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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_688_Библиотеки_им_академика_М_И_Перельмана
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Subunits andAnatomical Considerations
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Fig. 9.1 Anatomical landmarks
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9 Auricular Reconstruction
Special Considerations
Care when handling cartilage. Use 4.0/5.0 long standing absorbable sutures, on a
round bodied/tapercut needle to approximate cartilage. Take particular care to accurately approximate the helical rim, to prevent notching. Consider a pressure dressing to prevent the occurrence of a haematoma. Avoid clothing which need to be
removed over the head in the immediate post-operative period.
Concha (Cymba andCavum)
Healing by Secondary Intention
Indications: Partial thickness defects (skin only/skin+cartilage).
Technique: The partial thickness defect is left to heal by secondary intention. In
case of skin only defects consideration can be given for perforating the underlying
cartilage with a small punch biopsy core, to encourage granulation tissue ingress
from the medial tissues. This can be useful, especially when perichondrium is lost.
Tips: A good wound care regimen is essential. The obvious disadvantage of this
approach is the prolonged healing period and reliance on patient/career co- operation.
Distortion due to scarring can be minimised by careful case selection and restricting
its use to small- and medium-sized defects.
Skin Grafts
Indications: Partial thickness defects (skin only/skin+cartilage).
Technique: A suitable template is made of the defect, which is transferred to the
donar site to harvest the graft. The graft is sutured to the defect, with additional
“long” sutures that can be used for “tying” over the bolus. The graft can be “quilted”
to the base, to decrease the risk of haematoma and dead space. A non-adherent
dressing is laid over the sutured graft, over which a cotton wool ball/sponge soaked
in proavin or a suitable antibiotic ointment is paced. The tie-over bolus sutures are
now used to hold the dressing in place. The sutures and pack are removed in
7–10days time (Fig.9.2a–d).
Tips: For skin only defects, consideration can be given for perforating the under-
lying cartilage with a small punch biopsy core, to encourage granulation tissue
ingress from the medial tissues. This can be useful, especially when perichondrium
is lost. Full-thickness grafts are preferred to split skin grafts.
Subunits andAnatomical Considerations
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ab
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c
Fig. 9.2 Excision and skin graft. (a) Lesion concha, (b) Excision defect, (c) Skin graft and donar
site sutured, (d) Tie over bolus dressing in situ
d
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9 Auricular Reconstruction
Revolving Door Flap
Indications: Medium and large skin+cartilage defects and posterior skin intact.
Technique: A template is made to accurately reect the defect and the dimen-
sions marked out in the posterior auricular surface/mastoid skin, with the base centred along the auriculocephalic sulcus. Skin is circumferentially incised and
undermined anteriorly and posteriorly, taking meticulous care to maintain a central
subcutaneous pedicle, along the auriculocephalic sulcus. The ap is pulled through
the defect, like a revolving door and sutured into the defect. The secondary defect is
closed primarily by undermining the surrounding tissues (Fig.9.3a–j, k–s).
Tips: The anterior margin of the ap in the posterior auricular surface is marked
out to overlap the underlying cartilage defect. The pinna will be “pinned” back
when the secondary defect is closed. This can interfere with the t of an existing
hearing aid and would have to be discussed with the patient.
Subunits andAnatomical Considerations
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a
c
b
d
Fig. 9.3 Revolving door/ip-op ap. (a) Markings for excision, (b) Excision defect, (cartilage
intact), (c) Excision defect after removal of cartilage, (d) Flap incision with intact pedicle along
auriculocephalic sulcus, (e) Anterior edge pulled through into defect, (f) Posterior edge pulled
through into defect, (g) ap transferred into conchal defect, (h) Flap sutured into place, (i) Closure
of posterior donar site, (j) Final closure, (k) Markings of excision, (l) Excision defect, (skin/cartilage), (m) Flap markings, (n) Anterior margin of ap raised, (o) Posterior margin raised maintaining pedicle along auriculocephalic sulcus, (p) Flap transfered into conchal defect, (q) Flap sutured
in place, (r) Donar defect and auriculocephalic pedicle, (s) Final closure
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e
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9 Auricular Reconstruction
f
g
Fig. 9.3 (continued)
h
Subunits andAnatomical Considerations
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i
k
j
l
Fig. 9.3 (continued)
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mn
op
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9 Auricular Reconstruction
Fig. 9.3 (continued)
Subunits andAnatomical Considerations
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q
r
s
Fig. 9.3 (continued)
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9 Auricular Reconstruction
Post-Auricular Artery Island Flap
Indications: Skin+cartilage defects and posterior skin intact.
Technique: An accurate template is made of the defect and the dimensions
marked on the posterior auricular surface/mastoid skin. The ap is incised laterally,
superiorly and medially down to the periosteum, but only through the skin inferiorly, to maintain the vascular pedicle. Inferiorly the skin is raised in the subcutaneous plane and the island ap elevated deep to the vascular pedicle (post- auricular
artery/post-auricular muscle), on the surface of the periosteum. The required mobility is obtained by undermining the ap inferiorly around the pedicle. A tunnel is
created from the anterior margin of the ap into the defect. The ap is mobilised
into the defect and sutured into place. The secondary defect is closed primarily by
undermining the surrounding tissues (Fig.9.4a–f).
Tips: Care should be taken to avoid damage to the pedicle during dissection and
transfer. The tunnel should be of an adequate dimension to avoid compression of the
pedicle. The pinna will be “pinned” back when the secondary defect is closed. This
can interfere with the t of an existing hearing aid and would have to be discussed
with the patient.
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