Author: Walid Sabbagh

Ear Reduction – Macrotia Surgery: What is involved?

Ear Reduction – Macrotia Surgery: What is involved?

Written by Walid Sabbagh, April 11, 2022

Why reduction in ear size may be required

Macrotia is the medical term for oversized ears. The term is used to describe ears that are significantly larger that the average ear size. An increase in the vertical height and width of the ear beyond the normal range makes the ears appear excessively large which can be an unattractive feature and a significant source of concern for patients.

The vertical height of a normal ear ranges from 5.5 -6.5 cm. The average for a female ear is around 5.9cm and for a male ear 6.2 cm. Usually when the vertical height exceeds 6.5 cm the ear can appear enlarged. Age, sex, height and head size all play a part in how large the ear may appear.

What parts of the ear are usually enlarged?

In the majority of cases the enlargement is in the upper third of the ear as a result of a wide enlarged scapha, also known as scaphoid fossa (shaded blue in photo diagram). The scapha is the flattened area between the helical rim (red) and the antihelix (yellow). This is the part of the ear that is most commonly reduced in ear reduction surgery. Enlargement of the scapha will make the ear appear tall and wide. The upper half of the ear may also appear prominent but ear pinning operations (otoplasty) for enlarged large ears will result in an unsatisfactory outcome. The correct procedure is to reduce the size of the scapha.

In some patients the ear lobe is the cause of the enlarged ear which makes the ear look very bottom heavy. This can be addressed by an earlobe reduction procedure. Some patients require a combination surgery to reduce the scapha and the ear lobe. Both types of reductions are safe to do and can also be performed under local anaesthetic.


How is Macrotia Surgery performed

Reducing the upper pole of the ear (Scapha reduction):

A crescent shaped area is marked on the scaphoid fossa as shown in the photo diagram. The size of this will depend on how much reduction in size the patient wants and the overall balance of the ear. Both the skin on the front of the ear and the underlying cartilage outlined by this crescent are removed leaving a gap between the rim and the antihelix. The skin on the back of the ear is not removed.

The intervening area created by the excision is closed by advancing the helical rim in a downward direction towards the antihelix. To avoid any distortion of the ear some excess in the helical rim will also need to be removed. The degree and location of the rim removal will vary between patients. The optimum scar for removing the excess rim is at the junction with the ear lobe as shown in the photo (at 3 weeks). This, however, could be located anywhere along the rim of the ear depending on the shape and structure of the individual ear as well as any previous surgery.

The closure of the crescent results in a scar hidden within the fold of the ear. The site of excess rim excision is closed meticulously and the resulting scar will be almost invisible after a few months.
The surgery normally takes about 90 minutes and is performed under local anaesthesia. The antibiotic ointment is used on the suture line which is covered with a strip of cotton wool. A wrap around bandage is applied after surgery which can be removed the next day. All the sutures are dissolvable and most activities can be commenced within 1-2 days.

How is ear lobe reduction Surgery performed?

There are two techniques to reduce the size of the ear lobes. The first is to remove the lower part of the lobe. The front and the back are then approximated together and the scar is hidden on the lower margin of the ear lobe and will not be visible.

This is an excellent technique for heavy drooping ear lobes and the reduction can be fully tailored to any size the patient would like to have. This technique is not optimal for ear lobes that also stick out as the reduction will not bring them closer to the head.


In the second technique a vertical and a horizontal wedge are removed from the ear lobe as shown. This advances the ear lobe forward and can also partially bring in an ear lobe which sticks out. The technique will leave a scar at the junction of the ear and the face and after about 6 months the scar is almost invisible.

Both techniques are very effective in reducing the ear lobe. As they achieve this aim in different ways the outcome is slightly different between them and it is best to assess this accurately in the clinic to decide which is most suitable.

Is ear reduction safe?

Ear reduction surgery is a very safe operation when performed by an ear specialist as it requires experience, accuracy and appreciation of how the ear alters its shape during the reduction process. When the operation is performed with focus on precise marking, meticulous technique and appreciation of ear skin blood supply complications are negligible. In addition, by performing the procedure under local anaesthetic risks from a general anaesthetic, although extremely rare, are also eliminated.

What are the risks?

Complications that can occur following ear reduction are rare and minor. There is always a degree of swelling, most of which resolves by the second week. In the first 24 hours minor bleeding from the wound may occur which is of no consequence. Infection risk is very small (1%) and responds well to antibiotics. Scars can be slightly red in first 3 months but always settle down.

