Arterial supply of the anterior ear

Influence of vascular anatomy and perfusion on complications in the first stage of total auricular reconstruction

BACKGROUND

The aesthetic quality of total auricular reconstruction for microtia has improved significantly in recent years, resulting in favourable outcomes for many patients. However, complications such as skin necrosis and infection remain. Adequate skin perfusion is essential to prevent these complications, but the vascular anatomy of patients with microtia is poorly understood. We evaluated the relationship between vascular anatomy assessed by indocyanine green fluorescence angiography performed during the first stage of autologous total ear reconstruction for microtia and postoperative complications.

METHODS

Fifty patients with microtia undergoing autologous total ear reconstruction and intraoperative indocyanine green fluorescence angiography were prospectively enroled from October 2020 to December 2021. Postoperative complications, including skin necrosis and infection, were determined from photographs taken one week postoperatively.

RESULTS

Of the 50 patients, 39 had lobule type microtia and 11 had concha type microtia. Fourteen patients had skin necrosis, 2 of whom required revision surgery due to infection. These 2 patients did not have subcutaneous pedicle perforators. Indocyanine green fluorescence angiograms showed subcutaneous pedicle perforators in 80% of patients. Modified Poisson regression analysis revealed that sex, subcutaneous pedicle perforator, three-branch score, and microtia type were associated with skin necrosis ≥20 mm2.

CONCLUSION

The extent of skin necrosis may be influenced by the presence or absence of subcutaneous pedicle perforators and the subdermal vascular plexus in the first stage of autologous total ear reconstruction for microtia. Females and patients with concha type microtia require more attention to avoid skin necrosis.

Chondrocutaneous Advancement Flap and Postauricular Skin Flap: An Effective Combination for Large Helical Rim Defect Reconstruction

Background

Defects of the ear helix are a frequent challenge in plastic surgery, with more than 5% of all skin cancers occurring in this region. The Antia-Buch flap is a single-stage reconstruction technique utilizing chondrocutaneous flaps for helix repair. However, for defects exceeding 2 cm, it can lead to auricular distortion. To address this limitation, we propose a modified Antia-Buch technique combining chondrocutaneous advancement with a postauricular skin flap to optimize outcomes.

Methods

A retrospective review was conducted of 15 patients who underwent our modified Antia-Buch flap procedure between 2019 and 2022. This approach incorporated chondrocutaneous advancement for primary defect closure and a postauricular skin flap for improved contouring. Functional and aesthetic outcomes were assessed using a questionnaire developed in collaboration with a clinical psychologist. The questionnaire evaluated surgical satisfaction, cosmetic results, self-image, and social integration postreconstruction.

Results

No complications, including ischemic necrosis or the need for surgical revision, were observed in any case. The technique demonstrated excellent vascularity, with no occurrences of flap failure. Patient-reported outcomes revealed high satisfaction rates, with no evidence of self-image distortion or social barriers. Aesthetic results were rated as superior, with minimal risk of auricular distortion even for larger defects.

Conclusions

The modified Antia-Buch technique is a reliable and effective method for helical rim reconstruction, particularly for defects larger than 2 cm. It offers technical simplicity, low complication rates, patient convenience, and excellent cosmetic outcomes, making it a preferred option for many auricular defect reconstructions.

A comparison of ear amputations replantation techniques

BACKGROUND

The management of traumatic ear amputations remains a rare and difficult occurrence for surgeons. This is due to the fact that the chosen replantation technique must ensure the best vascular supply and the surrounding tissues have to be preserved as to not jeopardize a future auricular reconstruction in the event of replantation failure.

OBJECTIVE

This study aimed to review and synthesize the literature about the different surgical techniques described to date in the management of traumatic ear amputations (partial or total).

MATERIALS AND METHODS

Relevant articles were searched on PubMed, ScienceDirect, and Cochrane Library databases in accordance with the PRISMA statement guidelines.

RESULTS

A total of 67 articles was retained. When possible, microsurgical replantation enabled the best cosmetic result but required important care.

CONCLUSION

Pocket techniques and local flaps should not be performed because of the lower cosmetic result and the use of the surrounding tissues. However, they could be reserved for patients without access to advanced reconstructive techniques. When possible, microsurgical replantation can be attempted after patient consent for blood transfusions, postoperative care and hospital stay. Simple reattachment for earlobe amputations and ear amputations up to one third is recommended. When microsurgical replantation cannot be attempted, and if the amputated segment is viable and bigger than one third, simple reattachment may be attempted with an increased risk of replantation failure. In case of failure, an auricular reconstruction by an experienced microtia surgeon or prosthesis may be considered.

