If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Corresponding author. Address: Plastic and Reconstructive Surgery Unit, Royal Preston Hospital, Sharoe Green Lane North, Fulwood, Preston PR2 9HT, UK. Tel.: +44-7799-520199; fax: +44-117-9753846
Reconstruction of partial ear defects represents a difficult challenge to the plastic surgeon, due to the delicate and intricate architecture of the chondrocutaneous sandwich of the external ear.
These defects could be the result of laceration and avulsion injuries, animal and human bites, burns and tumour excision.
Since its introduction to the plastic surgery field, by Gillies, in 1917, tube flaps have been successfully used to reconstruct many defects. Although, in the past two decades, tube flaps have been replaced by the more modern single-stage reconstruction techniques, it still represents an excellent tool for reconstruction of partial ear defects.
We present three cases of reconstruction of partial ear defects using a modified two-stage post-auricular tube flap technique, which is simple and reliable technique with good aesthetic outcome.
Reconstruction of partial ear defects present unique and complex challenges to the plastic surgeon due to the delicate and intricate architecture of the structure of the external ear that is difficult to duplicate surgically.
These defects could be the result of laceration or avulsion injuries, animal or human bites, burns and iatrogenic defects after tumour excision. These usually present as marginal loss of the ear frame involving a variable segment of the helix.
Numerous techniques have been described to correct defects of the external ear, the diversity of which shows how difficult it is to achieve a quick and certain solution to this problem.
It is a two-stage technique with 2–3 week intervals which can be done under local anaesthetic.
1. Flap design
The width of the ear defect is measured, at its widest part, from the edge of the wound to the proposed helical rim. The result is doubled to allow the tube to be folded to cover the posterior aspect of the defect. The length of the flap is that of the defect with an extra few millimetres to allow easy mobility and attachment of the flap to the ear. These measurements are projected over the hair-free skin of the mastoid area and outlined with the anterior flap margin adjacent to the auricular-cephalic sulcus.
2. Operative technique
2.1 Stage 1
The flap is raised at the level of subcutaneous tissue using nontraumatic technique (Fig. 1) . The scar along the margin of the defect is excised or debrided if needed. The posterior margin of the flap is stitched to the posterior ear defect with 5/0 nonabsorbable sutures. When a cartilage graft is needed, it can be inserted at this stage and stitched with 6/0 absorbable sutures to the edges of the helical cartilage. The anterior margin of the flap is then stitched to the anterior edge of the defect with 5/0 nonabsorbable sutures. The free caudal and cephalic parts of the flap are tubed using nonabsorbable sutures (Fig. 2) . The donor site is closed directly by anterior advancement of the mastoid skin.
Fig. 1Stage 1: the flap is designed and raised at the level of subcutaneous tissue.
At 2-week interval, ‘weaning’ of the flap is performed by tying a 0 silk knot around the caudal and cephalic pedicles for 10, 20 and then 30 min intervals. This helps the flap to get used to its new blood supply from the ear, and can be repeated hourly. If the flap colour remains unchanged, it can be separated safely. If flap congestion or ischaemia shows, the flap should be left attached for another week. When cartilage graft is used, flap separation is done after three weeks to give time for the graft to set in place and acquire nourishment.
The caudal and cephalic limbs of the flap are separated and inserted at the helical edges using a V or Z-plasty (Fig. 3) .
A 24-year-old male patient lost almost the whole upper two-thirds of the helix of his left ear following a knife injury. The wound was minimally debrided and immediate reconstruction was done using the bi-pedicle post-auricular tube flap with a cartilage graft from the severed part. The interval between the two stages was 3 weeks (Fig. 4) .
Fig. 4Case 1 reconstruction: (A) Traumatic loss of upper two thirds of the helix. (B) With cartilage graft included. (C) The tube attached to the ear defect. (D,E) Completion of reconstruction.
A 28-year-old male sustained traumatic amputation of the upper pole of the left ear following an assault with a sharp object. He presented to us 6 months after the injury requesting ear reconstruction and scar revision over left cheek. Bi-pedicle post-auricular tube flap reconstruction was done with 2-week interval between the two stages (Fig. 5) .
