Aesthetic  Ear  Reconstruction    Ellis  Tavin,  MD  

 The  loss  of  the  soft  tissue  of  the  helical  rim  and  the  adjacent  antihelical  fold  can  present  a  significant  deformity.    When  patients  exhibit  ear  wounds  with  exposed  cartilage,  restoration  of  the  normal  ear  contour  may  be  accomplished  with  a  chondrocutaneous  rotation  flap1.    In  larger  defects  however,  this  technique  may  result  in  a  noticeable  decrease  in  pinna  size.    For  helical  rim  losses  greater  than  2.0  cm  we  have  been  performing  a  two-­‐stage  retro-­‐auricular  flap  including  placement  of  cartilage  graft  harvested  from  the  contralateral  conchal  bowl  when  needed.    We  describe  our  technique  and  present  our  results  including  complications.    The  following  modifications  to  existing  techniques  have  helped  improve  the  aesthetic  results.    The  flap  is  elevated  starting  on  the  posterior  aspect  of  the  pinna  distal  to  the  post-­‐auricular  sulcus  so  as  to  have  a  very  thin  flap  of  adequate  length  The  flap  is  elevated  in  the  immediate  subdermal  plane  and  thickened  to  the  deep  subcutaneous  plane  as  the  base  of  the  pedicle  is  approached.    This  creates  a  very  thin  flap  and  avoids  blunting  the  contours  of  the  exposed  cartilage  or  the  cartilage  graft.    When  a  cartilage  graft  is  needed,  its  leading  edge  is  inserted  under  the  intact  antihelical  cartilage  and  secured  with  horizontal  mattress  sutures  to  create  a  strong  construct  that  can  resist  the  forces  of  scar  contraction.    A  full  thickness  skin  graft  is  usually  needed  to  close  the  flap  donor  site  at  the  time  of  division  and  inset.    Before  (Figure  1)  and  after  (Figure  2)  photographs  of  a  patient  who  underwent  reconstruction  with  a  cartilage  graft  and  retroauricular  flap  5  years  after  skin  cancer  resection  are  reproduced  below.      Between  March  2007  and  February  2013  we  performed  25  ear  reconstructions  in  23  patients.    Eight  reconstructions  included  replacement  of  missing  cartilage.    The  patient  ages  ranged  from  10-­‐83  years.      Patients  were  followed  for  at  least  3  months.    24  reconstructions  were  for  skin  cancer  and  one  was  for  trauma.    There  was  one  partial  flap  and  cartilage  graft  loss  in  an  insulin-­‐dependent  diabetic  patient  and  one  skin  graft  loss.    Two  patients  developed  local  wound  infections  requiring  oral  antibiotics.    Three  patients  requested  minor  revisions.    All  patients  were  ultimately  satisfied  with  the  natural-­‐looking  appearance  of  their  reconstructed  ear.    The  two-­‐staged  retroauricular  flap  with  or  without  cartilage  graft  restores  the  normal  pinna  contour  without  creating  size  asymmetry  in  larger  defects  of  the  helical  rim  and  anti-­‐helical  fold.          

          Figure  1               Figure  2      Reference  Citations:  1-­‐Antia  NH,  Buch  VL  Chondrocutaneous  advancement  flap  for  marginal  defect  of  the  ear.  PRS  1  967:39:472.