Download 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
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Etiology
Goals
Relevance
Anatomy
Patient evaluation
Surgical techniques
Complications
Etiology
Goals of Auricular Reconstruction
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Primary
Wound healing
 Function: patent auditory canal
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Secondary
Topographic preservation & restoration
 Camouflage scar
 Maintain ear size
 Maintain anterior profile
 Maintain lateral profile
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Brodland, DG. Dermatol Clin 2005
Challenging Aspects
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Skin:cartilage ratio high
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Complex 3D structure
Psychosocial Impact of Auricular
Deformity
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Retrospective review- surgically corrected
auricular deformities
Significant psychosocial morbidity: reduced
self-confidence
Main motivation for surgery
Children = teasing
 Adults = appearance dissatisfaction
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Surgical intervention improved selfconfidence
Horlock N, et al. Ann Plast Surg 2005.
Auricular Deformity Due to
Psychosocial Issues
Anatomy
Embryology
Composition
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Lobule
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Areolar tissue
Fat
Skin
Auricle (excluding lobule)
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Elastic fibrocartilage
Subcutaneous tissue (minimal)
Skin
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Loosely adherent posteriorly
Tightly adherent anteriorly
Surface Anatomy
Cartilage Anatomy
Ligaments and Musculature
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Intrinsic
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Connects cartilage to itself and to external
auditory meatus
Extrinsic
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Connects auricle to side of head
Associated Muscles
Vascular Supply
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External carotid branches
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Superficial temporal artery (anterior)
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Occipital artery
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Gives off posterior auricular artery (posterior)
Vascular Supply
Innervation
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Sensory
Auriculotemporal branch of V3
 Great auricular nerve
 Lesser occipital nerve
 Facial nerve
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Innervation
Lymphatic Drainage
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Parotid nodes
Superficial cervical nodes
Retroauricular nodes (mastoid)
Lymphatic Drainage
Preoperative Evaluation
Preoperative Evaluation
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Compare auricles to each other
Overall symmetry
Projection
Proportion to facial features
Surface landmarks
Postauricular skin redundancy
Cartilage thickness and stiffness
Preoperative Evaluation
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Measurements
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Height and width
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Axis
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Angular relationship (projection)
Idealized Auricular Dimensions
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Male
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63.5mm X 35.3mm
Female
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59.0mm X 32.5mm
Auricular measurements according
to guidelines of anthropometry
Kompatscher, P. et al. Aesthetic Plast Surg. 2003
Auricular Protrusion
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Helical rim 1cm to 2cm from mastoid skin
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Auriculomastoid angle between 15° to 30°
Cephaloauricular Angle
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Normally < 45°
> 20mm protrusion excessive
Photodocumentation
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Preoperative and Postoperative
Anterior
 Posterior
 Oblique (bilaterally)
 Lateral (bilaterally)
 Close-up
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Auricular Reconstruction:
Traumatic Injury
Auricular Hematoma
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Etiology: blunt auricular trauma
Potential sequelae
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Infection
Cartilage necrosis
Contracture
Neocartilage: cauliflower ear
Treatment
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Small & acute = needle aspiration + bolster
Large = open approach ± drain
Aggressive debridement
Ghanem T, et al. Laryngoscope 2005
Auricular Hematoma
Human Bites
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Head & neck = 20%
Ear = 67%
Treatment goals
Infection prevention
 Healing + good cosmesis
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Recommendations
≥ 48 hours IV antibiotics
 Delayed surgical closure: > 24 hours
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Stierman KL, et al. Otolaryngol Head Neck Surg 2003
Human Bites
Stierman KL, et al. Otolaryngol Head Neck Surg 2003
Replantation Timeline
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1971- Mladick et al: retroauricular pocket
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1972- Baudet et al: postauricular skin flap
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1980- Pennington et al: microvascular
anastamosis
Mladick Technique
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First stage
Amputated auricle part deepithelialized
 Anatomic cartilage reattachment
 Retroauricular pocket burial
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Second stage
Cartilage elevation
 STSG
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Kyrmizakis DE, et al. Head Face Med 2006
Baudet Technique
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First stage
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Amputated auricle posterior surface deepithelialized
Cartilage fenestrated- improves vascular bed access to
anterior pinna skin
Postauricular skin flap elevated
Anterior pinna skin sutured
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Attached anterior skin
Postauricular flap
Second stage
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Ear elevation
STSG
Kyrmizakis DE, et al. Head Face Med 2006
Baudet Technique
Kyrmizakis DE, et al. Head Face Med 2006
Microvascular Replantation
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Arterial ± venous re-anastomosis
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Arteries
Superficial temporal
 Posterior auricular
