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Auricular Reconstruction
Garrett Hauptman, MD
Faculty Advisor: David Teller, MD
The University of Texas Medical Branch Department of Otolaryngology
Grand Rounds Presentation
May 16, 2007
Overview
Etiology
Goals
Relevance
Anatomy
Patient evaluation
Surgical techniques
Complications
Etiology
Goals of Auricular Reconstruction
Primary
Wound healing
Function: patent auditory canal
Secondary
Topographic preservation & restoration
Camouflage scar
Maintain ear size
Maintain anterior profile
Maintain lateral profile
Brodland, DG. Dermatol Clin 2005
Challenging Aspects
Skin:cartilage ratio high
Complex 3D structure
Psychosocial Impact of Auricular
Deformity
Retrospective review- surgically corrected auricular deformities
Significant psychosocial morbidity: reduced self-confidence
Main motivation for surgery
Children = teasing
Adults = appearance dissatisfaction
Surgical intervention improved self-confidence
Horlock N, et al. Ann Plast Surg 2005.
C
Auricular Deformity Due to
Psychosocial Issues
Anatomy
Embryology
Composition
Lobule
Areolar tissue
Fat
Skin
Auricle (excluding lobule)
Elastic fibrocartilage
Subcutaneous tissue (minimal)
Skin
Loosely adherent posteriorly
Tightly adherent anteriorly
Surface Anatomy
Cartilage Anatomy
Ligaments and Musculature
Intrinsic
Connects cartilage to itself and to external
auditory meatus
Extrinsic
Connects auricle to side of head
Associated Muscles
Vascular Supply
External carotid branches
Superficial temporal artery (anterior)
Occipital artery
Gives off posterior auricular artery (posterior)
Vascular Supply
Innervation
Sensory
Auriculotemporal branch of V3
Great auricular nerve
Lesser occipital nerve
Facial nerve
Innervation
Lymphatic Drainage
Parotid nodes
Superficial cervical nodes
Retroauricular nodes (mastoid)
Lymphatic Drainage
Preoperative Evaluation
Preoperative Evaluation
Compare auricles to each other
Overall symmetry
Projection
Proportion to facial features
Surface landmarks
Postauricular skin redundancy
Cartilage thickness and stiffness
Preoperative Evaluation
Measurements
Height and width
Axis
Angular relationship (projection)
Idealized Auricular Dimensions
Male
63.5mm X 35.3mm
Female
59.0mm X 32.5mm
Auricular measurements according
to guidelines of anthropometry
Kompatscher, P. et al. Aesthetic Plast Surg. 2003
Auricular Protrusion
Helical rim 1cm to 2cm from mastoid skin
Auriculomastoid angle between 15° to 30°
Cephaloauricular Angle
Normally < 45°
> 20mm protrusion excessive
Photodocumentation
Preoperative and Postoperative
Anterior
Posterior
Oblique (bilaterally)
Lateral (bilaterally)
Close-up
Auricular Reconstruction:
Traumatic Injury
Auricular Hematoma
Etiology: blunt auricular trauma
Potential sequelae
Infection
Cartilage necrosis
Contracture
Neocartilage: cauliflower ear
Treatment
Small & acute = needle aspiration + bolster
Large = open approach ± drain
Aggressive debridement
Ghanem T, et al. Laryngoscope 2005
Auricular Hematoma
Human Bites
Head & neck = 20%
Ear = 67%
Treatment goals
Infection prevention
Healing + good cosmesis
Recommendations
≥ 48 hours IV antibiotics
Delayed surgical closure: > 24 hours
Stierman KL, et al. Otolaryngol Head Neck Surg 2003
C
Human Bites
Stierman KL, et al. Otolaryngol Head Neck Surg 2003
Replantation Timeline
1971- Mladick et al: retroauricular pocket
1972- Baudet et al: postauricular skin flap
1980- Pennington et al: microvascular
anastamosis
Mladick Technique
First stage
Amputated auricle part deepithelialized
Anatomic cartilage reattachment
