AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Relevant Anatomy
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Relevant Anatomy
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

History of the Procedure

Ear reconstruction can be traced back as far as eighth century India and the Susruta, a text of ancient medicine, which described the use of a cheek flap to repair an earlobe defect. Other local flap ear reconstruction techniques described in the following centuries evolved into the use of autologous cartilage for total ear reconstructions by Gillies in 1920. This evolution stemmed from the need to cope with the results of congenital ear deformities. In 1959, Tanzer ushered in the modern era in ear reconstruction with the successful use of autologous costal cartilage grafts. Brent advanced the standards of ear reconstruction with autogenous materials and was the first to report the successful use of tissue expansion in reconstruction of the ear. Many of these innovative techniques used for total reconstruction of congenital ear defects can be applied to acquired defects.

Problem

Acquired ear deformities are largely the result of trauma, skin lesion excisions, and hematomas or infections. The critical reconstruction issues for each of these 3 etiologies are different.

The success of ear reconstruction after trauma depends on two main factors. The first of these is vascular patency. In smaller reconstructive efforts, the survival of a reconstructed auricle depends on sufficient arterial inflow to nurture the healing graft. In larger reconstructions, including amputations, the venous outflow can limit the reconstruction's success. The second factor concerns the availability of soft tissue cover over reimplanted or harvested cartilage framework. Lack of soft tissue cover following a traumatic injury can limit the options available for repair or can require more complex flap coverage.

For reconstructions after skin lesion excision, obtaining a balance between size and shape is important. To make the ear appear normal, the surgeon must sacrifice the size of the underlying cartilage to preserve a normal shape and avoid distortion. Because both ears are not typically seen at the same time, the preservation of anatomic landmarks is more important than maintaining symmetry of size.

Reconstruction after infections or ear hematomas depends on the amount of remaining cartilage support. More extensive cartilage framework involvement in infections or hematomas requires more debridement. Extensive cartilage loss may result in a total ear reconstruction similar to a congenital ear reconstruction.

This discussion presents basic plastic surgery principles and their application to acquired ear deformities. The subject of traumatic lesions to the ear is followed by techniques for repair following controlled extirpations of skin lesions. Many of the techniques described for reconstruction of skin lesion excision can be used in traumatic lesion reconstructions and vice versa.

Frequency

In the United States, approximately 800,000 people develop skin cancer every year. Of these incidents of skin cancer, 90% (720,000) are due to lesions in the head and neck region, and 12% of these (8,640) involve lesions on the ear and periauricular area. Almost all skin lesions of the external ear are squamous cell carcinomas (50-60%), followed by basal cell carcinomas (30-40%) and melanomas (2-6%). The helix is involved in 45-55% of these lesions. The cartilage is involved by direct extension in approximately one third of the cutaneous carcinomas of the ear, thereby making excision of underlying cartilage a prudent surgical decision.

The external auricle has a high potential for injury due to its exposed and unprotected position alongside the head. A retrospective study by Bardsley and Mercer looking at hospital records in auricular injury cases revealed that human bites constitute the most common cause of injury (42%). This was followed by falls (20%), automobile accidents (16%), and dog bites (14%). The most common injury observed was incomplete amputation of the ear, usually helical rim tissue loss. Untreated open auricular injuries invariably result in infection, ensuing deformities, and further tissue loss.

Etiology

Acquired defects and deformities of the auricle have various causes. Common etiologies are listed below.

Types of Auricular Defects

Defects that are smaller than 1 cm and have intact cartilage and vascularized perichondrium can be left to heal by secondary intention. Alternatively, a full-thickness skin graft from the contralateral postauricular sulcus can be used to cover the defect. Finally, excision of the area and direct closure is more invasive, but allows satisfactory healing in a matter of a few days with no donor site morbidity.

