Abstract
In this article, the authors describe a technique for total earlobule reconstruction in a patient who underwent earlobule excision for basal cell carcinoma.
The reconstruction was by means of an innervated retroauricular skin flap, folded double.
The flap presented preserved skin sensitivity over all the reconstructed area, which is compromised by those techniques using a cranially or medially based flap which lead to the reconstruction of an insensible earlobule. This is a very important aspect of this technique, especially for those who wear pendant earrings, since a non-sensitive lobule would be more vulnerable to traumas causing laceration.
In addition, it allows a good aesthetic result without evident donor site scars.
Further investigation is needed to decide if this method is suitable for other types of total earlobule loss (e.g. congenital, traumatic), or not.
Keywords
1. Introduction
The mimic and functional properties of the auricle in many animal species are not found in humans, where it only has an aesthetic significance augmented by the widespread custom of wearing earrings.
The earlobule is a three-dimensional, tongue-shaped pendant appendix of the auricle. It is made of skin and subcutaneous tissue and has no cartilage frame. What makes it unique is the fact that it is composed of three layers, with the subcutaneous tissue between two skin layers.
Total earlobule excision for tumour resection is a rare event. In the authors' experience of 273 tumours of the auricle, only 3 (1%), two basal cell carcinomas and one melanoma, originated from the lobule, in concordance with the data reported in the literature.
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Even though total earlobule loss is an extremely rare eventuality, earlobule reconstruction is a primary concern in women and men accustomed to wearing earrings for aesthetical or social reasons.
In the case reported a retroauricular, innervated skin flap was used for lobule reconstruction after total earlobule excision for a basal cell carcinoma.
2. Case report
A 64-year-old woman with Xeroderma Pigmentosum visited our hospital for medical attention with the complaint of a tough ulcerous mass in the right lobule.
The tumour appeared to involve the whole lobule thus leading to the rare eventuality of total earlobule loss. The patient requested the ear lobule be reconstructed in order to wear earrings as soon as possible.
Resection of the whole lobule was performed (Fig. 1) . The reconstruction was made using an innervated and folded retroauricular skin flap (Fig. 2) .
The pathohistologic examination confirmed the clinical diagnosis of basal cell carcinoma. The margins of the specimen were disease free. After 5 weeks, the reconstructed lobule was pierced (Fig. 3: result 5 weeks post-operation).
After 6 months the result is stable and the earlobule sensitive (Fig. 4) .
3. Operative technique
Before approaching cancer resection, the surgeon must measure the earlobule to be able to plan the flap.
It is better to keep the patient standing while measuring the lobule in order to observe the effects of gravity on the lobule shape.
Once the measurement is done, the retroauricular flap must be planned as follows.
- 1.Planning of the flap length: to obtain the flap length, the width of the anterior surface of the lobule must be doubled. This measurement must be increased by 3 or 4 mm in order for the flap to fold.
- 2.Planning of the flap width: the flap width corresponds to 1 or 2 mm added to the height of the lobule to compensate for the flap contraction after the tissues are incised.
The pivot of the flap must be planned at a height that corresponds to the incisura intertragica.
The flap is harvested in a deep fashion in order to ensure an adequate thickness and to include sensory fibers, that run 4 mm subcutaneously.
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The flap is raised and transposed to the recipient site to make its apex correspond to the anterior-medial edge of the defect.
The posterior margin of the flap (Fig. 5; AC) is sutured to the raw surface of the auricle. The superior half (Fig. 5; XC) is sutured to the anterior raw surface of the auricle (Fig. 6; XICI) while the inferior half (Fig. 5: AX) to the posterior raw surface of the auricle (Fig. 7; AIXI).
The anterior margin of the flap (Fig. 5; B) becomes the free margin of the lobule (Figure 6, Figure 7: B).
Before suturing, to obtain the optimal shape, remodelling of the flap may sometimes be required.
The donor site is closed by direct suture.
4. Discussion
The availability of a single-stage, simple and effective method for earlobule reconstruction is of great value when approaching tumours leading to total amputation of the earlobule. The authors went through the literature of the past thirty years to find a technique suitable for this case. Most of the techniques reported have been published in the 70s. All of the techniques published have focused their interest mainly on the aesthetic outcome, on simplicity, or both. None of the authors have considered the possibility of preservation of skin sensitivity. Some techniques try to reproduce the thickness of the earlobule by means of a fragment of cartilage.
