auricular reconstruction

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


Compare auricles to each other

Overall symmetry

Projection

Proportion to facial features

Surface landmarks

Postauricular skin redundancy

Cartilage thickness and stiffness


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

http://en.wikipedia.org/wiki/Image:ThisIsHowWeDoIt.jpg

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


Baudet Technique


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



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


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


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


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


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


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


Location

Upper 1/3

Primary closure

FTSG


Retroauricular & preauricular tubed flaps

Autogenous cartilage framework with FTSG –

vs- TPFF + STSG


Location

Middle 1/3

Primary closure

FTSG


Retroauricular composite advancement flap

Lower 1/3

Primary closure

Preauricular tubed flap


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



Stage 2



Results


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

http://www.logosoftwear.com/onlineembroiderydesigner.php?ident=LG0167

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


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

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


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


FTSG

Easy harvest

Minimal contraction

Necrosis more common than STSG

Common donor sites for facial defects

Preauricular

Postauricular

Supraclavicular

Clavicular


STSG

Nutritional requirements ↓ : ↑ survival

Mesh ↑ surface area

Last resort for cosmesis

Contraction

Donor site

Size

Wound care

Activity

Cosmesis


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.

Shieh SJ, et al. Tissue engineering auricular reconstruction: in vitro and in vivo studies. Biomaterials 2004; 25: 1545-1557.

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.

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