Revisiting and recreating plastic surgery concepts of Acharya Sushruta through Torn Ear Lobulue Repair vis-à-vis Karnasandhana w.s.r. to Lobuloplasty - A Single Case Study

JV Adithya; NN Nirmaladevi; Siddayya Aradhyamath

Revisiting and recreating plastic surgery concepts of Acharya Sushruta through Torn Ear Lobulue Repair vis-à-vis Karnasandhana w.s.r. to Lobuloplasty - A Single Case Study

Adithya J.¹, Nirmaladevi N.^2*, Aradhyamath S.³

DOI:

¹ JV Adithya, Assistant Professor, Department of PG Studies in Shalya Tantra, JSS Ayurvedic Medical College & Hospital, Mysore, Karnataka, India.

^2* NN Nirmaladevi, Post Graduate Scholar, Department of PG Studies in Shalya Tantra, JSS Ayurvedic Medical College & Hospital, Mysore, Karnataka, India.

³ Siddayya Aradhyamath, Professor and HOD, Department of PG Studies in Shalya Tantra, JSS Ayurvedic Medical College & Hospital, Mysore, Karnataka, India.

Plastic surgery is one of the oldest forms of surgery which was expounded to the world by Ayurveda through Acharya Sushruta in his treatise Sushruta Samhita. Reconstructive plastic surgical procedures were performed in ancient India. The plastic surgery of ear (Otoplasty) and Nose (Rhinoplasty) are described in the Sushruta Sutrastana 16th chapter. First methods are described for piercing the ear lobes of an infant which is still a wide spread practice in India. Often these ear lobes; due to the use of heavy Ornaments; gets considerably expanded - split and tear as time passes. Sushruta has described 15 methods of joining these cup-up ear lobes through basic concepts of plastic surgery under the broad heading of Karnasandana. For correcting ear lobe tear, people demand good cosmetically appealing surgery which comes with minimal scar formation. All these types of Sandana Karma with due consideration to its finest details were explained in detail, represent the school of surgery of Acharya Sushruta, who made significant contribution to the principles and techniques of plastic surgery which are surprisingly applicable even in todays modern surgical era. It highlights the status and sophistication of ancient Indian surgery. Here, A brief review on a patient suffering from split ear lobules, was operated on the lines of Karnasandhana as described by Acharya Sushruta,which can be compared with Lobuloplasty, is detailed below.

Keywords: Plastic Surgery, Karnasandhana, Torn Ear Lobule, Lobuloplasty

Corresponding Author	How to Cite this Article	To Browse
NN Nirmaladevi, Post Graduate Scholar, Department of PG Studies in Shalya Tantra, JSS Ayurvedic Medical College & Hospital, Mysore, Karnataka, India. Email:	JV Adithya, NN Nirmaladevi, Siddayya Aradhyamath, Revisiting and recreating plastic surgery concepts of Acharya Sushruta through Torn Ear Lobulue Repair vis-à-vis Karnasandhana w.s.r. to Lobuloplasty - A Single Case Study. J Ayu Int Med Sci. 2022;7(10):229-235. Available From https://www.jaims.in/jaims/article/view/2138

Introduction

During the Vedic period, the birth of plastic surgery took place in India. If we look in to the vedic rituals, we find the knowledge of Plastic and Reconstructive surgery was known to Bramha, Vishnu, Maheshwara, Indra, Dhanwantari, Dadhichi and Aswini Kumaras. In Rigved (1-158;4-6) Dakshya cut the head and trunk of Rishi Chyavan, then Ashwini Kumaras, Celestial Surgeons, performed the first plastic surgery on re-uniting the severed head and thus gave back life to Rishi Chyavan.^[1]

In Samhita period, Surgeons in ancient India utilizing the skin graft for reconstructive purpose was documented as early as 800B.C. Description regarding the methods of transplantation was first found in Sushruta Samhita (600 B.C). At that time, Rulers imposed punishment in the form of cutting the Ears, Ear lobules, Nose of captured enemies and the victims resorted to the surgeons help for the correction of the severed parts. Indian surgeons have applied their technique of correcting such deformity by usage of transposition of the skin flap to reconstruct the nose and ear lobule etc.^[1]

It’s revival can be traced to report from India in 1974 and illustrated accounts of Rhinoplastic operation upon one Cowasjee, a bullock cart driver, was published in gentle man’s magazine in England.^[1] Basic principles laid down by Sushruta for usage of skin flaps serves as the basis for modern day plastic surgeries.^[2]

The ear of the child was punctured for protective and ornamental purpose. Ancient authors belives that it protects the child from evil effects. From cosmetic point of view this procedure has equal importance. Often these ear lobes; due to the use of heavy Ornaments; gets considerably expanded split and gets torn as time passes. Acharya Sushruta has described 15 methods of joining these cup-up ear lobe which is dealt under the heading called as Karna Sandana.

