Auricular Reconstruction

Grand Rounds Presentation University of Texas Medical Branch Garrett Hauptman MD David Teller MD 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 selfconfidence

Horlock N, et al. Ann Plast Surg 2005.

Auricular Deformity Due to Psychosocial Issues

Anatomy

Embryology

Composition

Lobule

Areolar tissue Fat Skin Elastic fibrocartilage Subcutaneous tissue (minimal) Skin

Auricle (excluding lobule)

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

Preoperative Evaluation

Compare auricles to each other Overall symmetry Projection Proportion to facial features Surface landmarks Postauricular skin redundancy Cartilage thickness and stiffness

Preoperative Evaluation

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 Small & acute = needle aspiration + bolster Large = open approach drain Aggressive debridement
Ghanem T, et al. Laryngoscope 2005

Treatment

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

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

Kyrmizakis DE, et al. Head Face Med 2006

Baudet Technique

Kyrmizakis DE, et al. Head Face Med 2006

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

Microvascular Replantation

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

Microvascular Replantation

Best results: arterial + venous anastomosis Venous anastomosis

Difficult Necessity questioned Venous connections in 1 weekneovascularization

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

Auricular Reattachment Review

Steffen, A et al. Plast Reconstr Surg 2006

Auricular Reattachment Review

Steffen, A et al. Plast Reconstr Surg 2006

Auricular Reattachment Review

Techniques

Microsurgical replantation Pocket methods Periauricular tissue flaps Composite grafts Microsurgical replantation is best

Conclusion

Failed replantaion does not hinder later reconstruction

Pocket method & periauricular flaps should be abandoned

Steffen, A et al. Plast Reconstr Surg 2006

Microvascular Replantation

Microvascular Replantation

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 Acts at multiple sites in coagulation cascade Irreversibly inhibits platelet aggregation

Heparin

Aspirin

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

Shieh SJ, et al.. Biomaterials 2004.

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

Shieh SJ, et al.. Biomaterials 2004.

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 Mohs Database

= 8%
Leibovitch, I et al.Dermatol Surg. 2006

Types of Defects

Cutaneous Lateral surface

Cutaneouscartilagenous

Rarely close primarily Granulation FTSG on intact perichondrium Medial surface

Alters auricular shape May be full-thickness or have preserved skin < 1.5 mm defect

Primary closure

Wedge excise & primary closure

Many reconstructive options

General Principles

Defects unique Many reconstructive options

Primary closure Secondary epithelization Skin graft/composite graft Flap Size & depth Location Esthetic concerns Medical history/smoking history
Reddy, LV et al.. J Oral Maxillofac Surg 2004

Considerations

Reconstruction Based on Defect Location

Conchal Bowl
Preserved perichondrium: FTSG Island transposition flap

Helical Root

Helical advancement flap

Reconstruction Based on Defect Location

Upper 1/3
Primary closure FTSG Helical advancement flap Retroauricular & preauricular tubed flaps Autogenous cartilage framework with FTSG vs- TPFF + STSG

Reconstruction Based on Defect Location

Middle 1/3
Primary closure FTSG Helical advancement flap Retroauricular composite advancement flap

Lower 1/3
Primary closure Preauricular tubed flap

Reconstruction Based on Defect 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 Primary lobe equivalent size to defect Smaller secondary lobe Larger & less rotated than nasal bilobe
Alam, M et al. Dermatol Surg 2003

Flap design

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 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

Flap design

Bi-Pedicle Post-Auricular Tube Flap

Ellabban, MG, et al. Br J Plast Surg 2003

Chondrocutaneous Rotation Flap

Defects

Scapha, antihelix, triangular fossa 2cm Create wedge-shaped cutaneo-cartilaginous defect Incise scapha Elevate cutaneocartilaginous flaps superiorly & inferiorly

Flap design

Ladocsi, L. Plast Reconstr Surg 2003

Chondrocutaneous Rotation Flap

Ladocsi, L. Plast Reconstr Surg 2003

Postauricular Island Pedicle Flap

Defects

Conchal skin defect caritlage Postauricular skin & subcutaneous tissue Incise flap periphery Inset- revolving door

Flap design

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 Based on

Flap Design

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 2 incisions

Technique

Crus along tragal meeting point & extend superiorly Inferior crus attachment to cavum

Banar, M et al. Dermatol Surg 2003

Retroauricular Advancement Flap

Defects

Large First stage

Flap design

Often combine contralateral conchal cartilage Retroauricular skin elevation & advancement 2-4 weeks Division & inset flap

Second stage

Butler, CE. Ann Plast SurgI 2002

Retroauricular Advancement Flap: Stage 1

Butler, CE. Ann Plast SurgI 2002

Retroauricular Advancement Flap: Stage 1

Butler, CE. Ann Plast SurgI 2002

Retroauricular Advancement Flap: Stage 2

Butler, CE. Ann Plast SurgI 2002

Retroauricular Advancement Flap: Results

Butler, CE. Ann Plast SurgI 2002

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

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

Temporoparietal Fascia Flap

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

Temporoparietal Fascia Flap

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

Adams, D et al. Dermatol Surg 2005

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

Adams, D et al. Dermatol Surg 2005

FTSG

Easy harvest Minimal contraction Necrosis more common than STSG Common donor sites for facial defects
Preauricular Postauricular Supraclavicular Clavicular