Abrasions

Abraded areas must be cleaned and thoroughly irrigated. Debris must be removed fully with sharp and aggressive debridement. Cover the involved area with topical antibiotic impregnated gauze for 24 hours. Thereafter, treat these injuries as open wounds, taking care to keep the area moist with topical antibiotic ointment. Dilute 3% hydrogen peroxide can be used to remove crusting from dried blood and other secretions. Secondary epithelialization should be complete in 7-10 days. Antibiotic coverage for contaminated wounds needs to bracket pseudomonal coverage.

Blunt trauma

Injuries to the pinna from blows to the head commonly result in hematoma and seroma formation between the cartilage and the perichondrium on the anterior surface of the ear. If not corrected, fibroneocartilage forms in this area and a permanent deformity of the ear known as "cauliflower ear" may result (see Image 3). Acute treatment involves drainage of the effusion via needle aspiration or incision followed by application of a pressure dressing.

If the effusion recurs or if the injury is several days out and not drained initially, incision and debridement of the involved perichondrium and the newly formed fibroneocartilage may be necessary (see Image 4). Through-and-through sutures including bolster petroleum jelly gauze dressings on both sides of the auricle can be used to maintain pressure on the involved area.

Lacerations (simple vs complex)

Simple lacerations are linear defects in the skin of the auricle with no missing tissue. They usually involve skin with or without subcutaneous tissue. The cartilage is not involved; however, exposed cartilage may be encountered. This type of injury can be closed in a single layer with or without a bolster dressing.

Complex lacerations are also linear defects which involve cartilage. These injuries do not have missing skin or cartilage in the defect. Generally, multiple-layered closures including perichondrium are required with a bolster dressing. Bolster dressings are important to avoid hematoma formation (see Image 5).

Superficial defects (perichondrium present vs perichondrium absent)

Superficial defects are injuries in which an area of skin is avulsed and missing from the underlying cartilage. These injuries may have perichondrium present or absent from the cartilage. The presence of perichondrium must be determined, as it is highly vascular and essential for cartilage survival. This allows determinations of the type of reconstruction allowable. Nonstructural defects of the conchal bowl or those between the helix and antihelix do not need reconstruction with cartilage, unlike the helical rim.

Composite defects

Composite defects are injuries that involve both skin and cartilage and in which a portion of the auricle is missing.

Avulsion and amputation injuries

Auricle avulsion or amputations may present with the complete involved segment or a portion thereof available for reconstruction.

Burns

First degree, second degree, and third degree burns can all involve the auricle. The result can range from a simple denuding of the skin to a total loss of the ear. These injuries carry the risk of infection due to staphylococcal or pseudomonal contamination. Careful debridement is essential to prevent or limit these infections.

Causative pathogens are of mixed flora; Pseudomonas aeruginosa is present in 95% of incidents. The use of prophylactic mafenide acetate (Sulfamylon) cream has decreased the incidence of chondritis from 29-19% of auricular burn cases. Once diagnosed, suppurative chondritis can be treated with the local instillation of gentamicin, neomycin, and polymyxin antibiotics 2-5 times per day.

Frostbite

Temperatures -19°F or lower usually cause injury. First and second degree frostbite is usually superficial and results in erythema and edema of the skin with bullae (second degree) or without bullae (first degree). Deep wounds of the third and fourth degree result in necrosis of the skin without loss of the auricle and lead to complete necrosis, gangrene, and tissue loss.

Aplasia

Congenital deformities of the auricle require auricular reconstruction in staged procedures. Total auricular reconstruction is beyond the scope of this article.

RELEVANT ANATOMY

Section 3 of 9  

• Authors and Editors
• Introduction
• Relevant Anatomy
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The external ear is a conspicuous and characteristically shaped structure composed of the auricle, external auditory meatus, and lateral surface of the tympanic membrane. The auricle is typically oriented at an anteroposterior rotational angle of 15-20°. The distance from the lateral canthus of the eye to the top of the helical crus is about 6 cm. The typical height of the auricle from the top of the helix to the bottom of the lobule is about 6 cm. The normal protrusion off of the skull is 30°.

