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PARTIAL-THICKNESS DEFECTS
Presence of Perichondrium
Small defects can heal secondarily with local wound care.
Full-thickness skin grafts are recommended for larger
defects.
Absence of Perichondrium
Small defects <1.5 cm near the helical rim can be
converted to a full-thickness defect by wedge or shield
excision and closed primarily.
Large defects require coverage with a local flap.
Helical rim: same flaps used for full-thickness defects
of the upper and middle thirds
Conchal bowl: trapdoor flap, postauricular island
“revolving door” flap, and bipedicle advancement flap
Involvement of the External Auditory Canal
Stenosis is a common long-term complication
Treatment is application of a full-thickness skin graft over an
acrylic mold used as a temporary stent
FULL-THICKNESS DEFECTS
Can Be divided Into Thirds Based on Location
Upper Third Defects
Primary closure
Indication: limited to defects <1.5 cm to avoid a
significant size discrepancy with the contralateral side.
Commonly performed after wedge or shield excision of
skin cancers involving the helical rim.
To prevent buckling, a star-shaped resection pattern
can be used.
Contralateral chondrocutaneous graft
Indication: defects up to 1.5 cm and is usually
harvested from the contralateral helical rim or conchal
bowl.
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Design: the graft should be slightly larger than the
defect to account for postoperative contraction.
Predictable pattern of color changes during graft
takes starting with white initially (ischemia), then
blue for 24-72 hours (venous congestion), and
finally pink after 3-7 days (neovascularization).
Banner flap
Indication: for defects up to 2-3 cm.
A local transposition flap that can be based on either
the pre- or postauricular skin
Can provide soft tissue coverage to the helical rim,
antihelix, and triangular fossa
Design: performed with or without a cartilage graft;
however, if the defect involves more than 25% of the
helical rim, then costal cartilage is required for support.
Antia-Buch helical advancement (Fig. 22-1)
Figure 22-1 A-C.Antia-Buch helical
advancement.
Indication: for defects up to 3 cm
Design: a transcartilaginous incision is made in the
helical sulcus along its entire length from the scapha to
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the lobule preserving the integrity of the posterior skin
The posterior skin is then elevated off the remaining
ear cartilage in a supraperichondrial plane until the
entire helical rim is mobilized as a chondrocutaneous
composite flap (based on the posterior skin).
Additional length can be gained by performing a V-Y
closure at the root of the helix.
Chondrocutaneous composite flap (Fig. 22-2)
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Figure 22-2 Chondrocutaneous
composite flap of the ear. Helical rim
defect (A). Dotted lines indicate
incision to be made through both skin
and cartilage. Helical root is advanced
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on soft tissue pedicle (B). Remaining
helical rim is pedicled on lobule. Flaps
advanced (C). Final wound closure (D).
(From Urken ML. Multidisciplinary
Head and Neck Reconstruction.
Wolters Kluwer; 2010. Figure 11.6.)
Indication: for defects involving the superior helical rim,
especially when burn patients desire a stump to
support their eyeglasses and other local options are
not available.
Design: anterior skin and cartilage are rotated from the
conchal bowl as a composite flap based on either the
root of the helix (Davis) or the lateral helical rim
(Orticochea).
The donor site is skin grafted or left to heal by
secondary intention.
Middle Third Defects
Similar to full-thickness defects involving the upper third of
the ear, reconstructive options include primary closure,
contralateral chondrocutaneous graft, Banner flap, and
Antia-Buch helical advancement.
Tubed bipedicle flap
Based on the retroauricular skin and is performed with
or without a cartilage graft in three stages.
The flap is elevated and tubed with primary closure of
the donor site. Three weeks later, one end of the tube
is divided and transferred into the defect. Finally, after
an additional 3 weeks, the other end of the tube is
divided and transferred into the defect.
