TITLE: Auricular Reconstruction
SOURCE: Grand Rounds Presentation, UTMB, Dept. of Otolaryngology
DATE: May 16, 2007
RESIDENT PHYSICIAN: Garrett Hauptman, MD
FACULTY PHYSICIAN: David C. Teller, MD
SERIES EDITORS: Francis B. Quinn, Jr., MD and Matthew W. Ryan, MD
"This
material was prepared by resident physicians in partial fulfillment of
educational requirements established for the Postgraduate Training Program =
of
the UTMB Department of Otolaryngology/Head and Neck Surgery and was not
intended for clinical use in its present form. It was prepared for the purp=
ose
of stimulating group discussion in a conference setting. No warranties,
either express or implied, are made with respect to its accuracy, completen=
ess,
or timeliness. The material does not necessarily reflect the current or past
opinions of members of the UTMB faculty and should not be used for purposes=
of
diagnosis or treatment without consulting appropriate literature sources and
informed professional opinion."
Auricular reconstruction is a challenging reconstructive entity complicated by the high ratio of skin coverage to cartilage, inconsistent blood supply, and complex three-dimensional structu= re with subtle topographic details. The goal of reconstruction of the pinna = is normal appearance, position, and symmetry with respect to the contralateral ear.&n= bsp; Realistic expectations must be established with the patient prior to undertaking reconstruction.
In order to plan and perform a successful repair, several principles are important to apply:=
1.&n= bsp; The relationship of the periau= ricular skin and postauricular sul= cus should be preserved with reconstructive efforts.
2.&n= bsp; Thin and well-vascularized skin is a necessity. Furtherm= ore, scar tissue, poorly vascularized tissue, and noncompliant skin must be replaced.
3.&n= bsp; The surgeon must be able to anticipate the immediate and delayed consequences of tissue manipulation. Consider the effect of tissue manipulation on hair-bearing skin, but do not allow this to compromise your ultimate quest for contralateral symmetry as hair-bearing skin can be eliminated at a secondary stage.
Psychosocial Impact
Auricular reconstruction has been shown to have a significant psychosocial benefit in the majority of patients treated, despi= te donor-site morbidity and a range of technical results. This was established by Horlock et al in a retrospective review. The sample group included patients= with congenital or acquired auricular deformities that had either autogenous or osteointegrated reconstruction. There was significant psychosocial morbidity causing reduced self-confidence associated with auricular deformity. Teasing = was prominent and the main motivation for surgery in children, while dissatisfaction with appearance was the main motivation for surgery in adults. Surgical intervention resulted in improved self-confidence, thus enhancing social life and leisure activity.
Embryology
During the sixth week of gestation, the auricle = begins to arise from the first and second branchial arches. The anterior hillocks= from the first branchial arch give rise to the tragu= s, the root of the helix, and the superior helix.= The posterior hillocks from the second branchia= l arch give rise to the antihelix, the antitragus, and the lobule. The concha and the external auditory meatus is formed from the = first branchial groove.
Anatomy
The ear is morphologically unique. The skeletal structure is composed= of auricular elastic fibrocartilage which composes= the upper two-thirds of the auricle. Auricular cartilage is flexible, yet it maintains form. The cutaneous= coverage of the anterior-lateral surface of the ear differs from the poster= ior-medial surface. The anterior-lateral surface skin of the auricle lacks subcutaneous tissue and is adherent to th= e perichondrium. A layer of fascia containing a subdermal plexus of vessels separates the skin from the perichon= drium. The posterior-medial surface skin = has a deep subcutaneous fat layer that causes it to be less a= dherent to the cartilaginous framework.
The topographic features of the ear are incredib= ly important when considering reconstructive options.&n= bsp; They are as follows:
The blood supply of the auricle is supplied main=
ly by
branches of the external carotid artery which include the superficial tempo=
ral
artery and the occipital artery which gives off the posterior auricular
artery. The posterior-medial
surface of the ear is supplied by the posterior auricular artery. The anterior-lateral surface of th=
e ear
is supplied by both the posterior auricular artery and the superficial temp=
oral
artery, creating two arterial networks.&nb=
sp;
The triangular fossa and scapha
are supplied by the network arising from the superficial temporal artery.