Ohsumi
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proposed a postauricular condrocutaneous flap plus a local flap to reconstruct the earlobule and a skin graft to close the donor site. In the authors' opinion, this is a very complex technique as it employs two flaps plus a skin graft. Besides, it employs cartilage, not normally present in the earlobule, thus giving it an unnatural consistency. The lobule is fixed and non-pendant. What is more, it requires three donor sites.Alconchel
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proposed two flaps, taken from the pinna and the lateral neck, thus producing two donor site scars. The resulting earlobule is non-pendant. The use of the skin of the pinna compromises its eventual future use. Besides, the technique brings insufficient tissue to compensate for total earlobule loss.Okada
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proposed a V-shaped flap from the lateral neck. The reconstructed lobule seems to be too small and the ear's length is reduced by this technique. Scars are evident.The technique proposed by Zenteno Alanis
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is very simple and easy. It uses a cranially based lateral neck skin flap. Scars are evident, sensory branches to the flap are severed.The latter technique was the one that appeared more suitable to our case. However, scars would have been evident and it would have lacked innervation. The incisions made to raise the flap are in fact located along the course of the sensory branches innervating the earlobule, that are therefore severed.
Sensory innervation of the earlobule is brought by fibers of the great auricular nerve, originating from the second and third ansae cervicalis.
Nerve fibers run 3–5 mm under skin surface, lying over the superficial cervical aponeurosis. Nerve fibers for the lobule and retroauricular skin are located within 1 cm from the base of the earlobule. Thus incisions in this area are to be avoided. This suggested the possibility of raising an innervated skin flap from retroauricular skin without severing the cutaneous branches of the great auricular nerve.
The elevation of a caudally based skin flap from the retroauricular area would not only allow the surgeon to spare sensory branches to the flap, but would also hide donor site scars behind the ear.
The deepness of dissection necessary to include nerve fibers in the flap allows one to bring enough tissue to obtain a satisfying thickness of the lobule, once the flap is folded with no need to transfer cartilage or fascia. The rest of the ear is not involved in flap raising thus preserving its dimensions and shape. The simplicity of this method makes it feasible in a single surgical stage, under local anesthesia on an outpatient basis. The donor site scar is hidden in a shaded area like the retroauricular sulcus. Skin sensitivity all over the flap is preserved allowing the patient to distinguish between stimulation of the skin of the lobule and stimulation of the retroauricular skin.
In the case reported, the result is stable and six months post-operatively the ear lobule has a satisfactory shape.
References
- Istotipi e distribuzione topografica rilevati su 90 neoplasie maligne del padiglione auricolare.Giornale di Chirurgia Plastica Ricostruttiva ed Estetica. 1992; VII: 121-126
- La regione auricolare.in: Zaoli G. Motta G. La chirurgia ricostruttiva nel cancro della testa e del collo. Edizioni Piccin, Padova1978: 68-71
- Squamous cell carcinoma of the pinna: a 6-year study.Br J Plast Surg. 1994; 47: 81-85
- Squamous cell carcinoma of the pinna.Br J Plast Surg. 1983; 36: 171-175
- Le nerfs de l'oreille et la perte de sensibilitè du lobule de l'oreille dans les suites des incisions de la region parotidomastoidienne.Ann Chir Plast. 1976; 21: 75-82
- Earlobule reconstruction with a reversed-flow chondrocutaneous postauricular flap and a local flap.Plast Reconstr Surg. 1994; 94: 364-368
- A combined flap technique for earlobule reconstruction in one stage.Br J Plast Surg. 1996; 49: 242-244
- A simple method for earlobule reconstruction.Plast Reconstr Surg. 1998; 101: 162-166
- Lateral neck skin flap for earlobule reconstruction.in: Strauch B. Vasconez L.O. Hall-Finlay E.J. Encyclopedia of flaps. Head and neck. vol. 1. Little, Brown and Company, Boston1990
Article info
Publication history
Accepted:
July 17,
2003
Received:
January 14,
2003
Identification
Copyright
© 2003 The British Association of Plastic Surgeons. Published by Elsevier Inc. All rights reserved.
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