Accepted Manuscript Partial helix defect repair by postauricular advancement flap combined with ipsilateral conchal cartilage graft Jintian Hu, M.D. Qingguo Zhang, M.D. Yongbiao Zhang, Ph.D. Xu Zhou, M.D. Jin Qian, M.D. Tun Liu, M.D. PII:
S1748-6815(14)00178-8
DOI:
10.1016/j.bjps.2014.04.016
Reference:
PRAS 4161
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 8 January 2014 Revised Date:
9 April 2014
Accepted Date: 16 April 2014
Please cite this article as: Hu J, Zhang Q, Zhang Y, Zhou X, Qian J, Liu T, Partial helix defect repair by postauricular advancement flap combined with ipsilateral conchal cartilage graft, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), doi: 10.1016/j.bjps.2014.04.016. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Partial helix defect repair by postauricular advancement flap combined with ipsilateral conchal cartilage graft
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Jintian Hua, M.D. Qingguo Zhanga, M.D. Yongbiao Zhangb. Ph.D.
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Xu Zhoua, M.D.
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Jin Qiana, M.D. Tun Liua, M.D.* a
Department of Ear Reconstruction, Plastic Surgery Hospital, Chinese Academy of
Medical Sciences, Beijing, P.R. China.
Beijing Institute of Genomics, Chinese Academy of Sciences and Key Laboratory of
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b
Genome Science and Information, Chinese Academy of Sciences, Beijing, P. R.
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China.
Running title: Partial helix defect repair by flap and conchal cartilage Words count:1935 words
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ACCEPTED MANUSCRIPT *Corresponding author: Dr. Tun Liu Department of Ear Reconstruction
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Plastic Surgery Hospital Chinese Academy of Medical Sciences
No. 33 Ba-Da-Chu Road, Shi Jing Shan District, 100144, Beijing, P.R. China
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E-mail:
[email protected] This study was supported by grants from the National Natural Science Foundation of China (31201006, 31371347 to Y-B.Z., 81372085 to Q.Z., 81300863 to J.H.) and PUMC Youth Fund and the Fundamental Research Funds for the Central Universities
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(3332013091 to J.H.).
Competing Interests: The authors have no financial interest to declare in relation
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to the content of this article.
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Abstract Abstract
Objective: To investigate the usage and effectiveness of postauricular
advancement flap and conchal cartilage for surgical treatment of partial helix defect.
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Methods: Ten cases (8 males, 2females) of unilateral partial ear defects were treated by postauricular advancement flap combined with ipsilateral conchal cartilage graft.
age from 15-34 years (mean age=25.4 years).
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Nine cases were due to injury, 1 case was the result of frostbite. The patients ranged in
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Results: All cases were followed up for 3-12 months with satisfactory results, indicated by helix and scapha of similar colour. No hypertrophic scarring was reported.
Conclusions: Postauricular advancement flap combined with ipsilateral conchal
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cartilage graft is an effective way to repair partial helix defects, and a second procedure may be necessary to achieve a symmetrical cranioauricular angle.
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reconstruction
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Key words helix defect, postauricular advancement flap, conchal cartilage graft, ear
Introduction
Acquired ear defects can be the result of trauma or burn injuries. The
three-dimensional structure of the ear with its fine subunits presents a great reconstructive challenge for surgeons, and successful ear reconstruction requires both similar coverage tissue and a supporting framework. Various methods of total ear reconstruction have been developed, including 3
ACCEPTED MANUSCRIPT composite tissue free flap, composite tissue free flap combined with prosthesis, the Nagata technique and the expansion method[1-4]. Partial ear construction methods include wedge excision followed by primary suture, advancement of the auricular flap, [5-11]
. Partial ear
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tubed flap interpolation, and postauricular advancement flap
framework by costal cartilage has also been performed to achieve a stable auricular appearance.