Microvascular Ear Replantation: A Multicenter Study of 22 Patients with Complete Ear Amputation

Background: We aimed to report our experience in treating ear amputations with microvascular replantation, with the largest sample to date. Methods: Twenty-two patients with complete ear amputation underwent microvascular ear replantation at three medical centers between May 2003 and May 2020. Arterial anastomoses, venous anastomoses, or vein graft were performed depending on different situations. Re-exploration was performed in four patients due to venous congestion (n = 3) or arterial compromise (n = 1). Results: Eleven patients had vascular complications (venous congestion: 10, arterial compromise: 1) and four of them required re-exploration. Three ears were completely salvaged (75%) and one case failed. Eighteen (81.8%) replanted ears survived completely, with 15 repaired ears demonstrating a good contour and 3 ears showing atrophy. Three replanted ears sustained partial loss, and one sustained total loss. Three extraordinary cases with the longest ischemic time, smallest tissue size, and youngest age reported thus far all survived and had cosmetically satisfactory appearances. Statistical analysis indicated no significant correlation between replanted ear survival and potentially influential factors, including ischemic time, number of arterial and venous anastomoses, presence of vein graft, and re-exploration. Conclusions: Microvascular replantation for ear amputations achieved excellent results. It may be considered the primary choice for surgeons with microsurgical skill.

Effect of Tissue Pedicle Position on Postoperative Recovery From Severe Auricular Laceration

BACKGROUND

Postoperative recovery from severe auricular lacerations varies significantly. However, few studies have sought to clarify the risk factors associated with the prognosis of severe auricular lacerations, and little attention has been paid to the intraoperative management of severe auricular lacerations and early postoperative intervention. The purpose of this study was to analyze the risk factors that may affect the prognosis of severe auricular lacerations.

METHODS

Case data and imaging data of patients with severe auricular lacerations treated in our department between January 2018 and September 2022 were collected. A total of 90 patients (90 severe auricular lacerations) were included in the analysis and were divided into good group (68 cases) and poor group (22 cases) according to postoperative recovery, which was defined as poor postoperative recovery when postoperative auricular blood supply disorders required interventional treatment or second stage plastic surgery.

RESULTS

The percentage of ventral tissue pedicles in the poor recovery group was 77.3% ( P <0.001). The proportion of ventral tissue pedicle was significantly higher in the poor postoperative group than in the good postoperative group, and ventral tissue pedicle [odds ratio (OR)=12.22, P =0.002] was an independent risk factor for poor postoperative recovery from severe auricular laceration.

CONCLUSIONS

The prognosis of patients with severe auricular lacerations differs between the different tissue pedicle locations, and prophylactic treatment of patients with ventral tissue pedicles is beneficial. In addition, patients with ventral tissue pedicles should be informed in advance of their increased risk of surgical failure.

A Comparison of Ear Amputations Replantation Techniques

BACKGROUND

The management of traumatic ear amputations remains a rare and difficult occurrence for surgeons. This is due to the fact that the chosen replantation technique must ensure the best vascular supply and the surrounding tissues have to be preserved as to not jeopardize a future auricular reconstruction in the event of replantation failure.

OBJECTIVE

This study aimed to review and synthesize the literature about the different surgical techniques described to date in the management of traumatic ear amputations (partial or total).

MATERIALS AND METHODS

Relevant articles were searched on PubMed, ScienceDirect, and Cochrane Library databases in accordance with the PRISMA statement guidelines.

RESULTS

A total of 67 articles was retained. When possible, microsurgical replantation enabled the best cosmetic result but required important care.

CONCLUSION

Pocket techniques and local flaps should not be performed because of the lower cosmetic result and the use of the surrounding tissues. However, they could be reserved for patients without access to advanced reconstructive techniques. When possible, microsurgical replantation can be attempted after patient consent for blood transfusions, postoperative care and hospital stay. Simple reattachment for earlobe amputations and ear amputations up to one third is recommended. When microsurgical replantation cannot be attempted, and if the amputated segment is viable and bigger than one third, simple reattachment may be attempted with an increased risk of replantation failure. In case of failure, an auricular reconstruction by an experienced microtia surgeon or prosthesis may be considered.

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.

Auricular avulsion injuries: Literature review and management algorithm

Traumatic ear avulsion (TEA) may have tremendous psychological consequences if not managed properly. There are no clear guidelines on the surgical management of these injuries, especially in developing countries where microsurgical facilities are lacking. We aimed to review the literature on surgical management of TEA with the main focus on direct re-attachment (DR) so as to develop a surgical management algorithm that can be applied in the absence of microsurgical facilities. We performed an extensive review of the relevant English literature on papers indexed in PubMed describing TEA repaired with DR without restriction to a specific publication time window. A total of 28 cases in 18 publications were reviewed and analyzed. Our results indicate that in the acute setting with no available microvascular expertise, DR of auricular avulsion injuries can be better than other nonmicrosurgical techniques in generating good esthetic results, especially in incomplete auricular avulsion and small segment avulsion. The operative approach depends on the clinical setting. DR of the auricular avulsion injuries is an accepted approach. It produces good cosmetic outcomes while preserving the auricular area for future reconstruction in case of re-attachment failure.

