HEAD AND NECK SURGERY
Reconstructing a Large Helical Rim Defect Synergy of a Postauricular Perforator Flap, Diced Cartilage, and Otoplasty Technique Gavin Chun-Wui Kang, MBBS, MRCSEd, MMed(Surg), MEng, Yijun Wu, MBBS, MRCSEd, Shenthilkumar Naidu, MBBS, MRCSEd, MMed(Surg), FAMS(Plastic Surgery), and Shu Jin Lee, MBBS, MRCSEd, MMed(Surg), MD(Melb), FAMS(Plastic Surgery) Abstract: Large full thickness helical ear defects are a challenge to reconstruct. A 25-year-old woman presented to us with loss of a large portion of the helical rim after an assault. A successful 2-stage reconstruction was performed, incorporating the principles of perforator flaps, otoplasty techniques, and use of diced cartilage more commonly used for rhinoplasty. There was a 5 0.5-cm central helical defect of the right ear. In the first stage, the original defect was recreated and a 7 1.5-cm inferiorly based postauricular artery perforator flap was raised from the right postauricular sulcus. Diced cartilage was harvested from the adjacent conchal bowl and conchomastoid sutures were used to set the relatively prominent ear back so as to facilitate tension-free donor-site closure. Diced cartilage was wrapped in the deep fascia of the perforator flap and the edges of the deep fascia were sutured to the perichondrium of the exposed cartilage. The pedicle was divided at a second stage. At 1-year postoperation, the reconstructed ear maintained good form and symmetry, and the patient was satisfied with the outcome. This is a novel efficient technique of reconstructing large ear helical defects combining a postauricular artery perforator flap with wrapped diced cartilage augmentation, and incorporating classical otoplasty technique for virtually scarless donor-site closure. Key Words: ear helix defect, perforator flap, diced cartilage, otoplasty (Ann Plast Surg 2014;72: 663Y665)
E
ar defects involving significant full thickness loss of helical margin are challenging to reconstruct. A large composite helical defect would preclude the use of techniques like wedge excision and closure, and Antia-Buch repair. Optimal repair for a large helical defect would have to use larger locoregional scalp flaps or a chondrocutaneous repair involving autologous cartilage and skin grafting. We introduce a new approach to repair of large helical defects in 2 stages using a diced cartilage-augmented postauricular artery perforator flap.
CASE REPORT A 25-year-old woman presented to us with a healed right 50 5-mm helical mutilation defect involving the lateral quarter of the auricle (Fig. 1). The ear defect resulted from a human bite 1 year ago and it was allowed to heal without reconstruction. She requested
Received March 28, 2012, and accepted for publication, after revision, July 31, 2012. From the Department of Plastic, Reconstructive and Aesthetic Surgery, National University Hospital, Singapore. Conflicts of interest and sources of funding: none declared. Reprints: Gavin Chun-Wui Kang, MBBS, MRCSEd, MMed(Surg), MEng, Department of Plastic, Reconstructive and Aesthetic Surgery, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074. E-mail: gavinkangcw@ yahoo.com. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7206Y0663 DOI: 10.1097/SAP.0b013e31826cac47
Annals of Plastic Surgery
& Volume 72, Number 6, June 2014
helical rim reconstruction with minimal scarring and minimal stages. A template of the opposite ear superimposed on the mutilated ear revealed that she had lost a large portion of the helical rim and a portion of the scaphoid fossa with preservation of the antihelix. The defect required an elliptical skin flap measuring at least 5 cm long and 1.5 cm wide to allow for the flap to be folded. The temporal hair line was low and we proposed a reconstruction using the supple tissue of the postauricular sulcus (Fig. 2). In the first stage, the postauricular artery perforators in the vicinity of the postauricular sulcus were mapped with a Doppler. The opposite ear was used as a template for the reconstruction with an x-ray film template. The full length of the sulcus was used and this was the midline of the elliptical 70 15-mm flap (Figs. 1 and 2). The flap was elevated with the deep fascia and care was taken to avoid degloving of the bridge of postauricular conchal bowl skin medial to the postauricular sulcus. Two perforators in the postauricular region were preserved. This was to ensure that we retained the blood supply to this skin bridge from the perforators from the superficial temporal artery. Conchal bowl cartilage was carefully harvested through the area exposed by the flap. The cartilage was diced into very fine 0.5 to 1 mm pieces using a no. 11 blade.1 Conchomastoid sutures akin to those used in otoplasty were placed to allow for edge-to-edge apposition of the postauricular defect.2 The flap edge was first sutured to the raw edges of the superior and posterior aspect of the defect. The deep fascia of the flap was sutured to the perichondrium of the exposed cartilage and the diced cartilage was placed into the flap. The flap was then folded and the anterior and inferior aspects of the