Arterial supply of the anterior ear

Chondrocutaneous marginal ear flap

This paper discusses a technique for the treatment of helical tumors that most times occur in aging patients with precarious clinical conditions and who wish to solve the problem in a single-stage operation. For these reasons, we have used a chondrocutaneous marginal flap of up to 4.0 cm in length based on the artery of the lobe that penetrates the helix at the level of the antitragushelicin cleft. This flap is also convenient for repairing circumscribed traumatic injuries of the helical rim.

In vivo perfusion analysis of normal and dysplastic ears and its implication on total auricular reconstruction

INTRODUCTION

During the first stage of total auricular reconstruction with autologous rib cartilage, according to Nagata, the cartilage framework is placed in a subcutaneous pocket. Its posterior skin flap is relatively large and can be prepared with or without a subcutaneous pedicle. This represents the crucial part of the procedure, as impaired healing and infection can occur due to low perfusion. Nothing was known about the blood supply of ear remnants or flap perfusion during reconstruction. It was not clear whether the preservation of the additional subcutaneous pedicle secures high blood supply.

METHODS

We used laser fluorescence angiography with indocyanine green dye for anatomical and functional perfusion studies in eight normal ears. Subsequently the anatomical and functional vessel architecture of 18 dysplastic ears was investigated. Finally, five patients each were operated on with or without subcutaneous pedicle during auricular reconstruction and intraoperatively monitored with laser fluorescence angiography.

RESULTS

We showed that the vessel structure of normal ears detected by fluorescence angiography is equivalent to anatomical preparations. The surrounding skin in high grade microtia remnants is biphasically perfused by deep perforators and by the cutaneous vessel network. The preservation of the subcutaneous pedicle during auricular reconstruction leads to significantly better perfusion of the posterior skin flap. No signs of critical perfusion or complications were observed in these patients.

DISCUSSION

We present the feasibility of laser fluorescence angiography to simultaneously gain anatomical and functional data about skin blood supply. The first anatomical and functional description of blood supply of ear remnants in third grade microtia is given. Functional data of skin flap perfusion during and after complete ear reconstruction were evaluated. The present study shows that the subcutaneous pedicle of Nagata's procedure is of great importance for success of the first stage operation as it prevents impaired wound healing. In contrast, patients without a subcutaneous pedicle had a broad spectrum of reduced perfusion and therefore some had complications.

Use of vascularised cartilage as an additional interposition in temporomandibular ankylosis surgery: Rationale, advantages and potential benefits

Context:

Surgery for the release of temporomandibular joint (TMJ) ankylosis is a commonly performed procedure. Various interposition materials have been tried with varying success rates. However, none of these procedures attempt to recreate the architecture of the joint as the glenoid surface is usually left raw.

Aims:

We aimed to use a vascularised cartilage flap and to line the raw surface of the bone to recreate the articular surface of the joint.

Settings and Design:

There is a rich blood supply in the region of the helical root, based on branches from the Superficial Temporal Artery (STA), which enables the harvest of vascularised cartilage from the helical root for use in the temporomandibular joint.

Materials and Methods:

Two cases, one adult and the other a child, of unilateral ankylosis were operated upon using this additional technique. The adult patient had a bony segment excised along with a vascularised cartilage flap for lining the glenoid. The child was managed with an interposition graft of costochondral cartilage following the release of the ankylosis, in addition to the vascularised cartilage flap for lining the glenoid.

Results:

The postoperative mouth opening was good in both the cases with significant reduction in pain. However, the long-term results of this procedure are yet to be ascertained.

Conclusions:

The vascularised cartilage flap as an additional interposition material in temporomandibular joint surgery enables early and painless mouth-opening with good short-term results. The potential applicability of this flap in various pathologies of the temporomandibular joint is enormous.

[Near-total ear amputation: anatomical bases and management]

BACKGROUND

In cases of near-total ear avulsions, replantation is often successful without microsurgery. The purpose of our study was to investigate the relevant vascular anatomy associated for ear survival.

