The bi-pedicle post-auricular tube flap for reconstruction of partial ear defects

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1 The British Association of Plastic Surgeons (2003) 56, The bi-pedicle post-auricular tube flap for reconstruction of partial ear defects Mohammed G. Ellabban*, Maamoun I. Maamoun, Moustafa Elsharkawi Department of Plastic Surgery, Cairo University Hospitals, Cairo, Egypt Received 14 January 2003; accepted 4 June 2003 KEYWORDS Partial ear defects; Reconstruction; Tube flap; Post-auricular; Twostage technique Summary 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 Although, in the past two decades, tube flaps have been replaced by the more modern single-stage reconstruction techniques, it still represents an excellent tool for reconstruction of partial ear defects.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 twostage post-auricular tube flap technique, which is simple and reliable technique with good aesthetic outcome. Q 2003 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. 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. 1,2 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 *Corresponding author. Address: Plastic and Reconstructive Surgery Unit, Royal Preston Hospital, Sharoe Green Lane North, Fulwood, Preston PR2 9HT, UK. Tel.: þ ; fax: þ address: mohammedellabban@hotmail.com which shows how difficult it is to achieve a quick and certain solution to this problem The technique we present is a modification of the technique described by Dujon and Bowditch. 3 It is a two-stage technique with 2 3 week intervals which can be done under local anaesthetic. 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 S /03/$ - see front matter Q 2003 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi: /s (03)

2 594 M.G. Ellabban et al. hair-free skin of the mastoid area and outlined with the anterior flap margin adjacent to the auricularcephalic sulcus. Operative technique 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. Stage 2 Fig. 2 Stage 1: the flap is stitched to the margins of the ear defect and tubed. At 2-week interval, weaning of the flap is Fig. 1 Stage 1: the flap is designed and raised at the level of subcutaneous tissue. Fig. 3 Stage 2: flap inset with V-plasty.

3 The bi-pedicle post-auricular tube flap for reconstruction of partial ear defects 595 Fig. 4 Case 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. 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 afterthreeweekstogivetimeforthegraftto 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). Case reports Case 1 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). Case 2 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 postauricular tube flap reconstruction was done with 2-week interval between the two stages (Fig. 5). Case 3 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

4 596 M.G. Ellabban et al. Fig. 5 Case 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. 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). Discussion 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. 4 A classical example of circumference-reducing procedures is the helical advancement technique described by Antia and Buch, 2 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, 1,3 for larger defects scarring of the normal ear could be regarded as too much of a price to pay. Composite auricular grafts from the opposite ear were described to reconstruct helical defects. 1,5 It is only successful in small defects with graft breadth of no more than mm and scarring of the normal ear is inevitable. 2,5 Post-auricular advancement flaps 6 and bi-pedicle skin flaps 7 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. 8 Although it has been replaced by the more modern one-stage method of tissue transfer, it

5 The bi-pedicle post-auricular tube flap for reconstruction of partial ear defects 597 Fig. 6 Case 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. still remains a useful tool for reconstruction of helical defects. 3 Cosman and Crikelair 9 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. 7,10,11 Steffanoff 10,11 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 3 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 postoperatively, but for larger defects a strut of

6 598 M.G. Ellabban et al. 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 1. Brent B. The acquired auricular deformity. A systemic approach to its analysis and reconstruction. Plast Reconstr Surg 1977;59: Antia NH, Buch VI. Chondrocutaneous advancement flap for marginal defect of the ear. Plast Reconstr Surg 1967;39: Dujon DG, Bowditch M. The thin tube pedicle: a valuable technique in auricular reconstruction after trauma. Br J Plast Surg 1995;48: Renard A. Postauricular flap based on a dermal pedicle for ear reconstruction. Plast Reconstr Surg 1981;68: Nagel F. Reconstruction of a partial auricular loss. Plast Reconstr Surg 1972;49: Lewin ML. Formation of the helix with a postauricular flap. Plast Reconstr Surg 1950;5: Zenteno Alanis S. Retroauricular bipedicle skin flap for partial ear reconstruction. In: Strauch B, Vasconez LO, Hall- Findlay EJ, editors. Grabb s encyclopedia of flaps, 2nd ed. Philadelphia: Lippincott-Raven; p May H. Tube flaps. In: May H, editor. Plastic and Reconstructive Surgery, 3rd ed. Philadelphia: FA Davis Company; p Cosman B, Crikelair GF. The composed tube pedicle in ear helix reconstruction. Plast Reconstr Surg 1966;37: Steffanoff DN. Auriculo-mastoid tube pedicle for otoplasty. Plast Reconstr Surg 1984;3: Steffanoff DN. Retroauricular tubed skin flap to the helical rim. In: Strauch B, Vasconez LO, Hall-Findlay EJ, editors. Grabb s encyclopedia of flaps, 2nd ed. Philadelphia: Lippincott-Raven; p