PINNAPLASTY (Prominent Ear Correction) Pinnaplasty is surgery to correct protruding or lop ear deformity. This is a common malformation frequently associated with psychological disturbance. Children afflicted with this problem are often the subject of ridicule from their peers. Even adults that suffer this problem are sometimes ridiculed by workmates or others in the community. Because of the psychological problems that can occur with children we prefer to correct the problem at an early age – from six years on. At this time ear growth is nearly complete and any further growth should not cause a recurrence of the problem. Quite frequently adult men will not wear their hair short and women will avoid wearing their hair up because of the prominence of one or both ears. Mr A RICHARDS MSc FRCS (Plas) Consultant Plastic and Cosmetic Surgeon Stoke Mandeville Hospital The Three Shires Hospital The Saxon Clinic The Paddocks Hospital The Shelburne Hospital The Chiltern Hospital Cliftonville Eaglestone Aylesbury Road Queen Alexandra Road London Road Northampton Milton Keynes Princes Risborough High Wycombe Great Missenden NN1 5DR MK5 6LR Bucks HP27 0JS Bucks HP11 2TR Bucks HP16 0EN Tel: 01604 620311 Tel: 01908 665533 Tel: 01844 346951 Tel: 01494 888700 Tel: 01494 890890 All Appointments & Correspondence: Suite 3, Samuel House Chinnor Road, Thame Oxon OX9 3NU Tel: 01844 214362 Pinnaplasty Surgery (protruding ear correction) page 2 _____________________________________________________________________ Ear Anatomy Prominence of the ear can be caused by several problems but the two most common are - (i) enlargement of the concha of the ear as shown in the following diagram. This enlargement pushes the ear into a prominent position away from the skull. Pinnaplasty Surgery (protruding ear correction) page 3 _____________________________________________________________________ (ii) A poorly formed or nonexistant antehelical fold. This lack of folding along the antehelix causes the upper portion of the ear to be abnormally tilted out from the side of the head as shown below. Who Is Suitable For Surgery? Generally, it is preferable to carry out corrective pinnaplasty on children before they reach school age. Adults at any age can have a correction of their ears performed. With children the operation is generally performed under a general anaesthetic as a day case or one night stay in hospital. From teenage years on, the surgery can easily be performed under local anaesthetic on a day case basis. Pre-Operative Preparation A pinnaplasty corrects the external ear and does not usually affect the hearing process - however if you have any known hearing loss please let us know prior to surgery. There is no need for the hair to be shaved prior to surgery; however if the hair is long this should be pulled back in a ponytail to avoid the hair getting into the wound.You will be required to wear a head bandage for one week postsurgery, so for men it is a good idea to have a haircut first. Pinnaplasty Surgery (protruding ear correction) page 4 _____________________________________________________________________ Although your head bandage is removed at one week after surgery, you will still need to protect your ears from catching on the pillow at night whilst sleeping - an elasticised toweling headband is best (the type used for tennis) -you should purchase two of these before surgery so you can wear one and wash one when required post operation. Clean carefully behind your ears and wash your hair just before the operation. Avoid Aspirin or Aspirin containing medicine (Aspro, Disprin, Alka-Seltzer, or any medicine containing acetylsalicylic acid ) for 2 weeks prior to your operation as this can produce bleeding or bruising. Panadol is safe. Avoid vitamin E two weeks prior to surgery as this may also increase bleeding tendency. Vitamin B and C are safe to use. Stop smoking or at least cut back to only a few per day to avoid post-operative coughing which increases the risk of bleeding and bruising. Smoking also decreases blood supply to the healing tissues, increasing the risks of delayed and poor healing. Do not drink alcohol for at least two days prior to surgery as alcohol also increases the chances of bleeding and bruising. If you develop any sign of infection, such as cold or flu, during the week prior to surgery - please notify my office so that we can treat this effectively. Bring to hospital your normal toiletries and any regular normal medication that you are on. Your Surgical Experience The hospital, admission date and admission time will all be arranged preoperatively. If your operation is in the morning, then you will be admitted the night before and will have nothing to eat or drink i.e. nil by mouth from midnight. If your operation is in the afternoon, then you will be admitted on the morning of surgery with nothing to eat or drink i.e. nil by mouth from 8:00 a.m. If in any doubt be sure to ask. Incision The incision is usually placed behind the ear in the fold, either adjacent to the skull or on the back of the ear itself. Additional scars may be necessary on the front of the ear but these are rare. The correction targets the cause - with an enlarged concha, part of the conchal cartilage is resected and the remaining ear cartilage is