15 types of surgical repair of the ear is mentioned in Sushruta Samhita namely 1.Nemisandhanaka 2.Utpala Bhedyaka 3.Valluraka 4.Asangima 5.Gandakarna 6.Aharya 7.Nirvedhima 8.Vyayojima 9.Kapatasandhika 10.Ardhakapata Sandhiaka 11.Sanksipta 12.Hinakarna 13.Vallikarna 14.Yasti Karna 15.Kakaustaka.^[3] All these 15 types of surgical procedures explained for the correction of

various deformities revolves around the basic purpose of providing the following

a. Form

b. Function

c. Cosmesis

Even today, in contemporary medical science the basic aim of plastic surgery remains the same.

Correct method of Repair for Torn Ear Lobule

बाह्यायामिह दीर्घायां सन्धिराभ्यन्तरो भवेत्। आभ्यन्तरायां दीर्घायां बाह्यसन्धिरूदाहृतः।

एकैव तु भवेत् पालिः स्थूला पृथ्वी स्थिरा च या । तां द्विधा पाटयित्वा तु छित्वा चोपरि सन्धयेत् ॥ (Su.Su.16/15)

If there is only one flap split ear lobule and if it is thick, wide and fixed, then it should be divided, trimmed and joined with upper portion. The plastic surgeons now-a-days following this technique and named it as Y-V Repair.^[4]

ततोव्रण्ंसमुन्नाम्यस्थापयित्वायथास्थितम्।

सिव्येत्सूक्ष्मेणसुत्रेणावल्केनाश्मन्तकस्यवा॥ (Su.Su.25/20)

The edge of the wound should be raised, both the flaps should be brought in to opposition, then Suturing should be done by a fine thread.^[5] Now instead of Ashmanthaka, we have used Vicryl 6-0, for suturing.

After Suturing, the ear lobule should be irrigated with fresh sesamum oil continuously for three days, Dressings should be changed on every third days.^[6] When the wound is properly healed without any complication and attains its normal colour then proper measure should be taken to elongate the slit by means of Bardhanaka (Dilator). Otherwise complications like inflammation, burning sensations, suppurations, redness and pain will occur and the ear lobule again may split in to two parts .

Instead of Aamataila/Tilataila, now we are using Vranahari which is having Vranaropaka quality. Patient should follow the proper Patya, Apathya.

Lobuloplasty is the repair of torn ear lobule.Otoplasty is a general term for ear reshaping ear lobule repair is one of the procedure. It is done for enlarged; splitted, torn ear holes in the lobule.^[7] The main cause is due to wearing of heavy earing, that causes downward dragging pole causing expanded split and tear in the lobule.

Lobuloplasty procedure normally is done under local anesthesia where the local anesthetic agent is injected in to the lobule by piercing the needle in to the lobule to make it anesthetized. Then a 15 no. surgical blade is used to excise the scar all around the hole, following which the wound is sutured in anterior and posterior aspect with Appropriate suturing material.

Case Presentation

An old woman of 65yr/F house wife by profession came to the Shalya Tantra OPD on October 2021 with the complaint of B/L ear lobule tear.

She is N/K/C/O DM; HTN; BA.

H/O Present Illness

As per the statement given by the patient, she was apparently normal before 5 years. Later gradually developed ear lobe tear due to habitual wearing of heavy earrings. She does not give H/O of pain and swelling in the ear lobule. For the above complaints she approached our hospital for reconstructive ear lobule repair.

Personal History

Ahara: Vegetarian
Vihara: Madyama
Nidra: Disturbed sleep
Vyasana: Tea 3 times /day.
Mala: Once in a day.
Mutra: 4-5 times/day.

