Pinnaplasty - A dwindling art in today's modern NHS

A question of availability 

Pinnaplasty, the corrective surgical procedure for protruding ears is performed in children and adults in the NHS in England and other parts of the United Kingdom. In England, patients must fulfil the eligibility criteria as set out in the referral controls policy, which are developed by individual primary care trusts (PCT).3 A PCT is a local health organisation responsible for managing local health services. PCTs work with local authorities and other agencies that provide health and social care locally to make sure the community's needs are being met. PCTs covering all parts of England receive budgets directly from the Department of Health.4

In most PCTs, these ‘aesthetic’ procedures together with other types of ‘non-urgent’ procedures including gastroplasty, circumcision, gender reassignment and breast asymmetry surgery are deemed as ‘low-priority’ treatments.5 PCTs may vary in the treatments offered to patients, as recently highlighted in the English media. The ‘postcode lottery’ as it is colloquially known, refers to availability of certain treatments such as Herceptin® in some PCTs and not in others. In the case of pinnaplasty, evidence such as a school report demonstrating impaired social function has to be presented to some PCTs before the surgeon is given the ‘green light’ to proceed with surgery. Similarly some PCTs require psychological assessment (and its inherent costs) before agreeing to fund surgery for aesthetic procedures. In some centres, a multidisciplinary panel comprising specialist nurses, clinical psychologists, paediatricians and surgeons at Consultant level are involved in the decision-making process. In almost all cases in England, patients are assessed by a Consultant surgeon, measurements recorded and medical photographs taken as a minimum.3, 5

A question of patient choice 

Children affected by prominent ears are often bullied and teased at school. Consequently, their education and schooling suffers. Further they may avoid opportunities for social interaction, which may affect their interpersonal development.6 It is these factors that normally prompt a GP's referral. A study by Cooper-Hobson and Jaffe (2007) showed otoplasty to be a highly successful procedure both psychologically and socially for the paediatric patient.7 Of the 101 patients aged 5–16 who underwent pinnaplasty, 92% reported increased self-confidence, 97% reported increased happiness, 79% reported improved social interaction and 100% reported a reduction in bullying.6 Other studies have clearly demonstrated an improvement in social skills and development of stable personalities following pinnaplasty.8, 9, 10 Similarly, other groups have also supported the continued availability of pinnaplasty on the NHS for children with prominent ears.9, 10 There are few procedures that are performed well by surgeons that result in such a dramatic improvement in the self esteem of a child, with clear resulting psychosocial benefit. It is therefore hard to justify withdrawal of this effective treatment from the NHS in England.

A question of training 

Pinnaplasty, along with other aesthetic procedures including reduction mammaplasty and abdominoplasty, are procedures trainee plastic surgeons are frequently involved with, either assisting their Consultants or performing the procedures under close Consultant supervision. This is invaluable in developing surgical and conceptual skills which are transferable to the treatment of other more complex problems. With increasing financial constraints within the NHS in England, many such ‘non-urgent’ procedures have been sacrificed, depriving trainee surgeons of a valuable learning opportunity. A recent study showed that 92% of surgeons performing pinnaplasty were very satisfied with their results.11 Up until recently, knowledge and experience of these operations formed part of the Record of In-Training Assessment (annual appraisal and assessment for surgical trainees) and FRCS examination (Fellowship of the Royal College of Surgeons – a qualification required for entry to the specialist register in the UK and a necessary prerequisite to Consultant appointment). More recently, training in the UK has been restructured as part of the Department of Health's ‘Modernising Medical Careers’ (MMC) programme. A key element of this change is to move from a time-centered approach to competence-based assessment and progression.12 The Intercollegiate Surgical Curriculum Project, a newly developed online curriculum for surgical trainees in the UK, defines competency levels of initial, intermediate and higher surgical trainees. Intermediate stage trainees in plastic surgery, i.e. those trainees between the third and sixth years of training in the specialty are expected to be competent at aesthetic facial procedures comprising surgery to the face, nose, eyelids and ears, the majority without assistance.13 Specifically, it is expected that the trainee will demonstrate technical skills in the correction of prominent ears and the constricted ear deformity. Assessments have to be carried out on a regular basis and online forms have to be filled in to demonstrate competence in order to progress in training. In an era where formal assessment governs progression, how can trainees be assessed on their competence whilst at the same time being deprived of the opportunity to demonstrate it?

The impact of the European Working Time Directive which states that UK doctors must be limited to a 48-hour working week by 2009 will undoubtedly further limit training opportunities. MMC also aims to move from a Consultant-led service to a Consultant-delivered service by expediting the training pathway for doctors and thus increasing the number of Consultants. Ultimately there would be more Consultants at the ‘front line’. In theory, therefore, patients in England should have greater access to Consultants than ever before. What would be the likelihood of a junior Consultant in the future performing pinnaplasty in the NHS or indeed in the private sector for the first time (unsupervised)? The Consultant will undoubtedly relish the rare opportunity to perform these procedures themselves and increase their experience and indeed skill levels. Sadly of course, the trainee surgeon would be at the other side of the operating table retracting the skin hooks.

Fewer training opportunities for aesthetic procedures will no doubt gradually become a global training issue as financial constraints and increasingly expensive treatments will mean that the ‘less important’ procedures are sacrificed. In England one of the attempts at addressing this problem has been the development of aesthetic and reconstructive cadaver courses. Several regions have developed aesthetic fellowships especially designed for trainees in that region as part of their training programme. Furthermore, it is likely that National and indeed International aesthetic fellowships may allow a cohort of trainees further exposure in the aesthetic field, including pinnaplasty. There is little doubt that despite these valiant alternatives, there is no substitute for ‘hands-on operating’ under close Consultant supervision.