Posterior auricular artery helix root free flap-part I: radio-anatomical study

Full-thickness defects of the distal nose are an ongoing surgical challenge. Among the available techniques, pre-auricular chondrocutaneous free flaps based on the superficial temporal artery (STA) have good aesthetic and functional outcomes. However they often require autologous venous grafts. The aim of this radio-anatomical study was to evaluate the feasibility of the helix root free flap based on the posterior auricular artery (PAA). Vascular lengths, diameters, and networks were investigated in flaps harvested from cadavers. The perfusion of the flaps was studied by injecting patent blue. Some flaps were also injected with contrast agent and studied by angiography and computed tomography. Ten flaps from seven fresh cadavers were dissected and analysed. The mean length of the PAA was 114.2 mm and the mean diameter was 2.2 mm. Perfusion was investigated in six flaps and considered good in three of these. The study results demonstrate the feasibility of PAA-based helix root free flaps. This alternative technique provides an 11 cm pedicle with vessels of appropriate calibre, facilitating any potential microsurgery. The scar is mostly hidden behind the ear. This PAA-based helix root free flap could be a reliable and promising single-stage procedure to repair complex defects of the alae nasi.

Reconstruction of an iatrogenic anterior conchal defect with a revolving-door flap

Background

Auricular concha has been widely used as a supporting material in rhinoplasty or repairing of auricular defects. However, complications, trauma or iatrogenic excision often result in concha defects which destroy the normal structure of the external ear and further influence daily life. Local flaps are often applied to repair the defects because of their safety and satisfactory functional and aesthetic results.

Case presentation

We report a 24-year-old female who presented with a concha defect that resulted from a complication of concha cartilage graft for rhinoplasty. The anterior concha defect was covered by a revolving-door (RD) flap as a single-stage procedure. The aesthetic and functional outcomes were satisfactory at 6 months post operation.

Conclusion

We recommend the RD flap as an excellent choice for conchal defect reconstruction. Satisfactory aesthetic and functional results can be achieved by this easy-to-learn technique in relatively short surgical time.

Arterio-venous malformations of the ear: Description of distinct anatomical presentation and multidisciplinary management approach

BACKGROUND

Arterio-venous malformations (AVMs) of the ear are a rare entity and their management should be decided in a dedicated multidisciplinary team (MDT) setting. The aim of this study is to describe the distinct anatomical patterns of the auricular AVMs in our unit and propose a combined interventional radiological and surgical approach.

MATERIALS AND METHODS

All consecutive patients presenting with AVMs of the ear and reviewed by the Vascular Anomalies MDT between 2014 and 2019 were included in this study. Signs, symptoms, diagnostic investigations and operative findings were collected prospectively.

RESULTS

After reviewing our nine patients, we identified four anatomical patterns of auricular AVMs: I: involves just a component of the ear and should undergo embolization followed by excision and reconstruction without significant loss of form; II: affects the superior two-thirds of the ear, sparing the lobule and part of the conchal bowl; these patients should undergo embolization, excision and monitoring before formal reconstruction of the ear is offered; III: involves the entire ear and should undergo embolization and pinnectomy; if there is no recurrence, the patients can be offered either a carved-rib cartilage reconstruction or a prosthesis, depending on the quality of the surrounding soft-tissues; IV: involves the ear and surrounding tissue, making surgical management and subsequent reconstruction extensive.

CONCLUSION

The management of auricular AVMs is based on the extent of the ear involved. We feel that our combined interventional radiological and surgical approach will aid the management of these complex patients.

Risk Factors for Delayed Resorption of Costal Cartilage Framework Following Microtia Reconstruction

Background: Resorption of the cartilage framework results from hematoma or infection, deteriorating outcomes in microtia reconstruction. Delayed resorption still occurs for unclear reasons in patients without adverse events. The risk factors for delayed framework resorption were explored in this 20-year microtia cohort. Methods: Patients who underwent auricular elevation >5 years ago were reviewed from January 2001 to March 2019. Bilateral microtia, infection, and hematoma cases were excluded. Framework resorption was graded on the last photographs as none to minimal (grade 1), blunted but all components present (grade 2), loss of either the helical or antihelical component (grade 3), and loss of all components (grade 4). Logistic regression was used to evaluate independent risk factors for grade 3 and 4 resorption. Results: Of the 367 patients, 132 revisited our institution with a mean postoperative duration of 8.0 years. Grade 1 resorption was seen in 37.1%, 2 in 31.8%, 3 in 24.2%, and 4 in 6.8%. Canalplasty increased the risk of resorption regardless of timing (before auricular elevation, p = 0.017; after auricular elevation, p = 0.011). Body mass index at the time of cartilage harvest lowered the risk of resorption (p = 0.057) with clinical significance. Conclusions: Canalplasty may be avoided given the risk of framework resorption or may be performed with antiresorption strategies if the expected hearing outcome is superior. Our timing of harvest at the age of 10 years may have ensured cartilage maturation, both in terms of size and biomechanics, resulting in the resistance to resorption.