Fig. 5Case 2 reconstruction: (A) Traumatic loss of the upper pole of left ear. (B,C) First stage reconstruction. (D) One week after flap separation with small Z-plasty at the anterior edge of the flap and left cheek scar revision. (E,F) One month after completion of reconstruction.
An 18-year-old female sustained loss of the lower one-third of the helix and adjacent lobule from a human bite, 8 months before attending our clinic. Bi-pedicle post-auricular tube flap reconstruction was performed. At 2-week interval weaning of the flap was done and showed no colour changes in the flap and separation was done under local anaesthetic (Fig. 6) .
Fig. 6Case 3 reconstruction: (A) Traumatic loss of the lower third of the helix and adjacent lobule. (B) Intra-operative view of the tube. (C) Stage 1 reconstruction. (D) Weaning of the flap at 2-week interval. (E) Completion of reconstruction.
Numerous techniques have been described to correct partial external ear defects, they fall into two main categories: (1) the circumference-reducing procedures that necessitate removal of healthy tissue and result in smaller asymmetrical ears, (2) the techniques designed to maintain the volume of the ear by interposition of grafts, flaps or both.
where they reconstructed minor to moderate helical defects by advancing the caudal segment of the ear and transferring the defect to the lobule. In larger defects, the superior segment of the helix will be mobilised too, and the reconstructed ear will appear smaller in size than the normal ear. This asymmetry is corrected by wedge excision of the normal ear and setback if prominent. Although it is an excellent reconstructive technique for small to intermediate marginal defects of not more than 3 cm in length,
were used, but their donor sites needed a skin graft for closure. Since its introduction to the plastic surgery field by Gillies in 1917, tube flap reconstruction technique has been successfully used to reconstruct many defects. It is a double-pedicle, closed-flap method that minimise the risk of infection and reduce incidence of scarring.
Although it has been replaced by the more modern one-stage method of tissue transfer, it still remains a useful tool for reconstruction of helical defects.
used a three-stage ‘composed tube’ technique formed of superficial temporal artery and vein pedicle only without attached flap and cover it with skin graft, than transfer this tube to the ear with the drawbacks of leaving an apparent bald scar over the scalp and the poor colour match of the skin graft. The retroauricular tube flap has proved an excellent choice for reconstruction of the auricle because of its colour and texture match, rich blood supply and proximity to the deformity.
described ‘auriculo-mastoid’ tube flap for reconstruction of helical rim defects, which although gave excellent result, it took eight surgical procedures of delays and waltzing in a 5-month period to transfer the tube to the ear. Dujon and Bowditch
described a three-stage method of reconstruction of partial helical rim defects using a thin post-auricular tube pedicle at 2–3 weeks interval.
The flap used in this paper is a modification of the previous tube flap techniques. It is a two-stage reconstruction using a post-auricular bi-pedicle tube flap that can be safely used to reconstruct large defects of the helical rim and/or lobule. Due to rich vascularity of the post-auricular skin subdermal plexus, long flaps can be raised on two relatively narrow pedicles.
We found that the immediate transfer of the flap to the ear defect is more useful than tubing it away from the ear, as this has reduced the number of surgical procedures needed to accomplish the reconstruction, avoided the waste of the precious post-auricular skin that occurs due to shrinkage during tube transfer, and even more we believe that the vascularised edges of the ear defect could act as an extra source of blood supply that, with the two pedicles, maintain the nourishment of these long narrow flaps.
In reconstruction of small to intermediate helical defects, the tube maintains its shape without cartilage grafts aided by the fibrosis that forms post-operatively, but for larger defects a strut of cartilage is needed to maintain the flap shape which can be inserted during the first stage of reconstruction.
We recommend this technique for reconstruction of variable sizes of helical rim defects and/or lobule. It is safe, reliable two-stage method with excellent colour match and minimal donor-site morbidity.
References
Brent B.
The acquired auricular deformity. A systemic approach to its analysis and reconstruction.
00222-4&id=gr1.gif){kind=link}
00222-4&id=gr2.gif){kind=link}
00222-4&id=gr3.gif){kind=link}
00222-4&id=gr4.jpg){kind=link}
00222-4&id=gr5.jpg){kind=link}
00222-4&id=gr6.jpg){kind=link}