Retroauricular pocket burial
Second stage
Cartilage elevation
STSG
Kyrmizakis DE, et al. Head Face Med 2006
Baudet Technique
First stage
Amputated auricle posterior surface deepithelialized
Cartilage fenestrated- improves vascular bed access to anterior pinna skin
Postauricular skin flap elevated
Anterior pinna skin sutured Attached anterior skin
Postauricular flap
Second stage
Ear elevation
STSG
Kyrmizakis DE, et al. Head Face Med 2006
Baudet Technique
Kyrmizakis DE, et al. Head Face Med 2006
Microvascular Replantation
Arterial ± venous re-anastomosis
Arteries
Superficial temporal
Posterior auricular
Best cosmetic reconstructive option
Single procedure
Small vessel caliber makes challenging
Yong L, et al. Acta Otolaryngol 2004
Microvascular Replantation
Prerequisites
Short ischemic interval
Appropriately preserved amputated part
Saline gauze wrapped on ice
Compliant patient
Preserve secondary reconstruction options
Postauricular skin
Temporoparietal fascia flap
Proximal superficial temporal artery
Schonauer F, et al.. Scand J Plast Reconstr Surg Hand Surg 2004
Microvascular Replantation
Best results: arterial + venous anastomosis
Venous anastomosis
Difficult
Necessity questioned
Venous connections in 1 week- neovascularization
Venous anastomosis alternatives
Meticulous debridement
Wider contact area
Akyurek M, et al. Ann Plast Surg 2001
Auricular Reattachment Review
Literature review: acute ear trauma between
1980-2004
Categorized
Damage
Reattachment technique
Final outcome
56 publication: 74 cases
Steffen, A et al. Plast Reconstr Surg 2006
C
Auricular Reattachment Review
Steffen, A et al. Plast Reconstr Surg 2006
Auricular Reattachment Review
Steffen, A et al. Plast Reconstr Surg 2006
Auricular Reattachment Review
Techniques
Microsurgical replantation
Pocket methods
Periauricular tissue flaps
Composite grafts
Conclusion
Microsurgical replantation is best
Failed replantaion does not hinder later reconstruction
Pocket method & periauricular flaps should be
abandoned
Steffen, A et al. Plast Reconstr Surg 2006
Microvascular Replantation
Microvascular Replantation
Venous Congestion
Auricular replantation problem without
venous anastomosis
Treatment options
Leeches
Skin puncture
Venous Congestion: Leeches
First recorded use: 200BC
Microvascular tissue transfer caused reemergence
Salivary anticoagulant: Hirudin ↓ venous engorgement → ↓ capillary pressure → ↑ tissue perfusion
Therapy duration based upon clinical appearance
Precautions
Broad spectrum antibiotics + Aeromonas hydrophilia
prophylaxis
Monitor hematocrit
Frodel JL, et al. OtolaryngolHead Neck Surg 2004
Venous Congestion: Leeches
Antithrombotic Agents
Dextran
Alters platelet activity & fibrin network formation
Relatively lower post-op bleeding/hematoma risk
No clinical efficacy evidence after free tissue transfer
Heparin
Acts at multiple sites in coagulation cascade
Aspirin
Irreversibly inhibits platelet aggregation
Ridha H, et al. J Plast Reconstr Aesthet Surg 2006
Biomaterials: Alloplastic Implants
Advantages
Widespread availibility
Consistent shape
↓ OR time
Disadvantages
Infection- ↑ risk
Extrusion
Biocompatibility
Long-term durability
Shieh SJ, et al.. Biomaterials 2004.
Biomaterials: Alloplastic Implants
Shieh SJ, et al.. Biomaterials 2004.
Biomaterials: Tissue Engineering
Research involving biodegradable polymers and cell isolates
In vitro
In vivo
Advantages
↓ donor site morbidity
Precise structure creation
Donor & recipient tissue identical
Potential for implant growth
Shieh SJ, et al.. Biomaterials 2004.