defect similarly sutured so as to contain the diced cartilage between the deep fascia of the flap and exposed cartilage of the defect (Fig. 1). The base of the flap was tubed. The patient had an uneventful postoperative course with some concerns of hyperpigmentation of the skin over the flap that gradually resolved. Six weeks later, the tube was divided and inset. The conchomastoid sutures were not removed. The pedicle was divided and inset with a Z-plasty superiorly and inferiorly to smoothen the helical rim and break up the straight lines. The tube was carefully inset into a ‘‘V’’ akin to the reset of a forehead pedicled tube flap. A scapha neosulcus was pleated between the new helix and antihelix (Fig. 1). At 1-year postoperation, the reconstructed ear retained its form and projection with acceptable symmetry, and the patient was satisfied with the aesthetic outcome.
DISCUSSION Large helical rim defects are classically reconstructed in multiple stages with tubed flaps from the mastoid skin or with the use of costal cartilage frameworks implanted into the postauricular region and elevated in a second stage.3Y5 These techniques create a visible donor site and need multiple stages. Our patient declined rib cartilage harvesting, had a low lying temporal hairline which would require www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
663
Annals of Plastic Surgery
Kang et al
& Volume 72, Number 6, June 2014
FIGURE 1. A, Right ear traumatic defect measuring approximately 50 5 mm. B, Postauricular artery perforator was preoperatively mapped out and the flap planned. C, Postauricular flap based on postauricular artery perforator (arrowhead) elevated. D, Diced cartilage wrapped into the deep fascial layer of the perforator flap. E and F, At 1-year postoperation, the reconstructed ear retained good form and projection. G, Left ear lateral view showing a similar projection to the right reconstructed ear.
depilation of the flap in the future, and as the patient lived overseas, there was a need for minimal stages. The defect was missing cartilage and skin and ideally reconstruction should involve the use of cartilage grafts. We sought to combine the reconstructive techniques of perforator flaps that allow for the elevation of relatively large skin paddles with the refinements of otoplasty and rhinoplasty to provide a 2-stage reconstruction for our patient. Perforator flaps allow for the elevation of relatively large paddles of skin on a narrow pedicle and this was ideally suited to the postauricular region as the skin spanning the entire sulcus could be used. This allows reconstruction of almost the entire length of helix with supple and hairless skin, yet leaving an imperceptible donor-site scar. Although the postauricular artery perforator island flap has been used in the past, it is generally for smaller defects of the concha and inferior helical region.6,7 The use of conchomastoid sutures allows for tension-free closure of the donor site and decreases the dead space.2 Incidentally, the patient’s affected ear was originally more prominent than the opposite ear, and the setback resulted in more ear symmetry postoperation. Diced cartilage is a valuable tool in rhinoplasty as the material is moldable.1 It is useful on the dorsum of the nose and here in the ear as graft material functioning as a filler but not for structural support. The use of diced cadaveric cartilage in otoplasty has previously been described.8 We chose to wrap the diced autologous cartilage in well-vascularized deep fascia to decrease the risk of resorption and infection that comes with wrapping diced cartilage in Surgicel instead.9,10 In summary, we present a useful marriage of reconstructive techniques across flap surgery, rhinoplasty, and otoplasty to reconstruct a moderately large helical rim defect of the ear with local 664
www.annalsplasticsurgery.com
FIGURE 2. Left, Cartoon showing lateral view of right ear indicating perforator flap dimensions appropriate for the defect. Center, Posterior view showing the vascular territory of the postauricular artery perforator flap in relation to right ear defect. Right, Lateral view of right ear defect and adjacent conchal bowl (shaded) for cartilage harvest. * 2013 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Plastic Surgery
& Volume 72, Number 6, June 2014
tissues. Although the final reconstruction left an ear that is marginally smaller than the opposite ear with a less well defined scaphoid fossa, there is resultant minimal donor-site morbidity and an imperceptible donor-site scar. REFERENCES 1. Erol OO. The Turkish delight: a pliable graft for rhinoplasty. Plast Reconstr Surg. 2000;105:2229Y2241. 2. Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg. 2005;115: 60eY72e. 3. Steffanoff DN. Auriculo-mastoid tube pedicle for otoplasty. Plast Reconstr Surg. 1948;3:352Y360. 4. Yang D, Tang M, Geddes CR, et al. Vascular anatomy of the integument of the head and neck. In: Blondeel PN, Morris SF, Hallock G, et al, eds. Perforator
* 2013 Lippincott Williams & Wilkins
Helix Defect and Perforator Flap and Diced Cartilage
5. 6. 7. 8. 9. 10.
