Experience with the malleable ear dressing, a versatile silicone-lined bandage for the auricle.

Abstract

The repair of surgical wounds of the external ear--whether it be a primary skin closure, a skin flap, or a skin graft presents several challenges with respect to healing. One of these challenges is that it is not easy to fashion a wound dressing that has a smooth, moisture-containing surface, conforms to the shape of the auricle, and adheres to it while providing light pressure. An ear dressing that features these characteristic--the malleable ear dressing--is expected to become commercially available soon In this article, the author describes his use of this dressing in 48 patients and reviews the results of follow-up questioning of 20 of these patients. Based on these findings, the author concludes that this dressing is effective, comfortable, aesthetically acceptable, and can be worn continuously for 7 consecutive days without complications.

Introduction

The most common operative procedures of the auricle are small skin excisions and reconstructions. Other procedures include keloid excisions, drainage of auricular hematomas, and repair of other auricular traumas. The most common methods of repairing surgical defects are primary closures, rotation flaps, and skin grafts. Each of these procedures presents the surgeon with a particular challenge with respect to wound healing. One such challenge involves the placement of a wound dressing. Be cause the variable contour of every patient's external ear is unique, the application of a postoperative dressing can be difficult.

The first week of healing is critical because it is then that extravasation of blood and serum from the wound and neovascularization occur. For promoting optimal wound kin healing, the three primary functions of a dressing are to protect the wound from movement, to protect it from desiccation, and to keep it clean. For skin grafts, two additional functions are to provide a moist environment and to apply adequate pressure so that excessive blood and serum do not collect underneath the graft. (1,2) Moisture and pressure can also improve the healing of primary closures and rotation flaps.

The challenge in wound healing following the drainage of an auricular hematoma is that after the subcutaneous blood has been removed, the soft tissue requires several days to readhere to the underlying cartilage. During this period, constant pressure is required to prevent the formation of a space between the soft tissue and the external ear cartilage and to prevent the re-collection of blood and serum. Wrestlers and other athletes who undergo drainage of an auricular hematoma benefit from the use of a comfortable, thin dressing that easily fits underneath their protective headgear and allows them to return to their activities quickly. Historically, the primary dressings placed on the site of an auricular hematoma have included the tie-over dressing (made of gauze, cotton, sponge, or another material), Aquaplast thermoplastic material, (3,4) transcartilaginous sutures, gauze with tape, and simple bandages.

The optimal conditions for the prevention of keloid formation and hypertrophic scarring are still unknown, but the placement of a silicone gel sheet over the wound surface and the application of light pressure are known to be advantageous. (5-7)

An ideal external ear dressing (1) adheres tightly to skin but not to the wound, (2) is comfortable enough to be worn for 1 week, (3) is thin enough so that the patient can comfortably rest his or her head on it, (4) is aesthetic enough to be worn in public, (5) applies enough pressure to minimize blood and serum collection, (6) protects the wound from soiling, and (7) is malleable enough to conform to all the contours of the external ear. An ear dressing that features these characteristics--the malleable ear dressing--is expected to become commercially available soon.

In this article, the author describes his use of such a dressing in 48 patients and reviews the results of a follow-up questionnaire completed by 20 patients. Based on these findings, the author concludes that the malleable dressing is effective, comfortable, aesthetically acceptable, and can be worn for 7 days without complications.

Materials and methods

The author retrospectively reviewed the records of 48 patients who had received the malleable ear dressing (Invotec International; Jacksonville, Fla.) following ear surgery. This dressing is made up of a layer of nonadherent silicone sheeting, a thin layer of malleable metal, and a layer of cloth with adhesive (figure 1). The dressing is easy to apply to most wounds of the anterior and posterior surface of the external ear, the helical rim, and the earlobe.

[FIGURE 1 OMITTED]

Of the 48 patients in the study group, 20 consecutive patients completed a five-item follow-up questionnaire regarding their experience with the dressing. They were asked:

* Was your ear dressing comfortable? (Patients were asked to quantify their answers to this question on a scale of 0 [uncomfortable] to 5 [no discomfort].)

* Approximately how long were you able to wear the ear dressing?

* Was the appearance of the dressing acceptable?

* Did you prefer this dressing to a traditional Band-Aid?

* If so, why?

After each surgical procedure, the site was routinely cleaned of blood with hydrogen peroxide and dried thoroughly. The dressing's metal framework was bent to fit the contour of the wound site and then put into place. When appropriate, a thin layer of antibiotic ointment was applied to the silicone surface of the dressing. For some dressings that needed to be in place for several days, Mastisol[R] liquid adhesive or compound tincture of benzoin was applied to the surrounding skin before the dressing was secured.

All skin grafts were full-thickness grafts harvested from postauricular skin. They were cut to the shape of the surgical defect and secured with a single-layer nylon suture.

During keloid excision, a portion of the skin from the side of the keloid was preserved to serve as a flap. Subtotal excision of the scar tissue was performed in a manner that left the shape and thickness of the ear as close to its original state as possible. The remaining scar tissue was injected with a corticosteroid solution. The skin flap was positioned with a single layer of nylon suture.