Revisiting the temporal artery posterior auricular skin flap with an anatomical basis stepwise pedicle dissection for use in targeted facial subunit reconstruction

BACKGROUND

This study demonstrates the anatomy of the pedicled temporal artery posterior auricular skin (TAPAS) flap, its variable arc of rotation based on stepwise dissection, and case reports demonstrating clinical use. This flap provides excellent color match and ultrathin tissue for targeted reconstruction of small- to medium-sized facial subunit defects.

METHODS

Twenty-six cadaver dissections were performed. The authors measured the reach and rotation limits of the flap in a pedicled fashion depending on a stepwise approach for vascular pedicle dissection. Two clinical cases demonstrating maximum arc of rotation are seen.

RESULTS

The pedicled TAPAS flap maximal rotation limits allow for reconstruction of facial subunits encompassing nearly the entire ipsilateral face. No venous congestion, wound complications, or partial/total flap loss were encountered with extreme clinical applications.

CONCLUSION

The pedicled TAPAS flap has extensive versatility for reconstruction of a variety of facial subunit defects. The flap also has, in theory, multiple applications for intraoral reconstruction.

New Strategies for Remnant Ear Treatment in Lobule-Type Microtia Reconstruction

BACKGROUND

Numerous modifications have been successfully applied in microtia reconstruction over the past several decades, and lobular transposition has become a routine technique in a two-stage operation. However, it is still a demanding challenge to manipulate the remnant ear with various quantities or positions in lobule-type microtia. The authors demonstrate the relevant details of treating remnant tissue in different conditions.

METHODS

A total of 390 lobule-type microtia patients underwent autogenous costal cartilage auricular reconstruction between 2010 and 2015. Because the quantity or position of the remnant ear varies from patient to patient, corresponding tactics need to be taken into consideration for appropriate treatment. Four possible scenarios of remnant ear shape have been described, and relevant strategies for each were introduced.

RESULTS

Favorable reconstructed auricles with aesthetic natural earlobes have been produced; the location of the reconstructed ear is symmetric to the contralateral ear. It provides a harmonized framework and periphery tissue for the integrity of the contour of the constructed auricle.

CONCLUSIONS

Proper use of the remnant ear along with framework fabrication and skin flap dissection are critical factors for attaining a satisfactory contour of the auricle in microtia reconstruction. The authors' technique made it possible to construct a cosmetically refined ear with harmonious integrity.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

The Conchal Vascular Foramen of the Posterior Auricular Artery: Application to Conchal Cartilage Grafting

The posterior auricular artery (PAA), a branch of the external carotid artery, gives rise to a conchal network formed by PAA perforators through the conchal floor of the auricle. However, this branch and its entrance (foramen) to the anterior concha, is rarely illustrated in the literature and has not been studied in detail. Therefore, we aimed to investigate the morphology of the perforating artery (PA) and its vascular foramen (VF). Ten sides from five formalin-fixed frozen Caucasian cadaveric heads were used. The number, diameter of the VF, diameter of the perforating artery (PA), shape of the VF (circular or oval), distance from the middle of the tragus and origin of the artery were documented. The number of VF ranged from 1 to 2; one was seen on 90% of the sides and two were seen on 10% of the sides. The VF was oval in 36% of the sides and circular in the remaining 64%. The mean diameter of the long and short axes of the VF, and PA was 2.0±1.4 mm, 1.3±0.9 mm, and 0.7±0.4 mm, respectively. Diameter of the PA was 1.0 mm or greater in 18% of the sides. The mean distance from the middle of the tragus to the VF was 10.7±2.6 mm. The perforating artery of the concha originated from the posterior auricular artery on all 11 sides.

Reconstruction of Microtias with Constricted Ear Features: A 22-Year Experience

BACKGROUND

The surgical correction of microtias with constricted ear features has remained a challenge because of the variable shape and large volume of the remnant cartilage and skin involved. To clarify how this remnant cartilage and skin should be treated, the authors have reviewed and analyzed cases operated on at their center.

METHODS

A total of 167 cases of microtia with constricted ear features, operated on from 1992 to 2014, were included in the study. They were reviewed through medical records and photographs, analysis of surgical methods, and postoperative outcomes.

RESULTS

A total of 141 cases (84 percent) were followed for 2 months to 13 years (average, 28 months). The average score given for the aesthetic outcomes, rated on a four-point Likert scale (i.e., 1 = poor, 2 = fair, 3 = good, and 4 = excellent), was 3.1. For framework construction, the authors used remnant cartilage-saving methods (n = 37) or remnant cartilage-replacement methods (n = 104). The average scores for the aesthetic outcome for these methods were 2.56 (median, 3) and 3.36 (median, 4), respectively. The difference in these scores was statistically significant (p < 0.001). For the coverage of new frameworks, various flap techniques were used.

CONCLUSION

To correct microtias with constricted ear features with consistent postoperative results, the deformed cartilage remnant should be completely replaced with a costal cartilage framework, and the remnant skin should be maximally saved.