Landmarks are identified by folds and curves in the cartilage and skin (see Image 1). The most prominent superior turn is called the helix. It terminates anteriorly just superior to the tragus and laterally to the auricular concha at the helical crus. Just beneath the helix is the antihelix, which divides anteriorly and superiorly to form the fossa triangularis. Inferiorly, it ends as a prominence forming the antitragus. Contained medial to the antihelix and tragus is the cavum conchae, which is continuous with the cartilaginous portion of the external auditory canal. Its anterior limit is the tragus, a domed-shaped cartilaginous prominence oriented in a vertical place lateral to the external auditory meatus. Hanging from the cartilaginous auricle is loose skin called the lobule. The auricle is attached to the temporal bone by its fibrocartilaginous tissue.

The skin of the auricle adheres tightly to the underlying cartilage and contains little subcutaneous tissue. The posterior/medial ear has more subcutaneous tissue, has a rich blood supply, and is more loosely tethered to the framework. The external ear contains a single piece of elastic cartilage with closely adherent perichondrium. The upper two thirds of the ear contain cartilage; the lower third (lobule) is absent of cartilage. The cartilage has no direct blood supply, as nutrients are supplied and absorbed directly from its overlying perichondrium.

The auricle is connected to the scalp by 3 extrinsic muscles: the anterior, superior, and posterior auricular muscles. The anterior ligament extends from the tragus to the root of the zygomatic process of the temporal bone. The posterior ligament passes from the posterior surface of the concha to the lateral surface of the mastoid process.

The rich blood supply to the auricle consists of interconnections between the posterior auricular artery (PAA) and the superficial temporal artery (STA) (see Image 1). These provide extraordinary vascularization, allowing the auricle to undergo significant trauma, either surgically or accidentally, without losing its viability. The PAA supplies most of blood to the anterior ear. It arises from the STA just below the level of the lobule. The PAA passes cephalad in the postauricular sulcus, giving branches to the medial surface of the ear. It terminates by joining a posterior branch of the STA, completing a vascular ring around the base of the ear. The STA gives off an auricular branch just anterior to the tragus. By itself, it provides a lesser contribution to the auricle.

The depth of this vascular ring can vary from as deep as 1 cm beneath the skin to just a few millimeters. It supplies an area of 6 cm by 11 cm that extends from the tragus to 5 cm posterior to the external auditory canal and 6 cm inferior to the mastoid. Supply to the conchal area is derived from consistently found perforators piercing the conchal floor and originating from the PAA. Also, a rich anastomotic network exists between the PAA and the occipital artery.

The auricle also has a rich nerve supply, which is made up of multiple cranial nerves as well as branches of the cervical plexus. The greater auricular nerve supplies most of the auricle, from the posterior/medial aspect to the anterior/lateral lobule, helix, and antihelix. It extends superiorly, where it shares innervation with the auriculotemporal nerve. The auriculotemporal nerve is a branch of the mandibular division of the trigeminal nerve (CN V3), which supplies the tragus, helical crus, and skin superior to the auricle. The lesser occipital nerve supplies skin posterior to the auricle. Cranial nerves (CN) VII and X supply most of the innervation to the cavum conchae and posterior external auditory canal arising from the middle ear. These are important to address when trying to obtain a complete nerve block when repairing the auricle (see Image 2).

TREATMENT

Section 4 of 9  

• Authors and Editors
• Introduction
• Relevant Anatomy
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Surgical Therapy

Principles of Reconstruction

The auricle can be divided into zones in order to better enable the surgeon to plan reconstruction. These zones are anatomical subunits that require different methods of repair. The first of these is the helical rim and lobule. This creates the overall appearance of the ear compared to the opposite side. Mild defects or subtle deformities in this subunit can create the largest cosmetic asymmetry. Therefore, care is taken in this subunit to maintain continuity, reduce step-off deformities, maintain height, and prevent profile or smooth line abnormalities.

