How Can my Cauliflower Ear Be Repaired? (photo)

Question

I've had these for over ten years, a doctor already worked on the left one (which got worse after the surgery than pre-op!) I would really like to get this fixed if possible. A plastic surgeon or an Ear Nose Throat specialist? Also, how can I find a reputable plastic surgeon? It is quite daunting looking for one, there are so many and I am not sure who I can trust with this procedure! Please assist, thank you very much.

Thomas A. Lamperti, MD · Answer

Cauliflower ears are very difficult to fix fully. The process of improving the appearance of the ear involves raising the skin overlying the collection of scar tissue. Then the scar must be carved or shaved away. Next you have to get the skin flap to lay back down over the underlying cartilage without having more scar collect. The overlying skin is often thicker than normal after this kind of injury which makes it even more difficult to fully recreate the normal ear architecture.

	You should look for a board certified facial plastic surgeon or plastic surgeon who has experience repairing this type of problem. It is much more complex than a standard otoplasty. After the surgeon examines your ears you need to find out how much of the problem they think can be fixed.

Jacob Sedgh, MD · Answer

Cauliflower ear is a very difficult problem to fix cosmetically. It is best to prevent the problem at first place by seeking treatment when there is swelling in the area usually following blunt trauma. In such cases by timely drainage of the blood collection future scarring and deformities can be prevented. However, once the deformity has consolidated the only treatment would be shaving and carving of the deformed cartilage to resemble it’s original contour which will require close observation and possibly more adjunct procedures.

Matthew Richardson, MD · Answer

Cauliflower ear deformity is a difficult problem to fully correct. Either a facial plastic surgeon or plastic surgeon would be your best option for repair of this problem, although many ENT specialists would be very capable of performing the procedure as well. 
Cauliflower ear occurs due to trauma to the ear and the ear building scar tissue in response to the trauma. Unfortunately, surgical repair traumatizes the ear as well, so there is risk for recurrence. Part of the surgical consultation should include setting realistic goals for improvement. Severe cauliflower deformities are unlikely to ever look 100% normal (the way they were pre-injury), but can be made significantly better. The goal should be to make the ear as normal in appearance as possible to where people are no longer noticing the ears at all. 
All the best,

Leila Kasrai, MD, FRCSC · Answer

Cauliflower ears develop secondary abnormal cartilage development and scar formation following trauma to the ear. Surgical correction in itself results in another form of trauma and the healing will have to be controlled such that the same deformity does not recur. The extent of surgery will depend on the patient's expectations and degree of deformity.

Larry S. Nichter, MD, MS, FACS · Answer

Picking the best plastic surgeon for cauliflower ear deformity correction is important as this is a difficult condition to correct.  Make sure you ask about their experience in this particular type of repair.

	
	The most critical decision to be made in achieving the best plastic surgical result is picking the most experienced and talented, that is the best, plastic surgeon possible. Too often, patients choose a physician based on a catchy ad, the brand name of a technique, the basis of one or two before and after photos, or their web site’s search engine ranking. These criteria will not find the most experienced and talented plastic surgeon.

	My Background

	Dr. Larry Nichter
	I have been a practicing plastic surgeon for more than 25 years, having trained scores of plastic surgeons as a tenured professor of plastic surgery at USC, and I have had a private practice in Orange County since 1993. Speaking from all this experience, here is my advice and the criteria I would use to find the best plastic surgeon in Orange County, Los Angeles, California, or anywhere in the United States. These are the criteria I would use to select a plastic surgeon for my friends, my family, or myself.

	First, I want to stress some general observations I have found to be true over the years.

	Caveat Emptor: Buyer Beware
	The longer a surgeon trains at his craft, the finer his skills and the better his judgment become. Board certification in Plastic Surgery (see below) is a bare minimum. Board certification in an additional surgical field recognized by the American Board of Medical Specialties, or for that matter “triple-board certified,” attests to a doctor’s advanced training and skill and judgment. It also means that they have attained Chief Resident Status in more than one field during their training which means they essentially ran a large departmental service and had senior decision-making and independent operating responsibilities. It is this step that is most maturing for a surgeon.

	The institution where the surgeon trained is also important. More renowned schools usually attract the best faculty.

	You can use the internet to research the background of a prospective plastic surgeon quickly. Please do this prior to making an appointment. “Just because you wear a baseball cap it doesn’t mean you are a good ball player.” The same applies to anyone wearing a white coat—it doesn’t make you a plastic surgeon, much less a great one.

	Caveat Emptor in Latin means “Buyer Beware.” In most states, including California, any physician with a medical school diploma and state license is viewed as a doctor and a surgeon—even without any formal surgical training. In some cases even doctors who have completed only the minimal requirements (medical school, licensing examination, and a one-year internship that need not include surgical training) are touting themselves as “cosmetic surgical experts.” They make these claims of expertise despite the fact that they are only formally trained as family practitioners, OB/Gyns, emergency physicians, dermatologists, or ear-nose-throat specialists. Even physician assistants and nurses have made such claims.

	7-Step Process for Finding the Best Plastic Surgeon
	The following are my screening guidelines and criteria for picking the best plastic/cosmetic surgeon.

