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Dr. Carey Nease Explains Otoplasty

Dr Carey NeaseUnlike many cosmetic procedures, otoplasty, or cosmetic surgery for the ears, can be performed on patients as young as 5 years old. While often performed to reduce the appearance of protruding ears, otoplasty is more than just ear pinning.

In this edition of Inside Cosmetic Surgery, we speak to Dr. Carey Nease, a facial plastic surgery specialist, about this delicate procedure.

Listen to the full interview or read through the transcript below!

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Sharon Odom (SO): Hi everybody, this is Sharon Odom from Cosmetic Surgery Today and welcome to another episode of our continuing series Inside Cosmetic Surgery. Our special guest today is Dr. Carey Nease, a triple board certified cosmetic and facial plastic surgeon with offices in Chattanooga, Tennessee and Calhoun, Georgia. Hi Dr. Nease, welcome.

Dr. Carey Nease (DCN): Hi Sharon, how are you?

SO: I’m great. Thank you. Well, today’s discussion is otoplasty? Which is what exactly?

DCN: Well, it’s a cosmetic procedure for the ears.

And that often includes making the ears smaller or what most people call an ear pinning or pinning them back if they are too prominent, and sometimes it’s a reconstruction of the ear if there is a trauma or some sort of congenital deformity.

SO: So when children have ears that kids make fun of, this is the procedure they have?

DCN: That’s correct.

SO: Are ear pinning and otoplasty interchangeable?

DCN: It is, but that kind of simplifies it a little bit too much. I mean, an ear pinning seems like a procedure maybe you are worried that ears are prominent and you are just reducing their prominence or the projection from the side of the head. In many cases, it’s much more complicated than that. If it’s that’s simple, then it is a fairly simple and straightforward procedure, but it’s still a surgery and not just a few stitches.

An otoplasty really is a bigger term that can refer to just purely a cosmetic setback or pinning procedure. It can be a reduction in the size of the ear or the change in the shape and then probably more commonly if there are some sort of congenital or developmental deformity and it could be recreated in the certain folds the appearance of the ear as well as potentially some reconstruction if the ear doesn’t develop as normal.

SO: So it’s not just ear pinning, it’s surgery on the ear.

DCN: Correct, on the other part of the ear, not the ear canal or anything with the inside. So it’s still an aesthetic procedure, but it could be considered a reconstructive-type procedure as well, just depending on what the problem is.

SO: How long does the procedure take?

DCN: Well, if it’s simply just a setback for a prominent ear, then it may only take about 20-30 minutes per side, so about an hour. But if you are talking about doing a procedure where you are having to recreate the folds, like what’s called antihelical rim or something more invasive where you may need to do cartilage graft or something like sometime you would actually take cartilage from the rib to recreate it or even have to do like a skin graft, then you could be talking about three to four hours. So it could be a very short procedure or a very long procedure, depending on what the goal is and what we are trying to accomplish.

SO: I imagine that if it’s removing cartilage from different places then that will require a general anesthesia?

DCN: It does. Yeah, absolutely. If you are doing any kind of reconstructive work or borrowing cartilage from somewhere else to help reconstruct or skin graft, then absolutely general anesthesia is required. If it’s simply an ear pinning or just a setback-type procedure for a prominent ear, then that can be done with local anesthesia and/or with a little IV sedation, depending on the patient.

One good question is whether it’s something we do for children or adults or both. So when I do it an otoplasty on a child, which is commonly about five or six year old before they start kindergarten, then we do them under general anesthesia because they are not going to tolerate the numbing process that it takes for the procedure.

For kids that age, it’s not really reasonable to expect. So for children, we almost always do general anesthesia. For adults though, it’s fairly commonly done with local with light sedation, even just sometimes oral sedation like Valium, and they tolerate it very well.

SO: What percentage of your patients are adults versus children?

DCN: It’s about 50/50 actually. In certain centers, if you are in maybe in a university setting, probably you are more likely [performing the surgery on] children. I’m in private practice and I’m kind of away from the university setting and so I actually do more adults than children at this state. I probably do about 75% adult and about 25% children, just based on the nature of my practice.

SO: So these are adults that made it through childhood with ears that they were unhappy with and then when they got to adulthood…

DCN: Correct. It’s prominent to maybe, say, the 20- to 30-year-olds. So it’s rarely on someone over age 40, but definitely there are quite a few adults who made it through childhood or they’ve had issues with their confidence in this sort of things and they’ve gotten to be an adult and maybe got a job and then can afford to actually, you know, and will get the nerve up sometimes where they are embarrassed by it. They come in and actually have something done.

SO: Now, you mentioned the word “setback,” what is that exactly?

DCN: Well, if the ear is protruding from the side of the head, if you look at someone straight on, if you are seeing too much of the ear and it looks more prominent, then it’s just a matter or rotating the other part, the helical rim, back towards the side of the head so that it basically narrows the angle between the mastoid bone behind the ear and the ear itself. You are basically rotating the ear back towards or closer to the side of the head, so that’s called a setback procedure.