Astastana Pareeksha

Nadi: Vataja Nadi

Mala: Once in a day, Prakruta

Mutra: 4-5 times a day, Prakruta

Jihwa: Aliptata

Shabda: Prakruta

Sparsha: Prakruta

Drik: Prakruta

Akruti: lean built

Samanya Pareeksha

Built: moderately built
Appearance: normal

Temperature: 98°F
Pulse: 72bpm
RR: 20cpm
BP: 110/80mmHg
Nourishment: Poorly nourishment.
Pallor: Present
Icterus: absent
Edema: absent
Cyanosis: absent
Kilonechia: absent
Clubbing: absent

Systemic Examination

Central nervous system

Higher mental function test: Conscious, well oriented to time place and person.

Cardio vascular system

Auscultation S1 and S2 heard.

Respiratory system

Auscultation: B/L NVBS heard.

Gastro intestinal tract

O/P: soft, non-tender, not distended, no organomegaly.

no dullness sound heard.

Musculo Skeleton System Examination

All range of movement possible, without pain/difficulty.

Local Examination

On Inspection

Site: Lobular region

Healed scar present both the ear lobules.

No pain, tenderness

Discharge: absent

Bleeding: absent

Tear in the left ear measuring 1*2cm linear

Tear in the Right ear measuring 0.7cm*0.2cm linear

Investigation

RBS: 107mg/dl

Blood urea: 21mg/dl

Serum creatine: 0.8mg/dl

Troponin-T: 0.011ng/ml

Serum electrolytes: Sodium - 137meq/l, Potassium - 3-94meq/l

HB: 11.4gm/dl

TC: 11800Cells/cum

Neutrophils: 89.5%

Lymphocytes: 3.4%

Eosinophils: 0.1%

Monocytes: 6.7%

Basophils: 0.3%

RBC Count: 3.02mil/cu

PCV: 23.4%

MCV: 77.6fl

MCH: 27pg

MCHC: 34.8%

Platelet count: 2.68lakhs/cumm

BT: 2.10 min

CT: 5.10 min

Operative Procedure

Pre operative procedure

Oral consent to be taken

Inj. Xylocaine test dose given.

Inj. T.T 0.5ml inj given

Part Preparation

Fitness taken

Operative procedure

Under all aseptic measures patient was shifted to minor OT.

↓

Local Anesthesia infiltrated to lobular junction (ear lobule block).

↓

Part prepared painted and draped.

↓

Left ear torn lobule – had a tear measuring 1cm *2cm of linear shape, similarly right ear torn lobule had a linear tear measuring about 0.7cm *0.2cm.

↓

Then a 15 No Surgical blade is used to excise the scar in the Anterior aspect of the tear – excising out a rim of margin measuring 0.2cm all around the torn ear lobule and a fresh wound is created along the borders.

↓

Following which the margins of the wound is approximated in proper alignment in with Vicryl 6-0, wound is sutured to create a minimally visible scar line and at the same time, shape of the lobule is given consideration to maintain normal anatomical shape.

Same Procedure is repeated on posterior aspect with 6-0 Vicryl suture.

Left ear 11 suture done (6-anterior,5-posterior).

↓

Similar procedure is repeated in right Ear Lobule, and 4 Anterior and 3 posterior suture done.

Vranaprakshalana (Wound wash) given with Triphalakashaya.

Wound covered with Vranahari lotion

Pressure bandage applied and dressing done.

Post operative procedure

Tab. Triphala Guggulu (2-2-2) A/F For 15 Days.

Tab. Gandhaka Rasayana (2-2-2) A/F For 15 Days.

Follow up: 7, 14, 21 days

Observation findings

Vedana after Sandana Karma - Mild pain is noticed first 3 days of labuloplasty procedure.

No infection noted.

It took around 10 days for healing wound.

On 10^th Day sutures removed.

Wound was healthy and healing.

Very minimal Scar mark noted

Discussion

Lobuloplasty which can be compared with Karnapali Sandanavidhi explained by Acharya Sushruta. Sushruta mentioned that 6^th month and 7^th months are the right time for piercing the ear of the child. The ear of the child was punctured for protective and ornamental purpose. It means the child whose ear has been punctured will not afflicted then the bad effect will remain for a shorter period. In Dharmashastra it has clearly mentioned that it increases Prusti, Ayu, Shri of the child.