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Best cosmetic reconstructive option
Single procedure
Small vessel caliber makes challenging
Yong L, et al. Acta Otolaryngol 2004
Microvascular Replantation
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Prerequisites
Short ischemic interval
 Appropriately preserved amputated part
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Saline gauze wrapped on ice
Compliant patient
Preserve secondary reconstruction options
Postauricular skin
 Temporoparietal fascia flap
 Proximal superficial temporal artery
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Schonauer F, et al.. Scand J Plast Reconstr Surg Hand Surg 2004
Microvascular Replantation
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Best results: arterial + venous anastomosis
Venous anastomosis
Difficult
 Necessity questioned
 Venous connections in 1 weekneovascularization
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Venous anastomosis alternatives
Meticulous debridement
 Wider contact area
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Akyurek M, et al. Ann Plast Surg 2001
Auricular Reattachment Review
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Literature review: acute ear trauma between
1980-2004
Categorized
Damage
 Reattachment technique
 Final outcome
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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
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Techniques
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Microsurgical replantation
Pocket methods
Periauricular tissue flaps
Composite grafts
Conclusion
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Microsurgical replantation is best
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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
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Auricular replantation problem without
venous anastomosis
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Treatment options
Leeches
 Skin puncture
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Venous Congestion: Leeches
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First recorded use: 200BC
Microvascular tissue transfer caused reemergence
Salivary anticoagulant: Hirudin
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↓ venous engorgement → ↓ capillary pressure → ↑ tissue perfusion
Therapy duration based upon clinical appearance
Precautions
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Broad spectrum antibiotics + Aeromonas hydrophilia
prophylaxis
Monitor hematocrit
Frodel JL, et al. OtolaryngolHead Neck Surg 2004
Venous Congestion: Leeches
Antithrombotic Agents
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Dextran
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Heparin
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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
Aspirin
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Irreversibly inhibits platelet aggregation
Ridha H, et al. J Plast Reconstr Aesthet Surg 2006
Biomaterials: Alloplastic Implants
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Advantages
Widespread availibility
 Consistent shape
 ↓ OR time
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Disadvantages
Infection- ↑ risk
 Extrusion
 Biocompatibility
 Long-term durability
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Shieh SJ, et al.. Biomaterials 2004.
Biomaterials: Alloplastic Implants
Shieh SJ, et al.. Biomaterials 2004.
Biomaterials: Tissue Engineering
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Research involving biodegradable polymers
and cell isolates
In vitro
 In vivo
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Advantages
↓ donor site morbidity
 Precise structure creation
 Donor & recipient tissue identical
 Potential for implant growth
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Shieh SJ, et al.. Biomaterials 2004.
Biomaterials: Tissue Engineering
Auricular Reconstruction:
Surgical Defect
Auricular Cancer
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Most common locations
Helix
 Posterior auricle skin
 Antihelix
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Presentation size
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> 70% area < 3cm
Silapunt, S et al. Dermatol Surg 2005
Australian Moh’s Database
= 8%
Leibovitch, I et al.Dermatol Surg. 2006
Types of Defects
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Cutaneous
Lateral surface
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Rarely close primarily
Granulation
FTSG on intact
perichondrium
Medial surface
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Primary closure
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Cutaneouscartilagenous
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Alters auricular shape
May be full-thickness or
have preserved skin
< 1.5 mm defect
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Wedge excise & primary
closure
Many reconstructive
options
General Principles
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Defects unique
Many reconstructive options
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Primary closure
Secondary epithelization
Skin graft/composite graft
Flap
Considerations
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Size & depth
Location
Esthetic concerns
Medical history/smoking history
Reddy, LV et al.. J Oral Maxillofac Surg 2004
Reconstruction Based on Defect
Location
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Conchal Bowl
Preserved perichondrium: FTSG
 Island transposition flap
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Helical Root
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Helical advancement flap
Reconstruction Based on Defect
Location
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Upper 1/3
Primary closure
 FTSG
 Helical advancement flap
 Retroauricular & preauricular tubed flaps
 Autogenous cartilage framework with FTSG –
vs- TPFF + STSG
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Reconstruction Based on Defect
Location
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Middle 1/3
Primary closure
 FTSG
 Helical advancement flap
 Retroauricular composite advancement flap
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Lower 1/3
Primary closure
 Preauricular tubed flap
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Reconstruction Based on Defect
Location
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Preauricular
Primary closure
 Advancement flap
 Transposition flap
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Large
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Defects exceeding 1/3 of auricle require
multiple techniques
Bilobed Advancement Flap
