INTRODUCTION

Ear piercing is a worldwide practice. It was done with an aim to create a hole in the pinna for the insertion of earrings, the history of which dates back to centuries, when earrings were worn in Rome by slaves.[1] Piercing nowadays is being done on almost any part of the body. The ear is still the most common part that is pierced and provides the user with a whole range of styles.[2]

Anatomically, the pinna is a resilient structure, which is thrown into several folds by the contour provided to it by cartilage. On the contrary, the lobe is made up of fibro-fatty tissue, making it easy to pierce.[3]

Elongation post earlobe piercing is a common condition faced by the dermatologic surgeons. Pierced earlobes may encounter trauma from either heavy earrings, a sudden pull on the earring, chronic friction from use of headgear, or telephones while wearing earrings, or simply because of a poor piercing technique. Several retrospective studies have reported a 1%–2% incidence rate of torn earlobes in patients wearing earrings.[4]

Torn earlobes, or cleft earlobes, may be classified as either a complete or partial. A complete cleft usually occurs when the earring is acutely pulled out of the original pierced hole of the earlobe forming a divided medial and lateral limb. A partial cleft occurs when the piercing canal is elongated or deformed, but has not severed through the earlobe. Blanco-Davila and Vasconez[5] have reported a subclassification for partial clefts based on the distance between the original piercing and the inferior margin of the earlobe.

Several studies describe various techniques for surgical correction of an elongated earlobe, which include partial cleft repair, side-to-side closure with cold steel, side-to-side closure with punch biopsy technique, side-to-side closure with Z-plasty, and purse string closure among many others.

The aim of our study was to assess the elongation of the earlobe post repair and compare the outcomes of the two different repair modalities: simple side-to-side closure versus closure with anterior–posterior flap modification.

SUBJECTS AND METHODS

This was a prospective cohort study conducted in the Department of Dermatology in a tertiary care hospital in Maharashtra, India, after approval by the Research/Ethics committee.

The study was conducted over a period of 1 year from June 2017 to May 2018. Sample size calculation and randomization was not done as patients were taken as per the eligibility criteria during the study period.

We included 30 women with equal or almost equal bilateral earlobe clefts. After routine pre-operative investigations, a written and informed consent was taken from the patients prior to undergoing the procedure.

One side earlobe was repaired with simple “side-to-side closure” technique and the other with “closure with anterior posterior flap modification.” The repairs were performed under local infiltration anesthesia with 2% lignocaine and adrenaline mix and following strict aseptic precautions. The patients were followed up on the 2nd and 12th postoperative week.

PROCEDURE

Side-to-side closure

It involved freshening of the cleft with the help of cold steel and thereafter suturing the two freshened edges side-to-side [Figure 1A].

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Figure 1

(A) Side-to-side closure. (B) Anterior posterior flap modification

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RESULTS

In our study, we chose 30 women with bilateral earlobe clefts. They underwent surgical repair in both ears, which was assessed for any lobe elongation postoperative. The results are as follows:

On comparing the mean values of elongation(mm), it was seen that the mean value were higher with side-to-side closure than with flap modification technique, with a overall difference of 1.85 mm [Table 1 and Figure 2], which was statistically significant with at P < 0.001, as compared to the flap modification technique.

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Figure 2

Comparison of the mean values of earlobe elongation with both the techniques

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On comparing the elongation with respect to various age groups [Table 2 and Figure 3], it was observed that all the three chosen age groups (21–35, 36–50, >50 years) showed a statistically significant elongation with side-to-side closure than with flap modification.

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Figure 3

Comparison of the earlobe elongation with respect to various age groups

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On comparing the elongation with respect to the length of the clefts, it was seen that elongation with side-to-side closure was more than flap modification in all three size range values of cleft (4–6, 7–9, and 10–12 mm) and statistically significant in each size range, as seen in Table 3 and Figure 4.

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Figure 4

Comparison of the earlobe elongation with respect to the length of the clefts

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Table 4 (added as additional data) shows the mean, standard deviation, and median values of elongation overall with the two techniques.

DISCUSSION

Bilateral clefts occur commonly as earrings are worn in both ears as observed in our study. Various configurations of surgical flaps have been described in an effort to improve cosmesis, decrease scar formation, and preserve or create an earring hole.

McLaren[6] first reported a simple linear closure for partial earlobe clefts by de-epithelializing the partial cleft scar with a scalpel and closing the margins in a straight-line. This technique removes the entire partial cleft without incising through the inferior aspect of the earlobe. As seen in our study, on comparing the results of side-to-side closure with anterior–posterior flap modification, it was observed that postoperative elongation was lesser in the ears which received the flap modification with an average difference of 1.85 mm. This is ascribed to the fact that side-to-side closure entails tissue loss resulting in earlobe elongation visible immediately following surgery [Figure 5], whereas anterior posterior flap modification involves creation of flaps alone, thereby avoiding tissue loss and hence theoretically, no lobe elongation occurs [Figure 6 (A,B,C) and Figure 7 (A,B)].

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Figure 5

Ear lobe elongation post simple side-to-side closure

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Figure 6

Anterior posterior flap modification: (A) preoperative, (B) immediate postoperative, and (C) 2 weeks postoperative

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Figure 7

Anterior posterior flap modification: (A) preoperative and (B) 12 weeks postoperative

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In our study, the maximum numbers of patients (17/30) with split earlobes were in the age group of 36–50 years of age. This was also seen in a study conducted in Gujarat, where similar conclusions were drawn regarding the patient’s age.[7]

A study by Singh et al.[8] in Kanpur suggested that the best method for closure of lobe elongation was a simple side-to-side closure as compared to “V”-shaped flap approach or “L” plasty. Although anterior posterior flap modification has been used earlier in studies, it has never been compared with side-to-side closure. A study by Altıntaş et al.[9] in Istanbul stated that side-to-side closure does not give satisfactory results if the defect in the earlobe is large, which is similar to our study, wherein larger defects showed better postoperative results with flap modification as compared to side-to-side closure with significant elongation in the latter procedure. It is explainable by the fact that as the cleft size increases, the elongation of lobe also increases as freshening involves more tissue loss with larger cleft sizes.

Limitations: As per the eligibility criteria, females with equal or almost equal cleft sizes were included into the study. This comprised of only a small group and hence the small sample size.

CONCLUSION

On the basis of our results of repair of earlobe with two different techniques as described above, we propose anterior–posterior flap modification as a novel technique of earlobe repair with none to minimum elongation of earlobe post repair and hence suitable for unilateral cleft repairs where maintenance of the lobe symmetry is of prime importance.