Dieffenbach flap (Fig. 22-3)
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Figure 22-3 Method of reconstructing
marginal ear defects with the
postauricular flap, as originally
described by Dieffenbach. The
postauricular flap is initially elevated
(A), and the flap is transposed from the
posterior auricle to the anterior auricle
during inset (B). A helical cartilage
graft is strongly recommended to
preserve the shape of the ear and give
definition to the helix, although not
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included in the original description by
Dieffenbach. At a second stage, the
base of the flap is divided (C), and the
flap donor site is skin grafted (D).
(From Hanasono MM. Postauricular
flap for ear reconstruction. In: Chung
KC, Disa JJ, Gosain A, et al., eds.
Operative Techniques in Plastic
Surgery. Wolters Kluwer; 2020:1133-
1137. Figure 3.30.2.)
Similar to the tubed bipedicle flap, this flap is based on
the retroauricular skin and is also performed in multiple
stages.
A cartilage graft is harvested and placed into the helical
rim defect. The anterior surface of the graft is then
covered with a postauricular transposition flap. Three
weeks later, the flap is divided at its base and inset
using the additional length of the flap to cover the
posterior surface of the graft.
The donor site is skin grafted or closed by local tissue
rearrangement.
Converse “tunnel” technique
A prelaminated flap based on the retroauricular skin.
A cartilage strut is tunneled beneath the retroauricular
skin and secured to both ends of the helical rim defect.
Three weeks later, the cartilage strut is elevated along
with the retroauricular skin still attached.
The donor site is skin grafted or closed by local tissue
rearrangement.
Lower Third Defects (Fig. 22-4)
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Figure 22-4 Some methods of ear lobe
reconstruction with local flaps. A.
Transversely oriented, bilobe flap originally
described by Gavello. B. Inferiorly based
preauricular flap that is folded
longitudinally. A cartilage graft is needed to
maintain ear lobe height. C. Double-
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opposing flap technique in which a
postauricular flap becomes the posterior
surface of the ear lobe and a preauricular
flap becomes the anterior surface of the
ear lobe. No cartilage graft is usually
needed. The postauricular flap is divided
at its base to release the ear lobe from the
postauricular (mastoid) region, and the
donor site is skin grafted at a second
stage. D. Double-opposing flap technique
in which a superiorly based postauricular
(infra-auricular) flap becomes the posterior
surface of the ear lobe and a preauricular
flap becomes the anterior surface. The
donor sites are closed primarily, and a
second stage may not be necessary,
although, in practice, a second stage is
often needed to revise the anterior
attachment of the reconstructed ear lobe.
(From Hanasono MM. Reconstruction of
the ear lobe. In: Chung KC, Disa JJ,
Gosain A, et al., eds. Operative
Techniques in Plastic Surgery. Wolters
Kluwer; 2020:1138-1141. Figure 3.31.1.)
Many techniques have been described to reconstruct the
lobule, but the basic premise involves the use of local flaps
folded over on themselves.
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The lobule normally does not contain any cartilage;
however, contralateral auricular cartilage or nasal septal
cartilage can be placed subcutaneously as a graft to
provide additional support and contour.
If the lobule on the contralateral side is enlarged,
sometimes it can be surgically reduced to match the
reconstructed side.
For cleft lobules, our preferred technique is wedge excision
and primary closure with eversion of the wound edges to
prevent postoperative notching.
THE AMPUTATED EAR
NONMICROSURGICAL OPTIONS
Usually involves burying or banking cartilage in the temporal
scalp, abdomen, or volar forearm for delayed reconstruction.
Many techniques have been described, but often the results are
inconsistent and the cartilage loses its definition over time
becoming flattened and warped.
Baudet recommended removing only the posterior skin
from the amputated segment and fenestrating the cartilage
to allow for greater imbibition and neovascularization. The
cartilage was covered by a postauricular flap and later
divided at 3 months.
Mladick recommended dermablading the amputated
segment, reattaching it, and then burying it beneath the
retroauricular skin. Three weeks later, the reconstructed ear
was removed from its “pocket,” and the denuded areas
eventually re-epithelialized.
Destro and Speranzini recommended removing all the
skin from the amputated segment except for the concha
and then made small round perforations in the cartilage.
The cartilage was covered by a postauricular flap and later
divided at 3 months.
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