Torn/Split Earlobe

CHAPTER 157

Torn/Split Earlobe

Presentation

A patient comes to the emergency department or clinic with an earlobe torn by a sudden pull on an earring. Contributing factors might include previous lengthening of the earlobe hole because of long-term use of relatively heavy or dangling ear jewelry, or the original earring hole may have been placed in an excessively low position.

What To Do:

Discuss the options: attempting to salvage the original piercing track (which may tend to elongate more easily) or removing the track entirely and providing for a new piercing at a later time. Inform the patient of the possibility of future inclusion cyst formation (caused by any hidden remnants of the old epithelial track) as well as the potential for postoperative scar contracture with resultant notching or scalloping of the lobe.

If cosmetic appearance is of great concern, it may be advisable to consult with a plastic surgeon before attempting the primary repair.

Always perform a thorough evaluation based on the patient’s presentation. If there has been direct trauma to the ear, make sure to perform a thorough evaluation for signs of other clinically significant injuries, including intracranial, facial, and cervical.

Before repair, provide anesthesia, either by infiltrating the lobe with 1% lidocaine (Xylocaine) until the lobe becomes firmer and pale or by performing a block of the greater auricular nerve. The use of anesthetic formulations that contain epinephrine in the ear is somewhat controversial because of the potential for excessive vasoconstriction, although these formulations are advocated by some authors. Once the area is anesthetized, use a No. 11 or No. 15 blade to excise and undermine the wound edges as well as to make any required incisions for a Z-plasty repair.

Tears in the upper two thirds of the lobe may be excised and reapproximated. Tears in the lower third of the lobe should be converted to a full-thickness tear for easier management and better cosmetic results.

For repairs that attempt to salvage the original piercing track, excise the wound edges below the old track, including the lower segment of any elongated partial cleft (Figure 157-1, A and B). To encourage wound edge eversion, undermine the anterior and posterior skin edges to 1 mm (Figure 157-2).

Figure 157-1 A, Incomplete excision of skin lining a full cleft. B, Excision of skin at the inferior lobe margin to convert a partial cleft to a full cleft. Apex epithelium is preserved. C, Straight-line closure of both cleft conditions, with preservation of the original hole. (Adapted from Watson D: Torn earlobe repair. Otolaryngol Clin North Am 35:187-205, vii-viii, 2002.)

Figure 157-2 One-millimeter undermining of skin edges. (Adapted from Watson D: Torn earlobe repair. Otolaryngol Clin North Am 35:187-205, vii-viii, 2002.)

A loop of 2-0 nylon should be placed at the apex as a temporary earring site spacer, to be exchanged with an earring after being left in place for 1 month. Some authors do recommend repiercing with a sterile stud at the time of wound repair.

Approximating the wound edges is crucial for a good cosmetic result. Placing 1 to 2 absorbable sutures, such as a 5-0 gut, will decrease dead space and hematoma formation as well as reduce tension on overlying skin sutures.

The wound can then be sutured in a simple straight-line closure (see Figure 157-1, C) using a fine monofilament suture, such as 6-0 nylon.

Place a single suture at the most inferior portion of the lobe before placing the other sutures. This will ensure precise approximation and facilitate the remainder of the repair.

For repairs that remove the old track, excise the wound edges using an inverted V-shaped excision (Figure 157-3), removing all remnants of any cleft. Undermine the skin edges as previously (see Figure 157-2), and make a similar straight-line closure (Figure 157-4).

Figure 157-3 Inverted V-shaped excision of cleft. (Adapted from Watson D: Torn earlobe repair. Otolaryngol Clin North Am 35:187-205, vii-viii, 2002.)

Figure 157-4 Straight-line closure. (Adapted from Watson D: Torn earlobe repair. Otolaryngol Clin North Am 35:187-205, vii-viii, 2002.)

To reduce the risk for scar contracture with earlobe deformity, the straight-line closure can be replaced by a simple Z-plasty (Figure 157-5), closing the skin with the same fine (6-0) monofilament suture material.

Figure 157-5 Straight-line closure with inferior rim modification by Casson. A, Incisions for a Z-plasty on inferior margin. B, Z-plasty flap transposition and closure. (Adapted from Watson D: Torn earlobe repair. Otolaryngol Clin North Am 35:187-205, vii-viii, 2002.)

Aftercare should include daily showering and/or gentle wound cleansing with soap and water followed by application of bacitracin ointment or petroleum jelly is recommended.

Sutures should be removed in approximately 5 days. Consider using tissue adhesive (Dermabond) after the sutures are removed to reduce tension on the healing wound.

Patients should be instructed that repiercing, if desired, should not be done through the scar but should be placed adjacent to the repair site. This will create a stronger piercing that is less prone to cleft formation. Preferably, replacement of the earring site should be delayed by 3 months.

Provide tetanus prophylaxis if needed (see Appendix H).

What Not To Do:

Do not close an earlobe tear when remnants of the old earring track are known to be inside. This old epithelial track will eventually form an inclusion cyst, which will often require excision later.

Do not use ointment containing neomycin. The neomycin provides no advantage and can often produce severe contact dermatitis.

Discussion

Piercing the earlobes is a practice that has persisted since ancient times and is common throughout the world today. Current cultural and fashion trends have encouraged an increase in earlobe piercing for men and multiple ear piercings for women, which has led to a greater incidence of piercing complications, including torn earlobes.

Torn earlobes also are referred to as split or cleft earlobes in the literature. A variety of techniques have been described to repair torn earlobes. Some of these methods incorporate reconstruction of the original earring hole during earlobe repair, but many authors still recommend repiercing the earlobe at a later time.

Repiercing can be done safely by a physician or other qualified healthcare professional. The new piercing site should be placed in a nonscarred area of the lobe, preferably in a central location. Patients who have had multiple infections at the piercing site should not have the earlobe repierced.

Cleanse the earlobe with isopropyl alcohol or povidone-iodine (Betadine). Let the earlobe dry, and mark the desired piercing site approved by the patient.

Less than 0.5 mL of 1% lidocaine (Xylocaine) with epinephrine can be injected into the site using a 30-gauge needle. Then, take an 18-gauge sterile needle and insert it through the full thickness of the earlobe from the posterior surface through to the anterior surface. The needle tip must exit the anterior surface at the previously marked position.

The earring is slipped into the barrel of the 18-gauge needle. (Fitting the post into the lumen of the needle should be tested beforehand.) As the needle is backed out of the lobule, the earring post is guided into position through both the anterior and posterior punctures. Preferably, the post should be surgical grade or stainless steel and nickel free.

The backing piece should not squeeze the earlobe when it is slid into position on the post.

Patients should be instructed to gently cleanse the site with mild soap and water once or twice daily, followed by careful drying.

Patients should be instructed not to twist and turn the earring post, because this can increase the risk for irritation or infection.

The earring posts that are inserted initially should not be exchanged for at least 6 weeks to allow enough time for epithelialization in the new hole.

Avoidance of heavy and pendulous earrings is prudent.

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