In A Reverse Otoplasty Will A Rib Graft Strut Feel Stiff Behind My Ears?

Q: Dr. Eppley,I’m interested in undergoing a reverse otoplasty targeting the lower and middle portions of my ear. I previously had otoplasty and part of the ears are too close to my head. From my research, I believe this may require the use of a grafting material to achieve the desired projection. Given your extensive experience with these procedures, I’d greatly appreciate your insight into a few questions I have: 1. Is it possible to achieve the desired ear projection without using an implant? In other words, could existing ear cartilage be harvested and repositioned to act as a structural strut? If so, would this compromise the aesthetics, structure, or shape of another part of the ear? 2. If cartilage harvesting is not viable, what materials are commonly used as struts, and what are their pros and cons? I’ve researched several materials and would like to know your thoughts on each: • Cadaver Rib Cartilage: This seems quite stiff—comparable to a popsicle stick. But this is just my uneducated opinion in looking at online pictures and reading that ear cartilage is elastic while rib cartilage is hyaline (and much stiffer). Could this rigidity become problematic or painful/irritating when side sleeping? I’ve also read that cadaver cartilage may reabsorb over time. If that happens, would the ear lose its projection? And what does reabsorption mean in these cases? Additionally, why is cadaver ear cartilage not commonly used? Could it provide subtle support in projecting while preserving the natural softness of the ear? • Implantech ePTFE Ear Implant: This material appears to mimic the flexibility and texture of natural ear cartilage. However, it doesn’t seem to be widely used. Is there an elevated risk of infection associated with this implant? If so is it a lifelong risk or just for a period of time after surgery? • AlloDerm: While not commonly used for this purpose, could AlloDerm serve as a strut to project part of the ear outward? Is it strong enough to act as a buttress in the cartilage? Does it carry a significant infection risk? Is its texture similar to ear cartilage? Meaning it is softer/ flexible. Can it reabsorb like rib cartilage? It says this can promote tissue regeneration. What does this mean? Can something natural regrow to take its place and maintain this buttress in the ears? • Medpor Ear Implants: What exactly is Medpor? Is it a rigid plastic or something more flexible like the ePTFE material from Implantech? My primary concerns are: • Will the graft material remain stiff permanently if using cadaver cartilage or another material? • What is the long-term risk of infection? Is infection only a concern during initial healing post-surgery for some time, or can an infection on some materials develop years later even without injury to the area such as a cut? Thank you in advance for your time and guidance. I look forward to your thoughts.

A:You have correctly surmised that in a reverse otoplasty it takes a strong strut of material to push the ear out and maintain that position. I have used a wide variety of materials from titanium plates to cadaveric rib cartilage. They all have had various degrees of success but the rib cartlige has been the most successful as it provides the strongest strut. As you have also surmised the trade-off for its use is that it will be stiff on the back part of the ear. It is also a graft does not resorb as it acts more like an implant even though it is a biologic material.

The other most successful option would be an ePTFE wedge material from the ear implants that I developed for implantech. That could be placed in the released anti-helical fold and would avoid the stiff feeling strur on the back of the ear. Its trade-off is that it is an implant with associated higher risk of infection/extrusion. But in my experience to date that risk is very low. No implant material, however, can never better the negligible risk of infection with a biological material.

Dr. Barry Eppley

World-Renowned Plastic Surgeon