Auricular reconstruction with a postauricular myocutaneous island flap: flip-flop flap

Partial Central Anterior Reconstruction of the Auricle with One-Stage Combined Retroauricular Flaps

SUMMARY

Basal cell carcinomas of the central anterior area of the auricle limited to the antihelix and scapha without peripheral infiltration of the helix are not uncommon. Resection is rarely transfixing, but resection of the underlying cartilage is often required. The complex anatomy of the ear and the lack of local tissue available makes its reparation challenging. Defects of antihelix and scapha require special reconstructive techniques, taking into account skin structure and the three-dimensional architecture of the ear. The reconstruction usually consists of full-thickness skin grafting or anterior transposition flap, requiring an extended skin resection. The authors describe a one-stage technique that uses a pedicled retroauricular skin flap turned over the anterior defect, followed by immediate closure of the donor site with a transposition or a bilobed retroauricular skin flap. The one-stage combined retroauricular flap reparation optimizes cosmetic outcome and reduces the risk of successive surgical procedures.

Reconstructive Procedures of the Auricular Concha after Cutaneous Oncologic Surgery: A Systematic Review

Reconstruction of the auricular concha poses a challenge due to its difficult access and limited tissue flexibility; however, there are no recommendations in the literature on which reconstructive technique should be favored for this anatomical site. This systematic review intends to describe and compare the reconstructive techniques used in conchal bowl reconstruction following cutaneous oncologic surgery of this region, with regard to their complications and aesthetic results. In doing so, we aim to identify the best suited reconstructive procedure(s) for the conchal bowl. The six databases searched (PubMed, Scopus, Web of Science, Ovid, SciELO, and CENTRAL) yielded twelve eligible studies that explored the revolving door flap, split-thickness skin grafts (STSG), full-thickness skin grafts (FTSG), second intention healing, the preauricular translocation flap, subcutaneous pedicle grafts, and other local flaps. Qualitative synthesis of the results concluded that the revolving door flap could be the reconstructive procedure of choice for the auricular concha, following skin cancer excision. It has a low risk of necrosis, infection, and postoperative hemorrhage, as well as excellent aesthetic outcomes. STSG may be used as an alternative. Nonetheless, due to the low sample size and the high risk of bias in some studies, further investigations must be conducted on this subject.

The cover of an ear thermometer probe as a split-thickness skin graft mold in external auditory canal reconstruction

Maintaining the patency of the external auditory canal (EAC) during reconstruction is important because of its physiological role in hearing and immunological protective functions. The curved shape of the EAC presents a challenge when performing a skin graft. One of the key points for a successful skin graft is to ensure compression on the wound bed, and many novel methods, including prefabricated ear molds, have been reported for this purpose. In this study, we present a case of a skin graft performed to reconstruct a skin defect following excision of actinic keratosis in the EAC, using the cover of an ear thermometer probe as a mold for the graft to match the curvature of the EAC. This is an economical and practical method for secure compression dressing of a skin graft in the EAC.

Reconstruction of Extensive Auricular Defects Using a Retroauricular Artery Perforator-Based Propeller Flap

BACKGROUND

Various local techniques have been successfully used for the reconstruction of auricular defects. However, most local techniques are not suitable for extensive auricular defects. The aim of this study is to investigate the utility of a retroauricular artery perforator-based propeller flap for the reconstruction of extensive auricular defects by evaluating aesthetic outcomes using objective and quantitative parameters.

METHODS

Twenty-one patients with extensive full-thickness and partial-thickness defects were treated with retroauricular artery perforator-based propeller flaps harvested from the mastoid and neck regions. The surgical procedures were performed using single-stage reconstruction in postauricular partial-thickness defects and 2-stage reconstruction in full-thickness auricular defects. Levels of final satisfaction and tissue matching as well as donor scar perception were evaluated by the patients and objective observers.

RESULTS

The original sizes and projections of the auricles were achieved. The color, texture, and thickness of the flaps matched well with the adjacent auricles. The vast majority of the patients and observers were very satisfied with the surgical outcome.

CONCLUSIONS

Retroauricular artery perforator-based propeller flaps may preserve the size and projection in both partial- and full-thickness extensive defects of the auricle. With this procedure, there was also excellent matching of the color, texture, and thickness of the flap with the adjacent tissue, as well as acceptable levels of donor scarring, thereby achieving satisfactory aesthetic outcomes.

