A Comparative Study of Composite Versus Double Flap Technique for Repair of Traumatic Split Earlobes

Abstract

Background

Ear piercing is a common practice in all over the world and can result in complications such as torn or cleft earlobes. This study aimed to compare two surgical modalities for correction of earlobe splits; the Composite Closure technique and Double flap technique in terms of aesthetic results, preservation of original orifice, and prevention of relapse. It also assessed the possible superiority of one technique over another.

Materials and Methods

12 patients aged 25–61 years were randomly selected and treated with Composite Closure Technique (Group A) or Double Flap Technique (Group B) under local anesthesia. Clinical evaluation was done post operatively on 14th and 90th days.

Results

All patients had good post-operative outcomes, with preserved ear lobe thickness and minimal scar in both the methods. Data was entered in Microsoft Excel Sheet format and subjected to statistical analysis using SPSS Version 23. Comparisons were made using statistical tests to determine statistical significance.

Conclusion

Both the techniques offered good post operative results. The need for re piercing was avoided and proved to be well accepted by the patients.

Introduction

Ear piercing is a popular practice globally, particularly in India, where women wear them as a religious or fashion statement. However, prolonged wear can cause complications like torn or cleft earlobes due to poor piercing technique, heavy earrings, sudden pulls, chronic friction, or poor technique, necessitating repair. [1]

The history of earlobe cleft repair goes long back. In his book ‘Sushrutha Samhita’, the ‘father of plastic surgery’, Sushrutha, explained the procedure of restoring a severed ear lobe in comprehensive detail. He also went into detail about over fifteen various surgeries depending on the type and amount of ear lobe tear. [2]

It was Boo-Chai K. [3, 4] who first classified the cleft ear lobes as Congenital and Acquired which can be further classified into a Complete or Partial cleft [5]. Over the years, the original classification has undergone many modifications to aid in the repair of various degrees of split [6, 7]. A recent revised classification by Sadasivan K[8] includes three major components and subclasses within them with detailed focus on length of the cleft along with contour of normal tissue in the inferior border (Figs. 1 and 2).

Fig. 1.

Composite Closure Technique (A,B,C. Schematic representation of the technique D. Local anaesthesia, E. Type IIB Cleft earlobe, F. Taking single Triangular flap, G. Maintenance of patency, H,I. Suturing with preservation of patency)

Fig. 2.

Double Flap Closure Technique (A,B,C. Schematic representation of the technique D. Local anaesthesia, E. Type IIA Cleft earlobe, F. Raising Two triangular flaps, G. Suturing both flaps and maintenance of patency, H,I. Suturing the remaining part)

Irrespective of the causes and classifications, a split earlobe needs to be repaired and proper technique is needed for it. Split earlobe repair techniques include both nonsurgical and surgical techniques. Clefts can be corrected surgically utilizing various techniques like punch excision, wedge excision, excision followed by Z plasty and advancement flaps. [5, 9–11] Each technique is different in some way or another with its individual advantages and disadvantages. The most common surgical technique is a simple side to side closure with interrupted straight-line sutures described by McLaren [12] in 1954. It does not require preparing a flap, and it eliminates option of preserving the previous hole.

It was Pardue [13] who first described a technique to preserve the original orifice and repair the rest of the cleft by rotating a flap with intact skin from one side of the cleft and suturing the rest of it. However, it has certain disadvantages: The raised flap is long and extremely thin with compromised vascularity which can cause scarring and might lead to recurrence. To address the disadvantages with Pardue’s flap a Double Flap Technique was suggested by Staiano JJ [14] where instead of taking one flap, two triangular flaps were raised from the opposite ends of the cleft and were moved to the opposite directions and sutured preserving the original orifice.

Recently in 2020, Sadasivan K [8] proposed the Composite Technique by modifying the shape of the conventional Pardue’s flap and raising a wider triangular flap in addition to cleft border undermining to prevent suture line grooving, and if required, a lower border L-plasty to prevent inferior notching preserving the lower contour aesthetics of the earlobe. This technique offers advantages such as maintaining an aesthetically acceptable original site for an epithelium-lined perforation, and supporting weight better than full-length scars, which can cause recurrence. This study aimed to compare Composite Closure technique and Double flap technique in terms of aesthetic results, preservation of original orifice, and prevention of relapse. It also assessed the possible superiority of one technique over another.