The method of treating auricular hematomas generally depended on the duration and size of the injury. Hematomas that had occurred during the preceding 1 to 3 days were usually drained with a large-bore needle. In those that had occurred during roughly the preceding 4 to 14 days, the subcutaneous blood tended to be clotted and fibrin had accumulated. Therefore, adequate cleaning of the subcutaneous space sometimes required elevation of a skin flap. For older injuries, the clot was usually replaced with scar tissue, which had to be dissected and removed under direct exposure. For hematomas larger than 1 cm in diameter, the dead space was collapsed with a 6-0 chromic suture placed in a quilt-stitch pattern.

Results

The 48 cases included 19 skin grafts (figure 2), 14 primary closures, 10 skin flaps (figure 3), three wedge excisions (figure 4), and two wounds healed by secondary intention. These procedures had been performed for the treatment of 21 skin cancers, four auricular hematomas, and 23 benign skin lesions with 11 different pathologies, including six cases of chondrodermatitis nodularis chronica helicis and four cases of keloid.

[FIGURE 2-4 OMITTED]

Two of the skin grafts became ischemic and required a second treatment, as did two auricular hematomas. There were no reported wound infections. The most common problem that the author encountered was that the pressure he exerted when fixing the dressing in place sometimes caused blood to extravasate from the wound and soil the dressing.

Responses to the questionnaires indicated that the dressing was quite comfortable (mean comfort score: 4.4). Only two patients rated their comfort level as low as 3. Seventeen patients wore the dressing for 5 to 7 consecutive days; the other three patients either removed their dressing or had it fall off within 48 hours of placement. Eighteen patients characterized the appearance of the dressing as acceptable. All 20 patients preferred the malleable ear dressing to a traditional Band-Aid. Specific patients' comments included, "The dressing provided support for the ear [and protected it] from bumps and brushes," "It stayed on, even through a shower," "[It] looked better than a Band-Aid," "[It provided] protection from dirt and debris," and "It was easy to remove." Another described it as "low maintenance."

Discussion

The author's review of cases and his sampling of patient's opinions support the use of the malleable ear dressing as both a therapeutic tool and a comfortable, low-maintenance dressing.

Physicians will find the dressing easy to apply and that its clean, smooth, soft surface provides for optimal wound healing conditions. The dressing can be left alone for 5 to 7 days. For patients who undergo skin graft procedures, the malleable dressing can serve as a substitute for the placement of the tie-over bolster dressing, which is a time-consuming procedure. Another advantage of the malleable dressing is its capacity to exert light pressure and provide a silicone surface following removal of a keloid. Although the dressing alone might not provide sufficient pressure following treatment of an auricular hematoma, it can provide protection for the injury. The manufacturer might consider providing a clip or clamp that would exert additional pressure.

Patients appear to be quite receptive to the malleable ear dressing because it is lightweight, thin, comfortable, and tolerable in appearance. Moreover, unlike traditional gauze dressings, it does not require replacement for 7 days.

Use of this dressing requires that the wound be thoroughly cleaned and dried. This dressing is not appropriate for large wounds or for wounds that are located in the concha auricularis or the external acoustic meatus.

References

(1.) Svensjo T, Pomahac B, Yao F, et at. Accelerated healing of full-thickness skin wounds in a wet environment. Plast Reconstr Surg 2000; 106:602-12; discussion 613-14.

(2.) Schneider AM, Morykwas MJ, Argenta LC. A new and reliable method of securing skin grafts to the difficult recipient bed. Plast Reconstr Surg 1998;102:1195-8.

(3.) Henderson JM, Salama AR, Blanchaert RH, Jr. Management of auricular hematoma using a thermoplastic splint. Arch Otolaryngol Head Neck Surg 2000;126:888-90.

(4.) Ducic Y, Hilger PA, Fish FS, Bartlett AJ. A convenient and efficient moldable dressing for skin grafts. Laryngoscope 1997; 107:954-6.

(5.) Ahn ST, Monafo WW, Mustoe TA. Topical silicone gel: A new treatment for hypertrophic scars. Surgery 1989;106:781-6; discussion 786-7.

(6.) Sproat JE, Dalcin A, Weitauer N, Roberts RS. Hypertrophic sternal scars: Silicone gel sheet versus Kenalog injection treatment. Plast Reconstr Surg 1992;90:988-92.

(7.) Fulton JE, Jr. Silicone gel sheeting for the prevention and management of evolving hypertrophic and keloid scars. Dermatol Surg 1995;21:947-51.

Dr. Godley is in private practice in Providence, R.I.

Reprint requests: Frederick A. Godley, MD, Alliance ENT, 845 Main St., Providence, RI 02904. Phone: [phone]; fax: [phone]; e-mail: [e-mail]

The author received no professional or personal financial support from Invotec International, the manufacturer of the malleable ear dressing.