Greater Manchester EUR Policy
Statement
Title/Topic: Repair of Split / Torn Ear Lobes
Reference: GM023
Date: September 2015
Last Reviewed: September 2016
VERSION CONTROL
Page
number
Version
Date
Details
0.1
15/10/2014
Initial draft
N/A
21/11/2014
Greater Manchester EUR Steering Group agreed the policy for
consultation on 19th November 2014.
N/A
25/06/2015
Changes made following the GM EUR Steering Group meeting
on 20/05/2015 post Consultation:
1.0
Section 2 Definition - Following added:-
7
Trauma (for the purposes of this policy
Trauma is defined as injury resulting from an unexpected external
force that results in injuries which include the tear to the earlobe
e.g. as a result of a road traffic accident or an assault. It does not
include an earring being pulled through the earlobe over time
either by a child pulling on it or the weight of the ear
ornamentation used.
Gauge piercing
The piercing in the ear is gradually stretched until there is a hole
in the ear lobe – this can be extreme and is increasingly
fashionable
Section 4 - Criteria for Commissioning
8
The following wording was added under Mandatory criteria
Where repair was deferred as the result of a clinical decision at
the time the original trauma was managed due to the clinical
team assigning a lower priority to repairing the earlobe damage
than dealing with other injuries or where other surgery needed to
be completed before the repair to the earlobe was carried out.
The deferred repair will be commissioned via monitored approval
however the decision to delay repair should be clearly recorded
in the patient’s clinical notes.
Where repair of an earlobe has been funded it is on the
understanding that the ear will not be re-pierced.
Repair of a hole in the ear lobe resulting from gauge piercing is
not commissioned.
Policy approved by the GM EUR Steering Group on 20/5/2015
subject to the above changes being made.
GM Repair of Split Torn Ear Lobes Policy v2.0 FINAL
Page 2 of 14
1.1
2.0
06/04/2016
21/09/2016
List of diagnostic and procedure codes in relation to this policy
added as Appendix 2.
14
Policy changed to Greater Manchester Shared Services template
and references to North West Commissioning Support Unit
changed to Greater Manchester Shared Services.
N/A
Wording for date of review amended to read “One year from the
date of approval by Greater Manchester Association Governing
Group thereafter at a date agreed by the Greater Manchester
EUR Steering Group (unless stated this will be every 2 years)” on
‘Policy Statement’ and section ‘13. Date of Review’.
4 & 10
The policy was reviewed in August 2016 and no new papers
were found.
Following GM EUR Steering Group on 21
September 2016 it was agreed that only the following updates
need to be made:
•
Review date added to cover page and ‘Policy Statement’
1&4
•
The ‘Date of Review’ on ‘Policy Statement’ and in body of
report changed to “Three years from the date of last review
unless new evidence warrants earlier review”
4 & 10
GM Repair of Split Torn Ear Lobes Policy v2.0 FINAL
Page 3 of 14
POLICY STATEMENT
Title/Topic:
Repair of split/torn ear lobes
Issue Date:
September 2015
Reviewed:
September 2016
Commissioning
Recommendation:
This is an aesthetic procedure which is only available for the repair of totally
split ear lobes as a result of direct trauma. Repair should be carried out in
the period immediately following the trauma unless clinically
contraindicated.
See Section 4: Criteria for Commissioning
Date of Review:
Three years from the date of last review unless new evidence warrants
earlier review.
Prepared By:
Greater Manchester Shared Services Effective Use of Resources Policy
Team
Approved By
Greater Manchester Effective Use
of Resources Steering Group
Date
Approved
20/05/2015
Funding Mechanism
GM EUR Steering Group recommended funding
mechanism:
Funding will be via the relevant contracting
arrangements and referrals may be accepted in line
with the mandatory commissioning criteria.
Greater Manchester Chief Finance
Officers / Greater Manchester
Heads of Commissioning
11/08/2015
N/A
Greater Manchester Association
Governing Group
15/09/2015
N/A
Bury Clinical Commissioning
Group
07/10/2015
Recommended mechanism above
Bolton Clinical Commissioning
Group
23/10/2015
Recommended mechanism above
Heywood, Middleton & Rochdale
Clinical Commissioning Group
20/11/2015
Recommended mechanism above
Central Manchester Clinical
Commissioning Group
16/12/2015
Recommended mechanism above
GM Repair of Split Torn Ear Lobes Policy v2.0 FINAL
Page 4 of 14
North Manchester Clinical
Commissioning Group
21/10/2015
Recommended mechanism above
Oldham Clinical Commissioning
Group
15/09/2015
Recommended mechanism above
Salford Clinical Commissioning
Group
15/09/2015
Recommended mechanism above
South Manchester Clinical
Commissioning Group
01/10/2015
Recommended mechanism above
Stockport Clinical Commissioning
Group
23/09/2015
Recommended mechanism above
Tameside & Glossop Clinical
Commissioning Group
25/10/2015
Recommended mechanism above
Trafford Clinical Commissioning
Group
17/11/2015
Recommended mechanism above
Wigan Borough Clinical
Commissioning Group
07/10/2015
Recommended mechanism above
GM Repair of Split Torn Ear Lobes Policy v2.0 FINAL
Page 5 of 14
CONTENTS
Policy Statement ...................................................................................................................................... 7
Equality & Equity Statement ..................................................................................................................... 7
Governance Arrangements....................................................................................................................... 7
1.