Prominent Ear Correction: A Comprehensive Review of Fascial Flaps in Otoplasty

Over the last 100 years, more than 200 different methods have been described to correct prominent ear deformity. These techniques revolved around various combinations of postauricular incision, cartilage scoring, and strategic suture placement to reapproximate the antihelical fold and correct angular deformity. In the last two decades, fascial flap techniques have become prominent in otoplasty. This article gives a comprehensive review of the different surgical techniques employed to construct fascial flaps and their contributions to otoplasty.

Diagonal Earlobe Crease is a Visible Sign for Cerebral Small Vessel Disease and Amyloid-β

We investigated the frequency and clinical significance of diagonal earlobe crease (DELC) in cognitively impaired patients using imaging biomarkers, such as white matter hyperintensities (WMH) on MRI and amyloid-β (Aβ) PET. A total of 471 cognitively impaired patients and 243 cognitively normal (CN) individuals were included in this study. Compared with CN individuals, cognitively impaired patients had a greater frequency of DELC (OR 1.6, 95% CI 1.1–2.2, P = 0.007). This relationship was more prominent in patients with dementia (OR 1.8, 95% CI 1.2–2.7, P = 0.002) and subcortical vascular cognitive impairment (OR 2.4, 95% CI 1.6–3.6, P < 0.001). Compared with Aβ-negative cognitively impaired patients with minimal WMH, Aβ-positive patients with moderate to severe WMH were significantly more likely to exhibit DELC (OR 7.3, 95% CI 3.4–16.0, P < 0.001). We suggest that DELC can serve as a useful supportive sign, not only for the presence of cognitive impairment, but also for cerebral small vessel disease (CSVD) and Aβ-positivity. The relationship between DELC and Aβ-positivity might be explained by the causative role of CSVD in Aβ accumulation.

Single-Artery Human Ear Graft Procurement: A Simplified Approach

In the field of experimental facial vascularized composite tissue allotransplantation, a human auricular subunit model, pedicled on both superficial temporal and posterior auricular arteries, was described. Clinical cases of extensive auricular replantation, however, suggested that a single artery could perfuse the entire flap. In this study, variants of this single-pedicle approach have been studied, aiming to develop a more versatile replantation technique, in which the question of venous drainage has also been addressed. For arterial perfusion study, the authors harvested 11 auricular grafts, either on a single superficial temporal artery pedicle (n = 3) or a double superficial temporal and posterior auricular artery pedicle (n = 8). The authors then proceeded to selective barium injections, in the superficial temporal, posterior auricular, or both superficial temporal and posterior auricular arteries. Arteriograms were acquired with a micro-computed tomographic scan and analyzed on three-dimensionally reconstructed images. Venous drainage was investigated in eight hemifaces, carefully dissected after latex injection. Observations showed a homogenous perfusion of the whole auricle in all arterial graft variants. Venous drainage was highly variable, with either a dominant superficial temporal vein (37.5 percent), dominant posterior auricular vein (12.5 percent), or co-dominant trunks (50 percent). The authors demonstrated that auricular subunit vascularized composite tissue allotransplantation can be performed on a single artery, relying on the dynamic intraauricular anastomoses between superficial temporal artery and posterior auricular branches. Potentially, this vascular versatility is prone to simplify the subunit harvest and allows various strategies for pedicle selection. Venous drainage, however, remains inconstant and thus the major issue when considering auricular transplantation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

The Rolling Earlobe Flap for Dilated Ear Holes Following Ear Gauging: A Novel Approach to Aesthetically Preserving Earlobe Soft Tissue Volume

Patients are increasingly seeking repair of their earlobes following ear gauging. Research has shown that current repair techniques either excessively reduce the lobular volume or leave an obvious scar along the free edge of the earlobe. In our case series, we describe the use of a novel technique for repairing earlobes following ear gauging using a rolling earlobe flap that preserves the lobular volume and avoids leaving a scar on the free edge of the lobule. The procedure was performed on 3 patients (6 earlobes) who had defects from ear gauging that ranged from 3.0 to 6.5 cm. There were no postoperative complications of infection, wound dehiscence, flap necrosis, hypertrophic scars, or keloids, and all patients were highly satisfied with the postoperative results. This versatile technique allows for an aesthetically pleasing reconstruction of the lobule with the advantages of: the absence of a surgical scar on the free edge of the lobule, preserving the lobule volume, and presenting a highly customizable technique that allows lobules to be created with various shapes and volumes.

Partial Ear Defects

Reconstruction of partial ear defects represents one of the most challenging areas within reconstructive surgery of the head and neck. Each case of auricular reconstruction is unique and warrants a systematic approach that accounts for defect size and location, the quality of the surrounding skin, patient preference, and operator experience. In this article, the authors outline different reconstructive approaches for defects of the upper-, middle-, and lower-third of the auricle. The relevant anatomy is discussed in detail. Successful outcomes in auricular reconstruction rely on the surgeon's careful analysis of the defect as well as knowledge of the different reconstructive options available.