Biomaterials: Tissue Engineering
Auricular Reconstruction:
Surgical Defect
Auricular Cancer
Most common locations
Helix
Posterior auricle skin
Antihelix
Presentation size
> 70% area < 3cm
Silapunt, S et al. Dermatol Surg 2005
Australian Moh’s Database
Leibovitch, I et al.Dermatol Surg. 2006
8% =
Types of Defects
Cutaneous
Lateral surface
Rarely close primarily
Granulation
FTSG on intact
perichondrium
Medial surface
Primary closure
Cutaneous-
cartilagenous
Alters auricular shape
May be full-thickness or
have preserved skin
< 1.5 mm defect
Wedge excise & primary
closure
Many reconstructive
options
General Principles
Defects unique
Many reconstructive options Primary closure
Secondary epithelization
Skin graft/composite graft
Flap
Considerations Size & depth
Location
Esthetic concerns
Medical history/smoking history
Reddy, LV et al.. J Oral Maxillofac Surg 2004
Reconstruction Based on Defect
Location
Conchal Bowl
Preserved perichondrium: FTSG
Island transposition flap
Helical Root
Helical advancement flap
Reconstruction Based on Defect
Location
Upper 1/3
Primary closure
FTSG
Helical advancement flap
Retroauricular & preauricular tubed flaps
Autogenous cartilage framework with FTSG –
vs- TPFF + STSG
Reconstruction Based on Defect
Location
Middle 1/3
Primary closure
FTSG
Helical advancement flap
Retroauricular composite advancement flap
Lower 1/3
Primary closure
Preauricular tubed flap
Reconstruction Based on Defect
Location
Preauricular
Primary closure
Advancement flap
Transposition flap
Large
Defects exceeding 1/3 of auricle require
multiple techniques
Bilobed Advancement Flap
Cutaneous defects
≤ 2cm helical rim length
≤ 2cm posterior auricle skin
Flap design
Primary lobe equivalent size to defect
Smaller secondary lobe
Larger & less rotated than nasal bilobe
Alam, M et al. Dermatol Surg 2003
Bilobed Advancement Flap
Alam, M et al. Dermatol Surg
2003
Bi-Pedicle Post-Auricular Tube Flap
Cutaneous & cartilagenous
helical rim ± lobule defect
2-stage procedure
Post-auricular tubed pedicle
created & attached to auricle
Division with inset after 3
weeks
Flap design
Defect edge to proposed
helical rim edge X 2
Defect length + several mm
Close donor primarily
Ellabban, MG, et al. Br J Plast Surg 2003
Bi-Pedicle Post-Auricular Tube Flap
Ellabban, MG, et al. Br J Plast Surg 2003
Chondrocutaneous Rotation Flap
Defects
Scapha, antihelix, triangular
fossa
≤ 2cm
Flap design
Create wedge-shaped
cutaneo-cartilaginous defect
Incise scapha
Elevate cutaneo-
cartilaginous flaps superiorly
& inferiorly
Ladocsi, L. Plast Reconstr Surg 2003
Chondrocutaneous Rotation Flap
Ladocsi, L. Plast Reconstr Surg 2003
Postauricular Island Pedicle Flap
Defects
Conchal skin defect ±
caritlage
Flap design
Postauricular skin &
subcutaneous tissue
Incise flap periphery
Inset- “revolving door”
Redondo, P et al. J Cutan Med Surg 2003
Postauricular Island Pedicle Flap
Redondo, P et al. J Cutan Med Surg 2003
Peninsular Conchal Axial Flap
Defects Upper 1/3 of auricle
Middle 1/3 of auricle
Flap Design Based on
Superficial temporal artery
Posterior auricular artery
Incise conchal skin & cartilage laterally
Incise medial skin
Remove medial skin
Rotate/transpose flap
Skin graft
Dagregorio, G et al. Dermatol Surg 2005
Peninsular Conchal Axial Flap
Dagregorio, G et al. Dermatol Surg 2005
Crusotomy
Defects
Superior conchal lesion
Technique
2 incisions
Crus along tragal
meeting point & extend
