A preauricular skin tag, also called an accessory tragus, is a common “extra” part to the ear that is present at birth and, if left alone, continues to grow as a child grows. Embryologically speaking ears are extremely complex things, and it’s not uncommon that occasionally there are small extra nubbins of tissue that develop as the ears form. These small nubbins contain skin, fat and cartilage.
what is the process?
The image below outlines the process of consultation, procedure and follow up under our COVIDsafe approach, which uses videoconsultation where appropriate.
How is the extra tissue removed?
Removal of the extra tissue can be performed easily under local anaesthetic as a rooms procedure when a child is in the first months of life.
What does the procedure involve?
We arrange a time for you and your child to attend the rooms for the procedure. On arrival at our practice a member of our staff will apply local anaesthetic cream to the area and a clear adhesive covering. This local anaesthetic numbs the skin.
On your arrival at our rooms we encourage you to feed your baby as in our experience this increases the likelihood that they will sleep through the procedure.
During the procedure your baby is placed on his or her side in a comfortable foam pillow that is specifically designed to securely support your baby. We remove the clear adhesive covering and wipe away the local anaesthetic cream. A small amount of local anaesthetic is injected at the base of the skin tag with a tiny needle, ensuring that your baby will feel no discomfort from the procedure.
Dr Tomlinson and a registered nurse are with your baby at all times during the procedure. You are welcome to stay for the procedure, and we find that most parents prefer this, but you are also welcome to wait in another room or to step outside briefly for fresh air.
The extra tissue is surgically removed and the area is stitched with tiny absorbable sutures – usually two are used. We cover these stitches with a small steristrip and apply surgical glue over the top so that you do not have to do anything special with the dressings. Your baby can be bathed as normal after the procedure, and the dressings and stitches will lift off when they are ready.
We always send the tissue for pathology testing.
What follow up is required?
We routinely see you and your baby at 1 and 8 weeks after the procedure to check that everything is progressing satisfactorily. If these visits are difficult for you to attend and you prefer to send us a photo and email update we can offer feedback by this method if all is progressing as planned. If things are not progressing as planned or you have any concerns it is our strong preference that we see you to assess what is happening and provide you with advice and assistance.
What is the best age for treatment?
We prefer to schedule the procedure prior to three months of age - the earlier the better. After three months of age the procedure is more difficult because your baby is more aware of its surroundings. Older babies are less likely to sleep through the procedure and more likely to move their heads or arms during the procedure. They are more likely to need to be physically restrained as the procedure is performed, which can be more distressing for the infant and for its parents.
Older babies cannot be relied upon to “hold still” for a rooms procedure so we recommend that they have a general anaesthetic and that this be performed when they are at least two years of age. For this reason we advocate early treatment as it is simpler and easier for all involved, with fewer risks.
Are there any associated long term problems?
No, there are no long term problems associated with this condition or with surgical removal of the tissue.
What does the area look like after removal?
The following photographs show a typical patient with two skin tags for removal. The first photograph shows the area on the day of the procedure, after the local anaesthetic cream has been wiped away:
This second photograph shows the area with surgical marking texta marking the base of the two skin tags. Dr Tomlinson marks the site with surgical marker prior to administering the local anaesthetic fluid, as the fluid can cause swelling which alters the appearance of the area, making the exact area of extra tissue more difficult to determine. This marking also allows parents to confirm the areas that are planned for removal.
The third photograph shows the site after removal of the excess tissue. There are dissolving stitches at the site where the extra tissue was removed, and the shine on the skin surface is from the multiple layers of surgical glue that have been applied. The appearance of some remaining purple from the surgical marker is normal and temporary, as is the (very small) amount of red colour (blood) visible at the site of the lower excision. The pale discolouration of the skin in the treatment area is temporary and results from the local anaesthetic mixture.
How do I arrange a consultation with Dr Tomlinson?
These are before and after images of infants treated with ear molding by Dr Jill Tomlinson. For more information about ear molding please visit this page.