The auricle has sensory inn=
ervation
from the following nerves: the greater auricular nerve (C2-3), the auricula=
r-temporal
nerve (V3), the lesser occipital nerve, and a branch of the vagus
nerve (
The dimensions and proportions of the auricle are critical for reconstruction. = The vertical height of the ear is roughly equal to the distance from the lateral orbital rim to the helical root at the level of the brow. The width of the ear is approximat= ely 55% of its height. The helica= l rim protrudes between 20 and 30 degrees from the skull, which corresponds to 1 = to 2.5cm. The vertical axis of t= he ear is tilted posteriorly (when relating the apex o= f the helix to the lobule) 15 to 20 degrees.&nbs= p; The superior level of the ear is at the same height as the lateral b= row. The inferior aspect of the ear is = at the same height as the nasal base.
General Reconstructive Principles
Auricular reconstruction is dependent upon the defect. Auricular defects can= be classified into the following categories: cutaneous and cutaneous-cartilaginous which can be full-thickness defects.
Cutaneous defects of= the adherent lateral auricular surface can rarely be closed primarily. These defects are best treated wit= h skin grafts provided there is intact perichondrium.<= span style=3D'mso-spacerun:yes'> The contralat= eral postauricular skin can serve as a full-thicknes= s skin graft donor site. When latera= l perichondrium is lost due to the nature of the defect= , the cartilage may be removed if it is not a determinant of auricular shape, and= the full-thickness skin graft can be placed on the medial = perichondrium or medial skin. Medial cutaneous defects involve a more pliable skin and are= often repaired by primary closure. = For the same reason, medial auricular skin is an excellent donor site for a full-thickness skin graft, as previously mentioned.
Cutaneous-cartilagenous
defects may have preserved skin on one side of the defect or it may be a
full-thickness defect. The ma=
in
difference between this type of defect and a cutaneous=
defect alone is the alteration in auricular shape often caused by loss of
supporting structure. Small d=
efects
may be amenable to primary closure once the defect has been converted to a
full-thickness wedge excision. The
decision is based on defect size and location, keeping in mind that a loss =
in vertical
height of the auricle is inevitable.
Generally, small defects in the helix or antihe=
lix
less than 0.15cm are best treated with wedge excision and primary closure.<=
span
style=3D'mso-spacerun:yes'> When this is performed, some centr=
al conchal cartilage must be excised to alleviate
circumferential tension and prevent cupping of the auricle. Defects between 0.15cm and 2cm inv=
olving
the helix or antihelix may be reconstructed by =
using
a composite graft from the contralateral ear.
Many local flaps have been described for repair = of full-thickness auricular loss. Basic principles of design prevail in most of the flaps ranging from= chondrocutaneous advancement flaps to retroauricular island transposition flaps to tubed flaps. Vascular supply must be maintained= and decreased tension with closure is necessary for viability. All flaps used to reconstruct the auricle must provide cutaneous coverage and mai= ntain auricular structure including form and size. Regional flaps should be considere= d in place of local flaps when the vertical height of the auricle is decreased by more then 2cm. The most versa= tile regional flap used in auricular reconstruction is the = temporoparietal fascia flap. This flap is oft= en combined with an autogenous cartilage graft as a framewo= rk and can provide the required thin, highly vascular recipient site for a split-thickness skin graft.
Auricular Reconstruction Based on Defect Location
Conchal Bowl and Helical = Root Defects
Conchal bowl cutaneous defects can be repaired with skin grafting.= Likewise, when perichondrium or cartilage is absent, but skin remains on one side of the defect, skin grafting is used for repair. = Conchal cartilage is not necessary for auricular form= and can be resected without structural compromise.<= span style=3D'mso-spacerun:yes'> The retroauri= cular island transposition flap may be used for lateral skin and cartilage deficits. This same flap can = be used in full-thickness defects involving both the medial and lateral conchal skin and conchal cartilage by bivalving the flap. Defects of the helical root can be reconstructed using a helical advancement flap which includes advancing lat= eral skin and cartilage down towards the deficient area.