PATIENTS AND METHODS

Four cases of successful surgical intervention in near-total ear avulsions are presented. Injection studies using latex were performed to identify the blood supply to the auricle on 13 cadaveric ears.

RESULTS

A small superior branch of the superficial temporal artery above the tragus was identified extending along the upper border of the auricle and connecting with the helical arcade. Below the tragus, a second small horizontal branch of the superficial temporal artery was identified.

CONCLUSION

The auricle can survive near-total amputation based on a skin bridge above or below the tragus. One of the auricular branches of the superficial temporal artery seems sufficient for the blood supply to the ear and allows for a successful non-microsurgical operative repair.

Reconstruction of the distal third of the nose with composite ear-helix free flap

Full-thickness defects of the nose result in severe esthetic and functional problems. Regardless of the etiology of such defects, the complexity of the reconstruction process of full-thickness defects of this region is not correlated with the size of the defect. Local flaps are frequently used for reconstruction but often yielding facial scarring and bulky alae. Composite helical grafts are used for relatively small defects but defects of more than 2.0 cm in diameter require vascularized tissue transfer. Composite free flap from the root of the auricular helix has been used to reconstruct an anatomically diverse set of defects of the distal third of the nose, with satisfactory success in our series of 6 patients.

Chondrocutaneous advancement flap for reconstruction of helical rim defects in dermatologic surgery

The helical rim is often affected with cutaneous malignancies and requires special attention in the repair, owing to the complex cartilaginous contour, preservation of the aesthetic contour and restoration of its supportive function for eyeglasses and hearing aids. We review the surgical technique of chondrocutaneous advancement flap described by Antia and Buch as one of the most cosmetically appealing and versatile approaches for the repair of small defects of the ear helix.

The reverse auricular flap for the reconstruction of extended defects of the lower eyelid

The authors present eight cases of lower eyelid reconstruction after extended excision of cutaneous carcinomata. To recreate the supporting function of the lower eyelid it is necessary to reconstruct a rigid structure, which must replace the tarsus and has to be covered by sufficiently thin skin. A condrocutaneous helix island flap, based on the frontal branch of the temporal artery, allows us to reconstruct both lamellae of the eyelid at the same time. The reverse flow to the flap through this vascular pedicle is assured by the anastomotic branches from the supratrochlear and supraorbital arteries. Using this flap we have been able to recreate morphology and function of the lower eyelid with a good cosmetic result in the donor site as well.

Auricular reconstruction

Reconstruction strategies for the ear should address the major aesthetic goals of maintaining the helical curvature and the symmetric frontal profile. When the auditory canal is involved, maintaining its patency is a major functional goal. The anatomic location of the defect, by virtue of its topographic features and adjacent donor pools, will dictate the appropriate reconstructive option. Familiarity with these anatomically-specific options will enable the surgeon to more simply and effectively reconstruct the ear.

Vascular supply of the subcutaneous pedicle of Nagata's method in microtia reconstruction

Nagata's method is a two-stage method for total ear reconstruction in patients with microtia. In the first stage of this procedure, mastoid flap and posterior lobule flap are elevated with a subcutaneous pedicle. However, contribution to the vascular supply by this pedicle has been controversial. We investigated the presence or absence of apparent vessels in the subcutaneous pedicle in 14 primary cases of microtia in the first stage operation. In all cases some vessels were included in the pedicle. In lobular and small concha type microtia, the vessels originated from the parotid fascia or aponeurotic tissue behind the remnant cartilage. In concha type microtia, apparent vessels could be preserved by including the perichondrium of the conchal cartilage. These findings suggest that the mastoid and posterior lobule flaps or W-shaped flap in Nagata's first stage operation are actually the perforator-based flaps. The source vessel of the perforators seemed to be the posterior auricular artery because of its location although further dissection was not performed in order not to damage the vascular supply. The presence of the vessels can augment the blood supply of not only W-shaped flaps but also the skin flap cephalad to them. By confirming the preservation of the perforators in the subcutaneous pedicle the surgeon may be able to trim the covering skin more safely.

