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ONCOLOGICAL RESECTION
BARRY L. EPPLEY, MD, DMD
A variety of ear defects can occur after resection of malignant tumors, which presents the option for a diverse array
of surgical techniques for their reconstruction. Because the functional demands of the ear are few and the opposite
ear is usually unaffected, reconstruction should focus on the position, size, and contour of the resected ear. In
skin-only defects, secondary healing, skin grafts, and direct closure are effective options. In smaller partial- and
full-thickness defects, wedge closures and local chondrocutaneous flaps are effective one-stage techniques. In larger
full-thickness defects, staged local and regional flaps with cartilage grafts can recreate the shape and contour of the
ear. In total-ear defects, osseointegrated mastoid implants for prosthetic retention offer the most effective and rapid
method for ear replacement.All of these reconstructivetechniquesare outlined and the indicationsfor their use discussed.
Copyright 9 1999 by W.B.Saunders Company
KEY WORDS: ear, reconstructive surgery, grafts, flaps, implants
AURICULAR PATHOLOGY
Overwhelmingly, tumors of skin origin comprise almost all
of the auricular pathologies, with squamous cell carcinomas being the most common (>50%), followed by basal
cell carcinomas (30% t o 40%), and less frequently, melanomas (5%). 2'3 The presentation of basal and squamous cell
carcinomas on the helical rim and antihelix is common
given their unprotected position on the ear with continuous exposure to the sun and other elements. The absence of
subcutaneous tissue in the ear allows for the potential of
early perichondrial involvement. However, the perichondrium usually acts as a barrier against direct invasion into
the cartilage and often directs tumor spread laterally.
Cervical lymph node involvement is very rare in basal
carcinoma. However, a thorough examination of the neck
should be done in squamous cell and melanoma, because
up to one third of patients will have nodal spread. 6
RECONSTRUCTION
Reconstructive options can be categorized by either the
characteristics and location of the ear defect (eg, partial or
full-thickness or upper, middle, or lower third of the
auricle) or the type of surgical technique employed. Either
approach is a valid method for selecting the type of
reconstruction, but to avoid duplicity in their description,
surgical techniques will be reviewed from the simplest to
the most extensive ablative ear defect.
SECONDARY HEALING
Because of the excellent vascularity of the head and neck
region and its high resistance to infection, almost all facial
Operative Techniques in Plastic and Reconstructive Surge~ Vol 6, No 4 (November), 1999: pp 275-283
275
COMPOSITE GRAFTING
SKIN GRAFTING
Skin grafts have great versatility in ear reconstruction.
Because they are adaptable to even very concave or
convoluted surfaces, they work very effectively in those
superficial excisions that leave perichondrium (Fig 3).
Because of the strong support of the underlying cartilage,
276
DIRECT CLOSURE
The tight adherence of the skin to the underlying cartilage
limits the ability to directly approximate many ear defects.
If the defect is small and the excision lies parallel along the
helical rim, the surrounding skin may be approximated
with only slight flattening of the rim contour. For larger
defects along the helical rim that are full-thickness, the ear
segments may be brought together in a classic V-shaped or
BARRY L. EPPLEY
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Fig 2. Congenital microtia repair (A = preop at age 6; B = postop at age 8 after a four-stage reconstruction).
Numerous local flaps have been described for ear reconstruction that are based either on tissue within the existing
ear structure or adjacent non-hair-bearing skin from the
postauricular sulcus, mastoid, or upper cervical regions.
These are almost always random skin or skin-cartilage
flaps that can be advanced, rotated, or rolled to restore the
missing ear part. The following basic flaps are the most
commonly used but are not inclusive of all methods.
Helical Advancement
Postauricular Flaps
LOCAL
FLAPS
AURICULAR RECONSTRUCTION
277
Fig 3. Skin grafting of ear defects. Excellent results are obtained on all ear surfaces with cartilage and perichondrial support
with little risk of contracture.
278
tion of the conchal defect (Fig 8). The donor defect is closed
primarily.
Infra-auricular/Cervical Flaps
A variety of defects of the lower one third of the ear
including the lobule can be satisfactorily reconstructed by
adjacent skin flaps. The laxity of the upper neck skin, especially
in the older patient, compared with the postauricular skin over
the mastoid, makes flap transfer slightly easier. The trade-off
for easier skin movement of upper neck skin is that scars
and skin grafts of the donor sites are more visible. Small
wedge excisions or a reduction in the size of the lobule is
esthetically well tolerated as long as enough lobule remains to create a clear separation from the antitragus and
hangs below the lower border of the concha cavum.