sutured back to the skull. The incision behind the ear is closed with a dissolving suture as shown in the following diagram: Pinnaplasty Surgery (protruding ear correction) page 5 _____________________________________________________________________ If the antehelical fold needs to be formed, reshaped or refolded, then the ear cartilage is cut into from behind and its front surface is weakened by a series of scratches allowing the new fold to form. As well as weakening the cartilage, occasionally a few non-dissolving sutures (stitches) are required to prevent the cartilage springing out again. These remain permanently and rarely cause any problems. The incision behind the ear is closed with a dissolving suture. It should be remembered that normally shaped ears are not flat against the head but a little out, allowing easy wearing of sunglasses or spectacles. The procedure usually takes approximately one hour. After the operation is finished, the folds are packed with cotton wool to hold the skin closely to the underlying cartilage preventing the collection of blood between the layers. Pinnaplasty Surgery (protruding ear correction) page 6 _____________________________________________________________________ Anaesthesia For children up to the age of about 13 years, surgery is invariably performed under a general anaesthetic, i.e. with the patient asleep. For older patients, more commonly you are awake but well sedated whilst the ears are numbed by local anaesthetic so you have no memory or recall of the operation. The anaesthetist will talk to you prior to the operation to explain what is best. Advancement in anaesthesia over recent years has meant more comfort for patients - less pain with minimal post operative sedation and nausea and a quick recovery to "feeling normal". The anaesthetists in my team are highly skilled and experienced in modern techniques and devoted to keeping you comfortable. What Dressing Is Applied After the ear has been packed with the cotton wool dressing a thick pad is placed over each ear and a bandage is wrapped around the head. This dressing should then be left without removal for approximately eight days. This is used to prevent swelling and bleeding between the skin and cartilage. It is important not to remove the bandage in this early stage. After Surgery – What to Expect There is always some pain in the ears after surgery. This is usually of a throbbing nature similar to an infected or traumatised finger. The pain is due to the pressure of your head bandage and the fact that there are many nerve endings about the cartilage of the ear cut into at surgery. If there has been a general anaesthetic the soreness is usually felt soon after you wake. However, if a local anaesthetic has been used, there will be no soreness for approximately 4 to 6 hours. In order to minimise the soreness we ask you to lie with your head elevated or propped up in bed with at least three pillows so that the head is higher than the level of the chest. This will help to reduce the swelling and consequently the soreness. Pain killers, such as Panadeine, Digesic or Panadeine Forte, can be taken if the pain is becoming more severe - a prescription will be provided for you. Do not take Aspirin or Aspirin containing medication for the pain as this may increase bleeding. Severe pain can sometimes occur and this may indicate a problem with bleeding (called haematoma). This will be discussed later and should be reported. During the 8 days of bandaging it will be a little difficult to hear normal conversation as the yellow wool dressings cover the opening of the ear. The pain and soreness usually settles in approximately 48 hours. After that time itching under the bandages is common. Do not insert anything (e.g. pencils) to scratch under the bandage as this can cause problems with your surgery. An appointment will be given for you to have the bandages removed eight days after surgery by my nurse. The suture under the skin will dissolve and is not removed. Once the bandages are removed you can wash your hair normally using shampoo but the ears should not be pulled forward to wash behind them. Gently massage with the fingertips in the crease behind the ear. The hair should not be dried with a hot hair dryer as the ear skin will be numb and easily burned - nevertheless you can use a hairdryer carefully held well away from the ears. A cotton bud may be gently used to dry behind the ears. Pinnaplasty Surgery (protruding ear correction) page 7 _____________________________________________________________________ You should wear your headband over the ears at night for the first 6 weeks after surgery to help prevent any problems with rolling over and accidentally catching your ears on your pillow. It is also advised that any contact sport be avoided for one month postsurgery and then played only whilst wearing your headband for a further two months. Non-contact sports can be played at about three weeks after surgery. It will be noticed that the ears are a little swollen and a little bruised even after the bandages are removed at eight days. This bruising usually settles quickly over a few days but the swelling can take several weeks. You will notice that the ears are quite tender if bumped and that the rim of the ear is numb - this begins