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Dermatologic Approach to Ear Reconstruction Treatment & Management

  • Author: Neil Sandhu, MD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Mar 29, 2016
 

Surgical Therapy

Flaps, grafts, and primary linear closures can be used in reconstruction of the ear. Healing by second intention is also a valuable tool. The reconstruction technique best suited for a given defect is determined by the size and location of the defect. The goal of reconstruction is to restore the shape, size, and alignment of the ear.[6]

An important principle in ear reconstruction is that the entire anterior surfaces of both ears cannot be viewed simultaneously. Therefore, reconstructing the ear so that it is not distorted or deformed is important, but one ear does not have to exactly match the contralateral ear in terms of its size and appearance. The ear also has a functional importance for many patients as a supporting structure for eyeglasses.

The defects addressed below can occur as a result of Mohs micrographic surgery or excisional surgery to treat skin cancers. The reconstructions are categorized on the basis of the anatomic location of the defect. The regions are divided into the helix, the anterior surface, the posterior surface (preauricular sulcus and postauricular sulcus), and the lobule.

Helical defects

The contour and rigidity of the helix is due to the underlying shape and curvature of the auricular cartilage. The helix arises from the helical root and curves in a semicircular fashion upward then downward to the lobule. The lobule does not contain cartilage. Maintaining the shape and contour of the helix is paramount in recreating a normal-appearing ear. Even a subtle deviation from the normal curvature or a disruption in the contour makes the ear appear abnormal.

Primary linear repair

Small helical defects with intact cartilage can be repaired with linear layered closures (see the image below). However, this type of closure does narrow the width of the helix. To better blend this narrowing, the length of the closure may need to be lengthened to taper this effect. Even in larger defects in which cartilage is missing, primary linear closures can be used. In situations in which the patient's condition precludes a complicated closure, the exposed cartilage can be trimmed and the anterior and posterior skin simply reapproximated (oversewed).

Left image: Small defects on the helix can be clos Left image: Small defects on the helix can be closed with primary linear closures as long as the width of the defect is within the helix. Note the narrowing of the helix, which may not be ideal in certain locations. Right image: The incision may have to be lengthened to blend the narrowing of the helix.

Wedge excision repair

Defects on most aspects of the helix can be repaired with a wedge excision (see the image below). The principle behind the wedge closure is the conversion of the defect into a full-thickness (anterior skin, cartilage, posterior skin) triangular wedge. Ideally, the inner corner of the wedge is 30° to minimize the formation of a dog ear.

Wedge excision repair. Panel A: Defect after cance Wedge excision repair. Panel A: Defect after cancer excision. Panel B: Wedge-shaped defect is created. Panel C: The helix is approximated. Panel D: Image shows the result immediately after surgery.

For larger defects, full-thickness Burrow triangles can be superiorly and inferiorly excised to form a star (see the image below).[7] The wedge is repaired by carefully reapproximating each layer (ie, posterior skin, cartilage, anterior skin). The helix must be meticulously realigned to prevent notching. The use of vertical mattress sutures on the helix helps prevent this problem. The ear wedge always makes the ear smaller; therefore, the size of the defect is the limiting factor.

If the defect is large, Burrow triangles can be su If the defect is large, Burrow triangles can be superiorly and inferiorly excised to create a star.

With defects smaller than 1.5 cm, the shape and appearance of the ear is preserved.[8] With larger defects, the likelihood of distortion and deformity increases. Larger ears can tolerate larger wedge excisions and vice versa.

Chondrocutaneous advancement flap procedure

Defects confined to the helix with or without a cartilage defect can be repaired with the chondrocutaneous advancement flap, or Antia-Buch chondrocutaneous advancement flap. This flap is used for moderate-sized defects on the helical rim. The skin of the helix and the underlying cartilage are either unilaterally or bilaterally advanced.

The flap has 2 variations. In the first, the flap can be of full thickness and detached on both the anterior and posterior surfaces of the helix. This construction allows for maximal extension of the flap, although the flap pedicle is relatively narrow. (In the second, the flap can be designed with the posterior skin intact, leaving a broader flap base as Antia and Buch originally describe.[9] The entire posterior skin is undermined to elevate the flap. Then, the flap is advanced with a dog ear that is removed posteriorly (see the images below). The helix must be meticulously realigned.

Chondrocutaneous advancement flap. Panel A: A 2.5- Chondrocutaneous advancement flap. Panel A: A 2.5-cm defect is present on the helix. Panel B: Another view of the defect. Panel C: Undermining and lifting of the posterior skin off the perichondrium. Panel D: Immediate postoperative view.
Chondrocutaneous advancement flap. Panel E: Immedi Chondrocutaneous advancement flap. Panel E: Immediate postoperative view. Panel F: Anterior surface at 2 months after surgery. Panel G: Posterior surface at 2 months after surgery.