Upper One-Third Auricular Defects
The upper one-third of the auricle can be concea= led by hair to conceal a cosmetic defect. However, in many patients this portion of the ear has a functional purpose in supporting eyeglasses. Options for reconstruction of these defects include primary wound closure, full-thickness skin grafts, helical advancement flaps, retroauricular and preauricular<= /span> tubed flaps, and the use of auto= genous cartilage framework combined with temporoparietal fascia and split-thickness skin graft coverage. Again, the choice of the flap is dependent upon the size and location of the defect.
Middle One-Third Auricular Defects
Defects of the middle one-third of the auricle a= re often obvious. Small defects = may be closed primarily by converting the defect into a wedge. This has a direct impact on vertic= al height. Some larger defects a= re amenable to repair with helical chondrocutaneous advancement flaps. Tubed flaps should be limited to helical reconstructi= on only due to the lack of a cartilaginous framework for support. Larger defects are reconstructed u= sing a two-stage retroauricular composite flap using full-thickness retroauricular skin and autogenous cartilage. The cartilage is usually harvested from the nasal septum or contralateral or ipsilateral conchal cartilage.
Lower One-Third Auricular Defects
The lower one-third of the auricle is easiest to
reconstruct due to the pliability and laxity of auricular and periauricular skin in this area. Up to half of the lobule can be
PreauricularDefects
Options fro repair of preau= ricular defects include primary closure, advancement flaps, and transposition flaps. Careful planning can r= esult in the scar resting in the preauricular crease.= The facial nerve should always be = kept in mind when addressing these defects.
Large Auricular Defects
Auricular defects that exceed one third of the a=
uricle
are increasingly difficult to reconstruct.=
Multiple techniques are necessary including aut=
ogenous
cartilage grafting, skin grafting, and the temporal parietal fascia flap.
Etiology
Auricular Hematoma
An auricular hematoma occurs due to blunt auricular trauma. If untreated or improperly treated, it will result in cauliflower ear. Auricular hem= atoma potentially can result in infection, cartilage necrosis, contracture, and <= span class=3DSpellE>neocartilage formation. The actual location of the hematoma has been debated and is either between the <= span class=3DSpellE>perichondrium and cartilage or i= ntracartilaginous. A graduated treatment approa= ch is employed dependent on the severity of the injury and the time from the init= ial insult. Small hematomas discovered acutely typically require needle aspiration and a bolster dressing. Aspiration is not p= ossible a few days post-injury because the hematoma bec= omes a coagulated clot. After one we= ek, the clot breaks down and aspiration is a gain possible. Larger hemato= mas may require an open approach or drain placement. Further treatment involves removal= of all neocartilage and fibrous tissue through aggressive debridement.
Human Bites
Human bites involve the head and neck approximat= ely 20% of the time with the ear accounting for 67% of them. The treatment goals are infection prevention and healing with good cosmesis. Human bites have a higher infectio= n risk than bites of other mammals due to the abundant human oral flora. The infection rate in facial human= bites is lower than bites in other anatomic areas due to increased vascularity in the head and neck. Recommendations have been made that treatment should be both medical and surgical including 48 hours of intrave= nous antibiotics and delayed surgical closure (>24 hours postinjury) to prevent infection.
Skin Cancer
The most common locations for auricular cancer a= re the helix, posterior surface of the ear, and antihelix. Greater than 70% of auricular skin cancer at time of presentation has an area of less than 3cm. Malignant lesions of the ear accoun= t for approximately 6% of all head and neck skin cancers.
Techniques in Auricular Reconstruction
Cartilaginous Reconstruction with Costal Cartilage
Reconstruction of the auricular framework can be
performed using autogenous cartilage or alloplastic implants.