Congenital cleft ear: a case report

A case is presented of congenital incomplete clefting of a normally formed ear. Previous reports have been limited to clefting of the ear lobule or clefting in association with gross deformity of the ear.

Perforator-Preserving Chondrocutaneous Rotation Flap Reconstruction of Auricular Defects

A technique of chondrocutaneous flap reconstruction of the ear that preserves the perforating branches of the posterior auricular artery is described. Preservation of the perforators offers improved safety in high-risk patients because it maintains the blood supply to the anterior surface of the ear. This perforator-preserving technique also emphasizes simplicity of flap design, concealment of scars, and preservation of ear shape. It is best suited for reconstructing defects of the scapha, antihelix, or triangular fossa up to approximately 2 cm in diameter. A variety of chondrocutaneous rotation flaps have been developed for reconstructing helical and nonhelical defects. These flaps have been designed on the basis of the size and location of the surgical defect. Although previously described techniques are usually reliable, extensive dissection and mobilization can injure perforators, leading to vascular compromise. When flap reconstruction is used in high-risk patients, it is necessary to protect the blood supply, and perforator-preserving flap reconstruction offers improved safety. The perforator-preserving technique was used in six consecutive high-risk patients during a 2-year period. Good results were obtained in all cases, including in patients who smoked cigarettes or had extensive medical problems.

Microtia repair

Construction of the congenitally absent ear is a particular challenge. It represents the true essence of plastic surgery in that it not only requires sound surgical principles but artistic skill. Although a solid familiarity with the stages is important, the surgeon's own experience will direct gradual modification.

The supra-auricular arterial network: anatomical bases for the use of superior pedicle retro-auricular skin flaps

The authors present an anatomical study on vascularization of the retro-auricular skin, focusing on the origin, distribution and anastomoses of the superior auricular artery. This artery is used as the pedicle of a retro-auricular flap to repair defects in the upper third of the auricle and in the temporal region. The study was carried out on 13 fresh cadavers, with a total of 25 auricles. The common carotid artery had previously been injected with dyed latex. The superior auricular artery was found in all specimens. It had constant course and caliber, mean axial length 2.4 cm, mean caliber 0.8 mm. This artery connected the superficial temporal artery, or its parietal branch, and the posterior auricular artery network. This branch proved a reliable vascular pedicle for the mobilization of retro-auricular flaps. The results of this study are presented together with preliminary clinical results obtained using an antero-superior retro-auricular flap, never previously described, to reconstruct the superior third of the auricle and the temporal region.

Surgical correction of cauliflower ear

We have classified the cauliflower ear into different types according to the zone and the degree of deformity. One major group is deformity without change in the outline of the ear, and this is divided into four subgroups according to the zone. All of these subgroups can be treated by shaving the deformed cartilage through suitable incision lines. For deformities accompanied by a skin deficit, a postauricular skin flap should be used. The other major group is deformity accompanied by a change in the outline of the ear, which is divided into two subgroups. If the ear is rigid, a conchal cartilage graft is used. If the structural integrity of the ear is poor, costal cartilage is used to provide rigidity.

A newly defined conchal floor arterial flap for auricular reconstruction

A conchal floor composite flap pedicled by skin of the helical crus has been well described in the literature. Here the flap is elevated based on the supply by an upper auricular branch of the superficial temporal artery. In this article, a newly defined conchal floor arterial flap is proposed. The flap is based on the main stem of the posterior auricular artery and its venae comitantes. Two types of conchal floor arterial flaps were elevated: a proximally based chondral arterial flap and a distally based chondrocutaneous arterial flap. The proximally based flap was used for earlobe reconstruction, whereas the distally based flap was useful in the reconstruction of the upper auricle. Nine congenital auricular malformations were successfully corrected with this newly defined conchal floor flap procedure. This type of flap is easier to elevate, more reliable, and more versatile than the one currently in use.