There is am increase risk complication in smokers and it is recommended to stop smoking for 6 weeks before surgery as nicotine constricts the blood vessels decreasing the blood supply. Also ears which have had previous surgery need to be assessed carefully as any scarring interferes with the blood supply. In nearly al cases, however a reduction can still be safely performed.

What happens during ear reduction surgery?

The majority of ear reduction operations are performed under local anaesthetic. Measurements and precise marking are first performed. The ear is then made numb by direct injection of local anaesthetic (same as used by the dentists).

This process takes five minutes to complete and the ears will remain numb for 3-4 hours after. The ears are then cleaned and prepared so surgery can be performed in a sterile environment. The process takes about 90 minutes during which it is possible for the patient to chat and to listen to relaxing music if this is helpful.

The eyes will be covered during the operation with a damp gauze as the theatre light is quite bright. Once the ears have been reduced in size the patient will be given a mirror to see the result and minor adjustment can still be made at this stage if the patient wishes. It is only when the patient is satisfied with the outcome then a dressing is applied.


What happens after ear reduction surgery?

At the completion of the operation antibiotic ointment is applied to the wound and soft cotton wool placed over the stitches. A bandage is then applied which will hold the dressing in place over for the first night. The bandage is removed the next day and a very soft head band is provided to cover and protect the ears. There is minor discomfort following the operation which is well controlled with paracetamol / ibuprofen. Most gentle daily activities can be resumed the next day. It is best to delay vigorous physical activities for 2-3 weeks until the wounds have completely healed. Following wound healing the ears may remain slightly tender to touch for a few months as the scar remodels. After 6 months the scar is almost invisible.

When will I see the results of ear reduction surgery?

You will be able to see the results of ear reduction surgery immediately in the operating theatre at the completion of the operation before a bandage is applied. The bandage can be removed the next day and the result of the reduction will visible but at this stage there will be some cotton wool over the stitches in the scapha and it is important to appreciate that at this stage there is some swelling. The swelling will reduce over 2 weeks and the stitches will fall out on the third week. Most of the swelling would go by the third week. The final 10% of swelling may take up to 6 weeks. The surgical scar will be slightly red initially but will be almost invisible after three months.

If you are interested in ear reduction surgery, please contact the office.

Recovery from Stitch Otoplasty

Recovery from Stitch Otoplasty

Written by Walid Sabbagh, January 27, 2021


Otoplasty (correction of prominent ears) is the most common cosmetic surgical operation performed on the ear. Over the years the procedure has been refined so it has a quicker recovery with less down time. It is now performed under local anaesthetic (except in young children) without the need for bandages. The operation is very safe as the ear cartilage is manipulated from the back with stitches which eliminate any serious complications that can occur with more invasive techniques.


The terms stitch otoplasty or ear stitch are used to reflect the simpler approach. It is important to stress that despite its relative simplicity it should be performed by a surgeon who has an interest in ear surgery as the approach must be tailored to the individual depending on the elasticity and shape of the ear. 

For Otoplasty the recovery period is relatively short. Patients can expect to return to daily activities / work within a few days without having to wear a bandage and children can return to school after a week. There are various stages in the complete recovery after an Otoplasty and these are best sub-divided into the following timeline:

  • From surgery to Day 1
  • Day 1 to Day 7
  • Week 1 to Week 2
  • Week 2 to Week 4
  • Week 4 to Month 3
  • Month 3 to Month 6

From Surgery to Day 1

The surgery is performed from the back of the ear with no skin removal necessary. The skin is closed with dissolvable stitches and immediately after surgery antibiotic ointment and a thin strip of wool are placed on the back of the ear. A soft bandage is placed around the ears whose aim is not to compress the ears but just to provide a secure a dressing for the first night and make the patient comfortable. The ears will continue to be numb after surgery as the effect of the local anaesthetic would still be ongoing. This lasts for approximately one hour after which localised pain around the ears will be felt. Pain killers are given prior to discharge. I prefer to give co-codamol (paracetamol plus codeine) initially. This is then changed to paracetamol after about 2 days. The patient is advised to take pain killers regularly, sleep on his / her back for the first night and to slightly elevate the head.

From Day 1 to Day 7

The bandage is removed the next day after surgery. There will be some swelling to the ears although there is usually minimal visible bruising as the procedure is performed from the back of the ear. Pain around the ears is likely to be present during this period and the patient is advised to continue with regular co-codamol or paracetamol. There are no visible stitches from the front. Patients can resume many gentle daily activities from day 1 after surgery. It is even possible to do light work or return to the office within 2-3 days. It is normal for the ears to feel numb to touch at this stage.

