Otoplasty complications — Those to treat today and those seen at six months
The difference between surgical complication and aesthetic sequela, haematoma and chondritis as emergencies, suture problems by material, the dysaesthesias nobody asks about, and the catalogue of preventable deformities with their mechanisms.
Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.
Key points
- Two things the literature mixes must be separated: the surgical complication — haematoma, infection, necrosis — and the aesthetic sequela — telephone ear, asymmetry, re-protrusion. The second is what generates long-term dissatisfaction.
- Excessive pain, especially unilateral or asymmetrical, is the herald of a haematoma and mandates opening the dressing and inspecting the wound. One does not wait to see how it evolves.
- Patient satisfaction is above 90 % in all series and with all techniques, and surgeon dissatisfaction exceeds the patient’s: 7.7 % versus 4.3 %.
- Persistent dysaesthesias are far commoner than believed, but only surface when explicitly asked about. That is why they belong in the consent conversation.
- Almost every postoperative deformity has an identifiable and preventable mechanism: almost none is bad luck.
Why published figures do not resemble each other
The incidence of complications after otoplasty varies enormously in the literature, largely according to how diligently each author recorded them. Since most complications are minor and sometimes irrelevant to the final aesthetic result, a high level of vigilance is needed to capture them all, and since most studies are retrospective chart reviews, the less conspicuous ones are systematically under-reported. The consequence is paradoxical: papers applying strict objective criteria publish higher complication rates, not because they do worse, but because they look better. With that caveat, large series give a coherent picture: major complications decidedly uncommon, minor complications surprisingly frequent with any technique, and mandatory revision at around 2 %.
Haematoma: the one real emergency
The reported incidence is in the low single digits, and it should be rare if the surgical plane is respected. Risk rises with wide undermining and with cutting techniques, especially those involving the anterior surface. Bleeding typically starts as the vasoconstrictor is metabolised, and the precipitating factors are local — inadequate haemostasis, ineffective compression, trauma — or systemic — hypertension, undiagnosed bleeding diathesis. Management brooks no delay: reopen, evacuate the clot, cauterise if a vessel is found — unlikely — close loosely over a passive drain, redress and cover with a broad-spectrum antibiotic, because a haematoma is a culture medium. Left to evolve, what follows is infection, post-inflammatory fibrosis, perichondritis or frank chondritis, with a profound and largely irreversible postoperative deformity.
Perichondritis: rare, but it defines the result
It is exceptional after otoplasty: a review of over 2,000 patients documented no cases. It evolves from an undertreated haematoma or superficial infection, or from foreign material — retained sutures, especially braided ones — that promotes bacterial colonisation and a host inflammatory reaction. Historically it was blamed on silk, though some defend its safe use across an entire career and instead report infectious problems with monofilaments and braided polytetrafluoroethylene. Whatever the cause, it must be recognised and treated immediately: wound exploration and culture, aggressive intravenous antibiotics covering Pseudomonas aeruginosa and Staphylococcus aureus, admission and close observation, and debridement of compromised cartilage if needed. And one hard but almost always correct decision: if a suture technique was used, remove the sutures. Correction is certainly lost, but reoperating later is infinitely preferable to irreversible cartilage damage.
Nausea and vomiting: not a minor detail
- The incidence of postoperative nausea and vomiting after otoplasty is high, especially in children: 15 to 40 % with antiemetic prophylaxis and up to 52-85 % without.
- The proposed mechanism is an auriculoemetic reflex, with Arnold’s or the auriculotemporal nerve as the afferent limb. It is a direct consequence of the auricle’s rich sensory supply.
- Pretreatment with transdermal scopolamine or ondansetron significantly reduces both vomiting and time to resuming oral intake, and should be given at or before induction.
- General anaesthesia explains much of the difference from adults. In one paediatric otoplasty series under local anaesthesia with sedation the vomiting rate was zero in 41 children, versus nearly half of 44 operated under general.
- And it is not only comfort: vomiting raises blood pressure and capillary flow to the operated area, and with it the very real risk of postoperative haematoma.
Late complications and their mechanism
| Complication | Mechanism | Management |
|---|---|---|
| Suture reaction and extrusion | Insufficient soft-tissue coverage. Resorbable sutures give local inflammation and stitch abscess early; braided permanent ones, indolent infections and foreign-body granulomas; monofilaments are less reactive but slip more | Remove the offending stitch. Prevented with a postauricular fascial flap covering the sutures, and by not excising too much skin |
| Banding or bowstringing | A suture in too superficial a subcutaneous plane, especially at the superior pole, or placed too distal to the antihelical fold | It is aesthetic and functional at once: particularly troublesome for spectacle wearers. Worsened by excessive skin excision and tense closure |
| Hypertrophic scar and keloid | Incidence below 5 % in all series. Almost exclusive to susceptible individuals and younger patients, especially with postauricular incisions | Personal or family history is the essential risk factor and must be asked about beforehand. Serial triamcinolone 10-40 mg/mL, silicone sheeting, and excision if unresponsive |
| Inclusion cyst | Microscopic entrapment of epithelium in dermis or subdermis during healing. Greater risk with small-incision or incisionless techniques if the needle does not re-enter exactly at the exit point | Simple enucleation and excision |
| Periauricular dermatitis | Reported in up to 9.8 % in long-term surveys, in the newly created folds. Commoner where there is overcorrection with excessively deep furrows | It rarely reaches the surgeon because it appears late, after discharge. It is detected only if asked about |
| Early contact dermatitis | A reaction to the topical antibiotic ointment: around 10 % of the population has a positive patch test, slightly more with neomycin than bacitracin | Withdraw the agent and avoid it in future. Topical steroid for symptoms, with the caveat that it too can cause contact dermatitis |
The dysaesthesias nobody asks about
It has long been assumed that persistent sensory deficits after otoplasty are rare. A long-term survey in a large series, sent to patients at least two years after surgery, suggests otherwise: residual pain in 5.7 %, persistent hypoaesthesia in 3.9 % and sensitivity to cold and touch in 7.5 %. In another study, 9.7 % acknowledged persistent hyperaesthesia when asked directly. Injury to the auricle’s rich sensory supply explains the initial symptoms, which usually resolve over several months; persistent pain and hyperaesthesia probably reflect failed regeneration of terminal fibres or faulty central feedback. And one practical detail deserves explicit mention: in a small group of patients cold insensitivity poses a real risk of frostbite, probably from disruption of the auricular blood supply. It is worth warning about and advising precautions.