Materials and Methods

This prospective study was conducted in the Department of Oral and Maxillofacial Surgery, Saraswati Dental College and Hospital Lucknow, after approval by the Institutional Research Development Committee and Institutional Human Ethics Committee. (Protocol no. #SS2OS21122020D).

The study was done over a period of 1 year on patients with chief complaint of traumatic split earlobes. Twelve patients aged between 25 and 61 years were randomly selected based on our inclusion and exclusion criteria, irrespective of gender, caste, creed, religion and socioeconomic status. Necessary blood parameters and informed consent were taken prior to procedure. Patients were randomly divided into two groups by method of simple randomization using a random number producing algorithm. Six patients were treated with Composite Closure Technique (Group A), and six patients were treated with Double Flap Technique (Group B). Repairs were done under strict aseptic protocol and under local anaesthesia. Clinical evaluation was done post operatively on 14th day and 90th day (Three months). To remove operator bias, all the surgeries were performed by a single operator only.

Procedure

Composite Closure Technique

The cleft’s anterior edge and the lower quarter of the original perforation were excised. A similar tissue was preserved on the posterior margin of the cleft and the posterior rim of the original perforation. A full thickness triangular flap was removed from the upper part of the cleft’s posterior margin. To form the perforation, the flap was sutured onto the freshened anterior edge of the cleft and the lower quarter of the original perforation, over a stent (No. 20 cannula sheath). The free ends of the stent were sutured together with a 2–0 silk suture. To facilitate edge eversion during closure, undermining of the cleft’s margins was done. 6–0 Polypropylene mattress sutures were used to close the wound (Fig. 1).

Double Flap Technique

The length of the split was divided into thirds and two triangular flaps were marked on the lower two thirds on either side of the cleft. A no. 11 blade was used to incise along the markings to raise two skin flaps, one with intact skin and the other with a raw area. The first flap was sutured with 6–0 Polypropylene to form an epithelial-lined hole for the earring, and a cannula sheath was inserted as a stent to maintain the hole. The second flap was sutured to the raw surface of the first, and the rest of the lobe was sutured together in straight line fashion with 6–0 polypropylene sutures (Fig. 2).

In both methods, incomplete clefts were not converted into complete clefts until the intact inferior tissue margins were very thin or significant ptosis required additional L-plasty.

Initial dressing with topical antimicrobial was done which was removed after 48 h. Patients were instructed to keep rolling the stent to maintain its patency. After the 21st day, they were advised to wear a light earring and normal earrings after six weeks.

Data Collection and Analysis

Post-operative evaluating parameters were evaluated and noted for each patient after two weeks and three months. Patients were evaluated on the basis of six distinct parameters: Inferior margin notching, Inferior bulging, Suture Line Grooving, Side to Side elongation of orifice, Flap elongation and Relapse. Additionally, duration of surgery was noted and compared. Post-operative pain and patient compliance were measured with a graphic rating scale (GRS).

All collected data were entered in proper Microsoft Excel Sheet format. The data obtained were subjected to statistical analysis using Statistical Package for the Social Sciences (SPSS Version 23; Chicago Inc., IL, USA). Data comparison was done by applying specific statistical tests to find out the statistical significance of the comparisons.

Kolmogorov–Smirnov and Shapiro Wilk tests were performed to determine the normality of the data between the two groups to check for repair of split ear lobes. Both the tests showed no significant differences and hence confirmed that the data obtained were normally distributed.

Variables were compared using number, mean, percentages and standard deviation. The mean for different readings for duration of surgery, pain, side to side elongation and age between groups were compared using independent ‘t’ test. Chi square test was applied to find significant differences between gender, classification and suture line groove amongst the groups. P value lesser than 0.05 was considered to be statistically significant.

Results

In our study, we evaluated 12 patients with cleft earlobes. The results of our study showed that none of the cases were congenital and all were acquired defects after prolonged use of earrings.

Table 1 shows the classification of splits between groups. Group A predominantly had Type 1A in 66.7% of its sample, while Group B had 50.0% had Type IIA which was not significant at p = 0.122.

Table 1.