In either variation of the flap, a Burrow triangle may need to be excised if the defect is large. Additional length can be gained by using a V-to-Y advancement of the helical root.[10] The ear is smaller than it is at the baseline. However, it is not as small as it would be with a wedge excision closure because of the stretch provided by the flap and smaller sacrifice of the cartilage. The use of the chondrocutaneous advancement flap is usually limited to defects 2.5 cm or smaller.

Banner transposition flap procedure

Defects on the superior aspect of the helix are ideal for repair with the banner transposition flap. Originally described with use of the postauricular skin, the loose preauricular skin can also serve as the donor site for the flap (see the image below).[11, 12, 13] The base of the flap is superior and contiguous with the defect; this construction allows for the flap to be draped onto the defect. To preserve a wide flap base, the posterior dog ear must be removed with an incision away from the base. This flap can be used only for defects of the skin or for defects of both the skin and cartilage.

Banner transposition flap. Panel A: The preauricul Banner transposition flap. Panel A: The preauricular skin is used as the donor site of the flap. Panel B: The flap is lifted and draped into the defect. Panels C and D: Immediate postoperative views.

If a large portion of the cartilage is missing, a cartilage graft from the contralateral ear can be used. For more superior defects not involving the region of the helical root and not contiguous with the preauricular skin, the transposition flap can be converted to a tubed pedicle flap to cross over the intact intervening skin. The pedicle remains attached for approximately 3 weeks while the flap develops an adequate blood supply. The pedicle is then sectioned, and the flap is trimmed to fit the defect.

Bilobed flap procedure[14, 15]

Defects on the superior and mid helix can be repaired with a bilobed flap. Ideally, the cartilage should be intact, but the flap has enough bulk to offset a small cartilage defect. The loose postauricular skin is easily undermined and serves as the donor site for this flap. The classic bilobed flap has a base that is 180°, with 90° between each lobe. This flap can be modified to decrease the angles between the lobes to reduce the movement and the size of the dog ears (see the images below).[16] The pivot point of the flap must be understood to enable correct measurement of the appropriate length and width of the flap. Defects as large as 2 cm can be repaired with a minimal reduction in the size of the ear.

Bilobed transposition flap. Panels A and B: A 2-cm Bilobed transposition flap. Panels A and B: A 2-cm defect on the superior helix. Panel C: Outline of the classic bilobed flap with 90° between the pedicles. Panel D: The flap is cut with a modified bilobed flap with a relatively small turning radius.
Bilobed transposition flap. Panels E and F: Immedi Bilobed transposition flap. Panels E and F: Immediate postoperative views. Panel G: Anterior surface at 1 month after surgery.

O-to-T advancement

The O-to-T advancement flap is useful for defects that are predominantly on the posterior aspect of the helix. The flap allows for the repair of the helical contour without a significant reduction in the size of the ear or narrowing of the helix. It can be used in areas where the donor skin is insufficient for a bilobed flap. A longitudinal incision is made along the helix, and the flap is lifted off of the skin on the posterior part of the ear. The flap is advanced together to cover the defect (see the images below).

O-to-T advancement flap. Panel A: Defect with inci O-to-T advancement flap. Panel A: Defect with incisions lines marked. Panel B: Immediate postoperative view. Panel C: Immediate postoperative view of the anterior surface. Panel D: Posterior surface at 1 month after surgery.
O-to-T advancement flap. Anterior surface 1 month O-to-T advancement flap. Anterior surface 1 month after surgery.

Anterior surface defects

The triangular fossa, the scapha, the antihelix, and the concha are the regions inside the helical rim. Defects in these regions must be assessed for involvement of only the skin, the skin and perichondrium, or the skin and cartilage. Skin grafts are useful in covering a wide variety of ear defects. If the perichondrium is present, a full-thickness skin graft can be applied. Depending on the size of the defect, the common donor sites are the contralateral postauricular sulcus or the supraclavicular skin.

Split-thickness skin grafts (STSGs) can also be used, although the color and texture match may not be as good as with other methods.[17] STSGs have an advantage in that they can survive even if the entire perichondrium is not intact. If no perichondrium is present, the cartilage can be excised to reveal the posterior skin of the ear. For most defects within an intact helix, enough structural support is present even without the cartilage. A graft can be placed on this vascular bed (see the image below). Grafts placed in the concha should be generously sized to compensate for the profound concavity.

Skin graft. Panel A: Conchal defect with the carti Skin graft. Panel A: Conchal defect with the cartilage removed. Panel B: Split-thickness skin graft in place. Panel C: Split-thickness skin graft at 1-month follow-up.