The next region is the antihelix and antitragus. These complex cartilage folds give structure to the ear and support. Losing cartilage in this region has the probability to produce lop-ear deformities, cauliflower ear, and changes in protrusion of the helical rim.

Probably the least important region is the conchal bowl or cavum conchae. It offers little to the overall shape, support, or size of the ear. Cartilage in this subunit can be used as grafts in reconstruction of ipsilateral or contralateral defects without adverse consequences.

Surgical Anesthesia and General Treatment Principles

Local anesthesia or regional blocks are the mainstay for surgical treatment of the auricle. General anesthesia, of course, is offered as needed for patient comfort (ie, children), extended length of procedure, and complex reconstructions. However, the surgeon can achieve a complete block of the ear if the innervation described above is understood.

Complete regional anesthesia requires infiltration of local anesthetic (commonly, 2% lidocaine with 1:100,000 epinephrine) circumferentially around the auricle in the subcutaneous plane. Specifically, the great auricular nerve can be located in the postauricular sulcus and infiltration effectively anesthetizes the medial aspect of the auricle as well as contributions to the lobule, helix, and antihelix. The auriculotemporal nerve approaches anterior to the tragus, where a wide infiltration anesthetizes the tragus, helical crus, and the superior-lateral portion of the auricle. If the conchal bowl need be addressed, additional agents must be infiltrated widely around the posterior portion of the external auditory meatus, thus anesthetizing sensory branches of CN VII and X.

General treatment principles are recommended as follows:

1. The ear must be cleansed thoroughly with iodine-containing solutions.
2. Debride and remove any foreign body (FB). Debride jagged or macerated skin edges.
3. Irrigate with large quantities of sterile saline.
4. The perichondrium is sutured with small absorbable sutures (5-0, 6-0 monofilament).
5. The skin is then closed with nonabsorbable suture (5-0, 6-0 nylon).
6. Use vertical mattress sutures on the helical rim to prevent notching.
7. Daily cleaning with hydrogen peroxide and application of TELFA dressing with antibiotic ointment are recommended.
8. Use mastoid dressing and bolster dressing as required to prevent hematoma or seroma.
9. Use a broad-spectrum antibiotic for 1 week.
10. Sutures can be removed in 5-7 days.

Specific Techniques

The Pocket Principle

Described by Mladick in 1971, the pocket principle has proven to be a good salvage procedure for auricular cartilage. This principle can be used in various avulsion or amputation injuries to the auricle. First, the amputated or avulsed segment of the auricle is cleaned and denuded on its skin. Perichondrium should be left in place, if available. The amputated cartilage is then reattached to the auricle in its appropriate anatomical location. The denuded portion can then be buried in a postauricular pocket and left in place for 2 weeks. This allows the cartilage to maintain its essential blood supply. The pocket can then be resected and the amputated segment can be allowed to reepithelialize spontaneously over several weeks.

Variations of this technique have given better results. Small perforations can be placed in the denuded cartilage and left in place for as long as 3 months. The lateral portion of the skin flap can be left attached to the cartilage and the posterior/medial aspect may be skin grafted. Another variation involves sandwiching the cartilage between a retroauricular flap anteriorly and a fascial flap posteriorly.

Options for Reconstruction based on Location

Anterior-superior helical rim defects, upper third

Defects of the helical rim can result from various injuries described above. These injuries are particularly evident from a cosmetic standpoint and can be difficult to reconstruct. Superficial defects of the skin may be repaired by the use of vascularized skin flaps based on postauricular skin. This works well in the presence or absence of the perichondrium. Careful attention is given to provide a flap on non–hair-bearing skin. Full-thickness skin grafts are generally not recommended for the helical rim. Poor outcomes of skin grafts are due to contracture-producing cookie bite defects. Small helical rim defects may be amenable to chondrocutaneous advancement flaps, especially if the defect is smaller than 2 cm. However, this likely results in a decrease in the height of the auricle.