Flaps: Anatomy, Technique and Clinical Applications. St Louis, Mo: Quality Medical Publishing; 2006:133Y160. Converse JM. Reconstruction of the auricle. Plast Reconstr Surg. 1958;22: 230Y249. Cordova A, D’Arpa S, Pirrello R, et al. Retroauricular skin: a flaps bank for ear reconstruction. J Plast Reconstr Aesthet Surg. 2008;61:S44YS51. Youn S, Kim YH, Kim JT, et al. Successful reconstruction of a large helical rim defect using retroauricular artery perforator-based island flap. J Craniofac Sur g. 2011;22:635Y637. Daniel RK. Diced cartilage grafts in rhinoplasty surgery: current techniques and applications. Plast Reconstr Surg. 2008;122:1883Y1891. Yarchuk NI, Limberg AA, Nekachalov VV. Clinical and histological results of late results of otoplasty using diced cadaver cartilage. Acta Chir Plast. 1975; 17:188Y197. Calvert JW, Brenner KB, DaCosta-Iyer M, et al. Histological analysis of human diced cartilage grafts. Plast Reconstr Surg. 2006;118:230Y236.
www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
665
Reconstructing a Large Helical Rim Defect Synergy of a Postauricular Perforator Flap, Diced Cartilage, and Otoplasty Technique Gavin Chun-Wui Kang, MBBS, MRCSEd, MMed(Surg), MEng, Yijun Wu, MBBS, MRCSEd, Shenthilkumar Naidu, MBBS, MRCSEd, MMed(Surg), FAMS(Plastic Surgery), and Shu Jin Lee, MBBS, MRCSEd, MMed(Surg), MD(Melb), FAMS(Plastic Surgery) Abstract: Large full thickness helical ear defects are a challenge to reconstruct. A 25-year-old woman presented to us with loss of a large portion of the helical rim after an assault. A successful 2-stage reconstruction was performed, incorporating the principles of perforator flaps, otoplasty techniques, and use of diced cartilage more commonly used for rhinoplasty. There was a 5 0.5-cm central helical defect of the right ear. In the first stage, the original defect was recreated and a 7 1.5-cm inferiorly based postauricular artery perforator flap was raised from the right postauricular sulcus. Diced cartilage was harvested from the adjacent conchal bowl and conchomastoid sutures were used to set the relatively prominent ear back so as to facilitate tension-free donor-site closure. Diced cartilage was wrapped in the deep fascia of the perforator flap and the edges of the deep fascia were sutured to the perichondrium of the exposed cartilage. The pedicle was divided at a second stage. At 1-year postoperation, the reconstructed ear maintained good form and symmetry, and the patient was satisfied with the outcome. This is a novel efficient technique of reconstructing large ear helical defects combining a postauricular artery perforator flap with wrapped diced cartilage augmentation, and incorporating classical otoplasty technique for virtually scarless donor-site closure. Key Words: ear helix defect, perforator flap, diced cartilage, otoplasty (Ann Plast Surg 2014;72: 663Y665)
E
ar defects involving significant full thickness loss of helical margin are challenging to reconstruct. A large composite helical defect would preclude the use of techniques like wedge excision and closure, and Antia-Buch repair. Optimal repair for a large helical defect would have to use larger locoregional scalp flaps or a chondrocutaneous repair involving autologous cartilage and skin grafting. We introduce a new approach to repair of large helical defects in 2 stages using a diced cartilage-augmented postauricular artery perforator flap.