	1. Board Certified Plastic Surgeon by the American Board of Plastic Surgery
	The American Board of Plastic Surgery is the only certifying board in Plastic Surgery that is a member of the American Board of Medical Specialties. Use these links to look up a prospective surgeon’s status.

	To become a plastic surgeon certified by the American Board of Plastic Surgery requires a minimum of five years of surgical training with a minimum of two years of training specifically in plastic surgery. Then the applicant must also pass a comprehensive written board exam. If successful, the candidate must present his/her clinical cases for critical review by board examiners (I was one such board examiner) and if accepted will take a series of oral examinations.

	Since the 1990s, the American Board of Plastic Surgery Certification is only valid for ten years. To retain your board certified status, a plastic surgeon must complete a Maintenance of Certification including written testing and case review. This means that all who pass are trained and experienced in all plastic surgery procedures including facial procedures, breast, and body; essentially all cosmetic and reconstructive procedures.

	If a Plastic Surgeon is additionally board certified by another surgical specialty recognized the American Board of Medical Specialties, then this also marks additional expertise and training at the highest level. The American Board of Facial Plastic Surgery (ABFRS) is not a licensing body nor an educational institution and the certificates it issues are not legal licenses to practice facial plastic and reconstructive surgery. The ABFRS is not recognized by the American Board of Medical Specialties (although it does note additional specialty training/interest in facial aesthetic surgery).

	Likewise, beware of physicians armed only with certification from other non-ABMS recognized boards or special society memberships other than those I have recommended (eg. “Cosmetic Surgery Board,” “Lipoplasty Society of North America,” etc.).

	2. Fellow of the American College of Surgeons: FACS
	The American College of Surgeons is dedicated to improving the care of the patient and to safeguarding standards of care in an optimal and ethical practice environment. Members of the American College of Surgeons are referred to as “Fellows.” The letters FACS (Fellow, American College of Surgeons) after a surgeon’s name mean that the surgeon’s education and training, professional qualifications, surgical competence, and ethical conduct have passed a rigorous evaluation, and have been found to be consistent with the high standards established and demanded by the College.

	To be a member you have to:

	be board certified in a surgical specialty recognized by the American Board of Medical Specialties
	be in practice in one location for a number of years, with a background check, nomination, and interviews which verify that you are an ethical and safe surgeon among other criteria.
	Hint: Look for the “FACS” (or “FRCS,” see below) after the “MD” in a doctor’s title or in his/her Curriculum Vitae to see if he/she is a “real surgeon.”

	Note for patients in Canada: The equivalent of FACS in Canada is the Royal College of Physicians and Surgeons of Canada, FRCS.

	3. Member of the American Society of Plastic Surgeons (ASPS)
	The American Society of Plastic Surgeons is the largest organization of plastic surgeons in the United States and one of the largest in the world. ASPS members are uniquely qualified because of the society’s membership requirements:

	Members of the American Society of Plastic Surgeons must be Board Certified by The American Board of Plastic Surgery complete at least 5 years of surgical training with a minimum of 2 years of training specifically in plastic surgery. The more years of Plastic Surgical Training the better – this includes fellowships in a plastic surgical field.
	American Society of Plastic Surgeons members are required to adhere to a strict code of ethics and must fulfill rigorous Continuing Medical Education (CME) requirements including patient safety issues.
	Lastly, ASPS members are required to operate at accredited surgical facilities certified by one of the following USA organizations: American Association for Accreditation of Ambulatory Surgical Facilities, Inc., Accreditation Association for Ambulatory Health Care, Inc., or the Joint Commission on Accreditation of Health Care Organizations.
	Beware of physicians without this membership but belonging only to similar-sounding societies as their claim to excellence eg. “American Society of Cosmetic Surgery,” “Lipoplasty Society of North America,” etc.

	4. Member of the American Society for Aesthetic Plastic Surgery (ASAPS)
	This is the most elite society in the United States and perhaps the world for Aesthetic Plastic Surgery. To be a member means that your career is focused in cosmetic surgery at the highest level. Among the requirements for invitation and election to ASAPS membership, a plastic surgeon must:

	Be certified by the American Board of Plastic Surgery (or in plastic surgery by the Royal College of Physicians and Surgeons of Canada);
	Be in at least the third year of active practice following board certification;
	Participate in accredited Continuing Medical Education (CME) to stay current with developments in the field of cosmetic plastic surgery and patient safety;
	Document the performance of a significant number and variety of cosmetic surgical cases to demonstrate wide experience;
	Be sponsored by two ASAPS-member plastic surgeons to help ensure that the applicant’s professional reputation meets the high standards required by ASAPS;
	Adhere to current ethical standards for professional conduct as outlined in the Code of Ethics observed by all ASAPS-member surgeons;
	Operate in accredited surgical facilities; and
	Be elected by at least 80% of the Active Membership.
	Find an ASPS member online.

