After ear reconstruction

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1 Great Ormond Street Hospital for Children NHS Foundation Trust: Information for Families Ear reconstruction This leaflet explains about the ear reconstruction process and what to expect when your child comes to Great Ormond Street Hospital (GOSH) for treatment. What is ear reconstruction? Ear reconstruction is a specialised kind of plastic surgery, which is used to form an ear that looks as normal as possible. The plastic surgeon will use a piece of cartilage (material that holds body structures together) from your child s ribcage to form the framework for the ear. Where possible, the surgeon will use your child s existing ear as a model for the new one. The reconstruction process is in two stages about six to twelve months apart. Why is it needed and are there any alternatives? Ear reconstruction tends to be suggested either because your child s ear has not fully developed, is missing or has been damaged. There are options available to you, including no treatment (leaving the ear as it is) or a prosthetic (false) ear. For more information about these options, please see our Microtia information sheet. With all these options, it is important to remember that the aim of treatment is cosmetic, that is, it will improve the appearance of the ear but not how well it works. Before ear reconstruction After ear reconstruction Sheet 1 of 10 Ref: 2013F0089 GOSH NHS Foundation Trust February 2014

2 The first stage This stage is where the surgeon removes the cartilage and forms the ear shape under the skin. Outpatient appointment and pre-operative assessment clinic At the outpatient appointment, the surgeon will explain about the operation in more detail, discuss any worries you may have and ask you to give permission for the operation by signing a consent form. We will invite you to attend a preoperative assessment clinic before the operation either immediately after the outpatient appointment or on another day. The aim of this clinic appointment is to prepare you and your child for the operation and give you an opportunity to ask questions and meet the team. We suggest making a note of the questions you want to ask before the appointment. Pre-admission involves photographs, swabs and meeting the surgical team. The clinical nurse specialists will also teach your child to do breathing exercises, which will help reduce any discomfort after the operation. Please bring in any prescription medicines he or she is currently taking and tell us if he or she has any allergies. The day before the operation We will contact you on the day before the operation to explain fasting times. Your child must not have anything to eat or drink after the time given in the telephone call. If you do not follow these instructions exactly, your child s operation may be delayed or even cancelled. Your child should have a bath or shower and hair wash the night before the operation. We will also tell you what time to arrive on the day of the operation. Please leave plenty of time for travelling and come to the unit promptly as the surgeon and anaesthetist have to visit you before they start the operating list. If you are travelling a long distance, we will try to book you a room in the Patient Hotel. Please let us know in advance if you will need a room. Operation day When you have arrived on the preadmission unit, the nurses will help you and your child get ready for the operation. If you did not sign a consent form at the pre-operative assessment clinic, the surgeon will visit you to explain the operation in more detail and ask you to give permission for the operations. An anaesthetist will check that your child is fit and well enough for surgery. He or she may offer a pre-medication ( pre-med ) to relax your child. Local anaesthetic cream may also be put on your child s hand or arm so that inserting a cannula (thin, plastic tube) into a vein will not hurt so much. Your child will need to change into a theatre gown for the operation Sheet 2 of 10 Ref: 2013F0089 GOSH NHS Foundation Trust February 2014

3 and will need to wear special stockings. What does the operation involve? These prevent clots forming in his or her The operation is carried out while your legs during and after the operation. The child is under a general anaesthetic and stockings will be removed once your child usually lasts about four hours if one ear is up and about again after the operation. is being reconstructed. The operation can Your child can wear his or her dressing take around seven hours if both ears are gown and slippers to go to the operating being reconstructed. theatre. Usually one or both parents can The surgeon will make a small incision go as well, as can a favourite toy. When (cut) in your child s chest and remove a your child has been given the anaesthetic piece of cartilage from his or her ribcage. and is asleep, you will be taken to the Your child will be given a local pain post-operative ward to wait for your child. injection into the rib wound in theatre, which will help take away some of the pain after he or she has woken up from the anaesthetic. The surgeon will also save another small piece of cartilage to use in the second operation. He will secure this just underneath the skin on the chest next to the incision. The surgeon will then carve one piece of cartilage using a stencil drawing of your child s existing ear (where possible) to form the framework for the new ear. He will then make a pocket of skin on the side of your child s head, slip the framework inside and close the incision with stitches. The stitches are usually dissolvable so do not need to be removed. Sometimes, it is not possible to create a pocket so the surgeon will create a flap of skin on the scalp instead. Two drains, which look like test tubes, will be visible. Sheet 3 of 10 Ref: 2013F0089 GOSH NHS Foundation Trust February 2014

