form the ear. Microtia is sometimes seen as an isolated problem or sometimes as part of a syndrome such as Goldenhar syndrome, hemifacial microsomia or Treacher Collins syndrome.
In most cases there is a small fold of skin at the site where the ear should be, rather like a misplaced ear lobe. Sometimes there is little tissue present at all.
 Simple microtia |
 Two remnant microtia |
There is usually hearing loss on the affected side as the middle ear is underdeveloped. If only one side is affected, then a hearing aid is not normally needed. When the condition affects both sides, however, treatment to improve the hearing is important. If bone-anchored hearing aids are to be used, it is very important that the aids are properly positioned so as not to compromise the tissues for autogenous ear reconstruction. A badly positioned BAHA can greatly increase the difficulty of autogenous ear reconstruction, although the situation can usually be rescued with a temporoparietal fascial flap.
 Correctly positioned BAHA |
 Enough room has been left to position the new ear in the right place |
Surgery
Some patients do not wish to have the defect reconstructed. For the rest, there are now two reconstructive options - to have the ear rebuilt from their own tissues (autogenous ear reconstruction) or to have a prosthetic or false ear anchored to the bone of the side of the head by titanium fixtures.
Autogenous Reconstruction
If the tissues have not been damaged by previous attempts at reconstruction, it is possible to fashion a completely new ear in two operations six months apart. The first stage, under general anaesthetic, takes between four and five hours. Under general anaesthetic, a replacement ear framework is carved from costal cartilage taken from the ribcage and inserted into a pocket made beneath the skin on the side of the head. If one ear is present, it is used as a model for the new one. Patients are often discouraged by those unfamiliar with ear reconstruction that the chest scarring is severe, but this is untrue. Scarring on both the chest and the thigh from which a skin graft may be taken at the second stage) is minimal.
 chest scar |
 donor site on thigh for skin graft |
If one ear is present, it is used as a model for the new one. The material used for the framework, known as costal cartilage, joins the ribs to the breastbone. It is white in colour, and usually fairly easy to carve. If an entire ear is missing, it is assembled from several carved components, one for the rim, one for the main part of the ear, and separate pieces to resemble the individual ridges and valleys that make a realistic ear shape.
 template |
 template framework |
Using special suction drains, the skin is sucked onto the framework to allow the ear shape to show through. This leaves an ear shape which lies flat against the side of the head, under the skin. Over a period of several months, the skin nestles into the framework and the detail becomes established. Six or so months later, at the second stage, the ear is released from the side of the head to make the groove behind the ear. The back of the ear is resurfaced using grafts and flaps harvested locally. Second stage surgery takes almost two hours.
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 after the first stage |
The ideal age for microtia surgery is over the age of 9 but if the patient is being teased, or if there are other pressures to have the reconstruction carried out a little earlier, it is possible to proceed, although the costal cartilage used to carve the replacement ear is not so plentiful and the result is sometimes not as good.
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 after the first stage |
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 completed reconstruction |
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Although the cartilage used is a little stiffer than the opposite normal ear, most people prefer the autogenous technique. As results improve, it is unusual to choose a prosthesis unless the local tissues are so badly damaged that there is no other option, and it is not uncommon for patients who were originally offered only the prosthetic option to undergo autogenous reconstruction at a later date.
Once the advice was to cover the defect with long hair, or simply learn to live with it. A new “real” ear is now a realistic option.
Complex Autogenous Reconstruction
Surgery for ear loss
Some patients do not wish to have the defect reconstructed. For the rest, there are now two reconstructive options - to have the ear rebuilt from their own tissues (autogenous ear reconstruction) or to have a prosthetic or false ear anchored to the bone of the side of the head by titanium (Branemark) fixtures.
Autogenous ear reconstruction
If the tissues have not been further damaged by previous attempts at reconstruction, it is possible in some cases to fashion a completely new ear in two operations six months apart. The first stage takes between four and five hours. Under general anaesthetic, a replacement ear framework is carved from costal cartilage taken from the ribcage and inserted into a pocket made beneath the skin on the side of the head. If one ear is present, it is used as a model for the new one.
For tissues which have been damaged, it is sometimes necessary to first increase the amount of skin cover by inserting a tissue expander before the first stage, or by raising a temporoparietal fascial flap at the time of the first stage surgery. Some patients are referred after failed attempts at reconstruction and these are especially challenging. In some of these, a bone anchored prosthesis is the only option. It is very important to resist attempts at surgery to improve the appearance of the ear or scalp area before definitive reconstruction, as the blood supply to the new ear can be irreparably damaged and the results compromised.
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For tissues which have been damaged by trauma or previous attempts at reconstruction, it is sometimes necessary to first increase the amount of skin cover by inserting a tissue expander before the first stage,. This patient underwent tissue expansion after removal of an ear for malignant melanoma.
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This patient underwent temporoparietal fascial flap reconstruction to rescue failed attempts to reconstruct a childhood dog bite.
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This patient underwent tissue expansion after a bite injury
 tissue expansion 1 |
 tissue expansion 2 |
 tissue expansion 3 |
 tissue expansion 4 |
After extensive surgery in his own country, this patient required a TP flap but a successful outcome was still achieved.
