eMedicine Specialties > Dermatology > Surgical

Ear Reconstruction

Author: Ken K Lee, MD, Associate Professor, Departments of Dermatology, Surgery, and Otolaryngology-Head and Neck Surgery, Director, Dermatologic and Laser Surgery, Oregon Health and Science University
Contributor Information and Disclosures

Updated: Feb 6, 2007

Introduction

Reconstruction of the ear can be a complex process. The 3-dimensional nature of the ear with its many curves, peaks, and valleys demand the utmost attention to detail. Yet, as challenging as it may seem, reconstruction of the ear can be made easier and predictable if one understands the surgical principles and anatomy.

The techniques discussed in this article address defects that result from skin cancer excision. More than 1 million cases of basal cell carcinoma, squamous cell carcinoma, and malignant melanoma occur per year in the United States (Miller, 1994). A significant portion of these malignancies arise on the ear because of its exposure to the sun. All areas of the external ear are at risk for skin cancer, and compared with other cancers, these tend to be more aggressive with higher recurrence rates. Given this setting, the defects on the ear can be relatively large.

Indications

Reconstruction of the ear is indicated when a defect is present after skin cancer extirpation. The reconstruction methods discussed in this article all follow the principles of Mohs micrographic surgery. Certain small defects may not need reconstruction and can heal by second intention. This concept is also discussed below.

Relevant Anatomy

The external ear is composed of skin and cartilage with the supporting nerves and blood vessels. The auricular cartilage provides a framework for the entire ear except the lobule. The tightly adherent skin extending from the preauricular sulcus to the helix produces distinct topographical landmarks on the anterior surface of the ear that are important in understanding and describing the ear (see Image 1). The concavities include the triangular fossa, the scapha, the cymba, and the cavum of the concha. The helix, the antihelix, the tragus, and the antitragus form the convexities. The skin on the posterior (medial) aspect of the ear that extends to the postauricular sulcus is less adherent to the underlying cartilage (see Image 2).

A well-proportioned ear is 50-60% as wide as it is high. The ear is positioned one ear length from the lateral orbital rim, and the top of the ear is level with the eyebrow and tilted back by 20° (Tolleth, 1978).

The auriculotemporal nerve, a branch of cranial nerve V3 innervates the superior aspect of the anterior surface of the ear. The lesser occipital nerve and the great auricular nerve are both derived from C2 and C3. The lesser occipital nerve innervates the superior aspect of the posterior surface. The great auricular nerve innervates the lower portion of both surfaces. The vagus nerve supplies the concha.

The ear is well vascularized, an important feature because most flaps are based on a random blood supply. The superficial temporal artery and the posterior auricular artery are branches of the external carotid artery and supply the anterior and posterior surfaces, respectively (Salasche, 1988). Because of the rich blood supply and collateralization, anesthetics that contain epinephrine can be used safely.

Contraindications

Reconstruction of the ear has relatively few contraindications. If the patient can tolerate the initial Mohs micrographic surgery, they can usually tolerate the subsequent reconstruction as well, although the complexity of the reconstruction may need to be tailored to the patient's medical state. In patients whose medical condition precludes surgery, other treatment options, such as irradiation, should be considered.

The patient's medical history should be assessed prior to surgery. Aspirin and warfarin increase the risk of intraoperative and postoperative bleeding complications. The use of these medications is not an absolute contraindication for skin surgery, but stopping these treatments prior to surgery is ideal, if possible.

More on Ear Reconstruction

Overview: Ear Reconstruction
Treatment: Ear Reconstruction
Follow-up: Ear Reconstruction
Multimedia: Ear Reconstruction
References
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References

  1. Antia NH, Buch VI. Chondrocutaneous advancement flap for the marginal defect of the ear. Plast Reconstr Surg. May 1967;39(5):472-7. [Medline].

  2. Brent B. The acquired auricular deformity. A systematic approach to its analysis and reconstruction. Plast Reconstr Surg. Apr 1977;59(4):475-85. [Medline].

  3. Brent B. Reconstruction of the ear. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb and Smith's Plastic Surgery. 5th ed. Philadelphia: Lippincott-Raven;1997:413-29.

  4. Crikelair GF. A method of partial ear reconstruction for avulsion of the upper portion of the ear. Plast Reconstr Surg. Jun 1956;17(6):438-43. [Medline].

  5. D'Arpa S, Cordova A, Moschella F. Further application of the bilobed flap: the split bilobed flap for reconstruction of composite posterior auricular and mastoid defects. J Plast Reconstr Aesthet Surg. 2006;59(12):1330-5. [Medline].

  6. Katzbach R, Frenzel H, Klaiber S, et al. Borderline indications for ear reconstruction. Ann Plast Surg. Dec 2006;57(6):626-30. [Medline].

  7. Lawson VG. Reconstruction of the pinna using pre-auricular flaps. J Otolaryngol. Jun 1984;13(3):191-3. [Medline].

  8. Miller DL, Weinstock MA. Nonmelanoma skin cancer in the United States: incidence. J Am Acad Dermatol. May 1994;30(5 Pt 1):774-8. [Medline].

  9. Quatela V, Cheney M. Reconstruction of the auricle. In: Baker SR, Swanson NA, eds. Local Flaps in Facial Reconstruction. St. Louis: Mosby-Year Book;1995:443-79.

  10. Salasche SJ, Bernstein G, Senkarik M. Surgical Anatomy of the Skin. Norwalk, Conn: Appleton & Lange;1988:217-21.

  11. Tolleth H. Artistic anatomy, dimensions, and proportions of the external ear. Clin Plast Surg. Jul 1978;5(3):337-45. [Medline].

  12. Wines N, Ryman W, Matulich J, Wines M. Retrospective review of reconstructive methods of conchal bowl defects following mohs micrographic surgery. Dermatol Surg. May 2001;27(5):471-4. [Medline].

  13. Zitelli JA. The bilobed flap for nasal reconstruction. Arch Dermatol. Jul 1989;125(7):957-9. [Medline].

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Further Reading

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Keywords

helical defects, helix defects, primary linear repair, wedge excision repair, chondrocutaneous advancement flap, banner transposition flap, bilobed flap, O to T advancement flap, anterior surface defects, preauricular sulcus defects, postauricular sulcus defects, lobule defects, skin cancer excision, defects on the ear, skin cancer

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Contributor Information and Disclosures

Author

Ken K Lee, MD, Associate Professor, Departments of Dermatology, Surgery, and Otolaryngology-Head and Neck Surgery, Director, Dermatologic and Laser Surgery, Oregon Health and Science University
Ken K Lee, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, and American Society for Dermatologic Surgery
Disclosure: Nothing to disclose.

Medical Editor

Shobana Sood, MD, Assistant Professor, Department of Dermatology, University of Pennsylvania Hospital
Shobana Sood, MD is a member of the following medical societies: American Academy of Dermatology and American Society for Dermatologic Surgery
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Director, Division of Dermatology, Scott and White Clinic; Director Dermatology Residency Training Program, Scott and White Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: 3M Pharmaceutical Grant/research funds Other; Graceway Pharmaceuticals Grant/research funds Other

Managing Editor

John G Albertini, MD, Consulting Staff, Dermatologic Surgery, The Skin Surgery Center
John G Albertini, MD is a member of the following medical societies: American Academy of Dermatology and American College of Mohs Micrographic Surgery and Cutaneous Oncology
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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