Otoplasty:  When do I split cartilage and Why?

Otoplasty refers to cosmetic reshaping of one’s ears.  Typically, the problem is one of protrusion where the ears stick out too far from the head.  There are two major types of protruding ear deformities:  lop ear deformities and cup ear deformities, or a combination of the two.  A lop ear deformity refers to the absence of the antihelical fold, a fold that runs down parallel and between the inner concha and the outer helix.  A cup ear deformity refers to the oversize of the conchal bowl, the area near the ear canal, making the ears a rounded looking cup.  In reality, there is oftentimes a combination of the two problems that co-exist.  A third type of protrusion refers to the lobule, or bottom third of the ear, that can stick outward and should be reduced.  Or sometimes reducing the top 2/3 of the ear without adequate reduction of the lobule causes it to stick out more than it initially did.  There are many types of ear deformities other than lop and cup ear deformities.  However, this blog article will focus on the technical issues of whether or not to cut the cartilage during Otoplasty, a controversial subject.

cup ear, lop ear, otoplasty
This gentleman underwent a combination lop ear reduction (non-cartilage splitting) and a cup ear reduction (cartilage splitting) to achieve the desired results.

After seeing so many bad otoplasties that walk through my door, I have come to be very careful when deciding who should have a cartilage cutting procedure and who should not.  The rule that will be very simple here that I follow is lop ear deformities almost never get any cartilage cutting and cup ear deformities almost always get cartilage cutting.  The real problem is seeing the unnatural cut piece of cartilage along the newly created antihelical fold following lop ear correction.  This almost never looks good and is visible from even a casual distance.  The tradeoff of not cutting the antihelical fold is that the ear may relax just a little bit after an Otoplasty procedure, and that is something a patient should be aware of.  Rarely will an ear completely relax back to its native position but some relaxation of several degrees can occur when working on an isolated lop ear deformity.  Although I do not cut through the antihelical fold, I do believe in scoring the ear cartilage in multiple directions, i.e., partially cut through the cartilage without penetrating the front side.  By doing so, you can get a much softer, pliable ear cartilage that resists return to its native position without the need for cutting through the cartilage and creating a deformity.

With cup ear deformities, I almost always consider cutting through and actually removing some conchal cartilage for a variety of reasons. First, removing some conchal cartilage does not cause visible edges to show up because the incision resides within the conchal bowl, as I remove conchal cartilage very often when I perform corrective rhinoplasties without any problems.  Second, removing some cartilage is necessary because the condition of a cup ear deformity arises due to excess of conchal cartilage and tacking an excess of cartilage back to the mastoid is just not good enough to achieve a good result.  Third, over reducing a large conchal bowl without cartilage removal can narrow the ear canal.  Fourth, the chance of keeping the ear in its reduced state is very low given the nature of trying to tack down excessively large conchal cartilage.  For all these reasons, removal of 1 to 3 mm of conchal cartilage is sufficient and warranted when performing a cup ear correction.

As mentioned, many individuals have a combination of a cup and a lop ear deformity that requires a graduated approach to Otoplasty.  More often that not, a cup ear deformity will have some component of a lop ear deformity that mandates modification of both conditions; whereas many lop ear deformities do not require a cup ear reduction.

Samuel M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. To learn more about Dr Lam’s Otoplasty procedures please visit our website www.LamFacialPlastics.com or call 972.312.8188 to schedule a consultation.