Some reconstructive surgeons speculate that patients adjust better, =
both
physically and psychologically, to reconstruction with autogenous
tissue compared to alloplastic implants. Additionally, alloplastic
implants have the risk of extrusion and a higher rate of infection. When patients are over 60 years ol=
d,
consideration must be given to the fact that cartilage is more brittle and =
may
be ossified depending upon location.
Costal cartilage provides a reliable donor site for autogenous
cartilage, specifically the sixth, seventh, and eighth rib cartilage. The synchondr=
osis
between the sixth and seventh ribs serves as the body of the framework, whi=
le
the eighth rib accounts for the helix.&nbs=
p;
Determination of the size and shape of the framework is obtained by
making a template from the contralateral ear.
The temporoparietal = fascia flap is composed of superficial temporal fascia which is continuous with the superficial musculoaponeurotic system (SMAS) an= d the deep galea.&nb= sp; The temporoparietal fascia is deep to th= e skin and subcutaneous tissue. It s= hould not be confused with the deeper temporalis fasc= ia which surrounds the temporalis muscle. The temporopo= rietal fascia is 2 to 3mm thick over the parietal area and is highly vascular. The blood supply is consistent and= comes from the superficial temporal artery. In order to harvest the temporoparietal = fascia flap, a 6cm vertical incision is made in the scalp immediately above the auricular defect to expose the temporoparietal fascia. Elevation of the flap= should be performed in the loose connective tissue or areolar= tissue which is between the temporoparietal fas= cia and the temporalis fascia. If this plane is maintained, it is= deep to the hair follicles and will avoid alopecia. The vascular pedicle of the flap is identified and protected. The frontal branch of the facial nerve is the anterior limitation of flap elevation. The posterior aspe= ct of the flap is elevated to the posterior branch of the superficial temporal artery. The flap is rotated 1= 80 degrees in an arc that is rotated superiorly to inferiorly so that the late= ral surface of the flap lies medially along the defect. The edges of the flap are tucked u= nder the existing skin edges. Split-thickness skin grafts are then applied to the flap. Optimal drainage is supplied by a = suction drain. The temporoparietal fascia flap often obliterates the supraauricular sulcus. As a result, a second stage procedure is often necessary to recreate this sulcus.
Biomaterials
Reconstruction of the total external ear has two= major approaches- alloplastic prosthesis implantation= and autogenous cartilage grafts. The advantages of alloplastic implants include widespread availability, consistent predetermined shape, a= nd shortened operating time. The disadvantages are increased risk of infection, extrusion, biocompatibility,= and uncertain long-term durability. To counteract some of the disadvantages, tissue engineering is being investiga= ted using predetermined biodegradable polymers and cell isolates. Additional advantages include mini= mized donor site morbidity, precise creation of a complex structure, donor tissues identical to recipient tissue, and the potential for implant growth.
Porous Polyethylene Implant (Med= por)
There are multiple alloplas= tic auricular implants including silicone, polypropylene, and polyethylene. The porous polyethylene implant has several advantageous qualities for auricular reconstruction as it can be ea= sily shaped, sterilized, and implanted underneath appropriate soft tissue coverage. Additionally, it is non-toxic and causes little foreign body reaction. Most importantly, this implant all= ows for tissue ingrowth into the material which anc= hors it into position and provides resistance to infection.
Microvascular Techniques<= /p>
Auricular injury involving sub-total or complete
amputation makes for a more complex reconstruction. Microvascular=
techniques have been described in complete amputations in order to avoid
necrosis and distortion of auricular cartilage due to a lack of blood suppl=
y. Arterial anas=
tomosis
makes use of the primary supplying branches off of the external carotid whi=
ch
are the superficial temporal artery and the posterior auricular arteries.
