INTRODUCTION
Otoplasty, or "ear refinement," is surgery to correct excessively protruding, oversized, or otherwise malformed ears. The procedure typically involves repositioning the ears with sutures and cartilage adjustment and may include removing some cartilage and skin from the external ear, or auricle. The goal of surgery is to give the patient a set of natural-looking ears with little or no visible scarring.

In most cases, ear protrusion is a developmental defect in which the ear cartilage fails to fold back toward the head properly. This may be caused by an inherent weakness in the muscles of the external ear.

Ear protrusion can also be an acquired defect. For example, babies can fold one ear forward when lying with their head turned to one side for the first few weeks of life, notes the website of the Medical Genetics-Birth Defects Center at Cedars-Sinai Medical Center in Los Angeles.

In some cases, surgery can be avoided if the baby wears a special tubular elastic net headband when lying down. So-called "head banding" is recommended throughout the entire first year of life, the Cedars-Sinai website states.

About the Procedure
The surgeon begins by making a small incision behind the ear to access the cartilage. Several cuts are then made in the cartilage, and permanent stitches are placed in such a way as to tack the ear back into a normal position. These permanent stitches are made of nylon, polypropylene, or another non-absorbable material. The material used is the surgeon's preference.

If necessary, some ear cartilage and skin may also be removed during surgery. After correcting one ear, the patient is turned so the procedure can be repeated on the other ear. In rare instances, only one ear requires otoplasty. Symmetry is often more important than the actual distance of protrusion from the ear to the head.

Once the permanent sutures are in place, the skin is sewn closed, and the ears are bandaged. The bandages are worn for a week before the external stitches are removed.

The procedure takes 60 to 90 minutes per ear, and is usually performed on an outpatient basis. Adult otoplasty patients typically receive local anesthesia plus a sedative. Most surgeons prefer to give children general anesthesia. If, however, the child is highly motivated to have the surgery and is extremely cooperative, local anesthesia with sedation can be used.

Who Is a Candidate?
Anyone with protruding ears, too much cartilage in the ears, or other ear defects is a potential candidate for otoplasty. Children comprise the bulk of otoplasty patients in the United States. About 4,700, or 59 percent, of more than 8,000 otoplasties performed by members of the American Society of Plastic Surgeons (ASPS) in 1998 were on patients 18 years old or younger. According to the ASPS, most children who undergo otoplasty are between 4 and 14 years of age.

A strong argument for having otoplasty early in life is to protect the child from taunts. When it comes to teasing, children are nondiscriminatory. They will key in on any obvious defect to make a peer feel miserable and self-conscious. While protruding ears is not considered unattractive in all cultures, an American child with protruding ears is far more likely to be called "Dumbo."

Even though the ears in males naturally protrude more than females, ear protrusion is more of a social problem for American boys since they tend to wear their hair short. Girls can hide the defect by wearing their hair long. However, as girls grow older, protruding ears may discourage them from wearing their hair short or pinning it back, or showing off earrings.

Preparing for Surgery
Avoid eating for eight hours before the operation. This reduces the risk of vomiting from the drugs you will be given for the surgery. To help reduce your infection risk, take a shower and wash your hair the night before and the morning of surgery.

Pain
Otoplasty may be followed by mild postoperative pain, which can usually be controlled with acetaminophen. If pain continues longer than 24 hours or is more severe on one side than the other, contact the surgeon right away.

Recovery
After the bandages come off a week after surgery you will need to wear a sweatband-like splint day and night for about six weeks to keep your ears folded back and protected. To help protect the permanent sutures from breaking, you should avoid all sports and physical activity during the recovery period, which can last six weeks or longer. Most children who undergo otoplasty need frequent reminders to not touch their ears throughout the healing process.

As long as you are wearing the headband and avoiding physical activity, you will probably be able to return to work or school a day or two after surgery.

Risks
As with any type of surgery, otoplasty carries a risk of postoperative infection, excessive scarring, and deformity of the ears. Treatment or touch-up surgery can often correct these problems, which occur in about 5 percent of otoplasty patients. The original deformity would reassert itself if the permanent stitches break within the first month after surgery. In such cases, otoplasty would be repeated.

Should the permanent stitches behind the ear become infected, treatment with antibiotics is required. In a small percentage of patients, the permanent stitches eventually erode through the ear cartilage. In such cases, repeat otoplasty would be indicated.

Another risk is ending up with asymmetrical ears. If the asymmetry is readily apparent, touch-up surgery can often correct the problem. Patients should realize going into surgery that most people's ears are not perfectly symmetrical to begin with. By keeping your expectations realistic, you are likely to be more satisfied with your result.

Costs
The surgeon's fee generally ranges from $2,000 to $4,000, depending on whether one or both ears are being operated on. Another $1,500 is assessed for the anesthesiologist and operating room fees. Health insurers usually do not cover otoplasty.

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