For defects that are larger than 2 cm, a staged tube flap from postauricular skin can be an excellent choice. Two parallel incisions are made in the postauricular skin adjacent to the helical rim defect. The skin is undermined between incisions and the bipedicled flap is tubed in the center. The next stage involves excising one of the pedicles and transposing the flap onto the adjacent helical rim defect. After 2 weeks, the second pedicle is excised and the tubed flap is inset in the remaining defect of the helical rim. The postauricular defect is then closed primarily.

For larger defects of the upper third of the auricle, temporoparietal flaps may be used. Based on the superficial temporal artery, these flaps may provide good vascularity to harvested cartilage. Scalp flaps are not suitable due to the thickness of the skin and hair-bearing properties. Temporoparietal flaps are extremely thin and can be rotated inferiorly to cover a broad area. After cartilage is harvested and trimmed to fit the defect, the temporoparietal flap is rotated and tunneled under the temporoparietal sulcus to cover the graft. A full-thickness skin graft is then placed over the flap and a bolster dressing is applied. This technique is valuable for larger defects and results in acceptable cosmesis.

Scaphoid fossa and triangular fossa of the antihelix

Defects of this region generally are combined with a defect of the helical rim. They may be superficial, with perichondrium absent or present. They may also involve full-thickness defects, including cartilage and postauricular skin. This is probably the most common defect acquired from full-thickness excisions of auricular lesions.

Superficial defects with perichondrium present are amenable to full-thickness skin grafts or healing by secondary intention. Full-thickness skin grafts must be aggressively thinned and color-matched to provide a good cosmetic result. Postauricular skin provides an adequate donor site for these defects. If the perichondrium is absent, a vascularized skin graft must be used.

For composite defects of the helical rim and antihelix, various methods of reconstruction exist. For defects smaller than 2 cm, a primary closure may be appropriate. Skin edges should be freshened, and skin and cartilage closures should be staggered, if possible. Cartilage is reapproximated with long-lasting absorbable sutures in an interrupted fashion. Skin is closed with monofilament permanent sutures, which are removed in 5-7 days.

For defects larger than 2 cm, a composite graft may be taken from the contralateral ear. This graft is generally the size of the defect, which provides symmetry with the donor ear. Again, the skin and cartilage reapproximations should be staggered with overlapping vascularized skin. A second technique would be a stellate-shaped excision of the lesion involving the full thickness of the auricle. This facilitates closure by distributing tension throughout the auricle. A downside of this technique is the significant reduction in the size of the auricle. It may necessitate a contralateral auricle reduction to provide symmetry.

Posterior-inferior helical rim; antihelix defects, middle third

Similar to superior helical rim and antihelix defects, the region of the middle third of the auricle requires support and symmetry. Various composite grafts, advancement flaps, and transposition flaps are available for reconstruction of this region. The most simple of these is the helical advancement flap, which can be used for composite defects up to 25 mm in length. The region of the defect is freshened and debrided, if necessary. The opposing cartilage, perichondrium, and skin are reapproximated primarily. The major downside of this flap is the overall reduction in the size of the ipsilateral auricle. However, this flap is simple to use and has minimal complications.

Transposition flaps are also available from the postauricular region. They are typically used for skin-only defects in which the cartilage is intact. A staged procedure is required to preserve the vascularity of the flap and support the cartilage, if necessary. The flap can then be divided from the pedicle and replaced in the posterior donor site after about 3-4 weeks. If the anterior and posterior skin is avulsed from the cartilage of the auricle, a modification of this flap may be used. Instead of replacing the transected flap into the donor site, it can easily be flipped posteriorly to cover to the medial defect and helical rim. The donor site can then be covered with a split-thickness skin graft.