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Cutaneous defects
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≤ 2cm helical rim
length
≤ 2cm posterior auricle
skin
Flap design
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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
Bi-Pedicle Post-Auricular Tube Flap
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Cutaneous & cartilagenous
helical rim ± lobule defect
2-stage procedure
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Post-auricular tubed pedicle
created & attached to auricle
Division with inset after 3
weeks
Flap design
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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
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Defects
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Scapha, antihelix, triangular
fossa
≤ 2cm
Flap design
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Create wedge-shaped
cutaneo-cartilaginous defect
Incise scapha
Elevate cutaneocartilaginous flaps superiorly
& inferiorly
Ladocsi, L. Plast Reconstr Surg 2003
Chondrocutaneous Rotation Flap
Ladocsi, L. Plast Reconstr Surg 2003
Postauricular Island Pedicle Flap
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Defects
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Conchal skin defect ±
caritlage
Flap design
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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
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Defects
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Upper 1/3 of auricle
Middle 1/3 of auricle
Flap Design
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Based on
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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
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Defects
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Superior conchal lesion
Technique
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2 incisions
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Crus along tragal
meeting point & extend
superiorly
Inferior crus attachment
to cavum
Banar, M et al. Dermatol Surg 2003
Retroauricular Advancement Flap
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Defects
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Large
Flap design
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First stage
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Often combine
contralateral conchal
cartilage
Retroauricular skin
elevation & advancement
Second stage
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2-4 weeks
Division & inset flap
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
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Perichondrium or cartilage inflammation
post-injury predisposes to tissue ischemia
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Pseudomonas infection may ensue
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May cause liquefactive necrosis
Prevention
Careful cartilage manipulation
 Sterile technique
 Prophylatic antibiotics: anti-Psuedamonal
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Kaplan, AL et al. Dermatol Surg 2004
Fundamental Tools
Temporoparietal Fascia Flap
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Temporoparietal fascia
Most superficial layer beneath temporal
subcutaneous fat
 Continous with
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Galea superiorly
 SMAS inferiorly
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Blood supply = superficial temporal artery
 Dimensions
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2-4mm thick
 14 X 17cm area
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Salem DK, Cheney ML. Arch Otolaryngol Head Neck Surg. 1995
Temporoparietal Fascia Flap
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Harvest
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Preauricular facelift incision extended temporally
Dissect subcutaneous plane over temporoparietal fascia
to zygomatic arch and frontal branch (CNVII)
Incise periphery- defect size
Pearls
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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
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Fundamental reconstruction option
Cutaneous free tissue transfer
Separate from donor site
 Transplant to recipient site
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Secondary intention & primary closure not
possible
Adams, D et al. Dermatol Surg 2005
Skin Grafting
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Survival dependent upon blood supply
establishment
 1st
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Imbibition: absorbs transudate
48 – 72 hours
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24 hours
Inosculation: vascular anastamoses
4 – 7 days
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Circulation restoration
Adams, D et al. Dermatol Surg 2005
Skin Grafting
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3 primary types
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Full-thickness skin graft (FTSG)
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Epidermis + dermis ± subcutaneous tissue
Split-thickness skin graft (STSG)
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Epidermis + variable thickness of dermis
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0.005 – 0.028 inches
Composite skin graft
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2 or more germ layers tissue
Adams, D et al. Dermatol Surg 2005
FTSG
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Easy harvest
Minimal contraction
Necrosis more common than STSG
Common donor sites for facial defects
Preauricular
 Postauricular
 Supraclavicular
 Clavicular
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Adams, D et al. Dermatol Surg 2005
STSG
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Nutritional requirements ↓ : ↑ survival
Mesh ↑ surface area
Last resort for cosmesis
Contraction
Donor site
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Size
Wound care
Activity
Cosmesis
Adams, D et al. Dermatol Surg 2005
Complications
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Infection
Hematoma
Perichondritis & chondritis
Failure
Poor cosmesis
Conclusion
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Maintain function, then cosmesis
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Careful patient assessment
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Consideration of multiple techniques
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Informed consent
Bibliography
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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: 5862.
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.