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We present a novel method of helix repair through postauricular advancement
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flap combined with a free ipsilateral conchal cartilage graft, which differs from a composite postauricular chondrocutaneous flap. A stable helix and scapha can be
Method
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achieved by conchal cartilage recontouring in lieu of using rib cartilage.
Surgical procedures were performed under local anesthesia. An incision was
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initially made in the distal part of defective helix. After exposing the superficial and
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deep layers of defective auricular cartilage, two approximately parallel postauricular incisions were made with an angle of 75-80° relative to vertical, generating an isosceles trapezoidal-shaped flap (Fig 1-1) with a length:width ratio of 1.5:1 to 2:1. The elevated layer of postauricular flap was positioned posterior to the auricular cartilage, which was further extended to the superficial fascia of the mastoid region and 0.5-1 cm into the hairline. Compared to the contralateral auricular template, the defect area was marked and replaced by a conchal cartilage graft, which was 4
ACCEPTED MANUSCRIPT harvested with adequate exposure. The cartilage was secured using several stitches of 5-0 Vicryl suture. In order to lowering the cartilage of cavity of auricular concha, 2-3 stitches of 0-1 silk sutures were used. The postauricular flap was advanced for
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coverage of the free conchal cartilage graft and sutured with Prolene. Two stitches of 5-0 Vicryl suture were placed under the craniofacial sulcus to aid in shaping. Two pieces of cylindrical Vaseline gauzes were placed in the anterior portion of the scapha
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gauzes were removed 10 days post-operation.
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and on the opposite side of the portion of the scapha (Fig 1). Sutures and Vaseline
Case 1
A 26-year-old man presented at an ear reconstruction center with partial ear defect caused by frostbite 20 years prior. The ear defect was classified as type II:
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partial full-thickness defects with healthy surrounding skin and soft tissue. During the surgical procedure, a contralateral ear template was used as a guide for the defect repair. Postauricular advancement flap combined with ipsilateral conchal cartilage
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graft was performed, with and aesthetically satisfactory appearance at 6 months
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post-operation (Fig 2).
Case 2
A 25-year-old woman presented with an acute partial ear defect due to a human
bite wound obtained 3 hours earlier. The ear defect was also classified as type II. Cefuroxime sodium 1.5g ivgtt bid (2 days) was administered to prevent possible infection. Postauricular advancement flap combined with ipsilateral conchal cartilage 5
ACCEPTED MANUSCRIPT graft was performed, followed 4 months later by ipsilateral cranioauricular augmentation, and a symmetric and satisfactory appearance was achieved 20 months
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post-operation (Fig 3).
Case 3
A 23-year-old man presented with a partial ear defect caused by injury. The
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minor defect was repaired and a satisfactory appearance was achieved 18 days
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following surgery (Fig 4).
Result
From May 2010 to October 2012, 10 cases of unilateral partial ear defect were
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treated by postauricular advancement flap combined with ipsilateral conchal cartilage graft (Table 1). The follow-up time ranged from 3 months to 12 months. No major complications arose, including hematoma, infection or flap necrosis. All of the
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Discussion
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patients were satisfied with the appearance of the 3-dimensional reconstructed helix.
Brent et al. described three types of ear deformities: skin defect, cartilage defect
and full-thickness defect; full-thickness defects may be further divided into six groups: upper third, middle third, and lower third defects; partial or total defect and ear lobule defects[12]. Luo et al. suggested five types of post-traumatic ear deformities: severely cicatricial ear without cartilage deficit, partial full-thickness defects, near-total or total ear loss with periauricular skin intact, near-total or total ear loss with involvement of 6
ACCEPTED MANUSCRIPT periauricular skin, near-total or total ear loss, with the status of healthy surrounding skin and soft tissue including temporoparietal fascia unknown[13]. Total ear reconstruction with autologous rib cartilage has been widely applied
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with satisfactory results. For minor ear defects, use of local or adjacent skin flaps was more frequently reported. Otero-Rivas et al. applied a one-stage advancement of the chondrocutaneous flap with a rectangular cartilage graft for repair of ear defects
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caused during tumor resection[5]. Youn et al. reported helix rim repair using a 90
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degree rotated retroauricular artery perforator-based island flap combined with contralateral cavum concha[6]. Di Mascio et al. suggested use of tubed flap interpolation alone for helical defect reconstruction; this three-stage procedure was successfully used in three different cases of acquired helix defects[7]. Soni et al.