The preventable deformities
| Deformity | How it happens | How to avoid it |
|---|---|---|
| Telephone ear | Antihelical suturing, conchal setback or skin excision excessive in the middle third, leaving the superior and inferior poles relatively prominent. Also from undercorrection or loss of correction at the poles | Tie the middle suture last and never overcorrect the middle third. Many authors recommend a dumbbell-shaped skin excision so as not to leave tension at the mid-pole |
| Reverse telephone ear | Antihelical overcorrection with conchal undercorrection: poles set back and the middle third standing off | It is the direct consequence of starting with the antihelix instead of the concha |
| Hidden helix | Over-tightening the scaphaconchal sutures: the helical margin ends up medial to the antihelix on frontal view | Check at each tie that the helix is still visible lateral to the antihelix. It is the rule that admits no exception |
| Occluded ear canal | Incorrect conchomastoid suture placement that displaces the conchal cartilage anteriorly | A posterior and superior vector of pull, and not placing the stitch too high on the conchal wall |
| Obliterated postauricular sulcus | Excessive setback reducing the helix-to-scalp distance below 10 mm: the stuck-down ear | Measure intraoperatively: target 15-18 mm at mid-auricle, no less |
| Protruding lobule | Correcting the cartilage and forgetting the cauda helicis and antitragus, which determine lobular position | A cauda-conchal or cauda-mastoid suture. Lobular asymmetry is also the one patients notice most easily |
Recurrence: distinguishing undercorrection from re-protrusion
They are not the same, though the literature conflates them. Residual deformity is undercorrection visible shortly after surgery; re-protrusion is a technical breakdown that degrades a previously acceptable result, usually becoming evident in the first months. Undercorrection occurs with any technique, but more so when a cartilage-sparing approach is used on a rigid framework whose spring has not been weakened. Re-protrusion is more typical of suture techniques, when intrinsic cartilage tension overcomes the suture effect: poorly located sutures, too few of them — concentrating tension so one pulls through — or failure to overcorrect intraoperatively. The most cited cause of pull-through is not having taken the perichondrial layers. Failures concentrate at the superior pole. And there is an honest divergence of schools: some add routine scoring because they consider slight re-protrusion inevitable; others prefer routine overcorrection, allowing for a loss that can reach 40 % of the initial correction. Less discussed, and sometimes the real culprit: failure to achieve sufficient conchal setback, a fault that has nothing to do with the antihelical sutures.
Asymmetry: what the surgeon sees and what the patient sees
- Exact replication of every manoeuvre in both ears — site and vector of sutures, location and extent of excisions — is what sustains symmetry. There is no shortcut.
- A rigorous statistical analysis found objective asymmetrical correction in 40 % of patients. But a protrusion difference of 2 mm or less goes unnoticed by the patient.
- Asymmetry is more noticeable in the lobule and less at the superior pole. And there is a geometric reason it is well tolerated: both ears are seen together only within about 15° of the midline in normal conversation.
- One figure worth keeping in mind: in a large series, surgeon-recorded asymmetry at follow-up was 5.6 %, but patient-reported asymmetry more than two years later was 18.4 %. Either patients judge symmetry differently, or asymmetry worsens over time. Both explanations demand the same thing: long follow-up.
- Overcorrection deserves an honest nuance: in one series with experienced surgeons it reached 39 % of patients operated with the Mustardé technique, and yet patients and families generally considered it attractive.
The patient who calls postoperatively
Is there excessive pain, especially unilateral or asymmetrical?
Is there erythema, warmth or discharge?
Months later: has the ear protruded again?
References
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- 2.Calder JC, Naasan A. Morbidity of otoplasty: a review of 562 consecutive cases. Br J Plast Surg. 1994;47(3):170-174.
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- 4.Mandal A, Bahia H, Ahmad T, Stewart KJ. Comparison of cartilage scoring and cartilage sparing otoplasty: a study of 203 cases. J Plast Reconstr Aesthet Surg. 2006;59(11):1170-1176.
- 5.Richards SD, Jebreel A, Capper R. Otoplasty: a review of the surgical techniques. Clin Otolaryngol. 2005;30(1):2-8.
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- 7.Honkavaara P, Pyykkö I. Effects of atropine and scopolamine on bradycardia and emetic symptoms in otoplasty. Laryngoscope. 1999;109(1):108-112.
- 8.Horlock N, Misra A, Gault DT. The postauricular fascial flap as an adjunct to Mustardé and Furnas type otoplasty. Plast Reconstr Surg. 2001;108(6):1487-1490.
- 9.McDowell AJ. Goals in otoplasty for protruding ears. Plast Reconstr Surg. 1968;41(1):17-27.
- 10.Adamson PA, Litner JA, Thomas JR. Aesthetic Otoplasty. Shelton: People’s Medical Publishing House; 2011.
Related specialty: Facial Aesthetic Surgery