Double helical rim advancement flaps with scaphal resection: selected cases over 10 years and review of the literature

Proportional Ear Reduction: The Rule of Threes

BACKGROUND

Human ear growth continues beyond puberty, resulting in ears that are typically approximately 10 millimeters (mm) larger in older individuals compared to their younger counterparts. Not only is the overall growth of the ear an indicator of age, but also the disproportionate growth of its parts. The largest part, the concha, shows the slowest growth rate, while the smallest part, the earlobe, shows the greatest growth rate. Thus, over time, the net increases in the scapha, concha, and earlobe become nearly equal. Therefore, it is appropriate to make approximately equal reductions from each unit in order to restore a youthful balance to the ear.

METHOD

Aged and large, but otherwise normal, ears were selected for use of the "rule of threes" technique. This technique involves reducing the height of each of the three units (scapha, concha, and earlobe) by approximately 3 mm. Depending on individual needs, reductions were also applied to two units or just one unit as necessary. Adjustments in reduction amounts were made for previously disproportionate ears.

PATIENTS AND RESULTS

A total of 32 ears from 16 patients were included in the study. Scapha reduction was performed on six patients, scapha and concha reduction on five patients, combined (including earlobe) reduction on two patients, and isolated earlobe reduction on three patients. All patients were followed up for at least 6 months. The planned reduction target was achieved in all cases, resulting in balanced youthful ears. Two skin sloughs in the earlobe, one requiring revision, and bilateral hypertrophic scarring behind the earlobe were observed in one case.

CONCLUSION

The described ear reduction technique yields satisfactory results when performed with precision. Each ear should be assessed individually, allowing for some flexibility rather than strict adherence to the proposed amounts of reduction. Care must be taken not to disrupt the blood supply to the ear structures. Achieving harmony at junction lines requires careful planning and meticulous technique.

LEVEL OF EVIDENCE IV

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Reconstruction of Full-Thickness Helical Defects Using a Superior Auricular Artery-Based Postauricular Chondrocutaneous Flap

BACKGROUND

The helix is the most common localization of auricular defects. Various techniques have been successfully used for the reconstruction of helical defects. However, redistributing the remaining auricular tissue to supply an ideal reconstruction base provides the best possible esthetic outcomes. The aim of this study is to present a new design for a postauricular chondrocutaneous flap to reconstruct the 3-dimensional curve and the folded structures in full-thickness helical defects.

METHODS

Nineteen patients with full-thickness helical defects were treated with the superior pedicle chondrocutaneous flap based on the superior auricular artery. The flap was designed on the postauricular area and comprised 3 sections, namely, deepithelialized, chondrocutaneous, and cutaneous sections (proximal to distal). Levels of patient's satisfaction on the final shape and auricular symmetry, and tissue compatibility between the flap and surrounding tissues were evaluated by the patients and objective observers.

RESULTS

The overall dimensions, projections, and curved structures of the defective helix maintained a smooth and contiguous appearance without asymmetry, notching, or trap-door deformities. The color, texture, and thickness of the flaps matched well with the adjacent auricles, and there was a moderate positive correlation between patient (9.47 ± 0.51) and observer (8.68 ± 0.63) correlation scores (r = 0.7485). The vast majority of the patients were very satisfied with the surgical outcome, and there was a statistically significant improvement in patient satisfaction (mean preoperative score, 1.26 ± 0.45; mean 12-month score, 4.79 ± 0.42; P < 0.00001).

CONCLUSIONS

Reconstruction of full-thickness helical defects requires "like tissue" characteristics and 3-dimensional cartilage support to avoid depression and notch deformities. The postauricular chondrocutaneous flap based on the superior auricular artery was shown to preserve the helical curve and folded sulcus, retain the size and subunits of the auricle, and ensure a color, texture, and thickness match between the flap and the adjacent tissues.

Revisited Arterial Supply of the Anterior Ear

BACKGROUND

Since arterial supply of the anterior ear was described in 1992 by Park et al, various anatomical studies and surgical techniques have been published in the literatures. Although anatomic studies about the vascular pattern of the ear have been previously reported, most were incomplete to understand the vascular anatomy of the ear and its surgical outcomes. In this report, the authors defined further detailed vascular pattern of the arterial networks and of the main perforators of the anterior ear.

METHODS

The authors dissected in a total of 11 auricles that had been fixed in 10% formalin solution. Prior to dissection, a red latex solution was injected into the common carotid artery. The anteroauricular and postauricular skin was dissected to expose the arterial network under ×10 microscope magnification.

