The London Centre for Ear Reconstruction
Before Surgery
General Advice
When we confirm your surgery, we will tell you if and when you should stop eating and drinking in order to be ready for a general anaesthetic. If you are having a local anaesthetic, you may have a light meal before your surgery provided you think that you will not become queasy. Please arrive on time, as you will need to be registered at reception, admitted by the nursing staff and seen by your anaesthetist (if you are having a general anaesthetic or intravenous sedation (twilight anaesthesia)) and Mr Gault before you go to theatre.
Smoking hinders healing and all surgical sites heal better if you do not smoke. Smoke causes tiny blood vessels which supply newly moved tissue to narrow almost instantly, and if vulnerable tissue is deprived of blood it dies. It is possible to successfully undergo most types of ear surgery if you cannot give up or cut down smoking with the strict exception of ear reconstruction, especially if it is performed because you have lost tissue previously (for example a bite injury) and if you need tissue expansion or a temporoparietal fascial flap. If you are undergoing ear reconstruction, you must give up six weeks before surgery, and not smoke again until at least six weeks after surgery. You should also stay away from smoky situations.
before
afterYou need not remove nail varnish from toes and fingers. False nails and nail extensions can also be left in situ.
Please do let Mr Gault know if you should develop a rash before surgery. Occasionally a rash can be due to Streptococcal bacteria and to proceed in such circumstances risks serious consequences - it is always best to let Mr Gault see the problem in advance, if possible.
before
afterWhen you come into hospital for your operation, please bring any medication that you take. Please tell Mr Gault and the anaesthetist if you or your child (if your child is the patient) have any allergies.
We ask that you discontinue aspirin medication SEVEN days pre-operatively, Warfarin four days pre-operatively and garlic and ginko tablets two weeks pre-operatively (these medicines can cause unwanted bleeding after surgery). Some patients on Warfarin need to keep up a certain level of anticoagulation, and you should discuss your surgery in advance with the specialist who monitors your Warfarin medication.
before
afterBecause of the increased risk of thrombosis in patients who undergo major surgery (such as ear reconstruction) under general anaesthetic when on the contraceptive pill and hormone replacement therapy, you are strongly advised to stop taking these medications six weeks before the date of your operation. You may resume two weeks after the surgery. You should contact your Family Doctor to discuss another method of contraception to cover the interval. Patients having a local anaesthetic do not need to discontinue the Pill or HRT.
before
afterFinally we ask you to discontinue Valerian- and Kava-containing herbal medicines two weeks before surgery as these medicines can increase the sedative effects of general anaesthesia.
Advice for parents
Certain procedures on the ear, such as the removal of pre-auricular tags, are best performed in early infancy. It is possible to avoid surgery for prominent or misshapen ears if the ears are splinted early using Ear Buddies™, preferably shortly after birth, but if not, within the first two years of life.
before
afterSurgery for prominent ears should generally not be undertaken before the child is at least five, and surgery to reduce the size of large ears or lobes is best left until growth is almost complete, except in extreme or unusual circumstances.
before
afterThe ideal age for ear reconstruction surgery is over the age of 9 or when the chest circumference is over 60cms. If the patient is being teased, or if there are other pressures to have the reconstruction carried out a little earlier, it is possible to proceed, although the costal cartilage used to carve the replacement ear is not so plentiful and the result is sometimes not as good.
before
afterDecisions about ear reconstruction, in particular, are best made by the whole family, but with strongest input from the patient themselves. Although most children are keen to be reconstructed at their earliest opportunity, and before they change schools at 11 or 13, there is a small group who opt to wait until they are adult to truly understand the options available to them. In such an important decision, this can be an essential part of the process to prevent any later regrets
before
afterChildren can only be operated upon at hospitals with a level of paediatric cover recommended by the National Care Standards. Some hospitals operate full time cover for babies and children of all ages (The Portland Hospital), others operate full time cover for children over 3 on certain weeks of the month (The Clementine Churchill), others have a limited day case or overnight cover (The Bishops Wood Hospital) and others do not admit patients under the age of 16 (The Garden, Thames Valley Nuffield and Wellington Hospitals).
For appearance-changing operations like correction of bat ears or ear reconstruction, parents often choose the summer break to coincide with a change in school, but when trying to fit it around school and family holidays, please remember that a wound needs time to heal and to gain strength. For the best results it should not be soaked in the salt water or the swimming pool, nor baked in the sun, as the results can be spoiled. Hot tubs and contaminated seas can be a particular infection risk. It is all too easy to convert a perfect fine-line scar into a thick, stretched one by having a long soak then scrubbing at it with a sandy towel.
Advice before ear reconstruction
Of the three options for ear reconstruction - no surgery whatsoever, a “living” autogenous ear reconstruction and a “Branemark” (or bone-anchored) reconstruction (to attach a silicone prosthesis) - most patients, particularly young people, will choose the “real” option. Although a reconstructed ear will feel a little more stiff than a normal ear, it behaves like one in most other respects- it is self-healing, and fairly resistant to knocks and bumps. The Branemark option may be considered more favourably by elderly patients, and by those who have suffered previous failed reconstruction or other serious tissue loss, especially through burn injury. The prosthesis and the skin around the bolts for a false ear need daily attention, and the prosthesis, costing from £600 to £2000 each, must be changed every 18 months or so because of deterioration of the silicone. The bone-anchored option may also be less suitable in dark-skinned people, or those living in hot countries, because of build-up of abnormal tissue called granulations around the bone-anchored fixtures.
before
afterIt is very important to resist attempts at surgery to improve the appearance of the ear or scalp area before definitive ear reconstruction, as the blood supply to the new ear can be irreparably damaged and the results compromised.
