What otoplasty involves, who it helps, and what to expect.

Otoplasty is surgery to reshape the outer ear. It is most often used to set back prominent ears, and the same principles are applied to other shape differences such as constricted, Stahl and cryptotic ears.¹ Prominent ears do not affect hearing, and the main burden is psychosocial, since protruding ears can lead to teasing and bullying.^1,2

Otoplasty is more than a century old, and over 200 variations have been described. Outcomes depend on the native anatomy of the ear, the surgical technique and attention to what the patient wants to achieve.⁷

Each third of the ear is assessed separately, because prominence can come from one or several parts at once.^1,2,8

• Upper Third: A weak or absent antihelical fold lets the rim and scapha stand away from the head.^2,8
• Middle Third: A deep or overgrown conchal bowl pushes the middle of the ear outward.^2,8
• Lower Third: A large or protruding earlobe causes prominence at the bottom of the ear, which is easy to miss before surgery.^1,8

The examination also covers the stiffness of the cartilage, existing asymmetry, prior ear surgery or trauma and any history of keloids.^2,8

Shortly after birth, maternal hormones keep ear cartilage soft enough to be reshaped with a splint. Molding ideally begins between 1 and 3 weeks of age, responds poorly after about 6 weeks and is not effective after 12 weeks.¹ Prominent ears are the shape difference most amenable to molding.¹

In a meta-analysis of 49 studies, success rates were 93% with a commercial system, 91% with custom methods and 88% with other commercial systems, without a significant difference between them.⁶ Complication rates ranged from 8% - 13% across methods, and a systematic review of 3,341 infants found that treatment typically started at about 5 weeks and lasted about 5 weeks.^6,9

Textbooks differ on the best age for surgery in children. Some surgeons operate from about age 3 or 4, while others wait until about age 6, when the child can take part in the decision.^1,2,8 Surgery does not need to wait for the ear to finish growing, and follow-up studies have not shown that otoplasty stops ear growth.^1,2,8

Children should not be pushed into surgery against their wishes.⁸ Adults can usually have otoplasty under local anesthesia, although stiffer adult cartilage can be harder to reshape and carries a higher risk of recurrence after suture techniques.^1,2,8

No single technique has been proven best. A systematic review found that all studies of cartilage-sparing otoplasty were low quality and concluded that a personalized approach, often combining methods, is needed.¹⁰ A meta-analysis found no significant difference in recurrence or reoperation between cartilage-sparing and cartilage-scoring techniques, and a 2026 review suggested that hybrid approaches may have lower recurrence, pending randomized trials.^11,12

A review coauthored by the author of this guide describes an integrated approach, in which known principles are matched to the patient's anatomy and goals.⁷

• Assessment: Both ears are prepared and measured so they can be compared for symmetry during surgery.^1,2
• Incision: The cartilage is reached through an incision behind the ear, hidden in the natural crease.¹
• Reshaping: The antihelix, concha and earlobe are corrected as needed, taking care not to pierce the front skin with sutures.²
• Check: The surgeon confirms that the rim is visible behind the antihelix from the front and forms a straight line from behind.^1,2
• Dressing: A bulky, protective head dressing is applied.^1,2

Setting the middle of the ear back too far creates a telephone ear deformity, in which the rim forms a curve rather than a straight line, so all three thirds are balanced.^1,8

Recovery milestones come from surgical textbooks and vary by surgeon. In a systematic review of 370 patients, regional nerve blocks lowered early pain scores compared with local infiltration alone.^1,2,13

In a meta-analysis of cartilage-sparing otoplasty, recurrence or reoperation occurred in 4.27%, suture erosion in 2.46% and hematoma in 1.34%.¹¹ In 562 consecutive cases, most revisions traced back to the design of the original operation rather than its execution.¹⁴

Overcorrection, sharp or unnatural contours, persistent asymmetry and narrowing of the ear canal from a displaced concha are additional risks surgeons plan around.^2,8

In a prospective study of 67 children followed for more than 2 years, health-related quality of life improved in 94.03%, and no child had a negative score.⁴ In 66 adults, 97% were satisfied, and the share with high self-esteem rose from 42.42% before surgery to 96.96% after.⁵

Some asymmetry between ears is normal in the general population and remains after surgery, so the goal is balance when the ears are seen from the front.¹

• Best Technique: Randomized trials comparing otoplasty techniques over the long term are lacking.^10,12
• Best Age: The ideal age for surgery in children is still a matter of surgeon preference.^1,8
• Molding Protocols: Ear molding protocols and outcome measures are not standardized.⁹