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reported a similar case of tubed flap interpolation, in which the donor site defect of the mastoid region was covered by skin grafting[8]. Mowbrey et al. described use of two bi-pedicled tube flaps for total helical rim reconstruction[9], while Masud et al.
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reported a similar two-stage-'double headed slug flap' method[10]. de Schipper HJ used
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a modified Antia-Buch protocol for middle auricular defect repair with great advancement of the chondrocutaneous flap[11]. Overall, microvascular replantation is the optimal method for repair of cases with total or near total ear amputation with retention of good vascular supply[14,15]. In contrast to previous reports, this report describes extension of the postauricular advancement flap into the hairline for better tension relaxation. Lowering the cartilage of the cavity of auricular concha with 2-3 stitches of 0-1 silk 7
ACCEPTED MANUSCRIPT sutures was critical in order to prevent severe retraction of the cartilage as a result of tension. Adequate ipsilateral conchal cartilage was harvested with direct vision. The upper incision was made for flap elevation while the length of the lower incision was
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adjusted according to the defect area in order to decrease tension. Thus, by adjusting the height of the craniofacial sulcus and the length of the lower portion of the incision, flap tension was greatly reduced. The shape and curvature of the cartilage was in
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accordance with the contralateral scapha and helix, and free cartilage grafts showed a
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low rate of absorption. The random isosceles trapezoidal-shaped postauricular flap with a length:width ratio of 1.5-2:1 was sufficient to ensure a stable venous supply, and vaseline gauze fixation was important for shaping of the scapha and helix. To achieve a symmetric cranioauricular angle, the second stage of ipsilateral
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cranioauricular angle augmentation and lateral cranioauricual angle reduction was accomplished by skin grafting.
In conclusion, postauricular advancement flap combined with ipsilateral conchal
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cartilage is suitable for repair of full-thickness defect of minor helix defect.
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Advantages to this technique include reduced trauma, no additional donor site deformity, surgical simplicity and generation of a flap of similar colour as the surrounding tissue.
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ACCEPTED MANUSCRIPT Conflict of Interest: None Funding: This study was supported by grants from the National Natural Science Foundation of China (31201006, 31371347 to Y-B.Z., 81372085 to Q.Z., 81300863
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to J.H.) and PUMC Youth Fund and the Fundamental Research Funds for the Central Universities (3332013091 to J.H.).
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Ethical Approval: N/A
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References
[1] Driscoll DN, Lee JH. Combining scalp tissue expansion with porous polyethylene total ear reconstruction in burned patients. Ann Plast Surg. 2010;64(2):183-186. [2] Brent B, Byrd HS. Secondary ear reconstruction with cartilage grafts covered by
1983;72(2):141-152.
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axial, random, and free flaps of temporoparietal fascia. Plast Reconstr Surg.
[3] Park C, Suk Roh T. Total ear reconstruction in the devascularized temporoparietal
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region: I. Use of the contralateral temporoparietal fascial free flap. Plast Reconstr
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Surg. 2001;108(5):1145-1153.