Microsurgical replantation<= /span> of the ear is technically challenging, but it allows for a single procedure option for auricular reconstruction. A more natural appearing pinna usually r= esults with this technique compared to other techniques for auricular reconstruction. Important prerequisites for successful replantation inclu= de short ischemic intervals, appropriately preserved amputated parts (in salin= e on ice), and compliant patients. Upon performing microsurgical replantation, secondary reconstruction options should be preserved including the postauricular skin, the temporoparietal fascia, and the main superficial temporal vessels. Small vessel caliber makes this procedure challenging. The best results can be achieved w= ith anastomosis of both the artery and vein. However, identification of a suita= ble vein and venous anastomosis is especially diffi= cult. The necessity of venous repair has= been questioned for ear replants. Studies have demonstrated that venous connections form in one week through neovascularization. It is the belief of several surgeo= ns that failure of ear replantation without venous= anastomosis is due to inadequate debridement, which in turn impacts neovascularization. Additionally, wider area of contac= t is believed to improve neovascularization which co= uld be provided with ear replantation by removing postauricular skin.&= nbsp; An ear replant with venous insufficiency needs venous drainage such = as leeches or skin punctures.
Nonmicrosurgical Reconstr= uction: Mladick and Baudet Techni= ques
Microsurgical techniques have been reported in t=
he
literature for auricliar reattachment, but
significant complexity limits wide practice of this technique. On the other end of the spectrum, =
simple
reattachment as a composite graft is almost certain to fail. As a result, numerous techniques h=
ave
evolved to improve survival of the replanted ear. In 1971, Mlad=
ick
et al proposed the principle of a retroauricular
pocket for non-microsurgical replantation. The amputated part was completely =
deepithelialized, followed by anatomic reattachment a=
nd
burial in a retroauricular pocket. A second stage procedure involved
elevation of the replanted cartilage from the retroaur=
icular
pocket and split-thickness skin grafting.&=
nbsp;
In 1972, Baudet et al reported a case of=
ear replantation where the posterior pinna
skin is excised from the amputated portion of the auricle, fenestrations are
made in the cartilage to allow improved vascular access to the anterior
Venous Congestion: Leeches
Use of leeches for medicinal blood letting dates=
back
to 200BC and remained popular well into the 19th century. Popularity waned in the late 19
Antithrombotic Agent:
Dextran is a heterog= eneous polysaccharide that is used after microsurgery for its antithrombotic effects on the microcirculation including alterations of platelet activity = and fibrin network formation. The= main advantage of dextran over other antithrombotic agents such as heparin and aspirin is the relatively lower risk of post-operative bleeding and hematoma formation.= There is no clinical evidence to s= upport the efficacy of dextran following free tissue transfer.
TPFF
The temporoparietal = fascia is the most superficial fascial layer beneath t= he subcutaneous fat in the temporal region and is continuous with the superfic= ial musculoaponeurotic system (SMAS) inferiorly and the <= span class=3DSpellE>galea superiorly.&nb= sp; The superficial temporal artery supplies this area of the scalp and = maintains a consistent posterior branch on which the temporopari= etal fascial flap (TPFF) is normally based. The TPFF is a lateral extension of= the galea and is continuous with the superficial musculoaponeurotic system of the face. It inserts on the zygoma. The TPFF has been extensively used= in auricular reconstruction. The= flap ranges from 2 to 4 mm in thickness and can be harvested in dimensions up to 17x14 cm. The TPFF is separat= e from the temporal muscle fascia, which is a thin layer of a= reolar tissue. The temporal muscle f= ascia is continuous with the pericranium above the su= perior temporal line. The TPFF is supplied by the STA, a terminal branch of the external carotid arte= ry, which ascends behind the ramus of the mandible = and becomes superficial 4 to 5 mm in front of the tragus. The STA lies anterior to the extern= al ear and supplies the scalp, the external ear, face, and the parotid gland. In the majority of cases, the STA d= ivides approximately 2 to 3 cm superior to the root of the helix into anterior (frontal) and posterior (parietal) branches. Before dividing, the artery gives r= ise to the middle temporal artery that supplies the temporal muscle fascia. The terminal course of the vascular pattern is variable. To prote= ct the frontal branch of the facial nerve, the TPFF is normally raised on the posterior branch of the STA. = The anterior branch is ligated approximately 3 to 4= cm from its takeoff. The distal = STA arborizes over the parietal and temporal regions. The STA runs beneath the subcutane= ous tissue and within the TPFF up to 12 cm above the superior attachment of the auricle. In this area of the = scalp, the vessels become more superficial and anastomose with the subdermal vascular plexus. Because of the vascular architectu= re, this area represents the most cephalad extent o= f flap dissection. The superficial temporal vein runs parallel to the artery and slightly superficial to it in= the majority of cases. The sensor= y innervation of the scalp in the area of the STA is su= pplied by the auriculotemporal nerve
TPFF Harvesting
The TPFF is harvested through a temporal extensi=
on of
a preauricular (supratraga=
l)
facelift incision. The tempor=
al
extension should follow the curvilinear temporal line within hear bearing
scalp. Dissection proceeds in=
a subcutaneous
plane over the temporoparietal fascia to the
Disadvantages of the TPFF include injury to the frontal branch of the facial nerve, hair loss from sub= dermal dissection, and ischemic necrosis of the distal flap if harvested beyond the temporal line.