	5. Hospital privileges to perform the same type of surgery
	Hospitals often examine qualifications of doctors applying for hospital staff privileges and restrict privileges to only surgeons best trained and qualified to do certain procedures. For example, in order for surgeons to be granted plastic surgery privileges in most hospitals in Orange County, California, that surgeon must have completed plastic surgery residency training and must be board-eligible or -certified in plastic surgery to be allowed to perform plastic surgical operations in that hospital.

	Non-surgeons and other physicians that are not plastic surgeons circumvent this process by performing surgery in their offices or in outpatient surgery centers where the credentialing process is less rigorous or nonexistent. In these settings non-plastic surgeons perform procedures in which they have no formal residency training.

	I am not warning against use of outpatient surgery centers or in-office procedures. I am only recommending that you check that your physician has hospital privileges for these same procedures.

	6. Surgical Experience in the procedure you are having
	Few patients ask how long doctors have been doing a certain procedure or how many they have performed. When you consult with a plastic surgeon:

	Ask to see typical “before and after” photos;
	discuss the details of the procedure in a manner that is clear to you;
	review benefits and potential complications;
	get full answers to your questions.
	7. Evidence of Excellence, Experience and Commitment to the field of Plastic Surgery
	Here are some additional criteria to look for in your plastic surgeon.

	Surgical Board Certification in more than one field
	Plastic Surgical Fellowships in addition to Plastic Surgical Residency.
	Number of years practicing.
	Peer Review Honors in their own board certification from groups such as Best Doctors, Top Doctors, Super Doctors.
	Current or Prior position denoting excellence in the field or high regard by their peers such as:
	Prior or present Professor or Faculty affiliation with a University Plastic surgical program (the higher the rank the better)
	Chairman of a Department of plastic surgery at a regional hospital
	Honors from surgical societies of which they are members such as Board Examiner, etc.
	Published Plastic Surgical papers in peer review journals are also a good sign that they are committed to being on top of their field.
	Feel Comfortable with your choice
	It is very important that after you have done this screening and met with your potential surgeon that you feel confident in your choice.

	Complications are not common in cosmetic surgery, but if one did occur are you confident that this surgeon would take charge and handle just about any problem?

	Do you feel that he listens to you and communicates well by answering your questions completely, doesn’t rush you in to a decision but rather makes you part of the decision-making process? You should truly feel that it is a combined effort.

	Does the surgeon’s office run smoothly? Do the staff take good care of you? If you answered in the affirmative and have gotten this far in your screening guidelines then I think you have found your “Dr. Right.”

	—Larry S. Nichter, MD, FACS

Stephen Prendiville, MD · Answer

Cauliflower ears form due to hematoma formation after trauma. If the hematoma is not drained and/or if pressure is not applied, the cartilage in the ear is stimulated to produce scar tissue and cartilage. The treatment for this problem is surgical, with elevation of a skin flap and shaving down of the cartilage. Pressure must then be applied in the form of a splint or bolster to prevent reformation of the deformity. Refraining from contact sports for 4-6 weeks is recommended after the surgery.

Ken Stewart, MD, FRCS Plast · Answer

So called 'cauliflower ears' can be improved by remodelling. Typically we would make an incision within the helical rim reflect the skin and perichondrium forward and thin the cartilage with a burr. 
If you have had this performed already it may not be possible to improve further as one has to leave a reasonable amount of cartilage to maintain the structural integrity of the ear.

Robert O. Ruder, MD · Answer

Cauliflower ears are from trauma causing bleeding beneath the "perichondrium" that covers the cartilage of your auricles.  With special instruments and post operative "compression" dressings, the ear can be successfully sculptured.  However, the results are variable and may require revision surgery depending on the severity of the deformity.
the procedure can be performed under local anesthesia with only mild sedation.

Michael Bassiri-Tehrani, MD · Answer

Scar and cartilage buildup in the external ears is a difficult problem to correct. It is best to prevent this from occurring in first place by draining any fluid or blood that collects under the skin of the ears as soon as possible. This prevents the formation of cartilage or scar in that area. Typically, a pressure dressing or bolster is placed for 3 days to prevent re-accumulation of any fluid. 
Once the cartilage is formed (as pictured), the only way to reduce it is to make incisions in the skin and shave the excess cartilage underneath. Unfortunately, the complex shape and contour of the ear is difficult to recreate completely, and the cartilage and scar tissue may return. This type of procedure can work well if only isolated areas of the ear are affected.

Mark Domanski, MD · Answer

Cauliflower ear is due to overgrowth of ear cartilage after an injury.
Surgery to repair the cauliflower ear involves placing the incision in an area where it will be least noticeable, contouring the cartilage, and then some sort of pressure dressing to prevent recurrence.
The body will interpret the cartilage contouring surgery just like it did an injury.  Thus recurrence is always a risk.  Steps to reduce the risk of recurrence may include a pressure dressing or sutures that close off "dead space."  The goal is the reduce the chance of blood accumulation between the cartilage and the skin.
Find a surgeon who you are comfortable working with even if things don't go perfect.  Both ENTs and Plastic Surgeons have experience performing this surgery.  Some surgeons are board certified in both ENT (American Board of Otolaryngology) and Plastic Surgery (American Board of Plastic Surgery) but this is rare.

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