Vascular Supply of the Auricle: Anatomical Study and Applications to External Ear Reconstruction

BACKGROUND

Reliable reconstructive flaps require convenient vascular supply. Thus, precise description of the vascular patterns of external ear is not completely elucidated.

OBJECTIVE

This anatomical study aims to provide comprehensive data of the arterial network of the auricular region, anastomosis, and patterns of arterial dependence regarding external ear subunits.

MATERIALS AND METHODS

After dyed latex injections in the external carotid artery, eleven auricles have been carefully dissected to examine the vascular network of the auricular region.

RESULTS

In all cases, the posterior auricular artery (PAA) supplied the cranial side of the auricle, as well as the concha on the lateral side through consistent perforating branches. The superficial temporal artery (STA) network supplied the upper third of the lateral aspect of the auricle. The authors' dissections showed a clear dominance of the PAA supply. However, the two arteries consistently developed anastomoses particularly in the cranial upper third of the auricle.

CONCLUSION

Consistent branches and anastomoses between the PAA and the STA network provide reliable pedicles for auricular and facial reconstruction.

More than just the helix: A series of free flaps from the ear

AIM

We herein present our experience using free flaps harvested from the ear region in facial, nasal and intraoral reconstruction.

PATIENTS AND METHODS

Between 2011 and 2016, 19 patients underwent reconstruction using 20 free flaps from the ear region based on the superficial temporal vessels. There were 10 males and 9 females with a mean age of 57 years. Defect aetiology consisted of post-tumour ablation (n = 15), trauma (n = 2) and burn scar (n = 2). Defect location involved the nose (n = 13), floor of mouth (n = 3), tongue (n = 1), lower eyelid (n = 1), and lower lip (n = 1).

RESULTS

Twelve helical, seven temporal artery posterior auricular skin (TAPAS), and one hemiauricular flap were performed. One patient required venous re-anastomosis but complete flap necrosis eventually occurred. This patient later underwent successful contralateral helix flap reconstruction. Overall flap survival was 95%. Follow-up ranged from 12 to 69 months. A moderate to excellent aesthetic and functional outcome was achieved in all cases, but most (13/19) required later minor refinement surgery.

CONCLUSION

As a versatile source of free flap options, the ear can provide more than just the helix.

Iatrogenic Through-and-Through Conchal Defect Secondary to Auricular Cartilage Graft

BACKGROUND

Over the past few years, conchal cartilage has been most often used in rhinoplasty. The donor site complications following conchal cartilage graft harvesting are scar formation, hematoma formation, and delayed wound healing, although hematoma is one of the most important and common complications. A complete conchal defect as a complication of auricular cartilage graft harvesting has not been previously reported in the literature. The authors report an unusual case of an iatrogenic conchal defect resulting from conchal cartilage graft harvesting that was treated using a posterior auricular island flap.

METHODS

A 24-year-old male with a left conchal inflammation and perforation visited our plastic surgery department after receiving augmentation rhinoplasty and tip plasty using a conchal cartilage graft. A tight dressing had been applied to the ear, and postoperative infection was uncontrolled, which resulted in iatrogenic conchal perforation.

RESULTS

A tie-over bolster dressing has been widely used to prevent hematoma following conchal cartilage graft harvesting with an associated donor site complication. However, a tight tie-over dressing and inappropriate postoperative care can cause complete through-and-through conchal defects. The posterior auricular island flap provides an elegant means of reconstructing conchal defects.

CONCLUSIONS

In the described case, aesthetic reconstruction of a conspicuous iatrogenic conchal defect was achieved with minimal scarring using the posterior auricular island flap. To the best of our knowledge, this report is the first to describe reconstruction of an iatrogenic defect in the concha as a complication of auricular cartilage graft harvesting.

LEVEL OF EVIDENCE V

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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.

Analysis of the microcirculation after soft tissue reconstruction of the outer ear with burns in patients with severe burn injuries

Reconstruction of soft tissue defects of the ear with burns remains one of the most difficult tasks for the reconstructive surgeon. Although numerous reconstructive options are available, the results are often unpredictable and worse than expected. Besides full and split skin grafting, local random pattern flaps and pedicled flaps are frequently utilized to cover soft tissue defects of the outer auricle. Because of the difficulty and unpredictable nature of outer ear reconstruction after burn injury, a case-control study was conducted to determine the best reconstructive approach. The microcirculatory properties of different types of soft tissue reconstruction of the outer ear with burns in six severely burned Caucasian patients (three men and three women; mean age, 46 years (range, 22-70)) were compared to those in the healthy tissue of the outer ear using the O2C device (Oxygen to See; LEA Medizintechnik, Gießen, Germany). The results of this study revealed that the investigated microcirculation parameters such as the median values of blood flow (control group: 126 AU), relative amount of hemoglobin (control group: 59.5 AU), and tissue oxygen saturation (control group: 73%) are most similar to those of normal ear tissue when pedicled flaps based on the superficial temporal artery were used. These findings suggest that this type of reconstruction is superior for soft tissue reconstruction of the outer ear with burns in contrast to random pattern flaps and full skin grafts regarding the microcirculatory aspects. These findings may improve the knowledge on soft tissue viability and facilitate the exceptional and delicate process of planning the reconstruction of the auricle with burns.