Introduction .................................................................................................................................... 7
2.
Definition........................................................................................................................................8
3.
Aims and Objectives ...................................................................................................................... 8
4.
Criteria for Commissioning ............................................................................................................. 8
5.
Description of Epidemiology and Need .......................................................................................... 9
6.
Evidence Summary ........................................................................................................................ 9
7.
Rationale behind the Policy Statement........................................................................................... 9
8.
Adherence to NICE Guidance ...................................................................................................... 10
9.
Mechanism for Funding ............................................................................................................... 10
10.
Audit Requirements ..................................................................................................................... 10
11.
Documents which have informed this Policy ................................................................................ 10
12.
Links to other Policies .................................................................................................................. 10
13.
Date of Review ............................................................................................................................ 10
14.
Glossary ...................................................................................................................................... 10
References ............................................................................................................................................. 11
Appendix 1 – Evidence Review .............................................................................................................. 12
Appendix 2 – Diagnostic and Procedure Codes...................................................................................... 14
GM Repair of Split Torn Ear Lobes Policy v2.0 FINAL
Page 6 of 14
Policy Statement
The Greater Manchester Shared Services (GMSS) has developed this policy on behalf of Clinical
Commissioning Groups (CCGs) within Greater Manchester, who will commission the repair of split/torn
ear lobes in accordance with the criteria outlined in this document.
In creating this policy the GMSS has reviewed this clinical condition and the options for its treatment. It
has considered the place of this treatment in current clinical practice, whether scientific research has
shown the treatment to be of benefit to patients, (including how any benefit is balanced against possible
risks) and whether its use represents the best use of NHS resources.
This policy document outlines the arrangements for funding of this treatment for the population of
Greater Manchester.
Equality & Equity Statement
The GMSS/CCG has a duty to have regard to the need to reduce health inequalities in access to health
services and health outcomes achieved, as enshrined in the Health and Social Care Act 2012. The
GMSS/CCG is committed to ensuring equality of access and non-discrimination, irrespective of age,
gender, disability (including learning disability), gender reassignment, marriage and civil partnership,
pregnancy and maternity, race, religion or belief, gender or sexual orientation. In carrying out its
functions, the GMSS/CCG will have due regard to the different needs of protected characteristic groups,
in line with the Equality Act 2010. This document is compliant with the NHS Constitution and the Human
Rights Act 1998. This applies to all activities for which they are responsible, including policy
development, review and implementation.
In developing policy the GMSS policy team will ensure that equity is considered as well as equality.
Equity means providing greater resource for those groups of the population with greater needs without
disadvantage to any vulnerable group.
The Equality Act 2010 states that we must treat disabled people as more equal than any other protected
characteristic group. This is because their ‘starting point’ is considered to be further back than any other
group. This will be reflected in GMSS evidencing taking ‘due regard’ for fair access to healthcare
information, services and premises.
An Equality Analysis was carried out on this policy. For more information about the Equality Analysis,
please contact [email protected].
Governance Arrangements
Greater Manchester EUR policy statements will be ratified by the Greater Manchester Association
Governing Group (AGG) prior to formal ratification through CCG Governing Bodies. Further details of
the governance arrangements can be found in the Greater Manchester EUR Operational Policy.
1.
Introduction
This commissioning policy has been produced in order to provide and ensure equity, consistency and
clarity in the commissioning of services for the repair of split/torn ear lobes by Clinical Commissioning
Groups in Greater Manchester. When this policy is reviewed all available additional data on outcomes
will be included in the review and the policy updated accordingly.
Body piercings are becoming increasingly common and this includes ear piercing(s). There has been a
recent increase in the practice of earlobe piercing for men as well as multiple ear piercings for women.
This has led to an increase in the number of patients seeking aesthetic repair of piercing complications
such as torn earlobes.
GM Repair of Split Torn Ear Lobes Policy v2.0 FINAL
Page 7 of 14
The earlobe can become split (torn) as a result of trauma – usually specific trauma arising from pulling
out an earring during an assault, or other general trauma. Ear lobes may also split as a result of the
wearing of heavy ear ornamentation which results in a slow splitting of the earlobe (a cheese wire type
effect that occurs over time).
2.
