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AN END TO PINNAPLASTY
A splint in time saves op aged 9
by MR DAVID GAULT FRCS
Consultant Plastic, Reconstructive and Aesthetic Surgeon
London Centre for Ear Reconstruction, The Portland Hospital, London
Article last updated: February 1st 2009
Advances
in surgery will filter down slowly, but eventually, and if they are
good, they change the way we all practice. We insert coronary stents
rather than pore for hours over vein grafts, and now the appendix can
be removed through the mouth using an endoscope. Time will tell, but
for the time being, appendicectomy is a standard first operation for
junior surgical trainees, and one of the first procedures they do
alone. Setting back the ears remains plastic surgery's appendicectomy,
but is it really safe, and why are we not avoiding it altogether when
non-surgical correction has been around for over 20 years?
Surgery
to set back prominent ears (pinnaplasty) is the most common paediatric
plastic surgical procedure in the UK. About 5% of the population have
ears which stick out more than 20mm from the side of the head, although
in a recent study [in preparation], over 20% of adults admitted
embarrassment about the shape of their ears to the extent that it
affected their hairstyle or their behaviour.
Teasing is the
most common reason for surgery in children, but pinnaplasty is best
delayed until at least the age of five, when the cartilage has hardened
sufficiently to hold the sutures, but many children are already being
teased by this age. The other notable groups who come to surgery are
those whose prominent ears prevent them from wearing hearing aids, and
adult males, often motivated by the onset of hair loss. Pinnaplasty is
perceived as a simple procedure by doctors and the public alike. My own
organisation, the British Association of Aesthetic Plastic Surgeons
(BAAPS), states on their website that "the vast majority of
patients....are well pleased by the result, and the procedure has a
high satisfaction rate" but a detailed review shows a steady incidence
of problems.
Well-acknowledged complications are pain and
discomfort 4%, recurrence (ears sticking out again) 7%, haematoma (a
collection of blood beneath the skin) 1%, infection 1% and keloid
(raised and itchy) scars 1%. However, some surgeons have a haematoma
rate of over 10%, and whilst this is bad enough, every now and then a
haematoma becomes infected. The resulting chondritis (a serious
inflammation of the cartilage framework of the ear), can cause a
devastating deformity of the ear. Of the ears that have presented to
me at the London Centre for Ear Reconstruction over the last three
years, about one quarter resulted from failed pinnaplasty surgery. In
some of these patients, a complete autogenous (using the body's own
tissues) reconstruction of the ear is needed. Some adult patients,
especially men, become reclusive and never work again. From a much
anticipated minor op in the school holidays, a child is catapulted into
major 4-6 hour surgery involving the removal of a rib and a week's stay
in hospital. Whilst it is true that those that are pleased are very
well pleased, those that are not are often devastated. Beware the Anterior Scoring Technique!
There
are a number of surgical techniques in use, but of the cases in which I
have acted as an expert in a medico-legal claim for failed pinnaplasty,
ALL have resulted from use of the 'anterior scoring technique', where
the cartilage framework of the ear is scored. This requires some
explanation. The cartilage framework is 'scored' as you would the fat
on a pork joint, to weaken it so that it can be bent into a better
shape. Occasionally, bleeding continues after surgery, and the
collection of blood beneath the skin becomes infected, causing loss of
tissue. Despite this, 'Scoring' remains the most commonly used
technique in the UK. Plastic surgery trainees cut their teeth on it,
but some of the most accomplished and reputable surgeons also fall prey
not because they failed to carry out the technique well enough but that
the technique failed them, given enough opportunity.
Neonatal
moulding of ears has been around for at least 20 years, but early
splintage has yet to become routine despite excellent results and few
complications. Controlling the very soft cartilage of a newborn ear
using a splint can reshape it as it hardens over the first few months
of life, such that prominent or otherwise deformed ears are cured
within a few weeks, but the technique is underused. Indeed, what is
worse, it is not unusual for a concerned parent to seek advice about
their baby's ears only to be told to "leave well alone", or to "allow
it to settle", when common sense would dictate that, if this were true,
no infant would grow up to need surgery. When one of my own children
was born with a misshapen ear, I developed Ear Buddies � splints.
There
are great advantages in splinting to correct ear deformity. There is no
teasing to prompt a referral for surgery. The cost of splinting is a
mere fraction of the cost of surgery at £50 versus at least £800
within the NHS, assuming that funding is available, and around £4000
including surgical, anaesthetic and hospital fees for a general
anaesthetic, day case stay in private practice. Almost 98% of splintage
is performed by the parents themselves. Anaesthesia is not required,
nor surgery, nor admission to hospital, nor is there a risk of post
operative complications. The only down side is that a precious
long-awaited infant has some tape applied to the ear to hold a splint
in place. A little hair might require shaving if it is abundant or the
baby is older. All is easily camouflaged by a mother-in-law-friendly
hat.