CASE REPORT A 25-year-old woman presented to us with a healed right 50 5-mm helical mutilation defect involving the lateral quarter of the auricle (Fig. 1). The ear defect resulted from a human bite 1 year ago and it was allowed to heal without reconstruction. She requested
Received March 28, 2012, and accepted for publication, after revision, July 31, 2012. From the Department of Plastic, Reconstructive and Aesthetic Surgery, National University Hospital, Singapore. Conflicts of interest and sources of funding: none declared. Reprints: Gavin Chun-Wui Kang, MBBS, MRCSEd, MMed(Surg), MEng, Department of Plastic, Reconstructive and Aesthetic Surgery, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074. E-mail: gavinkangcw@ yahoo.com. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7206Y0663 DOI: 10.1097/SAP.0b013e31826cac47
Annals of Plastic Surgery
& Volume 72, Number 6, June 2014
helical rim reconstruction with minimal scarring and minimal stages. A template of the opposite ear superimposed on the mutilated ear revealed that she had lost a large portion of the helical rim and a portion of the scaphoid fossa with preservation of the antihelix. The defect required an elliptical skin flap measuring at least 5 cm long and 1.5 cm wide to allow for the flap to be folded. The temporal hair line was low and we proposed a reconstruction using the supple tissue of the postauricular sulcus (Fig. 2). In the first stage, the postauricular artery perforators in the vicinity of the postauricular sulcus were mapped with a Doppler. The opposite ear was used as a template for the reconstruction with an x-ray film template. The full length of the sulcus was used and this was the midline of the elliptical 70 15-mm flap (Figs. 1 and 2). The flap was elevated with the deep fascia and care was taken to avoid degloving of the bridge of postauricular conchal bowl skin medial to the postauricular sulcus. Two perforators in the postauricular region were preserved. This was to ensure that we retained the blood supply to this skin bridge from the perforators from the superficial temporal artery. Conchal bowl cartilage was carefully harvested through the area exposed by the flap. The cartilage was diced into very fine 0.5 to 1 mm pieces using a no. 11 blade.1 Conchomastoid sutures akin to those used in otoplasty were placed to allow for edge-to-edge apposition of the postauricular defect.2 The flap edge was first sutured to the raw edges of the superior and posterior aspect of the defect. The deep fascia of the flap was sutured to the perichondrium of the exposed cartilage and the diced cartilage was placed into the flap. The flap was then folded and the anterior and inferior aspects of the defect similarly sutured so as to contain the diced cartilage between the deep fascia of the flap and exposed cartilage of the defect (Fig. 1). The base of the flap was tubed. The patient had an uneventful postoperative course with some concerns of hyperpigmentation of the skin over the flap that gradually resolved. Six weeks later, the tube was divided and inset. The conchomastoid sutures were not removed. The pedicle was divided and inset with a Z-plasty superiorly and inferiorly to smoothen the helical rim and break up the straight lines. The tube was carefully inset into a ‘‘V’’ akin to the reset of a forehead pedicled tube flap. A scapha neosulcus was pleated between the new helix and antihelix (Fig. 1). At 1-year postoperation, the reconstructed ear retained its form and projection with acceptable symmetry, and the patient was satisfied with the aesthetic outcome.
DISCUSSION Large helical rim defects are classically reconstructed in multiple stages with tubed flaps from the mastoid skin or with the use of costal cartilage frameworks implanted into the postauricular region and elevated in a second stage.3Y5 These techniques create a visible donor site and need multiple stages. Our patient declined rib cartilage harvesting, had a low lying temporal hairline which would require www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
663
Annals of Plastic Surgery
Kang et al
& Volume 72, Number 6, June 2014
FIGURE 1. A, Right ear traumatic defect measuring approximately 50 5 mm. B, Postauricular artery perforator was preoperatively mapped out and the flap planned. C, Postauricular flap based on postauricular artery perforator (arrowhead) elevated. D, Diced cartilage wrapped into the deep fascial layer of the perforator flap. E and F, At 1-year postoperation, the reconstructed ear retained good form and projection. G, Left ear lateral view showing a similar projection to the right reconstructed ear.
