The Curse of Failed Pinnaplasty

18 October 2017

When surgery to set back a child’s stick-out ears was offered routinely by the National Health Service, it was one of the procedures regularly given to plastic surgery trainees to cut their teeth on. Many of these operations had the desired result, but a number did not go so well. I quite commonly see patients in their late 30’s, their 40’s and 50s asking for correction of deformities arising from surgery they had when they were children. These are usually “telephone ears”, where the ear looks stuck to the head, especially in the middle, as though they had spent too long on an old-fashioned phone.

Far from one of the bread and butter operations that Plastic Surgeons undertake, surgery to pin back ears, sometimes called pinnaplasty or otoplasty, can be challenging, and the choice of technique is important. Having corrected many failed pinnaplasties, and acted as an expert witness in negligence cases, it became clear that the technique with the potential to allow the worst complications, such as the total loss of the ear, involved cutting out of the ear cartilage responsible for the stick-out deformity.  In fact, 85% of the legal cases I reviewed were the result of techniques which excised cartilage (such as the Chong Chet technique). Removing the cartilage might seem common sense, but the post-operative accumulation of blood in a haematoma (essentially a large, semi-liquid bruise) and, sometimes, an infection which develops within it, is what causes the overlying tissue to die.  This sounds dramatic, but anyone who has seen the blackened, dying tissue of what once was an ear on the side of a young person’s head after what was supposed to be a minor cosmetic procedure will not forget it.  Any death of ear tissue means that the result is forever spoiled, even with the benefit of further difficult reconstructive surgery.

By 1999, I developed a technique which avoided cartilage excision by “sewing in” the missing folds in the cartilage which caused the stick-out deformity in the first place. Details were shared in the surgical journal Plastic and Reconstructive Surgery in 2001, and I was pleased to see that, in a recent comprehensive review of surgery for stick out ears, the technique remains the safest and most reliable almost 20 years later.

This does not necessarily mean that cartilage excision procedures are wrong.  Certainly, however, I would recommend that any surgeon using such a technique does not bandage the ears too tightly afterwards, and that the increased possibility of haematoma is kept in mind should there be unexpected pain or other problems post-op. 

Once surgery to set back the ears goes wrong, the way back to achieving the result originally expected can be long and tortuous.  Some patients I see for the first time may have had five or more attempts at revision surgery beforehand. If stick out ears run in your family and you have a child, consider correcting the ears as soon as the problem shows itself (some baby ears don’t start to stick out for three months). I developed EarBuddies when my first child was born with an ear problem to avoid him having surgery. Available worldwide for 25 years, the simple device is now available on the NHS in some areas, and in prestigious hospitals such as the Mayo Clinic in the US, Boston Children’s Hospital and The Portland Hospital, London.

If you are reading this, you will be too old for EarBuddies to be effective, but whichever surgeon and technique you choose for your own surgery, consider carefully.  All surgery has risks, but it is possible to manage these by careful matching of problem with technique and careful practise. Not all complications are equal, either, and for pinnaplasty, an ear which is not set in enough is much better than an over set-back ear.  Ask questions about the rate of adverse events particularly.  Beware any technique or surgeon with an adverse event rate of more than 5% at the very most – this means 5 out of every 100 cases will suffer a problem. And importantly, look for feedback on techniques on research-based, peer-reviewed sites such as the NCBI and on surgeons using truly independent reviews by real people.  These days, once reputable publications stoop low in search of a new cosmetic crumb. Beware too, PR driven drivel, the single happy patient in a sea of discontent, “star or featured” members of directories (they paid), “top” awards (they usually paid), advertorials and sponsored sites. Likewise, be aware of trolling designed to denigrate competitors. It is worth asking your surgeon how many legal cases they have faced and how many they have settled,. Older surgeons who take on difficult cases should be expected to have figures which are higher than young ones working on easy cases. But any proper person will be able to give you an immediate response. Lastly, remember that surgery undertaken lightly can take years to recover from. And if in doubt, wait.

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