Small defects can heal by second intention whether or not the perichondrium is intact. If the perichondrium is absent, small holes should be made through the cartilage to facilitate healing from the posterior skin (see the first image below). Concave or flat surfaces are ideal for second intention healing because the resultant scar is usually slightly depressed (see the second image below). If the defect extends into the external auditory canal, an STSG should be placed to prevent strictures of the canal.[18]

Second intention healing. Panel A: Postoperative d Second intention healing. Panel A: Postoperative defect with exposed cartilage. Panel B: Holes punched through the cartilage expose the undersurface of the posterior skin.
Second intention healing. Wound healing by second Second intention healing. Wound healing by second intention at 1-month follow-up.

Preauricular sulcus defects

Defects in this region often extend onto the tragus and the helical root. Because of the laxity of the cheek skin, a flap can be raised and advanced posteriorly to close the defect (see the image below). Loss of the tragus and subtle loss of the helical root are usually unnoticeable from a frontal view. The resultant scar blends nicely into the face-lift line.

Preauricular advancement. Panel A: Defect on the h Preauricular advancement. Panel A: Defect on the helical root, the tragus, and the preauricular sulcus. Panel B: Cheek advancement into the face-lift line.

Postauricular sulcus defects

Skin cancers in this region are relatively large because they can go unnoticed for long periods. Defects on the posterior surface can be closed with grafts, flaps, or primary closures as described above. Many cancers arise in the sulcus. The defect straddles the sulcus, resulting in premastoid and posterior ear components that are similar in size and shape. STSGs are commonly used to cover large defects, but they may result in the anterior protrusion of the ear.

A simpler repair technique is to pin the ear back, adjoining both sides of the defect in a fashion similar to closing a postauricular skin graft donor site. Large defects encompassing almost the entire posterior surface of the ear can be closed in this manner (see the first and second images below). A single layer of modified vertical mattress sutures (3-0 Vicryl) is used to close the entire defect. The modification entails grabbing the base of the sulcus with the suture to close the dead space. The sutures are left untied until all the vertical mattress sutures are in place (see the third image below). The sutures are removed in 2 weeks.

Postauricular sulcus defect. Panel A: Large defect Postauricular sulcus defect. Panel A: Large defect straddling the postauricular defect. Panel B: The defect is reapproximated with a single layer of modified vertical mattress sutures. Panel C: Posterior surface at 1 month after surgery.
Postauricular sulcus defect in the same patient as Postauricular sulcus defect in the same patient as in Image 17. Panel D: Anterior surface at 1 month after surgery. Panel E: Symmetry, as depicted in the posterior view at 1 month after surgery. Panel F: Symmetry, as depicted in the anterior view at 1 month after surgery.
Modified vertical mattress sutures. Panel A: The n Modified vertical mattress sutures. Panel A: The needle is passed through fascia at the base of the sulcus. Panel B: Completion of one vertical mattress suture. Panel C: The sutures are tied after all of them are in place.

Although the postauricular sulcus becomes narrower than the contralateral ear, it typically does not appear asymmetric from either the frontal or the posterior views. If tacking back of the ear is too excessive for the patient, the wound edges can be pulled slightly apart at the time of suture removal and allowed to heal by secondary intention.

Split bilobed flaps have been used to repair composite posterior auricular and mastoid defects.

Lobular defects

Defects of the lobule and lower helix can be repaired with either a primary linear closure for partial-thickness defects or wedge excision for full-thickness defects. Defects involving as much as 50% of the lobule can be repaired in this fashion (see the image below). To prevent notching or separation, wound eversion is important.

Panel A: Defect on the lobule. Panel B: Primary cl Panel A: Defect on the lobule. Panel B: Primary closure of lobule defect with full-thickness wedge excision.
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Outcome and Prognosis

Given the great number of skin cancers on the ear, a tremendous variety of defects can result from their treatment. A systematic practical approach must be adopted to meet the challenge of these defects. By categorizing the defects by their size and location, these defects can be reproducibly repaired to restore the symmetry, aesthetics, and function of the ear.

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Contributor Information and Disclosures
Author

Neil Sandhu, MD Dermatologist (Medical/Cosmetics) and Mohs Surgeon, Gulf Coast Dermatology

Neil Sandhu, MD is a member of the following medical societies: American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

John G Albertini, MD Private Practice, The Skin Surgery Center; Clinical Associate Professor (Volunteer), Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine; President-Elect, American College of Mohs Surgery

John G Albertini, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery

Disclosure: Received grant/research funds from Genentech for investigator.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

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, American Society for Dermatologic Surgery

Disclosure: Nothing to disclose.