Neonatal moulding
Neonatal moulding can
correct over 97% of all external ear deformities, including all folding
deformities of the ear (stick-out ears, rim kinks, lop ear, Stahl's
bar) and cryptotia (a hidden ear - a condition in which the ear,
particularly the top or upper pole, is hidden beneath the skin of the
side of the head). Although the speed at which the ear cartilage
hardens after birth is variable, it begins in all babies with the
withdrawal of maternal oestrogens. Successful splintage requires the
cartilage to be soft enough to be remoulded, and then to become hard
enough to maintain the new shape. In most babies, this period is
shortest in the first few weeks of life.
Correction of the
neonate's ear is especially straightforward. In addition to a
favourable moulding/hardening profile, newborns do not have the
dexterity to dislodge ear splints, the head is mostly still, and the
skin sweats little so adhesive tapes stick well. Thus, early splintage
is better tolerated by parent and child alike.
The main ear
deformity encountered is prominence. However, only two-thirds present
at birth and some arise or are made worse by external deforming forces
from, for example, the head cosies of car seats or high-collared
clothing. In these children, splintage is both prophylactic and
curative. More parental persistence is required is older babies,
however, and certainly, where there is a family history of late
presentation of bat ears, or where the antihelical fold is absent,
there is a case to be made for prophylactic splinting at birth.
Splintage is especially important in children likely to need a hearing
aid, since a well-developed antehelical fold is required as a
supporting pillar. Likewise, in cases of Stahl's bar, splints are
almost universally successful whereas surgery is unpredictable.
Another
variable is delayed hardening of the cartilage, which can relate to
breast-feeding. Such ears are especially susceptible to being pushed
forward when sleeping, for example, and parents report that the ears
are bent forwards at night. Splintage is again indicated, but extra
patience is required to ensure that the cartilage is sufficiently
patterned by the moulding to give a permanent benefit. A "wibble-meter"
to test such malleability would identify susceptible ears for early
splintage more reliably, and would also identify those not yet "cooked".
The
benefits of the introduction of Ear Buddies splints into the UK in 1996
may already be showing in statistics. Despite an increase in most types
of aesthetic procedures, pinnaplasty rates have not followed, and in
some studies, in Scotland, for example, rates have decreased. Ear
splintage is increasingly audiology-, nurse- or occupational
therapist-led and this is to be encouraged. In some UK units, such as
The Portland Hospital, it is now almost routine to check the ears to
see if splints are required, but this is an exception.
Off-label
use of wires and tubing not manufactured for the purpose risks a
variety of unforeseen complications, and liability insurance should be
first checked with the relevant authorities in each country. In the UK,
advice from the MHRA is as follows: "As well as the possible risks to
the patient and user, there is the potential for litigation against the
hospital or healthcare professional. Liability for off-label use rests
with the user, not the manufacturer of the medical device or product in
question. Healthcare professionals should also be aware that the
modification of a medical device (other than those sanctioned by the
instructions for use) may lead to the healthcare professional becoming
the manufacturer of a new device and thus subject to the requirements
of the Medical Devices Regulations." The use of metal cores within
clear plastic tubes in patients undergoing phototherapy is a particular
hazard.
As surgeons, we need to be as sure as is possible
that we, at least, do no harm. We look out for clicky hips and
instigate measures to limit the consequences, and ears should be
treated the same way. Pinnaplasty complications are common and
sometimes devastating, and the less surgery is required, the better, so
that it is a last resort, rather than a first. This certainly resonates
with parents, who dislike the idea of waiting until the child is at
least 5 years of age for a surgical fix. I believe that it is both
desirable and possible to drastically cut the need for pinnaplasty such
that it is a rare event in the UK, Europe and the USA by 2030.
Contact Mr Gault
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References
(1)
Complications of otoplasty: a literature review. GC LImandjaja, CC
Breugem, AB Mink van der Molen, M Kon. JPRAS 2009, 62, 19-27.
(2) Ear reconstruction following severe complications of otoplasty. F Firmin, C Sanger, G O'Toole JPRAS 2008 61, S13-S20.
(3)
Calder JC, Naasan A. Morbidity of otoplasty: a review of 562
consecutive cases. British Journal Plastic Surgery 1994; 47: 170-174.
(4) Chan LKW, Stewart KJ. Pinnaplasty tends in Scottish Children. JPRAS 2007; 60: 687-9.
(5) Medical and Health Care Products Regulatory Agency document MDA/2004/006 issued 2nd February 2004
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