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Although the cartilage used is a little stiffer than the opposite normal ear, most people prefer the autogenous technique. As results improve, it is unusual to choose a prosthesis unless the local tissues are so badly damaged that there is no other option, and it is not uncommon for patients who were originally offered only the prosthetic option to undergo autogenous reconstruction at a later date.
Once the advice was to cover the defect with long hair, or simply learn to live with it. A new “real” ear is now a realistic option.
Prosthetic ear reconstruction
The prosthetic technique also requires two stages, again both under general anaesthetic. The first involves removal of any ear remnant and the placement of two or three small titanium implants into the bone on the side of the head. These metal fixtures become firmly embedded into the bone and at a second stage, metal “abutments” are attached to the implants.
Once all has healed, extensions can be attached to the abutments and a false ear can be attached, in turn, either by a system of clips or magnets. A good prosthesis will last approximately eighteen months before it requires replacement. It should generally be removed at night so that the ear and the area around the abutments can be very carefully cleaned. Granulation tissue can build up around the abutments, and is a particular problem for those who normally live in hot countries.
 prosthetic fixtures |
 prosthetic ear |
Prosthetic reconstruction is preferred when the tissues or the blood supply at the site of the missing ear have been very badly damaged, either by trauma, disease or by previous surgery. Costs of regular prosthesis replacement (£1000 - £2500) can be prohibitive, however. It is not uncommon for patients who were originally offered only the prosthetic option to undergo autogenous reconstruction at a later date.
Relevant publications
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
Gore S, Myers S, Gault D
Mirror ear: a reconstructive technique for substantial tragal anomalies or polyotia
Journal of Plastic, Reconstructive and Aesthetic Surgery 59, 499-504 2006
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
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.
Tan ST & Gault DT. (1994)
When Do Ears Become Prominent?
British Journal of Plastic Surgery 47: 573 - 574
Tan ST, Shibu MM & Gault DT. (1994)
A Splint for Correction of Congenital Ear Deformities
British Journal of Plastic Surgery 47 : 575 - 578
Gault DT, Grippaudo FR & Tyler M. (1995)
Ear Reduction
British Journal of Plastic Surgery 48: 30 - 34
Gault DT. (1995)
Invited commentary on:
Congenital anomalies of the auricle: correction through external splints
European Journal of Plastic Surgery 18: 291 - 292
Laing H & Gault DT. (1995)
Bat Ears - A European Perspective
Christmas Edition of the British Medical Journal 311: 1715
Graham KE & Gault DT. (1997)
Endoscopic Assisted Otoplasty: a preliminary report
British Journal of Plastic Surgery 50: 47-55
Horlock N, Grobbelaar AO & Gault DT. (1998)
5-year Series of Constricted (lop & cup) Ear Corrections: Development of the mastoid hitch as an adjunctive technique
Plastic and Reconstructive Surgery 102: 2325-2332
Graham KE and Gault DT. (1998)
Clinical Experience of Endoscopic Otoplasty (Letter)
Plastic & Reconstructive Surgery 102:2275
Gault DT. (1998)
Ear Splintage
Face 5: 211-212
Gault DT. (1998)
Ear Reconstruction : Pitfalls and Tips
Face 6: 15-16
Gault DT
Reconstruction of the ear - a chapter for Principles and Practice of Head and Neck Oncology
Editors Peter Rhys Evans, Patrick Gullane & Paul Montgomery. Martin Dunitz 2003
Winner for George Davey Howells Memorial Prize for most distinguished published contribution to the advancement of Otolaryngology during the preceding five year
Gault DT
Total Reconstruction of the Pinna - a chapter for Scott Brown’s Otorhinolaryngology, Head and Neck Surgery, 7th Edition Arnold
Chana JS, Grobbelaar AO and Gault DT (1998)
Tissue expansion: a useful adjunct to auricular reconstruction
Face 6: 65-68
Gault D. (1999)
Reconstruction for microtia.
Journal of Laryngology and Otology Supplement no 23. Vol 113, page 27.
Botma M, Aymat A, Gault D, Albert D
Rib graft reconstruction vs Osseointegrated prosthesis for microtia: A significant change in patient preference.
Clinical Otolaryngology. 2001, 26, 274-277
Lawson K, Waterhouse N, Gault DT, Calvert ML, Botma M, Ng T.
Is hemifacial microsomia linked to multiple maternities?
British Journal of Plastic Surgery 2002 55, 474-478
Sabbagh W and Gault D
Location, location, location
Journal of Laryngology and Otology; 2004 118: 738-740
Bajaj Y, Wyatt M, Gault D, Bailey M, Albert DM
How we do it: BAHA positioning in patients with microtia requiring auricular reconstruction
Clinical Otolaryngology 2005 30: 468-471.
Horlock N, Vogelin E, Bradbury ET, Grobbelaar AO, Gault DT
Psychosocial outcome of patients after ear reconstruction - a retrospective study of 62 patients.
Annals of Plastic Surgery 54: (5): 517-524 2005
Harris P, Ladhani K, Das Gupta R and Gault DT. (1999)
Reconstruction of Acquired Subtotal Ear Defects with Autogenous Costal Cartilage.
British Journal of Plastic Surgery 52: 268-275.
Cicchetti S, Skillman J and Gault D
Piercing the upper ear: a simple infection, a difficult reconstruction
British Journal of Plastic Surgery 2002, 55, 194-197
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