RESULTS

There are 2 arterial networks in the anteroauricular surface of the ear: triangular-scapha fossa and concha network. In this study, triangular-scapha fossa network has 2 vascular patterns by a dominant arterial supply: the superficial temporal artery (STA) type (6/11, 54.5%) and the posterior auricular artery (PAA) type (5/11, 45.4%). The STA type is distributed by a subbranch of the ascending helical artery of the STA, whereas the dominant arterial supply of the PAA type is a perforator of the triangular fossa from the PAA. We describe an important inflow to the triangular-scapha fossa network as blood supply from the middle division of the PAA, which directly emerges from the posterior to the anterior surface over the cartilage border at midhelix.

CONCLUSIONS

The detailed vascular anatomy of this report allows surgeons to perform surgical procedures safely and to develop various flaps in the field of the ear reconstruction.

Reconstructive Options for Auricular Trauma

Given its prominent lateral position, the auricle is a common site of injury after blunt trauma. Auricular injuries can lead to both functional and aesthetic complications. A careful history and examination will help determine the mechanism of injury and identify factors that may influence repair. Auricular reconstruction is highly individualized and depends on the size, location, and nature of injury. Understanding the complex three-dimensional anatomy of the external ear is a necessity for appropriate reconstruction. This article reviews the reconstructive options for simple and complex auricular injuries based on the anatomical site and the intricate three-dimensional structures that form the auricle.

Helical Rim Reconstruction With Chondrocutaneous Hatchet Flap-Z Plasty

BACKGROUND

Helical rim reconstruction is relatively difficult because of the unique anatomical structure of the ear. The aesthetic and functional characteristics of the ear make such reconstruction even more important. This article presents the newly defined chondrocutaneous hatchet flap-Z plasty (HFZP) method in helical rim defects and evaluates the results.

METHODS

This study retrospectively evaluates 14 patients who were operated on using the chondrocutaneous HFZP method after a tumor excision located on the helical rim. The etiologies of the patients were basal cell carcinoma (n = 7), squamous cell carcinoma (n = 2), and actinic keratosis (n = 5). All patients were operated on under local anesthesia. The patients were evaluated regarding age, sex, etiology, defect location, and aesthetic outcomes.

RESULT

Five patients were female, and 9 were male. The mean age of the patients was 72.2 years. Nine tumors were localized in the upper one-third of the helical rim, and 5 were localized in the middle one-third. The average duration of operation was 24 minutes. The aesthetic results were 11 patients (78.59%) who recovered with excellent outcome, 2 patients (14.2%) with good outcome, and 1 patient(7.1%) with poor outcome. There were no postoperative complications, such as flap necrosis, infection, suture detachment hemorrhage, or hematoma.

CONCLUSIONS

The chondrocutaneous HFZP method is a simple, single-stage method that uses local tissues without color mismatch. In addition to the method's geometric gain, there is no removal of healthy skin or cartilage, resulting in minimal decreases in the vertical and horizontal diameters of the ear.

Otoplasty for Congenital Auricular Malformations

Among the less common congenital auricular anomalies are cryptotia, Stahl ear, constricted ear, and macrotia. The vast majority of these occur spontaneously without accompanying syndromes or other deformities. This article provides a comprehensive overview of these anomalies, as well as common techniques to correct these anomalies.

Reevaluation of the arterial blood supply of the auricle

The anatomical basis for auricular flaps used in multiple aesthetic and reconstructive procedures is currently based on a random distribution of the underlying arterial network. However, recent findings reveal a systematic pattern as opposed to the present concepts. Therefore, we designed this study to assess the arterial vascular pattern of the auricle in order to provide reliable data about the vascular map required for surgical interventions. Sixteen human auricles from eight body donors (five females/three males, 84.33 ± 9.0 years) were investigated using the unique 'Spalteholz' method. After arterial injection of silicone, a complete transparency of the tissue was achieved and the auricular arteries and branches were visible. Qualitative and quantitative evaluation of the arterial vascular pattern was performed. The superior and the inferior anterior auricular artery provided the vascular supply to the helical rim, forming an arcade, i.e. helical rim arcade. On the superior third of the helical rim another arcade was confirmed between the superior anterior auricular artery and the posterior auricular artery (PAA), i.e. the helical arcade. The perforators of the PAA were identified lying in a vertical line 1 cm posterior to the tragus, supplying the concha, inferior crus, triangular fossa, antihelix and the earlobe. The results of this study confirmed the constant presence of the helical rim arcade (Zilinsky-Cotofana), consistent perforating branches of the PAA, and the helical arcade (Erdman), and will help and guide physicians performing auricular surgeries toward fast and simple procedures with optimal patient satisfaction.