Dimensions, Function and Applications of the Auricular Muscle in Facial Plastic Surgery

PURPOSE

To determine the dimensions and function of the auricular muscle and to consider applications of this muscle in facial plastic surgery.

METHODS

Nonpreserved fresh frozen human cadaver dissections from the (HOSPITAL-Blinded) Body Donation program were dissected. The length and width of the superior auricular muscle were measured. One surgeon performed all dissections and measurements.

RESULTS

A total of seven left and five right hemifaces were studied. The average central height of the superior auricular muscle was 4.7 cm, and an average width was 5.0 cm. There was no significant difference between the average values of the left versus the right hemiface measurements. The muscle originated in the fibers of the galea and temporal fascia and inserted into the conchal cartilage in each specimen. Engaging the muscle in its line of action yielded slight elevation of the forehead and prevented movement of the galea along the vertex of the scalp.

CONCLUSIONS

The auricular muscle acts as an occipitofrontalis stabilizer and a weak brow elevator.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors - www.springer.com/00266 .

Middle-retroauricular Island Flap: A New Axial Flap for Reconstruction of Non-helical Ear Defects

Background:

Surgical treatment of ear carcinomas needs the selection of the appropriate reconstructive techniques, which depends on the location and the dimensions of the defect after excision of the cancer and the quality of blood supply to the peri-lesional skin.

The aim of this study was to evaluate the efficacy and reliability of a new axial island retroauricular flap (middle-retroauricular island flap M-RIF) for coverage of non-helical ear defects with direct donor site closure.

Methods:

All patients, from January 2013 to January 2020, with skin tumors of the non-helix region and undergoing a combined skin-cartilage excision with M-RIF local flap reconstruction under local anesthesia, were enrolled in the study.

Results:

18 patients (14 men and 4 women) underwent auricle skin-cartilage excision and M-RIF flap reconstruction. The mean age was 65 years (range, 60–85); the type of primary lesions were 12 BCC and 6 SCC. One flap wound dehiscence and one donor site infection and partial necrosis of the posterior auricular skin occurred; no other complications were recorded.

Conclusions:

The M-RIF flap is a valid surgical option when dealing with non-helical defects of the anterior pinna. It allows the reconstruction of the defect of the entire anterior surface of the auricle apart from the helix and the lobe and primary donor site closure.

Reconstructing Ear Defects Using the Revolving Door Island Flap: A Case Series

BACKGROUND AND OBJECTIVES

Defects of the anterior region of the pinna pose a reconstruction challenge owing to the complex topography and difficult access. We report our experience using the revolving door island flap (RDIF) to reconstruct pinna defects and present the surgical results.

MATERIAL AND METHODS

Retrospective descriptive study of patients undergoing ear reconstruction using RDIF at different sites of the anterior region after resection of malignant tumors.

RESULTS

Seventeen patients underwent surgery between 2011 and 2019 for squamous cell carcinoma (n=7) and basal cell carcinoma (n=10). Conventional histology showed disease-free surgical margins in all the resected tissue specimens. The mean follow-up period was 40 months. One local recurrence of squamous cell carcinoma was observed, which responded well to radiation therapy; all patients were free of disease at the end of follow-up. Only 3 patients presented minor complications (depression of the flap surface in 1 case and retraction of the ear toward the mastoid process in 2 cases). Subjective rating scales were used to evaluate cosmetic and functional outcomes as assessed by both the dermatologist and the patient. The normal contour of the pinna was conserved in all patients and no patients required additional corrective surgery.

CONCLUSIONS

Reconstruction of the pinna using RDIF allowed for satisfactory repair following complete resection of the tumors, while conserving structure and functionality. RDIF has been reported to be a very good option for reconstruction of the pinna. It is a simple technique that makes it possible to repair large defects with minimal risk of necrosis. In our series, the cosmetic results were excellent and recurrence rates were very low. RDIF provided optimal results in repairing lesions in the concha and in other regions, such as the antihelix, triangular fossa, and scapha.

