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Abstract
The earlobe is an important anatomical structure that has a significant role in aesthesis. An absent ear lobule may be congenital or acquired due to the result of trauma, infection or malignancy. Its surgical repair places a challenge due to the difficulty of obtaining a natural-appearing and durable outcome. Many procedures have been described for reconstruction including the Gavello and Zenteno Alanis techniques. We have described a new method which is single staged, easy to perform and aesthetically acceptable.
- Plastic and reconstructive surgery
- Oral and maxillofacial surgery
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Background
Earlobe loss is a relatively uncommon problem presenting to plastic and reconstructive surgeons. Many techniques have been described in the literature. We intend to present a novel, single-staged technique for the same. Its merits and demerits have been discussed in the article.
Case presentation
A female patient in her 40s presented to our department with loss of the right earlobe for 2 months. She was apparently normal 2 months ago when she was involved in domestic violence and her spouse bit off the right earlobe. She did not seek treatment immediately after the incident. Now she has come to us for earlobe reconstruction. She had no comorbid illnesses. On examination, there was a complete loss of the right earlobe (figure 1). Preauricular, postauricular, retroauricular areas and auricular surfaces were clear.
Clinical picture of the right pinna, preoperatively.
Treatment
We planned for earlobe reconstruction using a combined preauricular and a postauricular flap with a common base. Under general anaesthesia, the preauricular and postauricular flaps were marked using a lint pattern (figures 2 and 3). Tumescent was infiltrated and incisions were made accordingly. Flaps were raised and had good dermal bleed (figure 4). Flaps were positioned and sutured with 4–0 Nylon sutures (figure 5). The secondary defects were closed primarily.
Lint pattern of the flaps.
Markings of the preauricular and postauricular flaps.
Flaps raised.
Early postoperative picture.
Outcome and follow-up
On the seventh postoperative day, the sutures were removed. On 2-month follow-up, the flaps were well settled with good aesthetic neo earlobe (figure 6).
A 2-month follow-up photograph.
Discussion
The earlobe is an anatomical structure with a significant role in an individual’s aesthetic appearance, especially in women. It has an abundant blood supply without cartilaginous tissue and hence its reconstruction to obtain a long-standing and aesthetically acceptable outcome is difficult.1 The technique should be simple, preferably performed in one stage, suitable for earlobe defects of all sizes and volumes, and yield acceptable cosmetic results. A lot of techniques have been described for reconstruction such as local flaps, regional flaps and skin grafts, which could be multistaged or single-staged procedures depending on the status of the perilobal tissues.2 These are the use of local skin flaps from preauricular, postauricular, retroauricular and retromandibular areas or from the auricular surface.3–5 Folded single or bilobed flaps and superimposition of two opposing or paired flaps or double-crossed flaps may be used with a few requiring a split-thickness skin graft or full-thickness skin graft or incorporation of cartilage graft to maintain shape.6 Most of these procedures can be performed under local anaesthesia. In 1970, Gavello first described the bilobed technique in which an anterior based bilobed flap was taken below the auricular defect and folded horizontally to form a new earlobe. The superior edge of the flap is sutured to the auricular defect and the donor area is primarily sutured.7 The advantages of Gavello’s technique are that the flap has a predictable vascular supply, the occipital branch of the posterior auricular artery that runs horizontally behind the ear and is a constant vessel in the area where Gavello’s flap is raised, which allows the flap dimensions of the base-to-length ratio of up to 1:2 to be raised without any complication.5 The donor site scar is well concealed but the limitation of the procedure is the requirement of an intact donor area over the postauricular mastoid region. Brent’s technique was used for larger defects of the lower third of the auricle and earlobe, resorting to fold-over flaps and cartilaginous grafts to give volume and shape to the new earlobe. Brent recommended the increment of the flap by over 30% and used cartilaginous grafts (contralateral auricle or chondrocostal cartilage) to oppose tissue contraction. D’Hooghe’s bilobed flap consists of two wings, both nourished by an inferior base, located respectively on the preauricular and postauricular folds. Both wings are raised and brought together to rebuild the new earlobe. This flap is only used for the reconstruction of small earlobe defects.6 Alanis and Okada individually proposed single-stage methods but with adherent earlobes. Both consisted of a bilobed flap, with an anterior base in a vertical plane with an anterior wing slightly bigger than the posterior one that is sutured to the surgical defect. The major disadvantage of this flap is the visible scars beneath the earlobe. Nelton and Ombredanne reconstructed the ear lobule in multiple stages with the creation of a pocket to insert the cartilage graft and skin graft for the postauricular secondary defect. Seidnan and Novelly described a single-stage technique in which a U-shaped flap was taken from below the auricle. Joao reconstructed a small ear lobule defect by a vertical preauricular flap superiorly based in a single stage.8 Singh and Singh reported a reconstruction with Limberg flap from the skin below the defect.9 Sahai’s Y flap for earlobe reconstruction was single staged and easy to perform with good colour and texture match using non-hair bearing skin but it required scar-free supple preauricular and postauricular skin.10
The advantages of our flap over other flaps are as follows:
Gavello’s flap: more tissue is needed, the scar is transverse and not vertical and hidden as in our case. D’Hooghe’s bilobed flap is a very small flap only for small earlobes or for partial earlobe reconstruction. Nelaton and Ombredanne’s flap required multiple stages. Alanis and Okada’s method is for adherent earlobes. Finally, Seidman and Novelly’s technique required a large U-shaped flap which was bulkier than in our case.
Patient’s perspective
It was shocking, to say the least, that my husband pounced on me and bit off my ear that night during the fight. There were fights before and he used to throw things at me but never did he directly attack me before.
There was bleeding and there was a stinging sort of pain which I realised a few seconds later. The bitten-off part was lying on the floor. Someone brought a cloth and gave it to me and I held the bleeding part of my ear tight with it. With the help of the neighbours, I went to a hospital where first aid was done. I guess I was too much in shock, I did not ask the doctors if anything could be done about the missing part.
After coming out of the hospital and moving to my mother’s house with the children, I used to get dressings from a nearby nurse. Discussing what needs to be done about my marriage and the children was the main thing on my mind at that time. I felt humiliated that I had to go through this. Now there was a new problem, everyone I knew would keep asking about the obvious. I almost completely stopped going out of the house for this reason.
After 25 days the wound healed and I didn't need dressings. The nurse who did dressings for me enquired and told me that I can consult the plastic surgery doctors and they would be able to help.
After that, I met the doctors, surgery was planned and done. There was some pain, but bearable, in the first 3 days after surgery. After the 10th day or so, the sutures were removed and I was happy to see that it was a success. I have been visiting the doctors in OPD from then on.
Learning points
A multitude of techniques exist for earlobe reconstruction, each suitable for different circumstances.
The novelty of our technique is that a single flap is created and split to recreate the earlobe.
The advantages of this technique are that it is single staged, relatively easy to perform and is aesthetically acceptable.
The disadvantages are that it has not been studied in a large number of patients nor is long-term follow-up currently available.
Ethics statements
Patient consent for publication
Footnotes
Contributors PGP: study design, collection of data, data analysis, writing of the manuscript, patient care. MA: writing of the manuscript, patient care. ARD: writing of the manuscript, patient care. SRRVM: critical review, revision. SRRVM is the guarantor for this paper. The following authors were responsible for drafting of the textm sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content: PGP, MA, ARD. The following author gave final approval of the manuscript: SRRVM
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.