4 Are there any risks? Although the surgeon will give you further detail about the risks of this operation at the pre-operative assessment clinic, brief details follow: There is a small chance that your child could develop an infection, either at the chest incision or the ear incision. However, your child will have a course of antibiotics to reduce this risk. All surgery carries a risk of bleeding during or after the operation, usually in the form of blood collecting around the operation site, causing a bruise and swelling (haematoma). This can be painful and if significant may require a further operation to relieve it. There is a small risk that once the cartilage is in place at the ear site, it may be re-absorbed into the body. This is most likely to happen following an infection or damage to the operation site. The skin over the cartilage may also become damaged, again due to infection or trauma. If the skin is badly damaged, the cartilage may become visible, in which case a further operation may be needed. Your child s ear might look swollen for a few weeks afterwards, which can make it difficult to tell if the operations have been a success. Within a few months of the operations, the majority of the swelling will have gone down so you will be able to have a better idea about the final result. What happens afterwards? Your child will return to the ward to recover and will need to sit upright in bed for the first few days. Sitting upright will reduce swelling around your child s ear. We will encourage your child to get out of bed and moving around as soon as possible after the operation. It is important that your child does not lie on the affected side for three months. The small drains from the operation site will be regularly changed day and night for four days. They work by applying suction to your child s ear, which helps the skin stick to the cartilage framework of the new ear forming folds, and also drains any excess fluid collecting around the operation site. There is a very small chance that your child may have a drain in the chest incision but this will be removed when no longer required. We will encourage your child to do the breathing exercises he or she was taught at the pre-admission clinic. This will make the chest area more comfortable. Your child will be given a course of antibiotics to reduce the risk of infection, either through the cannula or as tablets or liquids once your child is drinking fluids comfortably. The nurses will check your child s pain level regularly and give pain relief medicines as needed either as tablets or liquid or as suppositories. Suppositories tend to be used when a child does not feel like drinking fluids after the operation. Sheet 4 of 10 Ref: 2013F0089 GOSH NHS Foundation Trust February 2014

5 Going home You and your child will need to take care of the new ear for several months after the operation to stop it becoming damaged. The following instructions will help reduce the risk: The nurses will usually remove your child s head bandage two to three days after the operation and give his or her hair a wash once the drains have been removed. They will also check both ear and chest wounds as well. The chest dressing may need to be changed before going home. This should then stay in place until the appointment one week later. We will give you an appointment to come back to the dressings clinic for a further wound check one week after going home. If your child s ear is uncomfortable at home, you can give paracetamol according to the instructions on the bottle or packet. Your child should wear clothes that button up the front to avoid pulling clothes over the head and potentially damaging his or her new ear. Your child should avoid sleeping on the reconstructed ear for three months. Pillows can be used to stop your child rolling on to the ear while asleep. It can also help to raise the head of the bed a little so your child is sleeping in a more upright position. Your child is free to have a shower or bath and hair wash once you are at home. However, he or she needs to take care drying the ear to avoid damaging it. We advise using a hairdryer on the cool setting to dry the ear rather than rubbing it. If you notice any signs of infection, such as heat, redness, swelling or discharge from the ear, please contact us straightaway. If you see any signs of exposed cartilage (whitish in colour) or wires (silver), please contact us immediately. Any pain in the chest area should improve over time. Wearing glasses can damage the new ear, so we suggest that you take the glasses to an optician to have them altered so that the arm does not rest on your child s new ear. It is often easier just to remove the relevant arm of the glasses until the ear heals. If your child has had both ears reconstructed, the optician should be able to fix the glasses on to a soft head band. Your child should be able to return to school after the dressings clinic appointment but there will be some restrictions on activities: - Start school a little later than usual and finish earlier - to avoid knocks and bumps from crowds - No PE for one month - No swimming for six weeks - No contact sports for three months Please make sure that the ear is gently cleaned with a cotton bud to prevent a build up of shampoo and dead skin. You should start this about a month after the operation. Sheet 5 of 10 Ref: 2013F0089 GOSH NHS Foundation Trust February 2014

6 We realise that it can feel strange to have a new ear so we advise that your child gets used to looking in the mirror regularly. Touching the ear gently can also help your child get used to the new ear and also helps desensitise the skin. Operation sites can become damaged in the sun, so ensure that your child wears a wide-brimmed sunhat and stays out of direct sunlight where possible for several months after the operation. We will arrange another outpatient appointment for three months after the operation. The second stage This stage usually happens between six and nine months after the first stage and is where the surgeon lifts the newly formed ear away from the side of the head. Pre-operative assessment clinic This is very similar to the appointment before the first stage operation. For further details, please see page 2. The day before the operation As with the first stage operation, we will contact you on the day before the operation to explain fasting times. Your child must not have anything to eat or drink after the time given in the telephone call. If you do not follow these instructions exactly, your child s operation may be delayed or even cancelled. Your child should have a bath or shower and hair wash the night before the operation. We will also tell you what time to arrive on the day of the operation. Please leave plenty of time for travelling and come to the unit promptly as the surgeon and anaesthetist have to see you before they start the operating list. If you are travelling a long distance, we will try to book you a room in the Patient Hotel. Please let us know in advance if you will need a room. Sheet 6 of 10 Ref: 2013F0089 GOSH NHS Foundation Trust February 2014