Chondrocutaneous advancement flaps are also available for helical rim defects of both the superior and inferior helical rim. A portion of the helical rim adjacent to the defect is dissected and freed from its medial attachments. This allows the chondrocutaneous flap to be rotated centrifugally around the auricle to maintain continuity of defects as large as 25 mm. Although a slight change in the curvature of the auricle may result, the overall decrease in the size of the ear will be minimal.

Tragus and helical crus

Tragal defects and those of the helical crus can result in significant abnormalities if cartilage is involved. Skin-only defects can be repaired in a variety of ways. First, tragal skin may be replaced by rotating a lobule flap superiorly. Also, preauricular skin may be advanced posteriorly with attention given to hair-bearing skin. Cartilage grafts may be placed appropriately under well-vascularized tissue, as needed.

Helical crus defects may be repaired using techniques discussed above. Temporoparietal flaps may allow good reconstruction of larger defects in this region.

Conchal bowl, cavum conchae

The conchal bowl offers little to the overall shape, size, and support of the auricle. Defects in this region may be repaired with local skin flaps alone or skin grafting, or can be left to heal by secondary intention. For defects that involve the lateral surface without cartilage involvement, allowing the defect to heal by secondary intention creates the best result. This will provide excellent cosmesis; the defect can be virtually imperceptible.

For composite defects, local advancement flaps may suffice with skin grafting to the posterior/medial aspect. Larger defects may require transposition flaps from the postauricular region with skin grafting posteriorly/medially.

Cartilage grafting is not required for reconstruction of this region. In fact, the conchal bowl may be an ideal donor source of cartilage for reconstruction in other regions of the auricle.

Surgical techniques, grafts, and flaps

Skin grafts

Skin grafts can be used to cover areas with exposed perichondrium (see Image 8). A graft does not take on cartilage without a perichondrial cover. A local flap of subcutaneous tissue can be used to cover the cartilage, and then a skin graft can be placed over the donor site (see Image 9). Skin grafts are particularly useful to correct external auditory canal defects, preventing stenosis of the canal. Postauricular skin provides excellent color match.

Cutaneous flaps

Thin tubed flap: This flap is used to reconstruct helical rim defects such as those that typically result after burn injuries. It consists of raising a strip of postauricular skin alongside the defect that is long enough to cover the helical defect (see Image 10). It is left attached at both ends in a delay stage. Then detach the flap from one end and suture it to the corresponding helical edge. After a second delay, raise the opposite border and attach it to its corresponding edge. Disadvantages associated with this reconstruction include multiple stagings.

Banner flap: This flap consists of supra-auricular skin based on the auriculocephalic sulcus used to reconstruct upper third auricular defects. The raised skin is folded over the defect. This flap first was described by Crikelair and can be used with a small cartilage graft to ensure structural stability (see Image 11).

Tunnel procedure: This technique was proposed by Converse in 1958 for correcting upper and middle helical defects. It uses a cartilage graft shaped to the size of the helical defect tunneled underneath the skin of the mastoid area and joined to corresponding ends of the defect (see Image 12). In a second stage, separate the auricle with the joined graft from the mastoid area. Use full-thickness contralateral retroauricular grafts to cover the resulting mastoid and postauricular defects.

Mastoid flap: Also termed the postauricular attachment technique, this technique is used to correct broad defects involving the middle auricular margin. In the first stage, incise the postauricular skin parallel to the axis of the defect where the edge of the defect meets the postauricular skin. Suture the anterior auricular skin to the postauricular skin on the posterior edge of the incision and suture the posterior auricular skin to the anterior edge of the incision. In the second stage, excise the posterior auricular skin needed to fill the defect. A skin graft usually is needed to cover the resulting mastoid and postauricular area defect.

Chondrocutaneous flaps

Antia-Buch chondrocutaneous advancement flap: This flap is used for the reconstruction of helical defects of 3 cm diameter or less (see Image 13). If greater than 3 cm, a noticeable decrease in ear size results with primary closures. In this technique, a wedge excision (see Image 14) is combined with a chondrocutaneous helical flap based on posterior auricular skin and perforating branches from the PAA (see Image 15). Rotate the flap along the intact conchal cartilage and suture together the wedge margins with minimal strain and buckling than that seen with primary closures of large wedge excisions (see Image 16).

