Introduction

Prominent ear correction (otoplasty) is a reliable and commonly performed procedure with a low complication rate. Infection is uncommon, and late-onset infection is particularly rare. In over four decades of plastic surgical practice, we encountered an unusual case of delayed Pseudomonas aeruginosa infection following revision otoplasty.

This blog aims to raise awareness, share the management, and—most importantly—highlight lessons for surgeons, theatre teams, and patients to minimise future risk.

Surgical Technique (Key Clarification)

In our standard otoplasty technique:

• The antihelical fold is recreated using braided non-absorbable sutures
• Suture knots are deliberately buried and covered using a posteriorly based fascial flap
• This flap coverage is intended to:
  • Reduce the risk of suture extrusion
  • Minimise long-term irritation and infection

This technique has been used safely and successfully in a large number of patients.

Case Summary

A 20-year-old healthy woman underwent bilateral otoplasty under local anaesthesia using a retro-auricular approach.
The initial outcome was satisfactory.

One year later, she requested minor refinement of the right upper pole, which was performed through the same scar using the same suture-based technique. Early postoperative review was normal.

The Unusual Complication

Approximately two months after revision surgery, the patient returned with:

• Painful swelling behind the ear
• No fever or systemic symptoms
• Poor response to oral broad-spectrum antibiotics

Surgical drainage was performed through the original retro-auricular incision.
Microbiology confirmed Pseudomonas aeruginosa.

Management and Outcome

• Managed with a multidisciplinary approach (plastic surgery, ENT, microbiology)
• Antibiotics tailored to culture sensitivity
• Ciprofloxacin selected as definitive therapy
• Prolonged treatment required to ensure eradication of infection from auricular cartilage and to minimise possibility of chronic chondritis.

The wound healed completely with no cartilage damage and no aesthetic deformity.

Environmental screening of the operating theatre was negative, suggesting the most likely source was:

• The external auditory canal, or
• The scalp/skin flora, rather than theatre contamination

Timeline of Events

Initial Otoplasty
→ Uneventful healing, satisfactory outcome

1. Year Later
→ Minor right upper pole revision

2. Months Post-Revision
→ Painful retro-auricular swelling

3. Management Phase
→ Surgical drainage
→ Culture-directed ciprofloxacin

4. Final Outcome
→ Complete resolution
→ Preserved ear shape and symmetry

Lessons Learned – Surgeon’s Perspective

1. Posteriorly based fascial flap elevation is critical
   • Ensures complete coverage of non-absorbable suture knots
   • Reduces risk of extrusion and chronic infection
2. Braided non-absorbable sutures, while effective, may:
   • Harbour bacteria
   • Contribute to infection if contamination occurs and can be a source of irritation
3. Early drainage and prolonged targeted antibiotics are essential
   • Ciprofloxacin remains the antibiotic of choice for pseudomonas
   • Treatment may be required for 4–12 weeks, depending on response

Pre-Operative Measures Now Implemented

For Patients

• Daily scalp and external ear hygiene for one full week pre-operatively
• Particular attention to the external auditory canal
• Pre-operative washing with chlorhexidine (Hibiscrub®) for:
  • Three days before surgery
  • Again on the day of surgery

For Theatre Team

• Careful intra-operative cleaning of the external auditory meatus
• Reinforced aseptic handling around the ear and hair-bearing scalp

Post-Operative Measures

• Routine follow-up at:
  • 1 week
  • 6 weeks
• Patients advised to report immediately if there is:
  • Pain
  • Redness
  • Swelling
  • Discharge

Early intervention remains the key to preventing cartilage involvement.

Take-Home Message

Even with meticulous technique and decades of experience, rare complications can still occur. What matters most is early recognition, appropriate microbiology-guided treatment, and continuous refinement of surgical protocols.

This case reinforces:

• The importance of flap coverage of non-absorbable sutures
• The unique microbiology of the ear
• The shared responsibility between surgeon, theatre team, and patient