Nonmelanoma Facial Skin Cancer: A Review of Diagnostic Strategies, Surgical Treatment, and Reconstructive Techniques

Nonmelanoma skin cancer is the most common form of cancer in the United States, and the face is a common area for skin cancer development due to its frequent exposure to the sun. This article focuses on the surgical management of facial nonmelanoma skin cancers, including diagnostic considerations, biopsy techniques, and staging. In addition, we discuss surgical treatment options, including indications, techniques, outcomes, and facial reconstruction following tumor excision.

A Simplified Reconstructive Technique for Full-thickness Central Defects of the Auricle with the Use of a Post-auricular Folded Flap

BACKGROUND

Post-auricular flaps have proved very effective in the reconstruction of most types of partial auricular defects. However, few reports exist regarding the reconstruction of centrally located perforating defects of the auricle.

OBJECTIVES

This paper aimed to describe a one-stage technique including a post-auricular folded flap (PAFF) for reconstruction of full-thickness defects of central auricular sites.

PATIENTS AND METHODS

Between March 2010 and November 2014, five male patients were treated with this reconstructive technique under local anaesthesia. At the time of surgery, patients' age ranged from 76 to 86 years (mean age, 79.8). The patients suffered from a central and full-thickness defect owing to surgical excision of a skin malignancy or failed reconstruction procedures secondary to surgical excision of a skin malignancy.

RESULTS

Healing was uneventful for all the included patients, without signs of dehiscence, necrosis, hematoma and infection. The defects were completely repaired, without the need of further operations. During the follow-up period, all the patients remained satisfied with the aesthetic outcome.

CONCLUSIONS

This technique constitutes an immediate, effective and low-morbidity procedure to repair full-thickness central defects of the auricle. Since PAFF requires only one surgical operation under local anaesthesia, patients with burdened medical history may profit from this technique.

The postauricular fasciocutaneous flap with an adipofascial extension: A case report

•

The postauricular flap has never been used with an adipofascial extension.

•

We present a case with an ear defect covered with this flap.

•

The indications and blood supply of the flap are discussed.

Introduction

A complex defect on the anterior surface of the ear requires flap cover; such as the postauricular skin flap. The postauricular skin flap has never been used with an adipofascial extension.

Presentation of case

A 5-year old boy was involved in a car accident resulting in an exposed cartilage of the upper part of the right ear. The defect was covered with a post-auricular fasciocutaneous flap with an adipofascial extension. The adipofascial part of the flap was covered with a skin graft.

Discussion

The adipofascial extension serves two purposes: Firstly, it allows easier primary closure of the donor site. Secondly, it is less bulky and hence it does not observe the definition of the ear cartilage.

Conclusion

Our case is the first case reported in literature using the post-auricular fasciocutaneous flap with an adipofascial extension.

Reconstruction of auricular conchal defects with local flaps

Reconstruction of the auricular conchal cavity is relatively difficult because of its unique structure, shape, and location. We compared different methods of repair of the auricular concha to determine the method that would cause the least injury to the donor site.The method selected was based on the location and size of the defect. If the defect was located in the upper part of the concha, or if the defect was >15 mm in diameter, we used a post-auricular subcutaneous pedicle island flap that was pulled through a post-auricular sulcus tunnel to cover the wound. If the defect was located in the lower part of the concha and was <15 mm in diameter, we used a pre-auricular translocation flap that was passed through the intertragic notch to cover the wound. The donor site was closed primarily. All flaps survived well and any scars associated with the surgery were unnoticeable. No tumor relapse or metastasis was observed over a mean follow-up period of 35 months. All patients were satisfied with the outcome.The periauricular flap technique chosen for reconstruction of skin defects in the auricular concha depends on the size and location of the defect. With appropriate flap selection, excellent functional, and aesthetic outcomes are achieved.

A novel lobule rotation flap for the reconstruction of middle third auricular defects

BACKGROUND

There are numerous techniques for the reconstruction of cutaneous defects of the pinna. Many of these distort the auricle, and several are challenging and time-consuming to perform.

METHODS

An illustrative case is presented to demonstrate a novel lobule rotational flap, which can be used to cover cutaneous defects of the middle third of the pinna.

RESULTS

Postoperative photography illustrates that this simple one-stage technique causes minimal anatomical distortion and allows the final scar to be concealed within the inner helical rim.