SO: And ear pinning is…

DCN: The same thing. Ear pinning is kind of like the more common term for otoplasty where you are simply just setting the ear back closer to the side of the head.

SO: And what sort of downtime are patients looking at after otoplasty?

DCN: Well, honestly, it’s just a few days. It’s pretty quick. The recovery is very, very quick. You get very little swelling, very little pain, and very little bruising, so the thing is on the first 24 hours, if easily you get all wrapped up with a special headband. It’s kind of a compression bandage and then for a couple of weeks after they have to wear kind of like a tennis a headband to hold the ears back and usually a very light gauze dressing.

So it’s really more just having to have that dressing on is what you would consider downtime. Otherwise, if it weren’t for that, it could be back to the normal routine activities within just a few days, but because of the dressing, I would say that the downtime is about a week.

When they have a funny dressing or headband on, they are kind of embarrassed by that and usually they kind of stay home or maybe around a little and do some errands. But they might not even go to work or not go to school for about a week.

SO: Do the kids get otoplasty mostly during the summer?

DCN: Yes, yes. It’s like summer or Christmas breaks, spring break or things like that, and again, it’s ideal for kids if we are going to do it before they even start school. The kind of a textbook answer is that we try to do it before they start kindergarten if possible, and that age is important because we want the ear to be fairly close to its adult size.

And that’s the age when it’s getting fairly closest when the kids are about five to six years old, so it’s kind of why that’s the perfect time to do an otoplasty on a child if necessary.

SO: So that means that the ears are pretty much the adult size at age six. Really? They don’t grow that much more from there?

DCN: Yeah, not much more. It’s pretty close to that by that age.

SO: Interesting. So what are the risks?

DCN: Well, I mean, the risks of any surgery are, of course, you have bleeding and infection, those sorts of things. But when you are talking about otoplasty specifically, an infection would be a risk that would be a concern because we are suturing a cartilage back to the lining of the bone, and so if a cartilage gets infected, that can be a problem. We’ve been using antibiotics before and the week after the surgery to minimize that, but an infection would be something definitely to discuss.

And the other risk is that you don’t get a great cosmetic outcome. It’s pretty rare, and because you have two ears, the risk of having asymmetry afterwards, meaning maybe one works really well and you got a great result and the other side is not quite as good and so you are also going to compare one to the other. The risk of needing to do a revision on one side or the other is there. It’s probably in the 10% range or so, which for aesthetic surgery that’s fairly normal.

But besides that, besides the infection, bleeding is very rare, and anytime you are under general anesthesia, a risk of having a reaction to the anesthesia, but with young, healthy people, especially kids, that’s really rare, too. The biggest risk is infection or needing a revision because the cosmetic outcome isn’t as good as you would like.

SO: How do you make sure? I guess that’s part of your experience, right?

DCN: That’s right. It’s big actually. It is. There is a lot of artistry to it because everything that we do as cosmetic surgeons, a lot of artistic ability comes into play and there are measurements you can do to make sure of this. If you are doing it, say, just the ear, any ear setback procedure with the outer part of the ear that you would call the helical rim at certain point has the same distance from the back of the scalp behind the ear. You should get some measurements and just do a general appraisal of your result at the end of the procedure. So that’s the nature of cosmetic surgery.

SO: Given that this is a popular procedure for children, would it fall under reconstructive surgery?

DCN: It depends. If the ears are too big or prominent or protruding from the side of the head too much, that really is an aesthetic procedure. That doesn’t need to be done. You are not going to go to your insurance company or health insurance company, and in those cases, you are not going to get them to pay for it.

Now, if the difference is what if a child is born with one ear that’s normal and one ear that’s only partially developed, and yes, that is a reconstructive problem. Now, it still would be considered cosmetic, but you could certainly argue that this would be a necessary indicated procedure for the child, not necessarily for improvement in hearing, but just to get from abnormal to normal, not just unappealing aesthetically to appealing.

So in children with a deformed ear or a poorly developed ear, then certainly that would be considered a reconstructive and probably medically indicated.

SO: And that goes back to the definition of plastic surgery versus cosmetic surgery, correct?

DCN: It does. Sure, I mean, plastic surgery is more common. I’m a facial plastic and reconstructive surgeon as well as a cosmetic surgeon, so there is definitely a difference between the two, of course.

They are different, no question, and it’s interchangeable in a lot of people’s minds because they just don’t understand the difference, but it’s easy. Most people just say plastic surgery and they think of everything.

They actually more commonly think of the cosmetic procedure than the reconstruction, and the reality is that whether it’s facial plastic surgery or general plastic surgery, a lot of our training is more in the dealing with trauma and reconstruction after cancer and those sort of things, and the cosmetic part is not as prominent in most plastic surgeon’s training.

That usually comes with more training after your residency or fellowship. It comes with experience and then there are cosmetic surgery fellowships that’s out there, which I’m actually a director of a cosmetic surgery fellowship program here in Chattanooga and there are about 25 around the country that are available.

SO: Didn’t you do some fellowship or training with the AACS? Could you talk about it a little bit?