superiorly
Inferior crus attachment
to cavum
Banar, M et al. Dermatol Surg 2003
Retroauricular Advancement Flap
Defects
Large
Flap design
First stage
Often combine
contralateral conchal
cartilage
Retroauricular skin
elevation & advancement
Second stage
2-4 weeks
Division & inset flap
Butler, CE. Ann Plast SurgI 2002
Retroauricular Advancement Flap:
Stage 1
Butler, CE. Ann Plast SurgI 2002
Retroauricular Advancement Flap:
Stage 1
Butler, CE. Ann Plast SurgI 2002
Retroauricular Advancement Flap:
Stage 2
Butler, CE. Ann Plast SurgI 2002
Retroauricular Advancement Flap:
Results
Butler, CE. Ann Plast SurgI 2002
Perichondritis and Chondritis
Perichondrium or cartilage inflammation
post-injury predisposes to tissue ischemia
Pseudomonas infection may ensue
May cause liquefactive necrosis
Prevention
Careful cartilage manipulation
Sterile technique
Prophylatic antibiotics: anti-Psuedamonal
Kaplan, AL et al. Dermatol Surg 2004
Fundamental Tools
Temporoparietal Fascia Flap
Temporoparietal fascia
Most superficial layer beneath temporal subcutaneous fat
Continous with
Galea superiorly
SMAS inferiorly
Blood supply = superficial temporal artery
Dimensions
2-4mm thick
14 X 17cm area
Salem DK, Cheney ML. Arch Otolaryngol Head Neck Surg. 1995
Temporoparietal Fascia Flap
Harvest
Preauricular facelift incision extended temporally
Dissect subcutaneous plane over temporoparietal fascia
to zygomatic arch and frontal branch (CNVII)
Incise periphery- defect size
Pearls
Maintain fat layer on skin side- avoids hair loss
Remain posterolateral to frontal branch (CN VII)
Do not harvest beyond temporal line- avoids distal necrosis
Dolan R. Dermatol Surg 2000
Temporoparietal Fascia Flap
Skin Grafting
Fundamental reconstruction option
Cutaneous free tissue transfer
Separate from donor site
Transplant to recipient site
Secondary intention & primary closure not
possible
Adams, D et al. Dermatol Surg 2005
Skin Grafting
Survival dependent upon blood supply
establishment
1st 24 hours
Imbibition: absorbs transudate
48 – 72 hours
Inosculation: vascular anastamoses
4 – 7 days
Circulation restoration
Adams, D et al. Dermatol Surg 2005
Skin Grafting
3 primary types
Full-thickness skin graft (FTSG)
Epidermis + dermis ± subcutaneous tissue
Split-thickness skin graft (STSG)
Epidermis + variable thickness of dermis
0.005 – 0.028 inches
Composite skin graft
2 or more germ layers tissue
Adams, D et al. Dermatol Surg 2005
FTSG
Easy harvest
Minimal contraction
Necrosis more common than STSG
Common donor sites for facial defects
Preauricular
Postauricular
Supraclavicular
Clavicular
Adams, D et al. Dermatol Surg 2005
STSG
Nutritional requirements ↓ : ↑ survival
Mesh ↑ surface area
Last resort for cosmesis
Contraction
Donor site
Size
Wound care
Activity
Cosmesis
Adams, D et al. Dermatol Surg 2005
Complications
Infection
Hematoma
Perichondritis & chondritis
Failure
Poor cosmesis
Conclusion
Maintain function, then cosmesis
Careful patient assessment
Consideration of multiple techniques
Informed consent
Bibliography Adams, D et al. Grafts in dermatologic surgery: review and update on full- and split-thickness skin grafts, free cartilage grafts, and composite grafts.
Dermatol Surg 2005; 31: 1055-1067.
Akyurek M, et al. Microsurgical ear replantation without venous repair: failure of development of venous channels despite patency of arterial anastomosis for 14 days. Ann Plast Surg 2001; 46: 439-443.