If a microtia remains unoperated until the definitive ear reconstruction is performed, then the standard two stage reconstruction is usually all that is required. For ears which have been damaged by trauma, failed surgery or previous insertion of Branemark implants, it is sometimes necessary to first increase the amount of available skin cover by inserting a tissue expander as an initial procedure, or by raising a temporoparietal fascial flap at the time of the first stage surgery.
before
afterMicrotia patients who are also deaf are often first referred for fitment of a bone-anchored hearing aid (BAHA). It is important to let your BAHA surgeon know that you are considering an ear reconstruction, so that the hearing aid is not drilled into the bone at the site at which the ear would normally sit, but is instead fitted further back. Correct placement of the hearing aid is helpful when answering the telephone, and especially mobile phones. A real ear can still be reconstructed even if fixtures for a hearing aid have been placed where the ear would normally go, but the fixtures must be removed and resited. If the tissues in the area have already been damaged by the fixtures, then the overall result can be spoiled.
For overseas patients, a total stay in the country of eleven weeks is required for first stage ear reconstruction surgery with insertion and inflation of tissue expander, a 17 day stay is required for first stage ear reconstruction surgery with TP flap, 14 days for a standard first stage (i.e. without a TP flap or tissue expander), ten days for the second stage and a week for a third stage. A third stage is rarely necessary. Each stage is best separated by six months to allow scars to settle and for blood supply to be re-established.
For those with bilateral microtia (on both sides), the first stage ear reconstruction procedure is normally undertaken on one side, and then after a gap of at least one month, on the other side. The second stage for both ears can then be undertaken, after an interval of at least six months, in a single surgical episode.
After Surgery
Ear reduction and set back of prominent ears can often be performed under local anaesthetic as either an Out-Patient (walk-in, walk-out) case or as a day case. All patients who elect to have aesthetic ear surgery under general anaesthetic need to stay in hospital at least for the day of surgery, but not usually the night.
cartilage framework
suction drainsEar reconstruction patients whose ears are rebuilt from cartilage taken from the chest stay in hospital for four to five nights after the first stage. Initially a small drain coming from the chest incision drains away any fluid that might otherwise accumulate. This drain is often used to give pain-killing medication directly into the chest wound. Tiny drains which come from the site of the new ear suck the skin of the new ear onto the cartilage framework.
abnormal 4-5 fusion
abnormal 4-5 fusion correctedAfter any operation, it is beneficial to elevate the affected part. This reduces swelling and discomfort and speeds healing. After any ear surgery, it is helpful to sleep with extra pillows for at least five days rather than lying flat, and ear reconstruction patients are usually nursed in a sitting position for five days.
To achieve the best possible result after surgery, it is important that sutures (stitches) and, later, scars are given proper care. If you wish to take pain relieving tablets after leaving hospital, paracetamol (Panadol) are best. Avoid aspirin, or aspirin-containing compound preparations, since these tend to cause bleeding. Medications containing non-steroidal anti-inflammatory ingredients (like Nurofen, Brufen, Ibuprofen, Ibuleve etc) can do the same.
bowed forwards conchal hollow
bowed forwards conchall hollow correctedWounds may be sutured in a variety of ways. Non-dissolving stitches must be removed. The timing of suture removal is variable and depends on the type of operation. Head bandages normally stay on, and stitches stay in, for 5-7 days after ear reconstruction, set back of prominent (sticking out) ears and reduction of large ears. Dressings and bandages after ear lobe surgery are often minimal. Overseas patients having aesthetic ear surgery may wish to have their sutures removed in their home country, but it is preferred that ear reconstruction patients remain in the country at least until their sutures are removed, and particularly after first stage ear reconstruction surgery.
cleft ear lobe
cleft ear lobe correctedPlease try to avoid clothing which pulls over the head in the first few weeks of surgery. You can return to work or to school the day after ear reduction, set back of ears or other aesthetic ear surgery. Ear reconstruction patients can return once to work or school after stitches are removed, but should avoid contact sports or very vigorous activity for three months.
constricted concha
constricted concha correctedDissolving stitches may be left beneath the skin to provide support; occasionally your body does not dissolve them and instead extrudes them, so that they appear just beneath or through the wound, often several months after surgery.
cup ear
cup ear correctedPlease keep your wound dry until you have been seen for review and your stitches removed. If a crust builds up around the stitches, it can be removed with a cotton bud dipped in warm water and, after washing, you should apply a fine smear of antiseptic ointment over the wound (usually Chloramphenicol “eye” ointment).
deficient hillock 5 causing cleft
deficient hillock 5 causing cleftWhen you are able to begin washing the area again, do so gently with soap and water and pat dry with a clean towel. Do not pull at the wound or soak it as this may cause it to stretch. Should your wound become inflamed or tender, you should contact us immediately.
pre-op
post-opWhen the stitches are out and the wound soundly healed (around the fourth post-operative week), the scar should be massaged with a little Nivea cream twice each day for three months. Massage should begin gently over ten minute periods several times per day; later, more firm massage can be given. This will soften the scar and help it to fade more quickly. Special silicone oil preparations such as Dermatix (available direct from the office) are even more effective. It is wise not to expose new scars to sunshine.
Stahl’s bar
Stahl’s bar correctedMost scars take three months to reach 80% of their full strength and for this period they are often active, red and a little raised. After this they fade and flatten: this full maturation process usually takes twelve to eighteen months but varies according to individual skin types. Those with red hair and fair skin tend to develop scars which stay redder longer than those with a darker complexion. Try not to scratch your scar as it may stretch. If itching is a problem, Eurax ointment may help.
lop ear
lop ear corrected