Prominent Ears

Prominent ears are not a congenital anomaly, and this must be clearly communicated to patients. Prominent ears are an aesthetic variation, which tend to be poorly accepted in Western cultures. In many Asian cultures, prominent ears are considered a desirable facial feature.

The parents usually decide whether their child will undergo setback otoplasty to correct prominent ears, because they want to reduce the amount of psychosocial harm to the child from bullying or teasing during the school-age years. The parents may also make this decision, because they have prominent ears or had setback otoplasty in the past.

Generally, we do not think that it is advisable to operate on aesthetic variations of prominent ears in very young children. We prefer to wait until children can express a desire to change their appearance, and we can personally assess their motivation. This may occur in children as young as 7 years old, which is the youngest age we will consider performing otoplasty.

This 7-year old patient was teased at school and asked his parents to consider fixing his abnormal-looking ears. Late follow-up shows a satisfactory result, and the patient demonstrates that correction of the prominent ears had a good psychological effect.

During the initial consultation, the various features of the prominent ear deformity should be examined. We consider four factors in this assessment, each of which will be explained in detail:

1. Unfolding of the posterior root of the antihelix

2. Valgus of the concha

3. Hypertrophy of the concha

4. Prominent lobule

These factors are often interrelated and should be corrected simultaneously in most cases.

Posterior Root of the Antihelix

Unfolding of the antihelical fold is commonly considered a hallmark feature of prominent ears.

The surgeon must assess which part of the antihelix has unfolded and the degree to which it has unfolded. The most frequently unfolded part is the posterior root of the antihelix, but it may be the whole antihelix.

Examples of Different Degrees of Unfolding

In this 7-year-old girl the superior part of her small ears is prominent mostly because of the unfolded posterior root of the antihelix.

Both the anterior and posterior roots of the antihelix are unfolded in this 9-year-old girl.

The entire antihelix is unfolded in the very large ears of this 7-year-old boy. In more pronounced cases such as this, we may consider surgery at a slightly younger age.

Valgus of the Concha

Some patients have a condition that we call valgus of the concha. In normal ears, the floor of the conchal bowl is almost in direct contact with the mastoid. Prominent ears typically have a valgus between the floor of the conchal bowl and the mastoid process.

As a result of this valgus, the conchal bowl appears excessive from the frontal view. After the conchal bowl is correctly repositioned posteriorly, it is usually of normal size; thus the enlargement was not a true hypertrophy of the concha. The surgeon must check from the posterior view the angle made by the floor of the concha with the mastoid.

In this case, correction of the prominent ears included folding the antihelix, but conchal bowl reduction was not needed, because it was sufficient to simply reduce the angle between the mastoid and conchal floor.

“True” Hypertrophy of the Posterior Wall of the Concha

Although the height of the posterior wall of the concha can be true excess (or conchal hypertrophy), we think this is far more rare than others may think. This should be checked from the posterior view.

These three patients have not only a valgus of the floor of the concha but also a very high posterior wall of the concha. In this situation, reduction of the conchal bowl may be indicated.

When the ears are observed from behind, the distance between the sulcus and the contours of the antihelix is very long. This demonstrates that the posterior wall of the concha should be reduced.

We perform a maneuver at the start of the operation (which can also be done in the consultation) showing that if we correct only the valgus of the concha, the antihelix may appear very prominent from the frontal view.

Prominence of the Lobule

Another deceiving feature of otoplasty is that the lobule may become prominent after the conchal bowl is repositioned. Many different techniques have been described to address a prominent lobule, including skin and subcutaneous tissue flaps, although few are reliable.

While performing otoplasty, we have noticed that the lobule becomes excessively prominent when the auricular fibrocartilage is manipulated into a setback position. The underlying reason for this is that a cartilaginous structure determines the position of the lobule. We consider this anatomic feature to be the tail of the antihelix, and we dissect and reposition this anatomic structure routinely.