depilation of the flap in the future, and as the patient lived overseas, there was a need for minimal stages. The defect was missing cartilage and skin and ideally reconstruction should involve the use of cartilage grafts. We sought to combine the reconstructive techniques of perforator flaps that allow for the elevation of relatively large skin paddles with the refinements of otoplasty and rhinoplasty to provide a 2-stage reconstruction for our patient. Perforator flaps allow for the elevation of relatively large paddles of skin on a narrow pedicle and this was ideally suited to the postauricular region as the skin spanning the entire sulcus could be used. This allows reconstruction of almost the entire length of helix with supple and hairless skin, yet leaving an imperceptible donor-site scar. Although the postauricular artery perforator island flap has been used in the past, it is generally for smaller defects of the concha and inferior helical region.6,7 The use of conchomastoid sutures allows for tension-free closure of the donor site and decreases the dead space.2 Incidentally, the patient’s affected ear was originally more prominent than the opposite ear, and the setback resulted in more ear symmetry postoperation. Diced cartilage is a valuable tool in rhinoplasty as the material is moldable.1 It is useful on the dorsum of the nose and here in the ear as graft material functioning as a filler but not for structural support. The use of diced cadaveric cartilage in otoplasty has previously been described.8 We chose to wrap the diced autologous cartilage in well-vascularized deep fascia to decrease the risk of resorption and infection that comes with wrapping diced cartilage in Surgicel instead.9,10 In summary, we present a useful marriage of reconstructive techniques across flap surgery, rhinoplasty, and otoplasty to reconstruct a moderately large helical rim defect of the ear with local 664
www.annalsplasticsurgery.com
FIGURE 2. Left, Cartoon showing lateral view of right ear indicating perforator flap dimensions appropriate for the defect. Center, Posterior view showing the vascular territory of the postauricular artery perforator flap in relation to right ear defect. Right, Lateral view of right ear defect and adjacent conchal bowl (shaded) for cartilage harvest. * 2013 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Plastic Surgery
& Volume 72, Number 6, June 2014
tissues. Although the final reconstruction left an ear that is marginally smaller than the opposite ear with a less well defined scaphoid fossa, there is resultant minimal donor-site morbidity and an imperceptible donor-site scar. REFERENCES 1. Erol OO. The Turkish delight: a pliable graft for rhinoplasty. Plast Reconstr Surg. 2000;105:2229Y2241. 2. Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg. 2005;115: 60eY72e. 3. Steffanoff DN. Auriculo-mastoid tube pedicle for otoplasty. Plast Reconstr Surg. 1948;3:352Y360. 4. Yang D, Tang M, Geddes CR, et al. Vascular anatomy of the integument of the head and neck. In: Blondeel PN, Morris SF, Hallock G, et al, eds. Perforator
* 2013 Lippincott Williams & Wilkins
Helix Defect and Perforator Flap and Diced Cartilage
5. 6. 7. 8. 9. 10.
Flaps: Anatomy, Technique and Clinical Applications. St Louis, Mo: Quality Medical Publishing; 2006:133Y160. Converse JM. Reconstruction of the auricle. Plast Reconstr Surg. 1958;22: 230Y249. Cordova A, D’Arpa S, Pirrello R, et al. Retroauricular skin: a flaps bank for ear reconstruction. J Plast Reconstr Aesthet Surg. 2008;61:S44YS51. Youn S, Kim YH, Kim JT, et al. Successful reconstruction of a large helical rim defect using retroauricular artery perforator-based island flap. J Craniofac Sur g. 2011;22:635Y637. Daniel RK. Diced cartilage grafts in rhinoplasty surgery: current techniques and applications. Plast Reconstr Surg. 2008;122:1883Y1891. Yarchuk NI, Limberg AA, Nekachalov VV. Clinical and histological results of late results of otoplasty using diced cadaver cartilage. Acta Chir Plast. 1975; 17:188Y197. Calvert JW, Brenner KB, DaCosta-Iyer M, et al. Histological analysis of human diced cartilage grafts. Plast Reconstr Surg. 2006;118:230Y236.
www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
665