CONCLUSIONS

Small local flaps can be raised from the lobule to cover challenging defects of the middle third of the pinna. In selected patients, with abundant lobular tissue, this technique can be as effective as more complex reconstructive options.

The trap door flap: a reliable, reproducible method of anterior pinna reconstruction

INTRODUCTION

Resection of skin cancers of the conchal fossa and anti-helical rim presents a challenging reconstructive problem. A full thickness skin graft is often used following excision of the cartilage underlying the lesion. Colour mismatch, a contour defect and a donor site scar are potential drawbacks to this method of reconstruction. The postauricular trap door flap offers a superior option for these defects.

AIMS

This study aims to assess the reliability and outcomes of the trap door flap for defects of the anterior surface of the pinna.

METHODS

A retrospective review of all trap door flaps carried out in Galway University Hospital was carried out. Charts were reviewed in order to examine operative notes and assess for any complications and length of follow up.

RESULTS

45 Patients were operated on by a single surgeon. The age range was 61-93 years. The majority of lesions excised were from the conchal area with 6 defects predominantly involving the scapha. No partial or complete flap loss occurred. 2 patients required further excision due to an incomplete margin and a local recurrence respectively. Follow up ranged from 3 months to 4 years with excellent cosmetic results were achieved in all cases with no scar issues at the flap or donor sites.

CONCLUSION

The trap door flap is an excellent method of conchal reconstruction. It is reliable and reproducible with no flap loss demonstrated in our series of 45 patients. Large defects can be reconstructed with this flap and the cosmetic result in terms of colour and contour, as well as a hidden donor site scar, make this a superior option to a full thickness skin graft.

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.

Versatility of the posterior auricular flap in partial ear reconstruction

BACKGROUND

The posterior auricular flap alone has always been popular because of its prompt availability, its rich vascularity, and the ease of closing the donor-site defect primarily.

METHODS

Fifty-seven patients with partial ear defects covered with posterior auricular flaps during the period between 2002 and 2007 were reviewed. In the authors' series, posterior auricular flaps were harvested based on a simple random vascularization and tailored to reach almost any defect of the ear by a simplified and standardized approach.

RESULTS

The authors propose a simple nomenclature after grouping the flaps according to skin paddle type, pedicle type, pedicle base, flap transfer method, and flap movement; they present a standardized algorithm with which to choose the flap design for a given defect from this group.

CONCLUSIONS

The authors contribute three new flap designs to enhance the versatility of the posterior auricular flap. These are the superiorly and inferiorly based twisted island flaps and the posterior auricular propeller flap.

Retroauricular island flap as an innovation for microtia ear reconstruction

The use of a local island flap, designed with retroauricular skin, is an excellent, simple, and reproducible innovation to the classic microtia ear reconstruction, allowing adequate coverage of the cartilage framework, specifically of the conchal area, sparing tense skin closure, reducing skin suffering and necrosis, with a better aesthetic result achieving the naturally depressed concha aspect. The flap design and surgical technique is described. This flap was used in 13 consecutive microtia ear reconstructions in our unit, no complications were encountered, and aesthetic results were excellent.

Extended posterior auricular artery flap for coverage of a large temporo-parietal defect

We present a case with a large 5×8 cm full-thickness defect in the temporo-parietal region, which was managed with an extended posterior auricular artery-based flap in one stage. The flap was shaped like a 'gandasa' (an axe-like agricultural implement used in Punjab, India). This allowed ample movement of the flap and also permitted a V-Y closure of the donor site. The flap also received additional blood supply from the ipsilateral superior auricular artery.

Ear defects

The projection and exposure of the auricle make it particularly susceptible to actinic injury and thus to cutaneous malignancies. Auricular reconstruction is challenging because of its unique surface anatomy and undulating topography. This article organizes auricular defects into different categories based on anatomic location and extent of tissue loss, including skin-only defects, small composite defects, full-thickness defects involving or sparing the upper third of the ear, and total auricular loss. The authors share an algorithm for repair of the array of auricular defects.