While replacement of the lobule can be done by a
one-stage transfer of a superiorly based (auricular) skin
flap, most excisional defects have a free-standing edge
rather than the defect already scarred to the neck. 12
Therefore, a two-stage approach to transfer both skin and
cartilage is devised. Initially, a contralateral conchal cartilage graft is inserted in a soft tissue pocket beneath the
lobular defect and the superior skin edge attached to the
lower edge of the lobular defect. During the second stage,
the chondro-cutaneous unit is released and its medial
surface skin grafted 14(Fig 9).
BARRY L. EPPLEY
Fig 4. Skin graft reconstruction of the entire ear in a 64-year-old male with a history of congenital hemangioma (A --- preop; B =
postop).
Temporoparietal Flap
A fascial flap from the superior area above the ear based on
the temporal vessels is an easily raised and reliable method
of providing vascularized cover for any portion or all of
the ear. It is commonly used in combination with splitthickness skin grafts for coverage of cartilage or synthetic
frameworks in major or complete loss of the ear, when
postauricular skin is unusable due to scarring from excision or burn injuries, and as a method of salvage for
exposed frameworks. While it is a more extensive procedure with the inherent risks of a temporal scar and possible
thinning of hair over the donor area, the temporoparietal
fascial flap offers a one-stage approach to any size ear
defect. When other methods of ear reconstruction are
available, they should be used first, always reserving this
fascial flap as a potential salvage method.
AURICULAR RECONSTRUCTION
279
280
BARRY L. EPPLEY
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The ability to gather and transmit sound to the tympanic membrane and provide support for visual or
recreational eyeglass wear are the only significant functional objectives of ear reconstruction. The majority of
the intricacies of the ear framework including the lobule
are decorative. In general, do not sacrifice tissue or
induce scarring from the postauricular sulcus or concha
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AURICULAR RECONSTRUCTION
281
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Fig 11. (A) Osseointegrated titanium implants secured to mastoid after removal of entire ear secondary to melanoma. (B) Total
ear prosthesis held in place by magnetic attachments to titanium implants.
282
BARRY L. EPPLEY
SUMMARY
The goals of auricular reconstruction after t u m o r excision
are to obtain a functioning a p p e n d a g e on the side of the
head that is as n o r m a l as possible in position, size, and
contour, in decreasing order of importance. A variety of
basic techniques to achieve these goals has been described
including secondary healing, skin grafts, direct closure,
AURICULAR RECONSTRUCTION
REFERENCES
1. Tolleth H: A hierarchy of values in the design and construction of the
ear. Clin Plast Surg 17:193, 1990
2. Songcharoen MD, Smith RA, Jabaley ME: Tumors of the external ear
and reconstruction of defects. Clin Plast Surg 5:447,1978
3. Menick FJ: Reconstruction of the ear after tumor excision. Clin Plast
Surg 17:405,1990
4. Bernstein G: Healing by secondary intention. Dermatol Clin 7:645,
1989
5. Zitelli JA: Wound healing by secondary intention. J Am Acad
Dermatol 9:407, 1983
6. Brent B: Reconstruction of the auricle, in McCarthy JG (ed): Plastic
Surgery, vol 3, Philadelphia, PA, Saunders, 1990,pp 2131-2146
7. Wilkes GH, Wolfaardt JF: Craniofacial osseointegrated prosthetic
reconstruction. Adv Plast Reconstr Surg 15:51, 1998
8. Wilkes GH, Wolfaardt JF: Osseointegrated alloplastic versus autogenous ear reconstruction:Criteria for treatment selection. Plast Reconstr Surg 93:967, 1994
9. Tjellstrom A: Osseointegrated implants for replacement of absent or
defect ears. Clin Plast Surg 17:355,1990
10. Antia NH, Buch VI: Chondrocutaneous advancement flap for the
marginal defect of the ear. Plast Reconstr Surg 39:472,1967
11. Renner G, Templer J: Reconstruction of the external ear. Facial Plast
Surg Clin North Am 4:491, 1996
12. Brent B: Reconstruction of the auricle, in McCarthy JC (ed): Plastic
Surgery, vol 3. Philadelphia, PA, Saunders, 1990,pp 2133
13. Lewin M: Formation of the helix with a postauricular flap. Plast
Reconstr Surg 5:542, 1950
14. Cheney ML: Local flaps in auricular reconstruction. Facial Plast Surg
Clin North Am 5:371, 1997
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