British Journul of Plustic Surgery (1997), 50, 552-554

CASE REPORT

Reconstruction of the tragus after tumour excision

J. M. Martinez, M. D. Alconchel, C. Olivares and G. A. Cimorra

Department of Plastic and Reconstructive Surgery and Burns Unit, Hospital Miguel Serve& Zaragoza, Spain

SUMMARY Reconstruction of the tragus is very difficult to perform and most techniques are described for the treatment of microtia where remnants of ear are used. The goal always consists in achieving a prominence that covers the canal. We present a novel and safe method, based on the vascularity of the lobule, that also provides a good appearance.

Surgeons have now begun to pay more attention to the shape of the tragus in ear reconstruction, with most techniques referring to the treatment of microtia.

Kirkham’ was the first author to report a method for the reconstruction of the tragus in cases of microtia, designing a flap to deepen the concha and making the tragus by carrying a U-shaped incision, undermining the flap and inverting it under itself.

Subsequently, various tehniques have been described for the reconstruction of the tragus using the concha (Tanzerz Converse,’ etc).

When correcting a microtia, we can also employ the transposition of remnants of lobule to create a new one in the correct position, as described by Tanzer, BrenP and Nagata.6

According to Ono’s method’ a chondrocutaneous flap is made using the upper third of the microtic ear pedicled inferiorly, and transposing it 120-l 80” down- wards to make the tragus.

We present a new method to create a tragus, follow- ing the excision of a basal cell carcinoma, based on the use of the patient’s earlobe.

Case report

A 60-year-old male presented with ulcerative lesion on his right tragus (Fig. 1). Under local anaesthesia we performed a wide excision of the tumour, including tragal cartilage (Fig. 2), and the pathologic diagnosis was of a basal cell car- cinoma with foci of squamous cell carcinoma.

The novel aspect of the technique we have developed in tragus reconstruction lies in the inverse use of the lobule. As Park et al8 have shown, the perforator artery of the earlobe is always present in dissected cadavers. We designed a flap with one half of the patient’s lobule, cutting it in its whole antero- posterior thickness (Fig. 3A, B, C). This flap was partially and carefully opened, like opening a book, in order to avoid injuring the perforating artery and to leave a pedicle based superiorly (Fig. 3D).

Once opened, we transposed it 180” upwards to its new position as a tragus (Fig. 3E), so that the anterior surface of the lobe covered the preauricular defect and the posterior one covered the defect in the outer part of the external audi- tory meatus. The ‘spine’ of the book formed the prominence of the reconstructed tragus (Fig. 3F).

To replace the rest of the lobule, we incised a horizontal Z on the mastoid skin, so that the common diagonal began at the base of the flap and was perpendicular to it, preserving the flow of the perforating artery (Fig. 3G). After the Z-plasty was performed, the diagonal became parallel to the lobe flap, but with another little flap between them which was used to create the intertragal notch (Fig. 3H).

The rest of the lobule was transposed to its position by suturing it to the edges of the diagonal (Fig. 31).

Discussion

We describe a novel method of reconstructing the tragus of the ear based on the use of the earlobe.

None of the previously described methods of tragal reconstruction techniques were applicable in our case due to the loss of continuity between the concha and the defect created by the excision. Additionally, because it was a normal ear, we had no remnants available, as with cases of microtia. We then performed the inverse of the classic procedure and transposed half the normal earlobe 180” upwards to its new position as a tragus. This flap seems to be safe due to the vascularity of the lobule (Figs 4, 5, 6).

We have applied our technique in a patient with a separated lobule from the skin of the neck and cheek. Modification of the design of the Z-plasty might permit its use in cases of lobes joined directly to the face or cheek skin.

In summary, we find that this method offers a better aesthetic result (Fig. 7A, B) than other techniques such as a full thickness skin graft, which provides neither projection nor hides the auricular canal, or a cheek rotation flap which can transpose beard hair to the canal. This flap is easy to design and safe.

552

Reconstruction of the tragus after tumour excision 553

Fig. 1 Fig. 2

Figure 1-Tumour of right tragus. Figure 2-Defect after wide excision.

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Fig. 3

Figure &Design of the flap. (A) Excision of the tumour, including tragal cartilage. (B,C) Cutting of the whole antero-posterior thickness of the lobe. (D) Opening of the lobule as a book. (E) Transposition of the flap 180” to the tragal site. (F) The anterior surface of the lobule covering the preauricular defect and the posterior one the external auditory meatus. (G) Placing of the Z-plasty. (H) Z-plasty with the flaps sutured. Note the intertragal notch. (I) The lobule sutured in its final position.

British Journal of Plastic Surgery

Fig. 4 Fig. 5 Fig. 6

Fig. 7

Figure &Half the lobe raised and opened as a book. Figure %The flap is transposed 180” upwards, in order to cover the defect. Figure &Flap sutured in place. Figure 7-(A) Final result, 6 months after surgery. (B) Contralateral ear.

References 1. Kirkham HLD. The use of preserved cartilage in ear recon-

struction. Ann Surg 1940; 111: 896. 2. Tamer RC. Correction of microtia with autogenous costal

cartilage. In: Tanzer RC, Edegerton MT, eds. Symposium on reconstruction of the auricle. Vol. X. Saint Louis: The C.V. Mosby Company, 1974; 467.

3. Converse JM. Acquired deformities of the auricle. In: Converse JM, McCarthy JG, eds. Reconstructive Plastic Surgery. 2nd ed. Vol. III. Philadelphia: WB Saunders, 1977; 172473.

4. Brent B. Auricular repair with autogenous rib cartilage grafts: two decades of experience with 600 cases. Plast Reconstr Surg 1992; 90: 355574.

5. Brent B. Reconstruction of the auricle. In: McCarthy JG, eds. Plastic Surgery. Vol III. Philadelphia: WB Saunders, 1990; 2094-152.

6. Nagata S. Modification of the stages in total reconstruction of the auricle: Part I. Grafting the three dimensional costal cartilage framework for lobule type microtia. Plast Reconstr Surg 1994; 93: 221-30.

7. Ono I, et al. Correction of microtia with construction of the tragus using a chondrocutaneus flap. Br J Plast Surg 1991; 44: 250-82.

8. Park C, et al. Arterial supply of the anterior ear. Plast Reconstr Surg 1992; 90: 3844.

The Authors J. M. Martinez, Resident M. D. Alconchel, Resident C. Olivares, Staff Surgeon G. A. Cimorra, Head of Department

Department of Plastic and Reconstructive Surgery and Burns Unit, Hospital Miguel Serve& P” Isabel La Catolica, 1. 50.009 Zaragoza, Spain.

Correspondence to: Dr J.M. Martinez, AvlCesareo Alierta 45, 9” J. 50.008 Zaragoza, Spain.

Paper received 20 January 1997. Accepted 17 June 1997, after revision.