to settle after four to six weeks but will not fully settle for twelve to sixteen weeks following surgery. This is a normal consequence of the ear corrective operation. Understanding The Risks And Complications As with any surgery, pinnaplasty involves risks and potential complications. You need to understand and accept these in order to make an informed consent to having the operation. Some risks are more likely to occur than others. Please ask for as much detail as you need to fully understand the procedure1 its benefits and its risks. (i) Haematoma Bleeding can occur between the skin and cartilage of the ear and create what is called a haematoma. This is a rare complication but it is easily recognised because of the severe pain that results. If severe pain is experienced in the post-operative period you should notify us immediately. Haematoma if left untreated could develop into a deformity called a "cauliflower ear", commonly seen in boxing where the ear is constantly hit. It is due to damage to the ear cartilage producing irregularities. Haematoma can also predispose to an increased risk of infection. (ii) Infection Infection can occur in any operation but is particularly a problem if it occurs after this surgery. The ear cartilage can be destroyed by the bacteria causing a significant deformity of the ear. It is fortunately very rare and minimised by washing of the hair pre-operatively and the use of antibiotics during and after surgery. Again pain is experienced if infection is developing and you should notify us if you are concerned. (iii) Scarring The incision behind the ear usually heals without a significant scar and is out of sight. However all scars are noticeable if they are looked for. The quality and appearance of a scar varies widely with an individual's healing process and can be influenced by personal, familial, and racial factors that cannot be controlled by the surgeon. On rare occasions the scar behind the ear can become keloid or enlarged, red and very thick - this type of scarring is able to be felt behind the ear (as shown in the following diagram) and can be quite itchy or tender. Pinnaplasty Surgery (protruding ear correction) page 8 _____________________________________________________________________ Procedures to help reduce thickened scars include - Moisturising cream and massage to healing scars helps improve their final appearance. This should be commenced within a few weeks of surgery. It is best carried out twice a day until the scars are mature i.e. lost their redness Pressure therapy - constant even pressure applied over a scar has been shown to improve the end result in most cases. The pressure mav be in the form of paper tape (Micropore or Steristrips) or a silicone gel mould (often prepared by an occupational therapist). To gain the best results the pressure should be applied for most hours of the day and occasionally for several months. Steroid injections into the scar may be indicated if your scar becomes overactive, thick, red, tender or itchy - i.e. Hypertrophic or Keloid scars. The injection may be repeated several times to achieve a satisfactory result Thickened scars can develop many months after surgery. They sometimes do not respond to treatment and reform. (iv) Asvmmetry All paired organs or parts of the body are not totally symmetrical. This is especially so with ears which almost always vary in size, shape, and position between sides. After your operation the ears will still be slightly uneven - a pinnaplasty corrects protrusion and shape, within reasonable bounds, but not size. This is not usually noticeable on a casual glance as the ears are rarely seen together when looking directly at the head. A minor degree of asymmetry is acceptable but obviously if the ears are vastly different then further surgery may be necessary to correct this problem. Pinnaplasty Surgery (protruding ear correction) page 9 _____________________________________________________________________ Follow-up After your bandages are removed at about 8 days, you will be seen again at about 6 weeks to check the shape of your ears. Healing takes several weeks, or longer, during which bruising, swelling, tenderness, and numbness will slowly settle leaving you with a much improved ear profile. CALL MR RICHARDS IF YOU EXPERIENCE THE FOLLOWING: Excessive pain or bleeding Abnormal swelling Fever during the first 24 hours or especially during the first 7 days Returning To Your Daily Activities You can return to your activities at a slow, gradual pace. You may be back to work as soon as 7 to 8 days after surgery when your bandages have been removed and may begin light exercise at about 3 weeks. It is wise to wear your towelling headband for any contact sports played within 3 months of surgery. Conclusion Pinnaplasty is an operation to correct the protrusion and shape of the ears. Providing you understand the limitations of this procedure and abide by the pre and postoperative instructions, you can look forward to enjoying a renewed personal confidence with your improved ear profile. I hope these notes have helped you. If you have any further queries please call my office. One last thing - beware of well-meaning friends, newspaper and magazine articles, which are generally not a good source of information.