7 Operation day The anaesthetist will see your child and explain the planned anaesthetic and pain relief for this operation. Your child will have a cannula inserted into a vein after some local anaesthetic cream has been applied, and may be given a pre-med to relax him or her before going to the operating theatre. As before, your child can wear his or her dressing gown over the theatre gown to go to the operating theatre. Usually one or both parents can go as well, as can a favourite toy. When your child has been given the anaesthetic and is asleep, you will be taken to the ward to wait for your child. What does the operation involve? The second stage operation is also carried out while your child is under general anaesthetic and is a bit shorter than the first one, lasting around two hours. The surgeon will lift the shaped cartilage and skin away from your child s head. After he has released the ear, he will make a small incision in your child s chest to remove the small piece of cartilage saved from the first operation. He will then use this like a wedge to push the ear forwards into the correct position. This will then be covered in a skin graft, usually taken from the side of the scalp above the new ear. This area will be shaved but hair will grow back as the hair follicles are not damaged by this procedure. The skin graft will be fixed behind the ear with dissolvable stitches and held in place with a special dressing. As with the first operation, the operation site will be covered with a head dressing and one drain will be visible. Are there any risks? The risks associated with the second stage operation are much the same as those of the first stage operation. The surgeon will explain them in more detail during the pre-operative assessment clinic where you will have the opportunity to ask questions. What happens afterwards? As with the first stage operation, your child will return to the ward to recover and will need to sit upright in bed for the first few days. The head bandage will need to be worn for about a week after the operation to protect the operation site while it heals. The skin under the bandage might feel hot, sweaty and itchy, particularly in hot weather, but please try to persuade your child not to scratch or rub as this could damage the ear and stop it healing well. The ribcage dressing will also remain in place for one week. The drain will usually be removed the day after the operation or as instructed by the surgeon. The nurses will check your child s pain level regularly and give pain relief medicines as needed, either as tablets or liquid or as suppositories. Suppositories tend to be used when a child does not feel like drinking fluid after the operation. Sheet 7 of 10 Ref: 2013F0089 GOSH NHS Foundation Trust February 2014

8 Going home Your child will be able to go home once the drain has been removed, usually the day after the operation. The head bandage and the ribcage dressing will both be checked before you go home. Your child s ear will need to be looked after carefully for another few months after the operation. The following instructions will help you: We will give you an appointment to come back to the dressings clinic to have both operation sites checked about one week after going home. Your child is free to have a hair wash once the dressings have been removed. As before, he or she needs to take care drying the ear to avoid damaging it. We advise using a hairdryer on the cool setting to dry the ear rather than rubbing it. Clean around the ear and behind it with a cotton bud to stop any build up of shampoo or dead skin. The graft site will also need cleaning to keep it free from scabs. When your child is washing his or her hair, we suggest brushing the area gently with a baby hairbrush. If the area develops scabs, these can be gently softened with baby oil or olive oil. You should also try to keep your child s hair away from the healing area of skin, although we realise that this may be difficult at school. Your child might find it difficult to find a comfortable sleeping position for the first few days, so might need some extra pillows to sleep in a more upright position. He or she should avoid lying on his or her new ear for three months after the operation. Pillows can be used to stop your child rolling on to the ear while asleep. If your child s ear is uncomfortable at home, you can give paracetamol according to the instructions on the bottle or packet. Your child should wear clothes that button up the front to avoid pulling clothes over the head and potentially damaging his or her new ear. Wearing glasses can damage the new ear, so we suggest that you take them to an optician to have them altered so that the arm does not rest on your child s new ear. It is often easier just to remove the relevant arm of the glasses until the ear heals. If your child has had both ears reconstructed, the optician should be able to fix the glasses on to a soft head band. Your child should be able to return to school after the dressings clinic appointment but there will be some restrictions on activities for a few weeks: - Start school a little later than usual and finish earlier - to avoid knocks and bumps from crowds - No PE for one month - No swimming for six weeks - No contact sports for three months Sheet 8 of 10 Ref: 2013F0089 GOSH NHS Foundation Trust February 2014

9 n Operation sites can become damaged in the sun, so ensure that your child wears a wide-brimmed sunhat and stays out of direct sunlight where possible for several months after the operation. Before ear reconstruction You should also apply some sun block cream (SPF 25 or more) to prevent any sun damage. If your child s operation occurred during the winter months, keep the ear warm as this will help the graft to heal. n We will arrange another outpatient appointment for three months after the operation. After ear reconstruction Sheet 9 of 10 Ref: 2013F0089 GOSH NHS Foundation Trust February 2014

10 You should call the ward if: Your child is in a lot of pain and pain relief does not seem to help; Your child has a temperature of 38 C or higher and pain relief does not bring it down; Your child is not drinking any fluids; The operation site is red or inflamed, and feels hotter than the surrounding skin; There is any oozing or bleeding from the operation site; If you have any questions, please telephone the Clinical Nurse Specialists for Plastic Surgery on ext Monday to Friday from 9am to 5pm. Out of hours, please telephone and ask to speak to the on call doctor for plastic surgery. Notes Compiled by the Plastic Surgery department and Peter Pan Ward in collaboration with the Child and Family Information Group Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH Sheet 10 of 10 Ref: 2013F0089 GOSH NHS Foundation Trust February 2014

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