The success of this technique depends on freeing the entire helical flap from the scapha and on undermining the posterior auricular skin superficial to the perichondrium. A V-Y advancement of the helical root can supply additional length. If the defect extends beyond the helix and into the scapha, a cutaneous extension of the chondrocutaneous helical flaps can supply cover to this defect.

As described by Argamoso and Lewin, the Antia-Buch flap can be modified for use in middle-third helical reconstructions using a combination of superiorly based and inferiorly based chondrocutaneous flaps rotated together at the site of a wedge excision or defect. This reconstruction also is limited to defects 3 cm or less in diameter. Further modifications of this technique include its use to reconstruct earlobe defects and its combination with local cutaneous flaps to reconstruct larger defects further from the helical edge.

Chondrocutaneous conchal flap: Davis first proposed this flap in 1974. It is used to reconstruct major losses of the upper third of the auricle. It consists of the chondrocutaneous conchal surface raised on a skin pedicle from the root of the helical crus and transposed to the marginal defect (see Image 17). Cover the donor defect with a postauricular subcutaneous pedicle flap turned over to supply postauricular skin for the preauricular defect. These flaps result in appropriate cover for the preauricular surface. Then cover the postauricular surface using a transposition skin flap to cover the posterior flap surface and a skin graft to cover the postauricular subcutaneous pedicle flap donor site surface.

Island chondrocutaneous postauricular flap: Also termed the posterior auricular rotation flap, flip-flop flap, revolving door flap, and postauricular myocutaneous island flap, this first was described by Masson in 1972. It is used to reconstruct conchal bowl lesions usually resulting from tumor excisions. Excise the lesion, including skin, subcutaneous tissue, and cartilage. Base the flap on the postauricular sulcus; it consists of skin on the postauricular sulcus with margins corresponding to the excised defect. Once the flap is lifted, rotate it on its long axis 180° so that the postauricular skin now covers the anterolateral defect of the conchal bowl. Then close the posterior skin defect primarily.

COMPLICATIONS

Section 5 of 9  

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• Relevant Anatomy
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Infections and chondritis

Infections present as pain, inflammation, swelling, or tenderness more than 3 days postoperatively. Initiate prompt antibiotic treatment to avoid development of suppurative chondritis. Chondritis appears as persistent edema, redness, and tenderness over the auricle. Hospitalization, drainage, wound culture, and appropriate intravenous antibiotic treatment for 1 week to 10 days should resolve the symptoms.

Hematomas

Hematomas are heralded by excessive pain or tenderness of the ear on the first or second postoperative day. Prompt exposure of the ear is needed. This complication can be avoided using a postauricular suction test-tube drain and a postoperative pressure dressing consisting of bolster dressings or dental rolls fitted to the contours of the auricle. These may be held in place by through-and-through sutures through the auricle.

Keloid formation

Keloid formation can be treated with intralesional steroid injections or pressure therapy. The steroid, triamcinolone acetonide, must be injected intradermally only. Subcutaneous injection can result in fat necrosis. Steroid injections must be administered every 2-4 weeks until clinical results, which include softening and flattening of the lesion, are evident. If the keloid persists, surgical excision combined with radiation and intralesional steroid injections may eliminate it. Steroid injections can be administered preoperatively, intraoperatively, and postoperatively. Application of pressure postoperatively can be accomplished with clip-on earrings with large baseplates. Discussing with the patient the possible complications of steroid use, including skin atrophy, hypopigmentation, and telangiectasia, is important.

Facial nerve injury

The facial nerve is at a greater risk for injury in the neonate and young child as it exits and courses more superficially due to the undeveloped mastoid process. Later in life, when the infant has reached approximately 6 months, it can lift its head from a supine position, and the facial nerve moves inferiorly and deep with the growth of the mastoid process. Anomalies of the facial nerve are associated with greater risks of transection because of abnormal positions.