Classification of splits

Classification	Type 1A	Type 1B	Type IIA	Type IIB	Total N (%)	Chi square statistic	P value
Group A (Composite closure)	4 (66.7)	1 (16.7)	1 (16.7)	0 (0.0)	6 (50.0)	5.800	0.122 (NS)
Group B (Double flap closure)	1 (20.0)	0 90.0)	3 (50.0)	2 (33.3)	6 (50.0)
Total	5 (41.7)	1 (8.3)	4 (33.3)	2 (16.7)	12 (100.0)

Surgery time was relatively higher in the Group B, with a mean of 42.83 ± 4.262 min as compared to 32.67 ± 4.131 min in Group A, which was statistically significant at p = 0.0018. 1 out of 6 patients in Group A and 2 out of 6 patients in Group 2 required additional L-Plasty. Higher duration of surgery was noted in these 3 patients. In Group A the mean surgical duration increased by an additional 8.8 min with additional L-Plasty. Likewise, in Group B the mean surgical duration increased by an additional 8.25 min with additional L-Plasty.

No significant difference was noted in side-to-side elongation between groups at 14 days or 90 days as seen in Table 2.

Table 2.

Side to side elongation of orifice

Side to side elongation	N	Mean	SD	Mean difference	‘t’ statistic	P value
Follow up—14 days
Group A (Composite closure)	6	1.31	0.388	0.058	0.219	0.831 (NS)
Group B (Double flap closure)	6	1.25	0.524
Follow up—90 days
Group A (Composite closure)	6	1.58	0.376	0.000	0.000	1.000 (NS)
Group B (Double flap closure)	6	1.58	0.492

Suture Line Grooving at 14 days:

No significant difference was found in the suture line groove between groups at 14 and 90 days as seen in Table 3.

Table 3.

Suture line grooving

Suture line groove	Absent	Present	Total N (%)			Chi square statistic	P value
Group A (Composite closure)	3 (50.0)	3 (50.0)	6 (50.0)			.343	.558 (NS)
Group B (Double flap closure)	2 (33.3)	4 (66.7)	6 (50.0)
Total	5 (41.7)	7 (58.3)	12 (100.0)
Suture line grooving at 90 days
Group A (Composite closure)	5 (83.3)	1 (16.7)	6 (50.0)	0.444a	0.505
Group B (Double flap closure)	4 (66.7)	2 (33.3)	6 (50.0)
Total	9 (75.0)	3 (25.0)	12 (100.0)

None of the cases showed flap elongation over a follow-up period of three months. Likewise inferior border notching and bulging was not found in any of the cases even after regular use of earrings.

Pain assessment was done with graphic rating scale (GRS) which is a modification of visual analogue scale (VAS). Patients were asked to report intensity of pain on a scale of 0–10 on 1st, 3rd and 7th post-operative day. Pain was not experienced differently between the groups at 1st and 3rd day as seen in Table 4. No pain was present on the 7th day between the groups.

Table 4.

Pain assessment at various time intervals between groups

Pain	N	Mean	SD	Mean difference	‘t’ statistic	P value
Pain—1st day
Group A (Composite closure)	6	0.6667	0.81650	0.00000	0.000	1.000 (NS)
Group B (Double flap closure)	6	0.6667	0.81650
Pain—3rd day
Group A (Composite closure)	6	0.1667	0.40825	0.16667	1.000	0.341 (NS)
Group B (Double flap closure)	6	0.0000	0.00000
Pain—7th day
Group A (Composite closure)	6	0.0000	0.00000a	–	Not computed	–
Group B (Double flap closure)	6	0.0000	0.00000a

^* = Significant; NS = Not Significant

Discussion

Cleft earlobe is a common complication caused by long-standing heavy earrings, which can become aesthetically unpleasing and functionally unstable. The preservation of initial earhole is a key factor and techniques focussing on preservation removes the additional burden of re piercing. [11, 15]

All of the 12 patients compared in this study were female with age ranged from 25 to 61 years with mean value of 54.16 years for Group A and 35.00 years for Group B. Age of the patients did not show any significant difference on recovery and post-operative results. This result was coherent to the study by Hemdani et al. [16]. A study in Gujarat [17] found similar conclusions regarding the patient's age.

A non-significant difference was observed in terms of duration of split in between two groups (p = 0.250). Mean duration of split ranged from 2.70 to 4.08 years in two groups which is incoherent to the study by Oh DY [18] in which their duration of split ranged from 18 to 67 years. This is significant in terms of patient awareness as patients in our study reported to us at a comparatively earlier stage. However, it was seen that younger patients reported early seeking for correction on the contrary to older patients who had been living with the split for longer period of time.