DCN: Yeah, sure. Yeah, I’m a fellow with the American Academy of Cosmetic Surgery, and also I’ve completed, after I did my head and neck surgery and facial plastic surgery training, I did a cosmetic surgery fellowship with Jim English in Little Rock, Arkansas. I spent an entire year devoted just to cosmetic surgery and that’s five years ago.

I actually just started my own program through the American Academy of Cosmetic Surgery. So I have a fellowship training program that is a postgraduate program, so you have to complete a surgery residency first and be board certified in one of the ABMS Surgical Boards, and then you can qualify to come and work with me for a year and learn cosmetic surgery and then you are qualified to sit for the boards in cosmetic surgery through the American Board of Cosmetic Surgery, which I’m a Diplomat of and I’m actually a board examiner as well.

SO: So it sounds like training is probably the most important factor in doing this type of surgery. How would you advise someone to find and go to the right doctor to do this kind of procedure?

DCN: Training is really important. Kind of having just what I would say is God-given talent for having some artistic ability as well as having great surgical training and then what’s your area of interest.

For me, I’m interested in both face and body surgery. But I would say my area of greatest expertise would be in facial rejuvenations or facelifts, rhinoplasty and otoplasty and brow lifts and things like that because that’s probably what I have done the most, even though I’ve done plenty of breast surgery and tummy tucks and things like that. My main interest is in the face.

That’s how you can kind of gauge of what surgeon is maybe right for you is find out what they really love to do, what’s most interesting to them. They maybe qualified to do everything, head to toe, based on their training and education, experience over time but if you would really say you want to have a face lift or rhinoplasty or even an otoplasty, you can interview a doctor and say, “Well, how many do you do? What’s your favorite procedure to do, and why?

Because the thing that you would like the most is likely what you are going to be best at.

SO: Now, do you have any patient stories you can share with us?

DCN: Yeah, with otoplasty, I actually had an otoplasty patient just about two weeks ago that is about 25-year-old gentleman who had been thinking about doing it. Honestly, he wanted to do it when he was about eight or nine years old, but he never had the resources. His parents didn’t have the finances because this is not cheap, and unfortunately for him, it was purely a cosmetic procedure.

He had very similar ears, but they were just really prominent, and the one thing that bothered him was that he has early male pattern baldness, so he couldn’t even grow his hair out to cover it. He felt like because of he had a significant amount of baldness that he shaved his head and that made his ears look even more prominent.

So when he graduated high school, he got a job. He has been working, saving money for almost six years to come and have it done. We were able to do it for him just two weeks ago and he came back the next day and we took off the dressing and looked.

He was just thrilled. It’s something he has been longing for for years and years and his self-confidence, you can see just immediately when he left the room that day, the next day in the office was dramatically better. So it’s really exciting to be able to do that for someone and just give them the confidence just to face the day, and every morning he get to look at the mirror, he has been happier with their results. It translates into all aspects of his life.

So that’s exciting to have. That’s really rewarding.

SO: What would you like to tell our listeners about your practice? I know that you’ve pioneered a procedure that maybe we can talk about another time. The laser facelift, right?

DCN: Yeah. We have two. It’s a new procedure that we developed over the last couple of years. One is a laser facelift. It’s a minimally invasive facial rejuvenation where we use two lasers. One is the subdermal laser for the neck and jaw line. The other one is a resurfacing CO2 or fractional CO2 laser.

That combination is really powerful to the right patient population, which are women in their like late 30s to late 40s. They don’t need a facelift. They don’t need the big procedure with scar and lots of downtime, but want to look maybe five years younger and it’s been really, really successful. There are a couple of other surgeons around the country who are doing the similar thing now, so it’s kind of catching on. I think it will become pretty popular as a rejuvenation procedure here in the next couple of years.

The other one is a type of breast lift with augmentation combination procedure. I can’t talk about too much of that here. We are just in a research phase with that, but we are thinking on making that available to the public and to other surgeons to learn it here in the next couple of months.

SO: Oh, that’s sounds like a scoop. Well, I’ll be definitely following up with you on that one.

DCN: Yeah, it’s very interesting. I’ll be able to talk about it after January.

SO: Okay. What’s your website address?

DCN: Well, our website is SouthernSurgicalArts.com. It’s Dr. Deal and myself, and we are in Chattanooga, Tennessee and another office in Calhoun, Georgia. It’s about an hour apart in North Georgia and Southeast Tennessee, and I’ve been here for five years and Dr. Deal has been with me for one year.

We’ve got a very busy practice, have our own surgery center, AAAC-accredited. We’ve got the fellowship program where we are training one surgeon a year right now and actually next year we’ve been approved to train two surgeons a year through our Academy of Cosmetic Surgery Fellowship Program, so we are excited about that, and I’m welcome to answering any questions that anyone might have and the website is extremely valuable as far as information with lots of before and after pictures that list all the procedures we offer, and of course, bio information about Dr. Deal and myself.

That’s definitely if you are interested in learning about me or Dr. Deal or our practice, the website would pretty much find anything you want.

SO: Thank you, Dr. Nease. It’s been a pleasure. Thank you for your time and we will speak to you soon.

DCN: All right, Sharon. Thank you.

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