Alam, M et al. Two-lobed advancement flap for cutaneous helical rim defects. Dermatol Surg 2003; 29: 1044-1049.
Banar, M et al. Crusotomy: a safe, simple surgical technique to facilitate resection and reconstruction of poorly accessible auricular tumors. Dermatol Surg 2003; 29: 1217-1221.
Brodland, DG. Auricular reconstruction. Dermatol Clin 2005; 23: 23-41.
Butler, CE. Extended retroauricular advancement flap reconstruction of a full-thickness auricular defect including posteromedial and retroauricular skin. Ann Plast SurgI 2002; 49: 317-321.
Dagregorio, G et al. Peninsular conchal axial flap to reconstruct the upper or middle third of the auricle. Dermatol Surg 2005; 31: 350-355.
Dolan R. Resurfacing extensive malar and preauricular cutaneous defects with pedicled temporoparietal fascia. Dermatol Surg 2000; 10: 949-954.
Ellabban, MG, et al. The bi-pedicle post-auricular tube flap for reconstruction of partial ear defects. Br J Plast Surg 2003; 56: 593-598.
Frodel JL, et al. Salvage of partial facial soft tissue avulsions with medicinal leeches. OtolaryngolHead Neck Surg 2004; 131: 934-939.
Ghanem T, et al. Rethinking auricular trauma. Laryngoscope 2005; 115: 1251-1255.
Hendi, A et al. Split-thickness skin graft in nonhelical ear reconstruction. Dermatol Surg 2006; 32: 1171-1173.
Horlock N, et al. Psychosocial outcome of patients after ear reconstruction. Ann Plast Surg 2005; 54: 517-524.
Kaplan, AL et al. The incidences of chondritis and perichondritis associated with the surgical manipulation of auricular cartilage. Dermatol Surg 2004; 30: 58-62.
Kyrmizakis DE, et al. Nonmicrosurgical reconstruction of the auricle after traumatic amputation due to human bite. Head Face Med 2006 1; 2: 45.
Ladocsi, L. Perforator-preserving chondrocutaneous rotation flap reconstruction of auricular defects. Plast Reconstr Surg 2003; 112: 1566-1572.
Leibovitch, I et al. The Australian Moh’s database: short-term recipient-site complications in full-thickness skin grafts. Dermatol Surg. 2006; 32: 1364-1368.
Ozturk S, et al. Reconstruction of acquired partial auricular defects by porous polyethylene implant and superficial temporoparietal fascia flap in adult patients. Plast Reconstr Surg 2006; 118: 1349-1357.
Reddy, LV et al. Reconstruction of skin cancer defects of the auricle. J Oral Maxillofac Surg 2004; 62: 1457-1471.
Redondo, P et al. Aggressive tumors of the concha: treatment with postauricular island pedicle flap. J Cutan Med Surg 2003; 339-343.
Ridha H, et al. The use of dextran post free tissue transfer. J Plast Reconstr Aesthet Surg 2006; 59: 951-954.
Salem DK, Cheney ML. An anatomic study of the temporoparietal fascial flap. Arch Otolaryngol Head Neck Surg. 1995;121:1153-1156.
[Description of flap taken directly from article]
Schonauer F, et al. Three cases of successful microvascular ear replantation after bite avulsion injury. Scand J Plast Reconstr Surg Hand Surg 2004; 38: 177-182.
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Silapunt, S et al. Squamous cell carcinoma of the auricle and Mohs Micrographic Surgery. Dermatol Surg 2005; 31: 1423-1427.
Steffen, A et al. A comparison of ear reattachment methods: a review of 25 years since Pennington. Plast Reconstr Surg 2006; 118: 1358-1364.
Stierman KL, et al. Treatment and outcome of human bites in the head and neck. Otolaryngol Head Neck Surg 2003; 128: 795-801.
Yong L, et al. Successful auricle replantation via microvascular anastamosis 10h after complete avulsion. Acta Otolaryngol 2004; 124: 645-648.