Reconstruction of congenital stenosis of external auditory canal with a postauricular chondrocutaneous flap

Superficial temporal artery capillary perforator-based island flap for conchal bowl and external auditory canal reconstruction

BACKGROUND

Reconstruction of the auricle is challenging to surgeons as a result of its complex anatomy. Defects including the conchal bowl and the external auditory canal (EAC) do not accept imperfection as functional consequences may add to aesthetic ones. Local flaps that are relying mainly on posteriorly based auricle flaps do not represent ideal solutions. This study aims to report the perforator modification of an anteriorly based pre-auricular flap that matches all requires goals of reconstruction.

METHODS

From 2015 to 2019, three capillary perforator-based island flaps (c-PBIF), with the Superficial Temporal Artery (STA) as source pedicle, were performed to reconstruct a combined Conchal Bowl-External Auditory Canal (CB-EAC) defect, secondary to basal cell carcinoma resection. Free margins were obtained via the Tubigen micrographic approach. All three flaps were raised on the perforator originating from the superficial temporal pedicle. In 2 of the cases, the perforator was found at the level of the tragus while in the last case, it was found 1cm more distal. Capillary perforators were isolated and dissected down to their origin from the STA thereby increasing their arc of rotation and pliability. The median follow-up time was 4 years.

RESULTS

All flaps survived. Aesthetic results were excellent leaving no distortion of the external ear and the hollow aspect of the conchal was well supported. The tragus mount was preserved, EAC lining was secured, and good audition was restored with no bulging of the flap into the canal in all the cases.

CONCLUSION

Harvesting pre-auricular flaps as c-PBIFs are safe and acts as an excellent solution for the reconstruction of the challenging combined CB-EAC defect. It allows a one-stage reconstruction that does not need a secondary revision, it also gives excellent correction and functional results. We would recommend it as a useful option for the reconstruction of the conchal-EAC defects.

Current Treatments for Congenital Aural Atresia

Congenital aural atresia is an ear malformation evident at birth, involving various degrees of failed external ear canal development. A true external ear canal is desirable, as devices that replace the canal are inconvenient and expensive. Therefore, an optimal surgical technique is required. Here, we review useful preoperative and operative techniques. Surgical correction is often not the preferred treatment; the hearing outcome is no better than the outcomes afforded by bone-conduction devices, and surgery may be associated with recurrence or complications such as meatal stenosis. Preoperative evaluation and appropriate management are important. Several means of preventing meatal stenosis are discussed in this review.

Aesthetic reconstruction of the upper antihelix in external ear with banner pull-through flap

Introduction:

We can use pre auricular and post auricular skin as a pull through flap for upper antihelix defects reconstruction.

Patients and Methods:

This was a prospective case-series study, which was done in the Department of Plastic and Reconstructive Surgery Ward. In this study, 15 patients (3 women, 12 men), ranging from 45 to 72 years old (mean, 58 years) underwent operation with pull through banner flap for reconstruction of upper antihelix (7 cases) and triangular fossa with superior and inferior crura (5cases) caused by BCC or SCC excision. Reconstruction of upper antihelix defects up to 20 × 30 mm with post auricle pull through flap and reconstruction of triangular fossa up to 20 × 20 mm with pre auricle pull through flap were done.

Results:

Our study showed that pull through flap with superior pedicle from post auricular and preauricular area was an effective method for reconstruction of upper ear antihelix defects.

Conclusion:

We advocate that the pull through flap with superior pedicle from post auricle and pre auricle is an excellent choice for reconstruction of upper antihelix ear reconstruction in both crura and triangular fossa.

Paraumbilical perforator flap for reconstruction of the external auditory meatus: A case report

We herein present a technique of using the umbilical stalk for reconstruction of the external auditory meatus. A 49-year-old female presented with locally aggressive melanoma affecting her mastoid region. She underwent radical excision including the skin and soft tissues around the external ear with simultaneous lymph node clearance. The resultant defect measured 15 cm × 8 cm in diameter and was 2.5 cm deep. This was reconstructed with a similarly sized microvascular paraumbilical perforator flap that included the umbilical stalk. In the post-operative course there was complete flap survival but a prolonged wound dehiscence near the auditory meatus that required revision surgery. At 15-months follow-up, the patient was melanoma-free and the auditory meatus was patent. Hearing was also preserved. The umbilical stalk is one of the few skin covered tubed structures in the human body that may be used without major donor morbidity to "replace like with like," the auditory channel.

A New Flap Technique for Reconstruction of Microtia and Congenital Aural Atresia

Atresiaplasty is still a challenge for otolaryngologist, although the operation technique has been modified several times over the past decades. This study describes a reliable flap technique for combining atresiaplasty with total auricular reconstruction by performing the total auricular reconstruction with the MEDPOR framework at the same time as the atresiaplasty for patients with microtia and congenital aural atresia. We performed a prospective study of the medical records of 18 consecutive patients with congenital aural atresia. All the patients had a Jahrsdoerfer grade of 6 or higher, and the mean age was 9.7 years. Atresiaplasty with the new flap technique was performed in 19 ears in our department from January 1, 2011, through July 31, 2013. Among the postoperative ears, 17 ears (89.5 %) had the excellent outcomes, without infections and stenosis. Only two ears (10.5 %) had postoperative stenosis and atresia after infection, respectively. There were no other complications. We concluded that the new flap technique combining atresiaplasty and total auricular reconstruction yielded satisfactory canal patency, low infection rates, and favorable cosmetic results, with acceptable rates of complications. This novel flap technique is a valuable option in the armamentarium of microtia and atresia surgeons.