Definition
Trauma (for the purposes of this policy
Trauma is defined as injury resulting from an unexpected external force that results in injuries which
include the tear to the earlobe e.g. as a result of a road traffic accident or an assault. It does not include
an earring being pulled through the earlobe over time either by a child pulling on it or the weight of the
ear ornamentation used.
Complete split/tear (or cleft)
Most complete tears are unilateral and result from acute trauma in which the earring is suddenly pulled
out, the lobule becomes divided into a medial and a lateral limb.
Incomplete or partial split/tear (or cleft)
This tends to be associated with the prolonged use of heavy, pendulous earrings, and is typically
bilateral.
Gauge piercing
The piercing in the ear is gradually stretched until there is a hole in the ear lobe – this can be extreme
and is increasingly fashionable.
3.
Aims and Objectives
Aim
This policy document aims to specify the conditions under which the repair of split/torn ear lobes will be
routinely commissioned by Clinical Commissioning Groups in Greater Manchester.
Objectives
•
•
•
To reduce the variation in access to the repair of split/torn ear lobes.
To ensure that the repair of split/torn ear lobes is commissioned where there is acceptable
evidence of clinical benefit and cost-effectiveness.
To reduce unacceptable variation in the commissioning of the repair of split/torn ear lobes across
Greater Manchester.
To promote the cost-effective use of healthcare resources.
4.
Criteria for Commissioning
•
Mandatory Criteria
Ear lobes split as a result of trauma should be repaired in the period of care immediately following the
trauma, where it will be considered part of the standard care pathway for trauma aftercare.
Where repair was deferred as the result of a clinical decision at the time the original trauma was
managed due to the clinical team assigning a lower priority to repairing the earlobe damage than dealing
with other injuries or where other surgery needed to be completed before the repair to the earlobe was
carried out. The deferred repair will be commissioned via monitored approval however the decision to
delay repair should be clearly recorded in the patient’s clinical notes.
GM Repair of Split Torn Ear Lobes Policy v2.0 FINAL
Page 8 of 14
Where repair of an earlobe has been funded it is on the understanding that the ear will not be re-pierced.
Repair of a split/tear (or cleft) that is result of the wearing of heavy ornamentation is not commissioned.
Repair of a hole in the ear lobe resulting from gauge piercing is not commissioned.
Policy Exclusions
Clinicians can submit an Individual Funding Request (IFR) if they feel there is a good case for
exceptionality.
Exceptionality means ‘a person to which the general rule is not applicable’. Greater Manchester sets out
the following guidance in terms of determining exceptionality; however the over-riding question which the
IFR process must answer is whether each patient applying for exceptional funding has demonstrated
that his/her circumstances are exceptional. A patient may be able to demonstrate exceptionality by
showing that s/he is:
•
Significantly different to the general population of patients with the condition in question.
and as a result of that difference
•
They are likely to gain significantly more benefit from the intervention than might be expected from
the average patient with the condition.
5.
Description of Epidemiology and Need
Cortese and Dickey1 studied seventy-three nursing students with pierced ears and found that thirty-eight
(52 percent) had experienced one or more local complications. Of these 1% had torn earlobes.
6.
Evidence Summary
There are very few evidence based studies available for these types of procedure as they are
considered aesthetic. Repair of a split/tear (or cleft), not done as part of the immediate repair of trauma,
will carry:
•
Lower success rates
•
The risk of keloid and hypertrophic scarring in this site
•
The risks of further trauma with re-piercing of the ear lobule
Full details of the Evidence Review are contained with Appendix 1.
7.
Rationale behind the Policy Statement
The repair of split earlobe is considered to be an aesthetic procedure of low clinical value. However,
funding is available as part of a package of care for the repair of ear lobes damaged as a result of
forceful trauma. This policy has been developed to ensure that resources are used in the most effective
way possible and targeted at those where there is a clinical need. To ensure the best outcome, repair of
earlobes following forceful trauma should be carried out as soon as possible after the trauma occurs.
The wearing of heavy earrings or other potentially damaging ear ornamentation is a personal choice and
any repairs carried out to address resulting damage are considered to be aesthetic procedures under
this policy.
GM Repair of Split Torn Ear Lobes Policy v2.0 FINAL
Page 9 of 14
8.
Adherence to NICE Guidance
NICE have not currently issued guidance on this treatment.
9.
Mechanism for Funding
Clinical Commissioning Group
Funding Mechanism
Bolton
Bury
Heywood, Middleton & Rochdale
Manchester Central
Manchester North
Manchester South
Oldham
Salford
Stockport
Tameside & Glossop
Trafford
Wigan
Funding will be via the relevant contracting arrangements and
referrals may be accepted in line with the mandatory
commissioning criteria.
10.
Audit Requirements
There is currently no national database. Service providers will be expected to collect and provide audit
data on request.
11.