Above: Cup ear, left
Above: Cup ear, right
Above: Helical rim irregularity, right
Above: prominent right ear
Above: prominent left ear
Above: prominent left ear
Above: prominent right ear
Above: prominent left ear
Above: helical rim irregularity, right ear
Above: helical rim irregularity, right ear
Above: constricted left ear
Above: cryptotia, right ear
Above: helical rim irregularity, left ear
Above: prominent antitragus, right ear
Above: Stahl's ear
Thank you to the parents of these infants who elected on our photography consent form to allow us to share these images with you on our website and via our Facebook Page.
Ear shape abnormalities are one of the most common congenital deformities, and affect 4-5% of the population. Embryologically ears are pretty complicated structures, as they form in the first 18 weeks of gestation from the coalition of six separate "hillocks". So it's not surprising that sometimes Mother Nature doesn't get them quite right.
We've known for a long time that it is possible to mold the ears of newborns to address misshapen ears without surgery, using tape, foam, wire and plastic tubing, but until recently there has not been simple or reliable ways to treat misshapen ears without surgery. Now there are, and these methods can be used in the first weeks of life to treat misshapen or deformed ears to save the need for future surgery.
The EarWellTM system was developed by US plastic surgeon Dr Steve Byrd and is available in Melbourne from plastic surgeon Dr Jill Tomlinson. We also fit EarBuddies on infants older than 6 weeks of age.
Is ear molding effective?
Yes, if started early. You can see before and after images of patients we have treated at our ear molding photo gallery. To be most effective and successful, ear molding should be started in the first weeks of life.
Plastic surgeons around the world are in agreement on the effectiveness of infant ear molding. Dr Steve Byrd's results with 831 infant ears with the EarWell system were published in 2010 in the Plastic and Reconstructive Surgery Journal (Byrd HS, Langevin CJ, Ghidoni LA. Ear molding in newborn infants with auricular deformities. Plast Reconstr Surg 2010 Oct; 126(4):1191-200), and the article concluded: "Congenital ear deformities are common and only approximately 30 percent self-correct. These deformities can be corrected by initiating appropriate molding in the first week of life. Neonatal molding reduces the need for surgical correction with results that often exceed what can be achieved with the surgical alternative."
British surgeon Dr Andrew Linford published on splinting of ear deformities in the British Medical Journal in 2007 (Lindford AJ, Hettiaratchy S, Schonauer F. Postpartum splinting of ear deformities. BMJ 2007;334:366) and stated: "Postpartum splinting can completely correct congenital ear deformities and obviate the need for later surgery."
New Zealand plastic surgeon Dr Swee Tan concluded in the New Zealand Medical Journal (Tan S, Wright A, Hemphill A, Ashton K, Evans J. Correction of deformational auricular anomalies by moulding - results of a fast-track service. NZMJ 2003 Vol 116 No 1181) that it "is an effective treatment strategy that will largely negate the need for surgical correction of deformational auricular anomalies".
New York Plastic Surgeon Melissa Doft published her results with the EarWell Infant Ear Correction System in the March 2015 edition of Plastic and Reconstructive Surgery reporting 96% effectiveness and 99% parental satisfaction. The Paediatric Plastic Surgery Institute in Dallas, TX, reports 90% success in achieving good or excellent results in infants who have constricted ears.
Ear molding can treat prominent ears, cup ear, lop ear, mixed ear deformities, Stahl's ear, helical rim abnormalities and cryptotia. Cryptotia requires longer than usual molding and Dr Tomlinson employs custom molding techniques in this condition.
How long is the molding performed for?
The duration of molding varies according to the age of the child and the response to molding. When molding is started in the first couple of weeks of life the duration of splinting (and the likelihood of a successful response to molding) is less than if it is started at an older age. It has also been suggested that babies who are breastfed may require longer splinting than those who are not, because the ears remain malleable for longer. Minimum durations of molding, according to the time that molding was commenced, are:
|Age at commencement||Duration of molding|
|at birth||2+ weeks of molding|
|4 weeks of age||4+ weeks of molding|
|8 weeks of age||8+ weeks of molding|
|12 weeks of age||10+ weeks of molding|
|16-24 weeks of age||at least 12 weeks of molding|
|over 6 months of age||at least 16 weeks of molding|
It is important to recognise that these are minimum timeframes only. Mild abnormalities take less time to reach a stable result than severe abnormalities, as less molding of the cartilage and the skin is required to achieve the desired outcome. Research suggests that some children who i) have prominent ears, and ii) have a family history of prominent ears, may show a tendency for the ears to become more prominent over time. In such circumstances we may recommend continuing the molding for a slightly longer period of time than is standard, and we certainly recommend keeping a closer eye on such ears for recurrence. To minimise the need to attend follow up appointments the monitoring for signs of recurrence is generally performed by parents comparing their child's ears with photographs on their smartphones.
