Innovative technique for partial earlobe tear repair using a customized elliptical biopsy punch

PROBLEM STATEMENT

Earlobe piercing is a common practice worldwide. In the Indian subcontinent, it has deep cultural roots. It is also used as a fashion statement and a form of self-expression in modern times. A common complication of earlobe piercing is the eventual widening of the ear hole. Common causes include the usage of heavy and pendulous ear jewelry. Chronic traction on the earlobe by the jewelry results in atrophy of tissue and gradual widening of the ear hole, subsequently leading to a split earlobe.¹ This problem often compels patients to avoid wearing small ear studs as they may not fit well and fall off.

Sadasivan and Kochunarayan proposed a revised classification of split earlobe deformity in 2020² [Figure 1]:

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Figure 1:

Types of Earlobe tear: (a) Type I: Elongated perforation with length less than that of normal tissue, (b) Type IIA: Elongated perforation with length more than that of normal tissue measured from the lower end of the cleft to the inferior margin of the earlobe, (c) Type IIB: Inferior contour abnormal, and (d) Type III- Total earlobe tear.

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• Type I: Elongated perforation with a length less than that of normal tissue

• Type IIA: Elongated perforation with length more than that of normal tissue measured from the lower end of the cleft to the inferior margin of the earlobe

• Type IIB: Inferior contour abnormal, ptosis of earlobe present

• Type III: Total earlobe tear.

The earlobe is one of the most fleshy and mobile areas on the body, making it difficult to keep steady during cosmetic repair. Maintaining linear cuts is challenging, especially with the earlobe’s tendency to slip during handling. For Type I and Type IIA earlobe tear repair, traditional methods often involve freshening the cleft margins by excising cleft tissue with a scalpel.³ However, incomplete excision or over-excision can result in grooving along the suture line, notching of the inferior margin, and contour irregularities. Creating equal margins on both sides of the cleft is challenging. In addition, this method is time-consuming, as incisions are required over the lateral as well as the medial aspect of the earlobe. Maintaining hemostasis is another challenge due to the time-consuming nature of the procedure.

RECOMMENDED SOLUTION

In this modified technique, we converted a traditional circular 5 mm biopsy punch into an elliptical one [Figure 2]. The biopsy punch was compressed on both ends using artery forceps to create an elliptical cutting edge with two symmetrical arcs that intersected at an angle of 30° or less [Video 1]. Depending on the length of the Type I and Type IIA earlobe, a punch of a smaller or larger size was used. The earlobe was held in place using a chalazion clamp. The flat surface was placed against the medial aspect of the earlobe, and the ring was placed over the lateral aspect such that the ear hole lay in the center. The clamp was then tightened.

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Figure 2:

(a) Biopsy punch and artery forceps, (b) compressing the biopsy punch to give elliptical margins, and (c) biopsy punch with uniform margin and angle of 30° at each margin.

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The innovative technique involved two main stages: Stamping and circumduction movement [Video 2]. The initial step involved positioning the oval punch over the enlarged ear hole and applying firm, even pressure, to create an imprint. This “stamp” marked the boundaries of the area to be excised, providing a guide for the next step. Following the initial imprint, the punch was carefully rotated by a circumduction movement while maintaining pressure. The punched-out area was then excised, similar to a skin biopsy sample, providing a cylindrical tissue sample with skin at both ends. The defect on the earlobe was closed with non-absorbable polypropylene intermittent vertical mattress sutures on the lateral as well as medial aspects [Figure 3].

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Figure 3:

(a) Pre-operative photo showing Type I deformity, (b) intraoperative photo showing a through and through a slit in the earlobe after punching, (c) post-operative photo after closing the slit with vertical mattress sutures, and (d) post-operative picture on day 10.

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This technique provides several advantages over the conventional method:

• The punch design ensures equal margin lengths on both sides, better approximation, and better cosmetic outcomes

• Reduced tissue handling and damage, as there is no need to excise tissue from both the medial and lateral sides of the lobule [Figure 4]

  

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  Figure 4:

  Cylindrical tissue sample with the skin at both ends and the cleft at its center along its length.

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• Reduced blood loss

• Time-saving

• Smooth contour of the earlobe post-procedure.

The use of an oval biopsy punch for lobuloplasty provides several advantages over the conventional technique. It has a friendlier learning curve, is less time-consuming, and results in satisfactory cosmetic outcomes.