What are the competing factors in the decision making process? Safety comes first in any decision in medicine.

There are several groups who present for consideration of otoplasty. The most common group is children who present with their parents. Their parents fear or the child may have experienced bullying and ridicule at school due to the prominence of their child’s ears.

There is also a group who present at the later age of adolescence or young adulthood. This group may have fleetingly thought about otoplasty throughout their lives or have not had the support of their parents in pursuing surgery at an earlier age. They have then had the time to consolidate ideas about self-image before making an informed decision to pursue otoplasty.

The last and least common group includes children and infants with more severe ear abnormalities such as “lop’ ears, “cup” ear deformities or incomplete formation of the ears. Otoplasty in this last group becomes a more complicated exercise and is dealt with on a case–by-case basis.

When parents bring their children in for consideration of otoplasty, decision making can be challenging. Children are not able to provide informed consent, therefore a judgment has to be made about the benefits versus the risks of the procedure. This is based on the parents’ concerns in light of the actual physical features of the child’s ears. If a child is being targeted at school because of his or her ears then this is just as distressing for the parents as the child. The real concern is for the child’s social development and confidence. A surgical procedure is not the solution in all cases and it is important to explore the particulars of each story.

It is important to establish common ground between parents and some sort of agreement from the child. The decision to go forward with surgery cannot be comfortably pursued unless both parents agree with the reasons for the surgery. Children are very perceptive. They will often pick up on the difference of viewpoints and this may become a source of confusion and anxiety for them. It is best to try and clarify these opinions before engaging the child in the discussion. If there is a real difference of opinions, it is not unreasonable to have a consultation with your surgeon in the absence of your child to explore these views. If you decide to first consult with your surgeon without your child present, it is worth bringing photos of your child’s ears from multiple perspectives (front, back, side, oblique, bird’s eye) to supplement the discussion. There is no right answer in every case, but the decision you make will be the right one for you.

What are the competing factors in the decision making process? Safety comes first in any decision in medicine.

There is no ideal age for otoplasty, but there are certainly significant considerations. A general anesthetic is safe in infants and toddlers, however, there is less room for error as they have limited physiological reserves compared to an adult. The risk benefit profile of this procedure therefore favors operating on an older child rather than an infant. In addition, a younger child may be less compliant with the process of consultation, anesthesia, and recovery, including dressings and pain relief.

From a technical perspective ear cartilage is most malleable at a younger age and becomes less so as we get older. The ear cartilage is still plastic in later years, but certainly has more memory, making the surgery slightly more difficult with a higher rate of operative failure. In addition, the ear has not reached its full dimensions until approximately 6 years of age. It is unwise to operate on an ear before it has come close to its full growth potential as this may impair or disrupt normal ear development.

From a psychosocial development perspective, bullying behavior and targeting based on physical features can happen in groups of children as early as three years of age, however, it is more common as children become more aware of others around them and are better able to articulate their opinions. At the age of five to seven they may experiment with all sorts of behaviors including highlighting differences that they see in other children. Some of these behaviors are learned and some reflect their growing awareness of the world around them. The timing of surgery ideally should precede behaviors from other children that might negatively affect a child’s self esteem or social development.

In teenagers or young adults, the timing of surgery is usually self-selected as they come to the decision to pursue surgery for something that they have thought about and have been concerned about for many years. It may have affected their daily lives significantly with many of these patients learning different strategies to hide their ears or avoid situations in which they are forced to expose their ears in some way. These strategies can involve having longer hair, pinning back ears with clips hidden in the hair, beanies or head gear and even avoiding jobs where head gear is worn that exposes the ears.

Having balanced all these considerations, the ideal age for otoplasty as you might imagine is a little different for every patient. For children, a convenient time to have it done is during the school holidays in children of the age five to eight years of age. During this age range most of the boxes are ticked making it a reliable and safe procedure.

The procedure involves a general anesthetic followed by a day or overnight hospital stay. The approach is through a skin incision in the crease behind the ear. The ear cartilage is then moulded with variety of techniques including sharp reshaping and permanent sutures. Sometimes excess cartilage and skin is removed to decrease the size of the overall ear. Local anaesthetic is infiltrated into the tissues to ensure that there is good pain control in the immediate post-operative period. Often there will be bandages, which stay intact for approximately 5 days. This is not always the case and depends on your surgeon’s practice. In the post-operative period some surgeons will recommend wearing a head-band or beanie at night and during at risk activities for a period of 2-4 weeks. This is to ensure that the ears are not inadvertently bent forward potentially breaking the repair. Once again this depends on your surgeons practice.

Other things to expect from otoplasty surgery include a scar behind the ear, which is tender for a short time but will heal to imperceptibility. Post surgical swelling and thickness of the ear can be quite pronounced. This will last for up to three months even though most of the swelling will have subsided by the first month. It is common to experience changes in sensation to the skin over and behind the ear. This once again settles with time, but occasionally there can be area of permanent loss or change in sensation. Subtle asymmetries are common and are to be expected. Over or under correction can occur, but would need the

luxury of time to assess the final outcome of the surgery before re-operation is considered. Some unexpected complications include infection and bleeding which are both very uncommon events. It is by and large a relatively pain free and well-tolerated surgery. In fact, the presence of pain raises the concern of possible unexpected bleeding, which may require a return to theatre to address the problem. If this does occur, it should not change the overall outcome of the repair.

Overall, otoplasty is a very effective procedure in addressing more than physically prominent ears. It alleviates the concerns related to having a prominent physical feature diverting the focus of daily life from the ears to things of greater importance. If you are thinking of having the surgery, explore this with your local doctor who can then refer you to ours surgeons.

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