Why must ear molding be started early?
The younger an infant is, the more malleable their ears are, and the better the ears respond to molding. Ear cartilage is very pliable immediately after birth, but becomes more elastic and firm within a few days of birth. This is attributed to oestrogen levels in the baby, which are high at birth due to the high maternal oestrogen levels during pregnancy, but fall rapidly in the first six weeks of life. The elasticity of ear cartilage is increased by oestrogen, because oestrogen increases the amount of hyaluronic acid, which increases the proteoglycan concentration in the cartilage. Treatment in the first six weeks of life is most effective, which is why we and others recommend treatment be started as early as possible.
We do not offer consultations for infants aged 5 months or older. We do not recommend ear molding for infants above 6 months of age due to the requirements for prolonged molding and the increased difficulty of molding in older babies who are able to grab at their ears, have greater head mobility and increased sweating which increases the likelihood that the skin will become moist and get irritated during the molding process.
In this video US plastic surgeon Dr Steve Byrd applies the EarWellTM system to an infant's ear to treat Stahl's deformity:
How do I make an appointment?
If you schedule an appointment with Dr Tomlinson then at your consultation you will initially meet with one of Dr Tomlinson's registered nurses who have been trained in ear molding by Dr Tomlinson, and who will explain the ear molding process and care requirements to you in detail. Dr Tomlinson will assess your baby's ears and apply the EarWell Infant Ear Correction device if this is appropriate.
Nurse consultations can also be scheduled with one of our registered nurses who have been trained in ear molding by Dr Tomlinson. This is particularly appropriate for babies who are 6 weeks or older. You do not need a doctor's referral to schedule an appointment with Dr Tomlinson's practice nurses. Medicare rebates are not available for nurse consultations.
Click here for more information on your appointments including patient registration forms. Additional information regarding your appointment, including costs, will be provided in the detailed appointment confirmation email that we send to you once you have scheduled your appointment.
What are the risks of treatment?
The risks of ear molding treatment are lower than the risks of surgery, and the outcomes of ear molding can be better than with surgery. The most common problem encountered with ear molding is skin irritation as a result of the ear getting moist. This moistness is usually due to water or milk running over the ear area, although in older babies tears can also be a source of wetness. Use of a hat, headband or carefully positioned flannel or bib can assist in preventing this.
We strongly recommend that parents keep their child's ears dry at all times, as moist tapes can lead to skin irritation, inflammation and even ulceration - exactly as happens with nappy rash. If there is a small spill of fluid onto the area a hairdryer on a cool setting may be of assistance in drying the tapes. If the tapes become moist, yellow, green or smelly the ear molding device needs to be removed and the skin allowed to dry and settle. The use of Medihoney barrier cream and antibacterial wound gel may be useful in this setting, but time is the more important factor than any topical cream or ointment. If the skin irritation is moderate or severe then 1-3 days of drying may be required before the ear molding device can be reapplied. Some of the images on this page show ears immediately after the removal of adhesive tapes; the redness seen in the photos is common, is not uncomfortable for the infant and settles within a day.
In addition to skin irritation and skin ulceration other possible risks include skin allergy, skin infection, skin ulceration, cartilage perforation, failure to achieve the desired results, having the device come loose or fall off earlier than expected (which means needing to reschedule your appointment to an earlier time) and needing to continue with ear molding for longer than anticipated.
What are the differences between the EarWellTM system and EarBuddies?