Nasal columella reconstruction with a composite free flap from the root of auricular helix

Defects of the nasal columella result in significant cosmetic and functional deformities. Over the years, a variety of methods for nasal columella reconstruction have been described in the literature, as have the technical difficulties of reconstructing this subtle structure. Here, a successful reconstruction of a 3.0 x 2.0 cm-wide nasal columella defect, with a chondrocutaneous microsurgical free flap from the root of the auricular helix, is presented.

Microvascular ear replantation

Microvascular ear replantation is a rare event, having been reported only 25 times since the first case in 1980. It requires a lengthy operative time and hospital stay, results in multiple blood transfusions, and has a significant failure rate. Nevertheless, a successful ear replantation is a dramatic demonstration of the power of microsurgery to restore a lost part. When successful, it obviates the need for other complex reconstructive efforts and provides an unsurpassed aesthetic result. This article reviews the history of microsurgical and nonmicrosurgical ear replantation and presents recommendations for treatment.

Anatomy and embryology of the external ear and their clinical correlation

The vascular anatomy for design and execution of various flaps of the auricular region is outlined with emphasis on clinical correlation. A new classification of various flap compositions from the postauricular region based on histologic and anatomic observations is proposed, together with a corresponding clinical example used in different clinical situations. Sound knowledge of the vascular pattern surrounding the auricle provides immense versatility in performing flap operations in this region. A summary of the controversy and updates on auricular embryology is provided in relation to various congenital malformations.

Reconstruction of the ear after skin and cartilage loss

Small defects (less than 1.5 cm) of the helix or antihelix of the middle third of the ear can be converted to a wedge-shaped excision and primary repair performed. In some cases, small Burrow's triangles on either side of the wedge must be exised from the scapha or antihelix to allow for closure without distortion or cupping. In addition, the resection may go across the conchal rim and include the bowl to allow for rotation without deformity.

Reconstruction of congenital and acquired earlobe deformity

The appearance and symmetry of the auricle is crucial for the maintenance of facial cosmetic harmony. The earlobe is considered to be an important attribute of beauty in most cultures, and earlobe decoration with color or earring is a common practice in many societies. A reconstructive technique for congenital or acquired deformity of the earlobe is described. In addition, the postauricular chondrocutaneous flap is very convenient for reconstruction of various auricular parts.

Retroauricular flap: its clinical application and safety

We report the application and safety of the retroauricular flap in 38 cases. The flap was used on the anterior auricular surface in 21 cases, in the peri-auricular region in five cases, in the region of the preauricular sideburn area in two cases, in the malar region in six cases, in the eyelid in three cases and in the intraorbital region in one case. When this flap was used in the auricular or periauricular region, the blood circulation was safe and the appearance was aesthetically good in flaps pedicled by the postauricular vessels or by the superficial temporal vessels. However, when the defect was more remote from the auricle, the blood circulation of the flaps pedicled by superficial temporal vessels, whether subcutaneous pedicle flaps or free flaps, was unstable. In some cases there was extensive or partial necrosis of the distal area of the flap. On the other hand, the free flaps pedicled by the postauricular vessels had satisfactory blood circulation, but the vessels were sometimes short, narrow and difficult to find, especially the veins. In these cases, we were obliged to use the superficial temporal vessels. A further problem is that some of the patients, especially younger women, were dissatisfied when the retroauricular flap was used in the malar region because of the reddish colour of the flap.

Complete ear replantation without venous anastomosis

Traumatic amputation of the entire auricle is a rare occurrence. Management ideally consists of microvascular reconstruction of auricular arterial, venous, and nerve continuity. However, appropriately sized veins are often not available and venous drainage must be accomplished with leech therapy. In occasional cases where leeches are unavailable or cannot be made to attach, mechanical drainage and anticoagulation can give satisfactory drainage. The authors present a case of mechanical wick venous drainage of a complete ear replantation, resulting in virtually normal appearance and function of the ear. In addition, the ear regained normal touch and two-point sensibility, although the great auricular nerve had not been repaired.