Documents which have informed this Policy
•
Greater Manchester Effective Use of Resources Operational policy
12.
Links to other Policies
This policy follows the principles set out in the ethical framework that govern the commissioning of NHS
healthcare and those policies dealing with the approach to experimental treatments and processes for
the management of individual funding requests (IFR).
13.
Date of Review
Three years from the date of last review unless new evidence warrants earlier review.
14.
Glossary
Term
Meaning
Acute
Refers to a disease or condition with a rapid onset and/or a short course that in
some cases can go on to cause a chronic (long term) condition. May also refer to
episodes of sudden and or more severe symptoms during a chronic illness
Bilateral
Affecting both sides of the body
Ear Lobe / Lobule
The soft, rounded fleshy part hanging from the lower margin of the ear
Hypertrophic
Scarring
Enlargement or overgrowth of a scar due to the increased size of the constituent
cells
GM Repair of Split Torn Ear Lobes Policy v2.0 FINAL
Page 10 of 14
Keloid
A keloid is the formation of a type of scar which, depending on its maturity, is
composed mainly of either type III or type I collagen. It is a result of an overgrowth
of granulation tissue at the site of a healed skin injury which is then slowly replaced
by collagen type 1.
Lateral Limb
Outer part of the split lobe
Medial Limb
Inner part of the split lobe
Trauma
Physical injury due to external forces
Unilateral
On one side only
References
1.
Complications of ear piercing
Cortese TA, Dickey RA.
Am Fam Physician. 1971 Aug;4(2):66-72.
GM Repair of Split Torn Ear Lobes Policy v2.0 FINAL
Page 11 of 14
Appendix 1 – Evidence Review
Title/Topic: Repair of split/torn ear lobes
Ref: GM023
Search Strategy
Searches were made using repair of split / torn ear lobes – in various combinations.
Database
Result
NICE
Nil found
NHS Evidence and NICE
CKS
NHS Modernisation Agency: Action on Plastic Surgery: Information for
Commissioners of Plastic Surgery Services – Referrals and Guidelines
in Plastic Surgery
SIGN
Nil found
Cochrane
Nil found
York
Nil found
BMJ Clinical Evidence
Nil found
BMJ Best Practice
Nil found
General Search (Google)
•
Multiple local policies (not cited here)all based on the Modernisation
Agency guidance
•
Guidance on types of repair
•
Multiple provider websites offering repair
Medline / Open Athens
Not done
Other
•
British Association of Plastic, Reconstructive and Aesthetic Surgeons
(BAPRAS) – website link to Modernisation Agency
•
BestBETs – Nil found
•
The British Association of Aesthetic Plastic Surgeons (BAAPS)
website – Nil found
Summary of the evidence
There are very few evidence based studies available for these types of procedure as they are
considered aesthetic. Repair of a split/tear (or cleft), not done as part of the immediate repair of trauma,
will carry:
•
Lower success rates
•
The risk of keloid and hypertrophic scarring in this site
•
The risks of further trauma with re-piercing of the ear lobule
GM Repair of Split Torn Ear Lobes Policy v2.0 FINAL
Page 12 of 14
The evidence
Levels of evidence
Level 1
Meta-analyses, systematic reviews of randomised controlled trials
Level 2
Randomised controlled trials
Level 3
Case-control or cohort studies
Level 4
Non-analytic studies e.g. case reports, case series
Level 5
Expert opinion
1.
LEVEL 5:EXPERT OPINION
NHS Modernisation Agency: Action on Plastic Surgery: Information for Commissioners of
Plastic Surgery Services – Referrals and Guidelines in Plastic Surgery
Repair of external ear lobes (lobules)
This procedure is only available on the NHS for the repair of totally split ear lobes as a result of direct
trauma.
Prior to surgical correction, patients should receive pre-operative advice to inform them of:
•
Likely success rates
•
The risk of keloid and hypertrophic scarring in this site
•
The risks of further trauma with re-piercing of the ear lobule
Rationale
Many split earlobes follow the wearing of excessively heavy earrings with insufficient tissue to support
them, such that the earring slowly “cheese-wires” through the lobule. Correction of split earlobes is not
always successful and the earlobe is a site where poor scar formation is a recognised risk.
GM Repair of Split Torn Ear Lobes Policy v2.0 FINAL
Page 13 of 14
Appendix 2 – Diagnostic and Procedure Codes
(All codes have been verified by Mersey Internal Audit’s Clinical Coding Academy)
GM023 - Repair of Split/Torn Earlobe Policy
Repair of lobe of external ear
D06.2
With the following ICD-10 diagnosis code(s):
Hypertrophic scar
L91.0
Other plastic surgery for unacceptable cosmetic appearance
Z41.1
GM Repair of Split Torn Ear Lobes Policy v2.0 FINAL
Page 14 of 14