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Chapter Nine The Ears Flyaway Ears Surgery

Flyaway Ears

The ear is an organ that controls balance as well as hearing. It is composed of three parts: the inner ear, middle ear and outer ear. The auditory nerve in the inner ear, that part of the ear nearest to the brain, transmits hearing signals to the appropriate parts of the brain through tiny parts called the “cochlea.” The middle ear contains the delicate bones named for their shapes - the “hammer”, “anvil” and “stirrup” - which collect information about hat we hear and pass it on to the cochlea of the inner ear. The middle ear also contains the “eustachian tube,” which is connected to the nasal cavity and acts to equalize air pressure on the inside of the eardrum with pressure outside. The eardrum itself, a thin membrane, separates the middle ear from the outer ear. It is the outer ear that we operate on with an otoplasty for flyaway ears.

The outer ear has several distinct parts, most of which are designed to collect sound waves and funnel them into the middle ear through the ear canal. The deepest part of this canal is the only part of the outer ear that is not visible to the eye. The parts of the outer ear that are visible - the folds of skin and cartilage known as the “pinna” - are the cosmetically important areas that otoplasty can improve.

There are three basic components to the phenomenon of flyaway ears. First, there is the “anti-helical fold,” which is the crease in the visible part of the ear just under the outer rim, which is called the “helix”. The fold causes the “helix” to curve inward at the top of the ear. Without the fold, the ear stands out from the head; it “flies away.” Some people are born without the anti-helical fold; it usually is a genetic defect, passed through generations of a family even if it skips a generation or two. Second, associated with this unfurling of the fold, the earlobe, or “lobule” as it is called, might extend from the head horizontally, instead of hanging down as it should. Third, the “conchal bowl,” the bowl-like depression in the middle of the outer ear, might be too big. Technically, the bowl is actually too wide, and its width causes the ear to push out, or rotate away from the head. None of these physical characteristics affect hearing; neither does an operation to correct flyaway ears.

Normally, ears protrude from the head by about fifteen to twenty millimeters. Flyaway ears stick our further, sometimes a little, sometimes a lot. It is not unusual to treat a patient with only one flyaway ear or ears that stick out at different degrees. The thing to remember is that no two ears are exactly the same even on the well-proportioned person with no need for otoplasty. Some of my adult patients need counseling before otoplasty to fully understand that it is not an exact art and that their ears still might not be identical after surgery. Usually, I can make my case by pointing out the differences that already exist in their ears. Most earlobes, for example, are at different heights. If all else fails, I’ll show them the evidence of my own ears, my secretaries’ ears and assistant’s ears: no two ears are the same on any one head.

We start the procedure, then, with an analysis of the degree to which the anti-helical fold has unfurled, the depth of the conchal bowl and the plane of the lobule. During the analysis, the cartilage of the outer ear is checked for its quality, or “spring”. (You can spring back into position, the quality of your cartilage is elastic or springy.) Cartilaginous quality will dictate some of the suturing technique in the last part of the otoplasty; a too springy ear may require more stitches or surgical techniques to weaken the cartilage a bit. In children, the cartilage is less springy, which makes their ears more amenable to correction.

What we are trying to accomplish with an otoplasty is to create a natural angle between the ear and the head. If it’s missing, we also want to create an anti-helical fold that looks as natural as possible. And we’ll air for angling the lobule so that it’s on the same plane as the anti-helical fold. If you take a look at yourself in the mirror, you’ll see that your lobules, or earlobes, are on the same angle as the upper part of the ear; they don’t, or shouldn’t, stick out independently. You might also notice that it’s important that they are as evenly proportioned as possible from the face-to-face view. Try pulling one lower than the other - it makes your face look a bit off-kilter.

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