The perichondrial cutaneous graft and "flip-flop" flap in facial reconstruction: a series of 41 cases

Reconstruction of defects of the nose and eyelids can be challenging. The standard surgical options include full thickness skin grafts and local flaps. Another technique that offers a reliable and dimensionally stable one-stage reconstruction is the perichondrial cutaneous graft. The donor site is closed with the postauricular flip-flop flap. We have used these techniques in a series of 41 consecutive patients. Good or excellent aesthetic reconstructions were obtained in 39 cases, with 3 complications: 1 failed graft, and 2 small postauricular wound dehiscences. The perichondrial cutaneous graft can produce excellent cosmetic results when it is used to reconstruct complex defects of the nose and eyelid. Closure of the donor site in the conchal bowl with the flip-flop flap is a reliable and elegant technique.

Reconstruction of the Anterior Surface of the Ear Using a Postauricular Pull-Through Neurovascular Island Flap

The auricular conchal cavity is a shallow structure in the central part of the ear. It is not only 3-dimensional, but it is a gateway to the external ear canal. Many methods have been described for reconstruction of the defect of concha-antihelix: split- or full-thickness skin grafts, regional skin, chondrocutaneous and musculocutaneous flaps, but none of the authors have described this flap with neurovascular pedicle. We used postauricular neurovascular pedicle island flap for conchal and periconchal areas of anterior surface of the external ear because it matches to the skin color, thickness and texture; scars are well hidden, and there is no donor-site morbidity. Moreover, it has a constant and reliable neurovascular pedicle. The flap edema which was present in the early postoperative period began to resolve gradually after 3 weeks and disappeared in a few months. The esthetic results were excellent in all of the patients and very satisfying for the patients, too. The sensibility was positive by light touch, pin-prick, temperature and static 2-point discrimination in the postoperative control. The static 2-point discriminations in the transferred flap and in the other ear, which corresponds to the same area, were measured. The results were nearly the same as normal values. We advocate postauricular neurovascular pedicle island flap for conchal and periconchal areas of anterior surface of the external ear because it matches the skin color, thickness and texture; scars are well hidden, and there is no donor site morbidity. Moreover, it has a constant and reliable neurovascular pedicle.

Variability of the postauricular muscle complex: analysis of 40 hemicadaver dissections

BACKGROUND

The postauricular area is often explored by reconstructive and otologic surgeons. We previously reported on the use of postauricular tissues as a graft for wrapping hydroxyapatite implants in orbital reconstruction. This procedure reduced the incidence of implant exposure, while achieving acceptable cosmetic results. Although much is known about the postauricular area, muscle and fascial relationships and potential variations in anatomy remain ill defined.

OBJECTIVES

To identify and analyze variations in the patterns of the postauricular muscle complex (PMC) and to study the relationships of the fascial contributions from the components that make up the PMC.

METHODS

Dissections were performed using 40 fresh specimens. Muscular and fascial components of the PMC were dissected, analyzed, and photographed.

RESULTS

The PMC receives contributions from the occipitalis and trapezius muscles, the deep temporal and sternocleidomastoid fasciae, and the superior and posterior auricular and platysma muscles. Major contributors to the PMC were present in every specimen. Minor contributors were more variable in their presence and contributions. The posterior auricular muscle was identified as having several muscle bundles in 1 specimen and absent in 2 specimens (5%). The occipitalis fascia was seen to insert superior to the auricle and to blend with the deep temporal fascia in 3 cases (7%). The platysma muscle contributed to the PMC in 8 cases (20%).

CONCLUSIONS

This study demonstrated important variations in the presence and contributions of 7 previously known muscular structures and their role in forming the PMC. Seven distinct patterns are identified, and the potential clinical implications of these anatomical variations are illustrated.

The trap door flap for reconstructing defects of the concha

We report six cases of conchal neoplasms where the defect was reconstructed with a Trap Door Flap based on the post auricular vessels. The flap was reliable and gave good cosmetic results.

Reconstruction of the ear after skin and perichondrium loss

Because no two auricular defects are exactly the same, the choice of a suitable method for ear reconstruction is essential. Location and size of the defect influence the choice of technique needed for reconstruction. The method of reconstruction varies if there is skin loss, skin and perichondrium loss, or full-thickness loss. The skin surrounding the defect should be examined to determined if it is lacerated, burned, or scarred to decide whether or not it can be used in reconstruction. A plan of treatment should be decided and explained fully to the patient. A small area of skin loss can be closed by undermining of the edges and direct closure. If this cannot be performed because the defect is too large, the perichondrium is then examined to decide whether or not it is intact.