Single-stage interpolation flaps in facial reconstruction

BACKGROUND

Relatively deep and complex surgical defects, particularly when adjacent to or involving free margins, present significant reconstructive challenges. When the use of local flaps is precluded by native anatomic restrictions, interpolation flaps may be modified to address these difficult wounds in a single operative session.

OBJECTIVE

To provide a framework to approach difficult soft tissue defects arising near or involving free margins and to demonstrate appropriate design and execution of single-stage interpolation flaps for reconstruction of these wounds.

METHODS

Examination of our utilization of these flaps based on an anatomic region and surgical approach.

RESULTS

A region-based demonstration of flap conceptualization, design, and execution is provided.

CONCLUSION

Tunneled, transposed, and deepithelialized variations of single-stage interpolation flaps provide versatile options for reconstruction of a variety of defects encroaching on or involving free margins. The inherently robust vascularity of these flaps supports importation of necessary tissue bulk while allowing aggressive contouring to restore an intricate native topography. Critical flap design allows access to distant tissue reservoirs and placement of favorable incision lines while preserving the inherent advantages of a single operative procedure.

Reconstruction of the zygomatic cheek defects using a flap based on the pretragal perforator of the superficial temporal artery

BACKGROUND

The aim of this study was to create a new flap based method for zygomatic cheek defect reconstruction using the pretragal perforator from the superficial temporal artery.

METHODS

Ten fresh cadavers were dissected after vascular injection to study pretragal perforator distribution, length, and diameter. Twelve clinical cases of zygomatic cheek defects were reconstructed using pretragal perforator flaps. According to the location of the perforator that was preoperatively probed using an ultrasound Doppler blood flow detector and the zygomatic cheek defect condition, size, and distance from the distal border to the tragus and the flabby surrounding skin, we designed a spindle-shaped longitudinal flap in the preauricular region based on the pretragus. The flap was raised superficially to the superficial musculoaponeurotic system from the caudal border incised primarily to the cephalic border to create the perforator flap. The flap was sutured to the defect and the donor site was closed.

RESULTS

Cadaver dissection showed a quite constant perforator given off by the superficial temporal artery or its auricular branches with an appearance rate of 85% anterior to the tragus. The average perforator length was 18.3 mm (range, 11.2-24.2 mm). The average perforator diameter was 0.65 mm (range, 0.4-1.15 mm). A total of 12 clinical cases were available for 6-12 month postoperative follow-up. Favorable survival, primary closure, and esthetic results were achieved without any complications.

CONCLUSIONS

Zygomatic cheek defect reconstruction using the above-mentioned flap can achieve satisfactory esthetic and functional results and boasts a simple design, convenient procedure, reliable blood supply, and concealed donor site incision.

Successful microsurgical revascularization of an almost totally amputated ear lobe by horse bite

Total or subtotal amputation of the external ear related to horse bite is an uncommon situation. In our case, we report successful microsurgical revascularization of almost totally amputated ear of a 75-year-old male patient caused by a horse bite.

Torsion of partial cleft of ear lobule

INTRODUCTION

Torsion is a well-known phenomenon involving organs with long mesentery. Torsion in the ear lobule is rare. Ear lobule is very well vascularized. In cases of partial cleft ear lobule, there is a small segment of lobule inferior to the cleft which is vascularized through the pedicles on either side of the cleft.

CASE REPORT

A lady aged 89 years presented with discoloration of the ear lobule. She was diagnosed as having gangrene of the central part of lobule. The segment of the lobule had undergone more than 360° torsion. She underwent debridement of gangrenous part and lobuloplasty.

DISCUSSION AND CONCLUSION

In our case laxity of the stretched lobule caused the torsion of the segment followed by gangrene. This rare complication indicates the need for correction of the cleft lobule not only for esthetic purpose, but also for the prevention of torsion.

Use of Hyperbaric Oxygen as Adjunct in Salvage of Near-complete Ear Amputation

Summary:

There have been several cases of microvascular repair of traumatically avulsed or amputated ears in the literature. It seems that, if possible at the time of operation, microsurgical techniques yield the best results. However, because of the nature, complexity, and acuity of traumatic injuries, this option is not always feasible. Although the possibility of microsurgical repair exists, the small size of these vessels is often prohibitive, even for a skilled microsurgeon. Here, we present the case of a 4-year-old boy with almost complete amputation of the left ear attached by an inferior narrow skin pedicle after a dog bite. He was treated with primary repair and postoperative hyperbaric oxygen therapy (HBOT) with good results. This case is another example that even a narrow skin pedicle can contain artery and vein that can supply a large segment of the auricle, making primary repair feasible because of the vascular anatomy and communicating helical arcade. Also, this case demonstrates the successful use of HBOT with a pediatric patient as an adjuvant postoperative therapy.