Traumatic cleft earlobe cases involve a slow enlargement of the orifice and a split that has been present for months to years. The traumatizing force is either acute due to abrupt traction or perpendicular force directed to the ground. Similar to our findings, Altintas [19] found partial cleft in eight cases (61.5%) and congenital cleft in one case (7.8%). Partial clefts are common in patients wearing earrings for longer time, but complete clefts are more likely due to sudden pull or trauma. Pardue [13] in his original article mentioned that incase of incomplete split, the bridging tissue should be incised in order to create a complete split to prevent bulging in the. inferior border. In their review, Vujevich J [20] prohibited converting a partial cleft into a complete one as it might cause notching at the inferior margin, resulting in an aesthetically unacceptable scar and low patient satisfaction. This is supported by Sadasivan [8] who also recommended not to convert an incomplete split into a complete one, especially in Type IA and IIA clefts. We also opted and further recommend not to convert incomplete splits into complete one except in Type IB and IIB clefts having ptosis or notching in the inferior margin. We found prevalence of Type IA and Type IIA clefts, with the inferior contour normal without ptosis. First stated by Fatah [21], with a L-plasty, the contour of the ear lobe border can be reconstituted. In our study we set a protocol to preserve the lower border and performed L plasty in all Type B cases, with no post closure inferior margin bulge.

In terms of duration of surgery more time was taken in raising double flap and do a proper undermining in order to reduce chances of post-operative grooving. However, the additional incorporation of L-plasty in Type B clefts increased the mean surgical duration with addition of 8.8 min in Group A and 8.25 min in Group B. Nevertheless, in terms of patient compliance it did not make much difference as both procedures were performed within an hour.

No previous studies evaluated post-operative pain over frequent intervals following auricular lobuloplasty. Post-operative pain was evaluated on post-operative day 1, day 3 and day 7. No significant difference was found between two groups on day 1 (p = 1.00) and day 3 (p = 0.341). Only one patient reported pain on day 3 (Pain score = 1 on GRS) which was also subsided on 7th day. Both techniques were well accepted by the patient in terms of pain.

The side-to-side elongation of the preserved orifice was evaluated on 14th and 90th post-operative days. No significant difference was noted between groups due to the use of a no. 20 IV cannula sheath and a 2–0 silk suture to maintain patency. Patients started wearing light earrings from 21st day and gradually shifted to heavier ones from 90th day. Both techniques involve creation of flaps and avoidance of tissue loss.

Flap elongation was not present in both the groups on 14th day and 90th day. With both techniques we avoided every possibility of tissue loss and adequate closure was achieved in all the patients. Therefore, no flap showed elongation in any direction.

Suture line grooving improved in all patients over 3 months, with only one patient showing minimal groove on 90th day. This is in contrast to Sadasivan's [5] study, which noted grooving in two out of 75 cases.

Because the surgical area is very small and does not involve any major vital structures, complications are rare but can include bleeding, infection, unfavourable skin attachment, lumpiness, a change in skin colour, and minor cosmetic irregularities. No patient involved in this study showed any sign of post-operative complications and both the techniques are safe to perform.

The study found that both techniques showed good results in terms of post-operative aesthetics, and all patients were satisfied with the final outcome. The duration of surgery was more in double flap closure, but this was not an issue in terms of patient compliance.

However, the sample size in our study was small and, therefore, a comparative study with large cohorts is needed to further assess the superiority of one technique over another.

Conclusion

On the basis of our results, we can conclude that both techniques showed good results in terms of post-operative outcomes with no complications. Contrary to earlier studies, converting a partial split into a complete one is not necessary unless the lower margin is excessively thin or there are some contour abnormalities. To achieve the best results, the procedure necessitates the use of finer instruments and proper armamentarium along with fine surgical skills of the surgeon. Surgical corrections, despite being invasive in nature, should be preferred over non-surgical methods as the later necessitates the need for frequent follow ups and a second re-piercing procedure. Therefore, surgical management should be the gold standard for repairing of cleft ear lobules.

Funding

Self-funded.

Declarations

Conflict of interest

No conflict of interest financially and non-financially.

Ethical Approval and consent to Participate

This study was approval by the Institutional Research Development Committee and Institutional Human Ethics Committee. (Protocol no. #SS2OS21122020D).

Consent for Publication

Available.