Adams, D et al. Dermatol Surg 2005

STSG

Nutritional requirements : survival Mesh surface area Last resort for cosmesis Contraction Donor site

Size Wound care Activity Cosmesis

Adams, D et al. Dermatol Surg 2005

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 update on fullgrafts. full- and splitsplit-thickness skin grafts, free cartilage grafts, and composite grafts. Dermatol Surg 2005; 31: 10551055-1067. Akyurek M, et al. Microsurgical ear replantation without venous repair: failure of development of venous channels channels despite patency of arterial anastomosis for 14 days. Ann Plast Surg 2001; 46: 439439-443. Alam, Alam, M et al. TwoTwo-lobed advancement flap for cutaneous helical rim defects. Dermatol Surg 2003; 29: 10441044-1049. Banar, Banar, M et al. Crusotomy: Crusotomy: a safe, simple surgical technique to facilitate resection and reconstruction of poorly accessible auricular tumors. Dermatol Surg 2003; 29: 12171217-1221. Brodland, Brodland, DG. Auricular reconstruction. Dermatol Clin 2005; 23: 2323-41. Butler, CE. Extended retroauricular advancement flap reconstruction of a fullfull-thickness auricular defect including posteromedial and retroauricular skin. Ann Plast SurgI 2002; 49: 317317-321. Dagregorio, Dagregorio, G et al. Peninsular conchal axial flap to reconstruct the upper or middle third of the auricle. auricle. Dermatol Surg 2005; 31: 350350-355. Dolan R. Resurfacing extensive malar and preauricular cutaneous defects with pedicled temporoparietal fascia. Dermatol Surg 2000; 10: 949949-954. Ellabban, Ellabban, MG, et al. The bibi-pedicle post593-598. post-auricular tube flap for reconstruction of partial ear defects. Br J Plast Surg 2003; 56: 593Frodel JL, et al. Salvage of partial facial soft tissue avulsions with medicinal leeches. OtolaryngolHead Neck Surg 2004; 131: 934934-939. Ghanem T, et al. Rethinking auricular trauma. Laryngoscope 2005; 115: 12511251-1255. Hendi, Hendi, A et al. Split1171-1173. Split-thickness skin graft in nonhelical ear reconstruction. Dermatol Surg 2006; 32: 1171Horlock N, et al. Psychosocial outcome of patients after ear reconstruction. reconstruction. Ann Plast Surg 2005; 54: 517517-524. Kaplan, AL et al. The incidences of chondritis and perichondritis associated with the surgical manipulation of auricular cartilage. cartilage. Dermatol Surg 2004; 30: 585862. Kyrmizakis DE, et al. Nonmicrosurgical reconstruction of the auricle after traumatic amputation due to human bite. Head Face Med 2006 1; 2: 45. Ladocsi, Ladocsi, L. PerforatorPerforator-preserving chondrocutaneous rotation flap reconstruction of auricular defects. Plast Reconstr Surg 2003; 112: 15661566-1572. Leibovitch, Leibovitch, I et al. The Australian Moh short-term recipientrecipient-site complications in full1364-1368. Mohs database: shortfull-thickness skin grafts. Dermatol Surg. 2006; 32: 1364Ozturk 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: 13491349-1357. Reddy, LV et al. Reconstruction of skin cancer defects of the auricle. auricle. J Oral Maxillofac Surg 2004; 62: 14571457-1471. Redondo, P et al. Aggressive tumors of the concha: : treatment with postauricular island pedicle flap. J Cutan Med Surg 2003; 339339-343. concha Ridha H, et al. The use of dextran post free tissue transfer. J Plast Reconstr Aesthet Surg 2006; 59: 951954. 951 Salem DK, Cheney ML. An anatomic study of the temporoparietal fascial flap. Arch Otolaryngol Head Neck Surg. 1995;121:11531995;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: 177177-182. Shieh SJ, et al. Tissue engineering auricular reconstruction: in vitro o and in vivo studies. Biomaterials 2004; 25: 15451557. vitr 1545 Silapunt, Silapunt, S et al. Squamous cell carcinoma of the auricle and Mohs Micrographic Surgery. Dermatol Surg 2005; 31: 14231423-1427. Steffen, A et al. A comparison of ear reattachment methods: a review eview of 25 years since Pennington. Plast Reconstr Surg 2006; 118: 1358r 1358-1364. Stierman KL, et al. Treatment and outcome of human bites in the head and neck. Otolaryngol Head Neck Surg 2003; 128: 795801. 795 Yong L, et al. Successful auricle replantation via microvascular anastamosis 10h after complete avulsion. Acta Otolaryngol 2004; 124: 645645-648.