The thin wool which was placed at the time of surgery behind the ear should stay on without the bandage. This covers the wound and therefore the patient is not required to do any change of dressing. If the wool behind the ears falls off then the patient is advised to gently wipe the wound with sterile saline and gauze (provided) every 1-2 days.

The patient is asked to avoid washing the hair and to wear a soft band at night to protect the ears. During the day a head band is not necessary but some patients may prefer to wear one as it gives a secure comfortable feeling. Towards the end of this period the pain will significantly subside.

Week 1 to Week 2

After the first week patients are allowed to shower the head as normal, preferably with a gentle shampoo. Pain should have resolved at this stage but the ears will be tender to touch. Patients should be able to comfortably return to work after the first week and children can safely go back to school. Specific advice will need to be given to children regarding playing and sports. There will still be mild swelling to the ears at this point and the ears will feel numb.

A soft head band is recommended to be worn at night to protect the ear during this week. During the day it is not necessary but may be preferable for children as they are accident prone or in adults if they are in a dusty environment. This can be removed as needed.

Week 2 to Week 4

Most of the swelling resolves during this period. The ears will not be painful but continue to be tender to touch with numbness which differs in patients. A head band is not required during the day but it is advisable at night to protect the ears. Patients are able to carry out all their daily activities but return to vigorous physical activity / sports should be gradual (see below section on physical activity).

The dissolvable skin stitches behind the ear fall off around week 3 and the surgical scar, which is not visible from the front, will be red at this stage. It is advisable not to enter a swimming pool till after week 4.

Week 4 to 3 months

Nearly all the swelling should resolve during this phase of healing. The ears may still feel tender to firm touch and there will still be some numbness at this stage. All aspects of daily life should have returned to normal. Sport activities can be increased back towards pre-surgical levels. Care will still need to be taken in contact sports.

3 Months to 6 Months

During this period any remaining swelling should fully resolve and the ears regain normal sensation. Very minor tenderness to touch (not pain) can persist up to 6 months. The red scar will become paler and by 6 months is usually only visible on close inspection. By the end of this period full recovery should have occurred.

Physical activity and Sport

Most of physical activities that involve no contact can be resumed after the second week although less vigorously. These include jogging, cycling and gym. Such activities would not affect the healing or the surgical outcome however strenuous exercise may increase swelling to the ears and patients are advised not to return to their pre-operative level till 4 weeks have passed. Swimming in the pool / sea should be avoided in the first 3 weeks to avoid exposure to any bacteria whilst the ear is healing.

Special precautions would need to be taken for contact sports such as football and rugby. Competitive football can re-start after 4 weeks and rugby after 6 weeks and it would be prudent to protect the ears with a sport headband or a rugby cap for up to 3 months. Sports that involve more significant contact and possible blows to the ears, such as boxing and martial arts, a delay of 3 months from surgery is recommended and the ears should be protected for up to 6 months.

Earfold, ear-stitch and non-surgical ear pinning: key points

Earfold, ear-stitch and non-surgical ear pinning: key points

Written by Walid Sabbagh, November 17, 2020

Terminology in ear pinning 

There are numerous methods to correct prominent ears and choosing the appropriate method can be confusing. Surgery to correct prominent ears is known either as pinnaplasty or otoplasty; both terms are inter-changeable. There are two main otoplasty techniques: the use of stitches to alter cartilage shape or cartilage scoring/weakening.

For most surgeons the use of stitches (stitch otoplasty) is the technique of choice as it is safer and more predictable. It can now be performed under local anaesthetic, without the need for bandages with a relatively short recovery. 

The term ear-stitch has recently been introduced. Ear stitch is essentially stitch otoplasty with emphasis on simplicity. It therefore differentiates stitch otoplasty from the more invasive cartilage scoring otoplasty.

The Earfold implant was developed to provide a simple ear pinning alternative procedure avoiding general anaesthetic, bandages and prolonged recovery. However, the stitch otoplasty /ear stitch has also become relatively straightforward so these advantages are not exclusive to the Earfold. This article will help to clarify advantages and disadvantages of the various techniques and help you make an informed choice.

What about non-surgical ear pinning?

There are some websites which promote the earfold as non-surgical pinnaplasty. This is misleading as the earfold is a minimally invasive minor surgical procedure. It requires the use of a minor operating theatre, local anaesthesia and surgical instruments. Like any minor procedure bleeding, bruising and swelling can happen as well as the small risk of infection.