Often these ear lobes; due to the use of heavy Ornaments; gets considerably expanded split and tear as time passes.

15 types of plastic repair of the ear is mentioned in Sushruta. Such as 1.Nemisandhanaka 2.Utpala Bhedyaka 3.Valluraka 4.Asangima.5.Gandakarna 6.Aharya 7.Nirvedhima 8.Vyayojima 9.Kapatasandhika 10.Ardhakapata Sandhiaka 11.Sanksipta 12.Hinakarna 13.Vallikarna 14.YastiKarna 15.Kakaustaka.

Utpalabhedaka and Nemisandanaka procedure done here, was told by Sushruta in Karna Bhanda technique.

The edge of the wound should be raised, both the flaps should be brought in to opposition, then Suturing should be done by a fine thread. Now instead of Ashmanthaka we are using Vicryl.

After Suturing, the ear lobule should be irrigated with fresh sesamum oil continuously for three days. Dressings should be changed on every third days.

Instead of Aamataila/ Tila Taila now we are using Vranahari which is having Vranaropaka quality.

Surgeons push ahead with innovations, improving current techniques and discovering new ones.

Conclusion

This was a case performed on the lines of Sandhana Karma i.e., Reconstruction surgery explained by Acharya Sushruta in his treatise. Classical textual references for Karnapali Sandhana can be compared to lobuloplasty and this procedure was successfully done on the lines of Shastra Karma Vidhi according to Ayurveda.

Image 1: Pre Opp Right Ear Lobule

Image 2: Pre Opp Left Ear Lobule

Image 3: Left anterior ear lobule sutures

Image 4: Left posterior ear lobule sutures

Image 5: Right posterior ear lobule sutures

Image 6: Right Anterior ear lobule

Image 7: Left Posterior ear lobule

Follow Up - Suture Removal

Image 8: Left anterior ear lobule suture removal

Image 9: Left anterior ear lobule suture removal

Image 10: Right anterior ear lobule suture removal

Image 11: Right posterior ear lobule suture removal

Image 12 & 13: Right and left ear lobule after 6 months of lobuloplasty

Reference

1. Hemanta Panigrahi, KK Sijoria. Concept of Plastic surgery in Ayurveda. In: Hemanta Panigrahi (ed.) Concept of Plastic surgery in Ayurveda. Varanasi: Chaukamba Orientalia; 2003. p.2,7.

2. Hemanta Panigrahi, K.K.Sijoria. Concept of Plastic surgery in Ayurveda In: Hemanta Panigrahi (ed.) concept of Plastic surgery in Ayurveda. Varanasi: Chaukamba Orientalia; 2003. p.8.

3. Acharya YT. Sushruta Samhita with Nibandhasangraha commentary Sutrastana, Karnavyadana Adhyaya by Dalhana and Nyaya Chandrika Panjika of Sri Gayadasa, p76. (9th ed.). Varanasi: Chaukhambha Orientalia; reprint edition 2009.

4. Acharya YT. Sushruta Samhita with Nibandhasangraha commentary Sutrastana, Karnavyadana Adhyaya by Dalhana and Nyaya Chandrika Panjika of Sri Gayadasa, p77. (9th ed.). Varanasi: Chaukhambha Orientalia; reprint edition 2009.

5. Acharya YT. Sushruta Samhita with Nibandhasangraha commentary Sutrastana, Astavidha Shastra Karmeeya Adyaya by Dalhana and Nyaya Chandrika Panjika of Sri Gayadasa, p118. (9th ed.). Varanasi: Chaukhambha Orientalia; reprint edition 2009.

6. Hemanta Panigrahi, K.K.Sijoria. Concept of Plastic surgery in Ayurveda In: Hemanta Panigrahi (ed.) Concept of Plastic surgery in Ayurveda. Varanasi: Chaukamba Orientalia; 2003. p.26.

7. SRB Manual of Surgery by Sriram Bhat M, 6th edition 2019.published by Jaypee publishers

Manuscript Received	Review Round 1	Review Round 2	Review Round 3	Accepted
2022-09-24	2022-09-26	2022-10-03	2022-10-10	2022-10-16
Conflict of Interest	Funding	Ethical Approval	Plagiarism X-checker	Note
Nil	Nil	Yes	19%

Case Report

Plastic Surgery

Journal of Ayurveda and Integrated Medical Sciences