The EarWellTM system was designed by US plastic surgeon Steve Byrd and is used and applied under a doctor's supervision. It can apply stronger forces than the EarBuddies device so can achieve more powerful molding. It is the only device available that addresses the conchal crus, which is commonly present in mixed ear deformities. The EarWellTM system is a single use device so the device cost applies at each re-application. We recommend the EarWellTM system for infants under 6 weeks of age; in older infants the size of the infant's ear may exceed the size of largest EarWellTM cradle.
The EarBuddies device was designed by UK plastic surgeon David Gault. It is designed to be suitable for at home use on infants by parents or grandparents. We offer a specialist fitting service to provide parents with assistance and guidance in using this device. In many instances parents prefer to attend our rooms for a fortnightly fitting; alternatively parents can reapply the reusable device at home. Successful DIY ear molding requires proper application of the device. If the device is reapplied at home incorrectly it is unlikely to harm your child, but ineffective application extends the duration of molding and will not improve the ear appearance.
Infants who have cryptotia (a "hidden ear") generally require customised ear molding which Dr Tomlinson also provides.
My child is too old for ear molding. What are the other options?
Once the ear cartilage has matured the options are to do nothing or to consider surgery. Surgery to correct ear deformities is termed "otoplasty", and it is generally performed on children when they are 4 years or older. The most common type of otoplasty surgery is performed to correct a prominent ear (sometimes termed a "bat ear") - more information about prominent ear correction is available here. There are different types of ear deformities so the surgery is always tailored to the individual ear. Like ear molding, ear surgery can address an underdeveloped antihelical fold, a prominent concha, a protruding earlobe, a Stahl's ear deformity, a macrotic (oversized) ear, a cryptotic (hidden) ear, a Wildermuth's ear and a constricted ear.
"Chondrodermatitis nodularis helicis" is a long phrase used to describe a surprisingly common and painful condition that affects the ear. Individuals who have chondrodermatitis nodularis helicis develop a painful ulcer or area of irritated skin on their ear, usually on a part of the ear where the cartilage is prominent. It keeps people awake at night and can be a real problem!
What causes chondrodermatitis nodularis helicis?
It is thought to be caused by pressure, usually pressure between your ear and your pillow at night. Many patients report that it affects the ear that they usually sleep on.
Non surgical treatment
A variety of treatments can be tried to fix chondrodermatitis nodularis helicis without surgery. First of all, try to keep pressure off the affected ear. Use a soft pillow and consider padding your ear so there is no pressure on the painful spot. Try to sleep on the unaffected ear. Use foam rubber or sponge to make a ear protector and hold it in place with a headband. Get a custom-made silicone device to protect your ear from pressure. Purchase a donut pillow to sleep on.
If your problem is worse during winter you may find keeping your ears warm by wearing a beanie or hat is useful. Warmth helps to encourage blood flow to the area, which helps with healing.
The first thing I do in treating this condition is to exclude skin cancer as a possible diagnosis. It's not possible to tell from looking at your ear if you have skin cancer or chondrodermatitis nodularis helicis, so I send a small piece of tissue (a biopsy) to a pathologist to confirm your diagnosis.
If there is no sign of skin cancer in the biopsy then we can go ahead and treat your chondrodermatitis nodularis helicis. This treatment involves removing the ulcer and sometimes the prominent bit of cartilage underneath it. The procedure can be performed under local anaesthetic, with or without sedation. Dissolving stitches are used so you don't need to have any stitches removed. Occasionally a skin graft is recommended, but this is not common.
What are the possible complications?
The most common complications of surgery include infection, bleeding and recurrence of the condition. The recurrence rate is 5-30%. The condition is less likely to recur if it is treated aggressively and if you can minimise pressure on the area in the weeks after the procedure while your skin is healing.
How do I make an appointment?
You can contact Dr Jill Tomlinson's rooms on 9427-9596. Click here for our full contact details including consultation locations.
For more information you may wish to read this patient information brochure on chondrodermatitis nodularis helicis from the British Association of Dermatologists.
Any surgical or invasive procedure carries risks.
Before proceeding you should seek a second opinion from an appropriately qualified health practitioner.