Congenital external auditory canal stenosis and partial atretic plate

OBJECTIVES

To report outcomes of surgery for severe congenital external auditory canal (EAC) stenosis with or without partial atretic plate (PAP).

DESIGN

Retrospective review.

SUBJECTS

Thirteen patients (18 ears) had surgery for severe EAC stenosis with (n=10, 56%) or without PAP (n=8, 44%). Indications included severe stenosis with hearing loss, cerumen impactions, and/or canal cholesteatoma. Mean age=7.8 years (range 0.4-19.9 years). Mean follow up=5.2 years (range 0.4-10.0 years).

SETTING

Tertiary care children's hospital.

INTERVENTIONS

Nineteen endaural canaloplasties were performed in 17 ears (2 revisions). There was one post-auricular approach. Fifteen tympanoplasties were performed in 13 ears (2 revisions). PAP was reconstructed with drilling to enlarge the bony annulus and fascia grafting to enlarge the tympanic membrane in 10 (56%) ears.

OUTCOME MEASURES

Patency of EACs; otologic findings; pure tone averages (PTA); complications.

RESULTS

All (100%) EACs had improved patency (>or=4mm). Findings included canal cholesteatoma (2/18, 11%), ossicular fixation (4/18, 22%), stapes abnormality (2/18, 11%), and incudostapedial discontinuity from cholesteatoma (1/18, 6%). Mean preoperative PTA=38.7 dB HL (range 60-20 dB HL). Mean post-operative PTA=23.6 dB HL (range 50-6.7 dB HL). Audiologic results were significantly better for cases without PAP (p<.01) and without ossicular fixation (p<.01). There were seven minor and no major complications.

CONCLUSIONS

Endaural canaloplasty is safe and effective for providing patent EACs and hearing improvement for severe congenital EAC stenosis. However, since hearing outcomes were worse for cases with PAP and ossicular fixation, alternatives such as hearing aids or BAHA may be considered.

The anatomy and application of the postauricular fascia flap in auricular reconstruction for congenital microtia

BACKGROUND

The various layers of the scalp are widely used in reconstructive procedures. The technique used for soft tissue coverage seems to influence the framework extrusion rate in auricular reconstruction. We have investigated the role of the postauricular fascial flap in providing ample, thin neurovascular cover to facilitate ear reconstruction in congenital microtia.

METHODS

Following postauricular cutaneous tissue expansion, the postauricular neurovascular fascia flap was raised to partially cover the projected three-dimensional autogenous cartilage framework. A suction drain was placed in the pocket to allow the skin to coapt to the framework and a split-thickness skin graft was applied to complete coverage.

RESULTS

At final assessment, the aesthetic results were analysed subjectively. Four hundred and thirty-eight ears underwent total ear reconstruction in 428 patients using the postauricular fascial flap technique. None of the reconstructions failed, and all patients were satisfied with the results.

CONCLUSIONS

The use of a postauricular fascial flap and skin graft enhances safety and provides better vascularisation of the underlying cartilage.

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.

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.

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.

Prevention of postoperative meatal stenosis with anteriorly and inferiorly based periosteal flaps in congenital aural atresia surgery

OBJECTIVE

The objective of this study was to evaluate postoperative meatal stenosis after surgery for congenital aural atresia using anteriorly and inferiorly based periosteal flaps (AIPFs). These were compared with the groups that did not use these flaps.

STUDY DESIGN

This was a retrospective clinical study.

SETTING

The study was conducted at the tertiary referral hospital.

PATIENTS

There were 133 patients (151 ears) who had undergone surgical correction for congenital aural atresia from November 1987 to March 1999.

INTERVENTION

The anterior approach surgical method was used to correct the congenital aural atresia.

MAIN OUTCOME MEASURE

A comparison between the 2 groups, 1 using the AIPFs and the other that did not use the AIPFs, was performed to evaluate both the incidence and the interval of postoperative meatal stenosis. The correlation between the age of the first operation to correct congenital aural atresia and the incidence of postoperative meatal stenosis was also investigated.

RESULTS

Meatal stenosis was the most common postoperative complication (23.8%) found. The incidence of meatal stenosis was much lower in the group using AIPFs (n = 105) than in the group that did not (n = 46) (19.0% versus 35.0%). The interval for the development of postoperative meatal stenosis showed similar distribution in both groups. In age distribution, the younger the age of the first operation, the more frequent the occurrence of postoperative meatal stenosis.

CONCLUSION

AIPF is an effective surgical method for reducing the incidence of postoperative meatal stenosis.

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.