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 Surgery, American Society for Dermatologic Surgery

Disclosure: Nothing to disclose.

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

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

  3. Sajic D, Archibald J, Murray C. Surface anatomy of the ear. J Cutan Med Surg. 2014 Mar-Apr. 18(2):137-40. [Medline].

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

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

  6. Brodland DG. Advanced reconstruction of the ear: a framework for successful wound closure. Dermatol Surg. 2014 Sep. 40 Suppl 9:S71-85. [Medline].

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

  8. 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.

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

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

  11. Crikelair GF. A method of partial ear reconstruction for avulsion of the upper portion of the ear. Plast Reconstr Surg (1946). 1956 Jun. 17(6):438-43. [Medline].

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

  13. Santiago F, Serra D, Vieira R, Figueiredo A. Postauricular pull-through transpositional flap: an option for one-stage reconstruction of anterior auricle defects. J Dermatolog Treat. 2010 Sep. 21(5):294-7. [Medline].

  14. 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].

  15. Vergilis-Kalner IJ, Goldberg LH. Bilobed flap for reconstruction of defects of the helical rim and posterior ear. Dermatol Online J. 2010 Oct 15. 16(10):9. [Medline].

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

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

  18. Kato H, Watanabe S, Nakamura M, Ijichi K, Morita A. Reconstruction of the external auditory canal using the random flap technique and laser Doppler evaluation. Dermatol Surg. 2014 Jul. 40(7):739-42. [Medline].

 
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Surface anatomy of the anterior (lateral) surface of the ear.
Posterior (medial) surface of the ear. The skin is less adherent than that of the anterior surface.
Left image: Small defects on the helix can be closed with primary linear closures as long as the width of the defect is within the helix. Note the narrowing of the helix, which may not be ideal in certain locations. Right image: The incision may have to be lengthened to blend the narrowing of the helix.
Wedge excision repair. Panel A: Defect after cancer excision. Panel B: Wedge-shaped defect is created. Panel C: The helix is approximated. Panel D: Image shows the result immediately after surgery.
If the defect is large, Burrow triangles can be superiorly and inferiorly excised to create a star.
Chondrocutaneous advancement flap. Panel A: A 2.5-cm defect is present on the helix. Panel B: Another view of the defect. Panel C: Undermining and lifting of the posterior skin off the perichondrium. Panel D: Immediate postoperative view.
Chondrocutaneous advancement flap. Panel E: Immediate postoperative view. Panel F: Anterior surface at 2 months after surgery. Panel G: Posterior surface at 2 months after surgery.
Banner transposition flap. Panel A: The preauricular skin is used as the donor site of the flap. Panel B: The flap is lifted and draped into the defect. Panels C and D: Immediate postoperative views.
Bilobed transposition flap. Panels A and B: A 2-cm defect on the superior helix. Panel C: Outline of the classic bilobed flap with 90° between the pedicles. Panel D: The flap is cut with a modified bilobed flap with a relatively small turning radius.
Bilobed transposition flap. Panels E and F: Immediate postoperative views. Panel G: Anterior surface at 1 month after surgery.
O-to-T advancement flap. Panel A: Defect with incisions lines marked. Panel B: Immediate postoperative view. Panel C: Immediate postoperative view of the anterior surface. Panel D: Posterior surface at 1 month after surgery.
O-to-T advancement flap. Anterior surface 1 month after surgery.
Skin graft. Panel A: Conchal defect with the cartilage removed. Panel B: Split-thickness skin graft in place. Panel C: Split-thickness skin graft at 1-month follow-up.
Second intention healing. Panel A: Postoperative defect with exposed cartilage. Panel B: Holes punched through the cartilage expose the undersurface of the posterior skin.
Second intention healing. Wound healing by second intention at 1-month follow-up.
Preauricular advancement. Panel A: Defect on the helical root, the tragus, and the preauricular sulcus. Panel B: Cheek advancement into the face-lift line.
Postauricular sulcus defect. Panel A: Large defect straddling the postauricular defect. Panel B: The defect is reapproximated with a single layer of modified vertical mattress sutures. Panel C: Posterior surface at 1 month after surgery.
Postauricular sulcus defect in the same patient as in Image 17. Panel D: Anterior surface at 1 month after surgery. Panel E: Symmetry, as depicted in the posterior view at 1 month after surgery. Panel F: Symmetry, as depicted in the anterior view at 1 month after surgery.
Modified vertical mattress sutures. Panel A: The needle is passed through fascia at the base of the sulcus. Panel B: Completion of one vertical mattress suture. Panel C: The sutures are tied after all of them are in place.
Panel A: Defect on the lobule. Panel B: Primary closure of lobule defect with full-thickness wedge excision.
 
 
 
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