Ear Reconstruction and Salvage Procedures Treatment & Management

In order to better enable the surgeon to plan reconstruction, the auricle can be divided into zones or subunits. These anatomical subunits require different methods of repair. The first of these is the helical rim and lobule, which 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 subunit is the antihelix and antitragus. These complex cartilage folds give structure to the ear and support. Losing cartilage in this zone can produce lop-ear deformities, cauliflower ear, and changes in protrusion of the helical rim.

Probably the least important zone is the conchal bowl or cavum conchae because it contributes 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. A wide infiltration anterior to the tragus anesthetizes the distribution of the auriculotemporal nerve: tragus, helical crus, and the superior-lateral portion of the auricle. If the conchal bowl needs to 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:

• Cleanse the ear thoroughly with iodine-containing solutions.

• Debride and remove any foreign body (FB).

• Debride jagged or macerated skin edges.

• Irrigate with large quantities of sterile saline.

• Suture the perichondrium with small absorbable sutures (5-0, 6-0 monofilament).

• Close the skin with nonabsorbable suture (5-0, 6-0 nylon).

• Use vertical mattress sutures on the helical rim to prevent notching.

• Clean daily with hydrogen peroxide and apply TELFA dressing with antibiotic ointment.

• Use a mastoid dressing and a bolster dressing as required to prevent hematoma or seroma.

• Use a broad-spectrum antibiotic for 1 week.

• Remove sutures in 5-7 days.

Options for reconstruction based on location

Anterior-superior helical rim defects, upper third

• Defects of the helical rim 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 paid to provide a flap of 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

• The most common defect acquired from full-thickness excisions of auricular lesions is likely of the scaphoid and triangular fossae 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.

• 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 flaps are available for reconstruction of this region. The simplest 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 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

• 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. Tragal defects and those of the helical crus can result in significant abnormalities if cartilage is involved. 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 cosmetic result.

• 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.

• In a study by Heinz et al, an anterior pedicled retroauricular flap was used to repair full-thickness conchal defects in 11 patients. The investigators reported that good aesthetic results were achieved with minimal donor site morbidity. ^[12]

Skin grafts

Skin grafts can be used to cover areas with exposed perichondrium but do 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. Postauricular skin provides excellent color match. Before and after photos are shown below.

Cutaneous flaps

Thin-tubed flap

This flap is used to reconstruct helical rim defects such as those that typically result after burn injuries. A strip of postauricular skin is raised alongside the helical defect that is long enough to cover it. See the image below. The flap is left attached at both ends in a delay stage, then detached at one end and sutured to the corresponding helical edge. After a second delay, the opposite border is raised and attached to its corresponding edge. Disadvantages associated with this reconstruction include multiple stagings.

Banner flap

This flap, shown below, consists of supra-auricular skin based on the auriculocephalic sulcus that is used to reconstruct defects of the upper third of the auricle. 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. ^[13]

Tunnel procedure

This technique, shown below, was proposed by Converse in 1958 for correcting upper and middle helical defects. ^[14] First, a cartilage graft shaped to the size of the helical defect is tunneled underneath the skin of the mastoid area and joined to the corresponding ends of the defect. In a second stage, the auricle is separated from the mastoid area with the graft attached. Full-thickness contralateral retroauricular grafts can be used 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, the postauricular skin is incised parallel to the axis of the defect where the edge of the defect meets the postauricular skin. The anterior auricular skin is then sutured to the postauricular skin on the posterior edge of the incision and the posterior auricular skin is sutured to the anterior edge of the incision. In the second stage, the posterior auricular skin needed to fill the defect is excised. A skin graft is usually 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. In this technique, a wedge excision is combined with a chondrocutaneous helical flap based on posterior auricular skin and perforating branches from the PAA. The flap is rotated along the intact conchal cartilage and the wedge margins are sutured together with less strain and buckling than that seen with primary closures of large wedge excisions. See the images below.

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. ^[15] This reconstruction also is limited to defects 3 cm or less in diameter. Further modifications of this technique include its use in reconstructing earlobe defects and its combination with local cutaneous flaps to reconstruct larger defects further from the helical edge.

Chondrocutaneous conchal flap

First proposed by Davis in 1974, it is used to reconstruct major losses of the upper third of the auricle. ^[16] The flap 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 below). The donor defect is covered on the preauricular side with a postauricular subcutaneous pedicle flap and on the postauricular surface with a transposition skin flap. A skin graft is then used to cover the postauricular subcutaneous pedicle flap donor site.

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. ^[17] It is typically used to reconstruct conchal bowl lesions resulting from tumor excisions. The flap is based on the postauricular sulcus with margins corresponding to the excised defect. Once the flap is lifted, it is rotated on its long axis 180° so that the postauricular skin covers the anterolateral defect of the conchal bowl. The posterior skin defect is then closed primarily.

In a study by Iljin et al, 19 patients, following excision of basal or squamous cell carcinoma, underwent postauricular island flap reconstruction of the auricular conchal bowl either with or without external auditory canal repair, with complications found to include congestion (26.3% of patients), pinning of the operated ear (21%), prominent earlobe (15.8%), and external auditory canal constriction (15.8%). Patients considered postoperative results to be good, with the exception of those who experienced ear pinning or prominent earlobe. ^[18]

Specific techniques

The pocket principle

• Described by Mladick in 1971, the pocket principle has proven to be a good salvage procedure for auricular cartilage in the setting of avulsion or amputation injuries. First, the amputated or avulsed segment of the auricle is cleaned and denuded of 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 is then buried in a postauricular pocket and left in place for 2 weeks. This allows the cartilage to maintain its essential blood supply. The pocket is resected and the amputated segment allowed to reepithelialize spontaneously over several weeks.

• Variations of this technique have yielded 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.

Microvascular replantation

• In 1980, Pennington performed the first successful microvascular replantation of an amputated ear. ^[19] Since then, approximately 25 additional successful cases of microvascular replantation of an amputated or avulsed ear have been reported in the literature. ^[9]

• Prior to initiating reimplantation, the vascular anatomy of the amputated part should be carefully evaluated and dissected. Gentle irrigation of the vascular lumen with heparinized saline allows for visualization of the intima and can help to determine the presence of damage. Once the microvascular dissection is complete, the amputated ear is sutured into place. Primary microvascular arterial repair is performed using a suitable artery found near the wound edge. Usually, the arterial anastomosis is followed by the venous repair. Once the microvascular repairs are complete, the skin is closed loosely. ^[9]

• If the artery is of insufficient length, a vein graft can be used. Moreover, when the only identifiable vessel is a vein, arteriovenous repair can be considered. Also, several successful ear replantations performed without a venous repair have been reported. This demonstrates both the ability of the ear to form new means of outflow during a period of venous congestion, and the feasibility of nonoperative methods to adequately decompress an ear without intact veins. ^[9]

Infections and chondritis

Infections present as pain, inflammation, swelling, or tenderness more than 3 days postoperatively. Antibiotic treatment should be initiated promptly 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 and held in place by through-and-through sutures.

Keloid formation

Keloid formation can be treated with either pressure therapy or intralesional injections of the steroid triamcinolone acetonide. The steroid must be injected intradermally only, since 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. This complication is treated with antibiotic cream and reduced pressure over involved skin.

Pressure necrosis

Pressure necrosis 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

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

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.

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. ^[20] 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.