Resurfacing partial nose defects with a retroauricular skin/cartilage free flap

BACKGROUND

The retroauricular skin has always received much attention by plastic surgeons for use in nose reconstruction because of its rich vascularity. Anatomically, the skin of this area lies hidden behind the ear and is very similar to that of the face. More importantly, the retroauricular skin flap along with the cartilage can be used to repair defective cartilage of the nose. All these reasons make this area an ideal donor site for nose reconstruction. This article presents the surgical procedures for reconstruction of partial nasal defects with the use of retroauricular skin/cartilage free flaps.

METHODS

Based on the anatomy and blood supply of the retroauricular region, a flap was designed and harvested with the retroauricular vessels as its pedicle. This flap was used to repair the partial nose defects in 10 patients, between the years 2002 and 2008. Of these, 4 patients presented with unilateral ala defects; 2 with nasal tip defects; 2 with defects on the nasal tip and bilateral ala; 1 with unilateral ala and tip defect; and 1 with unilateral ala and lateral defect. The size of the defect ranged from 2.5 × 1.5 cm to 4.0 × 3.0 cm. The flap varied between 3.0 × 2.0 cm and 4.5 × 3.5 cm. In all cases, the auricular cartilage of 1.5 × 1.0 cm to 1.0 × 0.5 cm was taken along with the flap. The retroauricular vessels were anastomosed with the facial vessels. The donor site was covered with full-thickness skin graft or local flap.

RESULTS

No flap failure was recorded. Excellent morphologic reconstruction was obtained with these flaps with no sequela at the donor site in terms of form and function. Postoperatively, the blood supply to the flaps was fairly good in 8 cases, although there was vein congestion in 2 cases on the fourth day. However, the postoperative results of the 10 cases were satisfactory after treatment.

CONCLUSION

The retroauricular skin-cartilage free flap is a good choice for partial nasal reconstruction, having the merits of a well-hidden donor site, good color match, and 1-stage operation for cartilage support and nose reconstruction.

Conchal defect correction by hinge flap and transposition flap

Reconstruction of old full-thickness conchal defects is rarely described in the literature. This article describes a simple technique for reconstruction of old through-and-through small defects of the concha. The anterior part of the defect is covered with hinge flap taken from the posterior surface of the ear. The resultant final posterior defect is covered with local transposition flap from the adjacent skin.

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

BACKGROUND

Auricular surgery is a challenging subject in plastic surgery due to the complicated surface topography of the external ear. Although various techniques for ear reduction and helical rim reconstruction have been reported in the literature, an ideal method is yet to be defined. Double helical rim advancement flaps with scaphal resection presented in this report represent a practical technique for correcting macrotia and reconstructing helical rim defects.

METHODS

The amount of full-thickness resection at the helical rim is planned according to the desired reduction or extent of tumor. After helical excision, an incision that transects all the layers of the ear is carried out along the helical sulcus inferiorly and superiorly to yield two advancement flaps. Using scissors, a crescent from the scapha is excised through the full thickness of the ear. The flaps are approximated and sutured to the scapha by means of stitches that pass through skin and cartilage.

RESULTS

The described technique has been performed successfully since 1998. It has been used for 12 cases of macrotia, 28 cases of tumor surgery, and 7 cases of ear reduction for asymmetric ears. No major complications have been encountered. Three cases are reported as examples of the procedure.

CONCLUSIONS

Double helical rim advancement flaps with scaphal resection represent a versatile and safe technique that can be used for ear reduction, helical rim reconstruction, and correction for discrepancy in size of ears.

Microvascular reconstruction of nasal defects

Microvascular reconstruction of nasal defects is a complex procedure and must consider 3 nasal components: skin, osteocartilaginous framework, and intranasal lining. These layers can be reconstructed with various flaps and grafts. The commonly used flaps are the first dorsal metacarpal flap, dorsalis pedis flap, auricular helical rim flap, and radial forearm and prelaminated flaps. These flaps can be composed of skin and cartilage or skin and bone. The decision is based on the patient's needs taking into consideration the extent of the defect and presence or absence of nasal septum and columella.

Modification of the second stage of auricular elevation in Nagata's technique for treating microtia

The ultimate goal in treating congenital microtia is the reconstruction of an auricle with a natural appearance as close as possible to the healthy one in terms of shape, contour, size, texture, position, and projection. Here we present another option to the second stage of raising the ear in Nagata's technique for treating microtia. The first step includes implantation of a cartilaginous framework and transposition of the ear lobe. Raising the cartilage leaves a skin defect behind the auricle. Instead of using a superficial temporoparietal fascia flap as described by Nagata, we raise a simple rotation flap from the mastoid and neck to close the defect with a minimal scar. The advantages of this technique include firm elevation, good frontal projection, and a natural appearance of the auriculo-cephalic sulcus with a normal retroauricular hairline. In addition, the procedure fast and practical, creates no additional scars on the scalp, and preserves the superficial temporoparietal fascia.