[4] Xiaobo Y, Haiyue J, Hongxing Z, et al. Post-traumatic ear reconstruction using postauricular fascial flap combined with expanded skin flap. J Plast Reconstr Aesthet Surg. 2011;64(9):1145-1151. [5] Otero-Rivas MM, González-Sixto B, Alonso-Alonso T, et al. Compound retroauricular advancement flap. J Plast Reconstr Aesthet Surg. 2014; 67(2):271-273. [6] Youn S, Kim YH, Kim JT, et al. Successful reconstruction of a large helical rim 9
ACCEPTED MANUSCRIPT defect using retroauricular artery perforator-based island flap. J Craniofac Surg. 2011;22(2):635-637. [7] Di Mascio D, Castagnetti F. Tubed flap interpolation in reconstruction of helical
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and ear lobe defects. Dermatol Surg. 2004;30(4 Pt 1):572-578. [8] Soni A, Sheoran S, Rajput A. Helical reconstruction in a post human bite defect. Indian J Plast Surg, 2006;39:79-80.
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[9] Mowbrey K, Wilkes GH. Helical rim reconstruction using two bi-pedicled tube
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flaps. J Plast Reconstr Aesthet Surg. 2013;66(12):e362-365.
[10] Masud D, Tzafetta K. The 'double headed slug flap': a simple technique to reconstruct
large
helical
rim
2012;65(10):1410-3.
defects.
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Reconstr
Aesthet
Surg.
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[11] de Schipper HJ, van Rappard JH, Dumont EA. Modified Antia Buch repair for full-thickness middle auricular defect. Dermatol Surg. 2012;38(1):124-127. [12] Brent B. Reconstruction of the auricle. In: Mathes SJ, eds. PlasticSurgery, Vol. 3:
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The Head and Neck, Part 2. 2nd ed.Philadelphia: Saunders, 2005:677Y697.
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[13] Luo X, Yang J, Yang Q, et al. Classification and reconstruction of posttraumatic ear deformity. J Craniofac Surg. 2012;23(3):654-657. [14] Lin PY, Chiang YC, Hsieh CH, Jeng SF. Microsurgical replantation and salvage procedures in traumatic ear amputation. J Trauma. 2010;69(4):E15-19. [15] Concannon MJ, Puckett CL. Microsurgical replantation of an ear in a child without venous repair. Plast Reconstr Surg. 1998;102(6):2088-2093.
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ACCEPTED MANUSCRIPT Fig 1 Elevation of postauricular skin flap and auricular cartilage harvesting (Fig 1-1), auricular cartilage fixation (Fig 1-2) and advancement of the postauricular skin flap (Fig 1-3).
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Fig 2 A 26-year old male patient presented with a right-sided ear defect caused by frostbite 20 years prior (Fig 2-1), intraoperatively (Fig 2-2) and 6 months postoperation (Fig 2-3).
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Fig 3 A 25-year old female patient presented with an acute left-sided ear defect
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caused by human bite (Fig 3-1), 10 days postoperatively (Fig 3-2), 20 months after the second stage procedure of cranioauricular augmentation (Fig 3-3). Fig 4 A 23-year old male patient presented with a right-sided ear defect caused by
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injury (Fig 4-1), 18 days post-operation (Fig 4-2).
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Table 1. Assembly of full-thickness helix repair by postauricular advancement flap combined with ipsilateral conchal cartilage
1 2 3 4 5 6 7 8 9 10
24/female 30/male 29/female 34/male 17/male 20/male 30/male 15/male 28/male 27/male
Accidant Frost bite Human bite Human bite Cutting Human bite Human bite Cutting Human bite Human bite
Helix defect
Defect
First stage
Second stage
Right, upper part (1/3) Right, middle part (1/3) Left, middle part (1/3) Left, lower part (1/3) Left, upper part (1/3) Right, middle part (1/3) Left, middle part (1/3) Left, middle part (1/3) Left, middle part (1/3) Right, upper part (1/3)
1.2*0.5cm 1.5*0.7cm 2.5*0.3cm 2.0*0.5cm 1.5*0.8cm 2.3*0.4cm 2.0*0.4cm 1.8*0.4cm 0.8*0.5cm 1.7*0.6cm
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
No Yes Yes Yes Yes No Yes Yes No Yes
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