The only non-surgical technique which may be applicable is ear splinting, such as the use of ear buddies. Ear splints work best for misshapen ears and are less successful for prominent ears. They are best applied to a new born baby up to the age of six months as the ear cartilage at this age is extremely soft and pliable and it may be possible to alter its shape without surgery. Such splints need to be applied for a minimum of six weeks. They are effective for ears with abnormal shape but the improvement in protruding ears is partial. In addition, prominent ears are not present at birth in over 50% of cases.

What is Incisionless otoplasty

Another technique which may be perceived as non-surgical ear pinning is incisionless otoplasty. This is also a surgical procedure which aims to insert exactly the same stitches needed in the ear stitch / stitch otoplasty technique without incising the skin by passing the needle and stitch through the skin. This technique has not gained popularity as it can be difficult to position the stitches accurately without visualising the cartilage. This may compromise the result as specific placement of the stitches is necessary. In addition, there can be problems such as stitches protruding through skin and a higher recurrence rate.

Making a decision between earfold or stitch otoplasty (ear stitch)

There are key differences between these two main techniques. The earfold is relatively new and is very effective. Stitch otoplasty / ear-stitch has been around for a long time but now simpler with easier recovery. Every person’s ears and concerns are different. Also, the ear cartilage shape, strength and elasticity are different in all people. Because of this, there simply is no “one-size-fits-all” solution. The correct solution will very much depend on the elasticity and shape of your particular ears.

Pros and cons of the earfold

The earfold is a small implant inserted through an incision on the front of the ear and holds the antihelix in the desired position. You can see the exact position of the ear before any incision is made using the pre-fold. This is exactly the same as the earfold but does not have the sharp teeth needed to penetrate the cartilage. The pre-fold can therefore be applied over the skin to replicate the result. 

Pre-fold applied
Pre-fold & Ear-fold

The earfold has a single mechanism of action which is to fold the antihelix of the ear. It is available in only one size, one shape and one strength. This may not give a good result in many ears as the elasticity and strength of the ear cartilage is different from one patient to another. Also, the earfold does not address the problem of enlarged conchal cartilage (bowl of the ear). In view of these factors the earfold is likely to give a good cosmetic outcome in approximately 20% of cases. It is therefore not a true alternative to stitch otoplasty as it is not applicable for many cases. 

The earfold has some distinct advantages which are:

  • Predictable: you can see the likely result before the procedure
  • Quick and minimally invasive with return to work the next day
  • Risk of recurrence is extremely low 

Although the recovery from the earfold procedure is quick the tenderness associated with the implants can take several weeks to settle very similar to a stitch otoplasty.

The earfold, however, is not fully problem free as often perceived online. Problems associated with the implant are rare but include implant visibility, tenderness, malposition, exposure and fracture. These can occur in 1-3% of patients. 

Pros and cons of stitch otoplasty (ear stitch)

The use of stitches to change the shape of the ear was described back in the 1960s. Recently there has been an emphasis to make the procedure safer and simpler with less down time. The use of the term ear stitch reflects this transition. Apart from very young children it is no longer necessary to have a general anaesthetic and almost all can be performed under local anaesthetic. Bandages used to be (and still in some practices) applied for up to 3 weeks. They are no longer deemed necessary and can be removed the next day. The operation itself involves an incision on the back of the ear to gain access to the cartilage and insert the stitches; it is not necessary to remove any skin. The patient is able to see the ear position immediately with a mirror and adjustments can be made if desired. 

The stitch otoplasty / ear stitch has distinct advantages:

  • The main advantage of this technique is the precise control in adjusting the shape of the ear so it is effective for all ear shapes. 
  • It is very safe with no risk of any serious complications
  • The conchal bowl of the ear can be corrected at the same time if needed.
  • The incision is hidden behind the ear and patient resume daily activities within days.

The disadvantage of this method is that it takes longer to do than the earfold and a few days longer to recover. Although the exact desired position of the ear can usually be achieved in this technique there may be a minor change (a few millimetres) after complete healing. Actual recurrence is relatively rare, if the technique is performed accurately, and can be relatively easily corrected.

So which technique should you choose?

In reality making a choice between the earfold and stitch otoplasty is not applicable in many cases. In situations where earfold cannot produce a good aesthetic outcome then the only viable surgical option is to use stitches. In the remaining cases where the earfold produces a good result then it should be considered in view of its simplicity and predictability. However, patients must note that earfold implant are not completely problem free long term and these issues should also be discussed.

It is recommended that you see an ear specialist for a consultation as the correct solution will depend on the elasticity and shape of your ear and this requires detailed evaluation of your ear.

Read more about Ear Stitch
Red more about Earfold