Reconstruction of the upper portion of the ear by using an ascending helix free flap from the opposite ear

Reconstruction of partial, marginal defects of the ear has been a challenge. The ascending helix free flap based on superficial temporal vessels has been described and used solely to repair nose defects. We used reversed pedicle helical free flap for the repair of a major loss of the upper one-third of the opposite auricle. The method permits the transfer of tissue of the same quality with satisfactory cosmetic result. The equalization of the ears in dimension was accomplished with minimal donor-site deformity.

The reverse auricular flap: a new flap for nose reconstruction

In the present article, the authors describe a new chondrocutaneous island flap from the ear helix for nose reconstruction. Anatomic studies showed that helix vascularization depends mainly on the superficial temporal vessels. The presence of vascular communications between the anterior frontal branch of the superficial temporal system and the supraorbital and supratrochlear arterial systems allows this flap to be used in a reverse vascular flow fashion. This new flap has been used successfully in seven cases for reconstructing composite defects of the nasal tip and ala. The donor-site defect is repaired with an advancement and rotation flap from the helical rim, leaving an inconspicuous scar and giving an acceptable cosmetic result of the donor area.

A simple method for earlobe reconstruction

We describe a technique for earlobe construction using the V-shaped flap with rotation and transposition techniques. This technique produces a natural appearing lobule without unpleasant secondary deformity. This method has been used on two patients, with very good results.

Reconstruction of the tragus after tumour excision

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.

A full-thickness chondrocutaneous flap from the auricular concha for repair of tracheal defects

A free full-thickness chondrocutaneous flap from the auricular concha for the repair of large tracheal defects was transferred successfully. The flap is based on the superficial temporal vessels (reversed flow) and the posterior auricular vessels. The advantages of this flap for the repair of tracheal defects are (1) its dissection is easy, (2) thin components of the flap provide a wide postoperative airway, (3) the structure of the reconstructed trachea is made firm by the conchal cartilage with vascularization, (4) the highly vascularized cartilage results in less resorption than a free cartilage graft, (5) the donor site can be repaired easily and is concealed by the remnant auricle, and (6) a long arterial pedicle (reversed flow) can be obtained. The disadvantages are (1) there may be temporary postoperative congestion of the flap, (2) postoperative narrowing of the auriculocephalic sulcus may occur, and (3) a short venous pedicle often requires a vein graft.

Earlobe crease in women: evaluation of reproductive factors, alcohol use, and Quetelet index and relation to atherosclerotic disease

BACKGROUND

The diagonal earlobe crease (ELC) has been found to be associated with atherosclerotic heart disease. Although atherosclerotic cardiovascular disease is less prevalent among women than among men, no studies have been reported for women on the possible relationship of reproductive factors, contraceptive and menopausal estrogen use, and alcohol use on the expression of the ELC.

SUBJECTS AND METHODS

The presence of ELC was determined in 625 white women who were seen as part of a breast research project. Information was obtained on age, height, weight, age at menarche, parity, age at first full-term pregnancy, use of oral contraceptives or menopausal estrogens, alcohol consumption, and smoking. Statistical methods used included estimation of the age-adjusted odds ratios and their 95% confidence intervals, and multiple logistic regression.

RESULTS

No association was found between the ELC and reproductive factors and smoking. Only age, Quetelet index, and alcohol use were associated with the ELC. The ELC was negatively associated with alcohol use, and was more marked in women under 59 years of age. The positive association of ELC with the Quetelet index progressively became more marked with advancing age, especially after 60 years of age.

CONCLUSION

The negative association found between the ELC and alcohol use is of interest because of the reported protective effect of moderate alcohol consumption on risk of coronary heart disease. No significant association was found between the ELC and reproductive risk factors. Based on events occurring during the embryonic development of the earlobes, a new hypothesis is proposed for the formation and peculiar diagonal localization of the ELC in adult earlobes in association with atherosclerotic vascular disease.