Full-Thickness Skin Grafting
A prospective study performed in
Skin Grafting
The skin graft is a fundamental reconstruction o= ption for coverage of surgical defects. A skin graft is defined as a cutaneous free tissue transfer that has intentional separation from a donor site followed by transplantation to a recipient site. The ultimate survival of a skin graft depends upon ingrowth of capillaries from the recipient site.&nb= sp; Keeping this in mind, avascular recipien= t beds including exposed bone, cartilage without perichondriu= m, tendon, nerve, and fascia are not ideal recipients. Skin grafts generally are used when healing by secondary intention or primary closure is not a suitable option = or when skin laxity prohibits the use of a skin flap.
There are three primary types of skin grafts: full-thickness skin grafts (FTSGs), split-thick= ness skin grafts (STSGs) and composite skin grafts.<= span style=3D'mso-spacerun:yes'> FTSGs = consist of the entire epidermis and dermis with or without small amounts of subcutaneous tissue. STSGs consist of the entire epidermis of the skin wit= h a variable amount of dermis and are classified by thickness. Composite grafts contain tissues f= rom two or more germ layers (skin and cartilage).
Graft survival is dependent upon the establishme= nt of a blood supply from the recipient site.&nb= sp; The first 24 hours involves sustaining the graft by imbibition. Approximately 48 to 72 hours after grafting vascular anastomoses between the recip= ient bed and donor graft begin to form in a process called inosculation. Circulation is restored to the gra= ft within 4 to 7 days.
FTSGs are relatively= easy to harvest and easy to secure to the recipient site. They tend to be more prone to necr= osis than STSGs, yet FTSGs tend to contract less than STSGs. FTSGs = are excellent for the repair of defects on the nasal tip, dorsum, ala, and sidewall, as well as on the lower eyelid and ear. FTSGs = should not be placed into infected wounds and smoking is a relative contraindication. Donor sites= shoud be carefully chosen to match the texture, thick= ness, and color the recipient skin. Common donor sites for facial defects include p= reauricular, postauricular, supraclavic= ular, and calvicular areas. The recipient site must be clean a= nd not actively bleeding. FTSGs must make direct contact with the underlying wo= und bed and must be immobilized in the post-operative period (typically with a bolster which should be in place for 1 week) to prevent separation of the g= raft from the recipient site. FTSGs are sewn into place with deep basting sutures a= nd perimeter sutures. Complete or partial graft failure is the main complication of FTSG which results from <= span class=3DSpellE>hematoma, graft-bed contact disruption, infection, sm= oking, and excessive electrocoagulation of the wound b= ase. If necrosis does occur, the tissue should not be debrided as it acts as a scaffold= .
STSGs lack their inn=
ate
vascular and adnexal structures. They are classified as thin, mediu=
m, and
thick based on thickness.
Complications
Standard complications with auricular reconstruc=
tion
apply including infection, hematoma, scarring, =
and
poor cosmetic outcome. When t=
he
auricular cartilage is involved in the injury or the repair, the risk of
Conclusion
Every ear defect is unique. Many options are available for
reconstruction of auricular defects including direct closure, secondary
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