Suture complications

Sutures, especially monofilament nonabsorbable sutures, may erode through the skin. This usually occurs months to years postoperatively. Removal of the sutures is warranted if they are no longer essential. Polyfilament sutures have less of a tendency for erosion but carry a higher rate of infection.

Pain

Persistent pain of late onset may result from injury to the rami nerves of the greater auricular nerve. Serial injections of bupivacaine are useful in relieving symptoms. A significant complication is the development of reflex sympathetic dystrophy of the ear following reconstruction. Massage therapy may be helpful in relieving pain associated with this complication.

Partial skin loss

Skin necrosis and loss can result from very superficial undermining of the skin flaps used in reconstruction, leading to circulatory impairment, desquamation, and atrophy. This is corrected by undermining at a deeper level, preserving the subdermal vascular plexus and a thin layer of subcutaneous tissue. Treat this complication with antibiotic cream and reduced pressure over involved skin.

Pressure necrosis

This is the most disastrous complication. All sutures must be placed with care to avoid pressure necrosis. Tight ear dressing should also be avoided to prevent this complication.

Poor color match

This occurs when using skin grafts from areas not contiguous with the auricular cartilages. Poor color match can be avoided using mastoid or supraclavicular skin.

Venous congestion of flaps

Optimum head positioning, removal of obstructive sources, hyperbaric oxygen treatment, and leeches can help to avoid this complication.

OUTCOME AND PROGNOSIS

Section 6 of 9  

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• Introduction
• Relevant Anatomy
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

As stated initially, postlesion excision reconstruction is a balance of size versus shape, and trauma reconstruction is a balance between vascular inflow versus outflow. All techniques herein described can provide excellent results under the coordination of experienced surgeons. Techniques exist for the salvage of most auricular acquired deformities, and satisfactory results are possible provided the many possible complications are foreseen and guarded against.

FUTURE AND CONTROVERSIES

Section 7 of 9  

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• Relevant Anatomy
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• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Advances in microsurgical techniques and the availability of surgeons trained in these techniques either through improved emergency transportation systems or telemedicine will make replantation a first-line option in the treatment of most major amputation injuries. In the near future, advances in transplant immunology and surgery will add the transplant of cadaveric auricles to the armamentarium of new procedures surfacing in this field. Additionally, the development of biocompatible synthetic cartilage through tissue engineering may result in the custom repair of traumatized auricular tissue with complete preservation of normal anatomy.

MULTIMEDIA

Section 8 of 9  

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• Introduction
• Relevant Anatomy
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Media file 1:  Anatomy of the posterior (medial) surface of the ear.
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Media file 2:  Anatomy anterior (lateral) surface of the ear.
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Media file 3:  Cauliflower ear.
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Media file 4:  Drainage of effusion between cartilage and perichondrium.
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Media file 5:  Ear laceration.
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Media file 6:  Primary repair of ear laceration.
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Media file 7:  Different patterns of star excisions.
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Media file 8:  Defect ready for skin graft cover.
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Media file 9:  Repair with full-thickness skin graft.
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Media file 10:  Thin tubed flap.
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Media file 11:  Banner flap.
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Media file 12:  Tunnel procedure.
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Media file 13:  Antia-Buch reconstruction (1).
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Media file 14:  Antia-Buch reconstruction (2).
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Media file 15:  Antia-Buch reconstruction (3).
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Media file 16:  Antia-Buch reconstruction (4).
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Media file 17:  Chondrocutaneous conchal flap.
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Media file 18:  Pardue cleft earlobe reconstruction.
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Media file 19:  Auriculomastoid flap with a mastoid extension.
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Media file 20:  Retroauricular and helix/antihelix surface flaps for lobe reconstruction.
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REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Relevant Anatomy
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

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Article Last Updated: Jun 29, 2006