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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. 9.4 Post auricular artery island ap. (a) Markings for excision, (b) Excision defect, (c) Falp
raised on subcutaneous post auricular artery pedicle, (d) Flap transposed into defect, (e) Flap
sutured into defect, (f) Closure of donar site
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9 Auricular Reconstruction
ef
Fig. 9.4 (continued)
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Post-Auricular Transposition Flap
Indications: Skin+cartilage defect and posterior skin intact.
Technique: A template is made to accurately reect the defect, and the dimen-
sions marked out in the posterior auricular/mastoid skin. The ap can be raised on
a superior or inferiorly based pedicle, consisting of skin, subcutaneous tissue and
post-auricular muscle (demonstration superiorly based ap). The margins of the
ap are incised down to periosteum and the ap raised in the supra-periosteal
plane. The ap is tunnelled anteriorly through to the conchal defect and sutured
into place. The section of the ap passing through the tunnel can be de-epithelialised, in case of a one-stage reconstruction. Alternatively, the ap pedicle is left
intact can be divided after 3weeks as a two-stage procedure and inset into the
defect. The secondary defect can be closed primarily by undermining the surrounding tissues (Fig.9.5a–h, i–p).
Tips: 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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9 Auricular Reconstruction
a
c
b
d
Fig. 9.5 Post auricular artery transposition ap. (a) Markings for excision, (b) Excision defect,
(c) Superiorly based ap markings with incision for tunnel, (d) Flap raised and tunneled into
defect, (e) Smal area of bridge de-epithelialised, (f) Flap sutured into defect, (g) Donar site sutured,
(h) Base of ap sutured, (i) Lesion pinna, (j) Excision defect, (k) Flap markings with bridge outlined, (l) Flap outlined, (m) Flap raised with broad pedicle, (n) Flap tunneled into defect, (o) Flap
inset into defect, (p) Donar site closure
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e
f
gh
Fig. 9.5 (continued)
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9 Auricular Reconstruction
i
k
j
l
m
Fig. 9.5 (continued)
n
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Fig. 9.5 (continued)
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9 Auricular Reconstruction
Pre-auricular Transposition Flap
Indications: Partial thickness defects (skin only/skin+cartilage).
Technique: A template is made to accurately reect the defect, and the dimen-
sions marked out in the pre-auricular skin. The ap can be based on a superior or
inferior pedicle and raised in the subcutaneous plane. A full-thickness incision is
made along the temporal/facial attachment of the ascending helix in case of a superiorly based ap, to create a tunnel into the defect. The ap is tunnelled anteriorly
through to the defect and sutured into place. The section of the ap passing through
the tunnel can be de-epithelialised, in case of a one-stage reconstruction.
Alternatively, the ap pedicle is left intact can be divided after 3weeks as a twostage procedure and inset into the defect. The secondary defect can be closed primarily by undermining the surrounding tissues (See Fig.9.12a–d).
An inferiorly based ap is more often considered when the conchal defect extends
more inferiorly and laterally to include the intertragic notch, antitragus and antihelix. The remaining attachment of the lobule can be detached to aid inset of the ap
and reattached (Fig.9.6a–d). The ap can be thinned as a second staged procedure.
Tips: The tunnel should be of adequate dimension to prevent compression of the
pedicle and vascular compromise. The hair distribution in the area should be taken
into account, when designing the ap to prevent its inclusion into the reconstructed
defect. Dog ears often have to be corrected and are best done inside the hairline and
along the auriculocephalic sulcus.
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a
c
b
d
Fig. 9.6 Pre-auricular transposition ap. (a) Lesion conchal bowl, (b) Excision defect and mark-
ings for ap, (c) Flap transposed into defect, (d) Final closure
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9 Auricular Reconstruction
Antihelix
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 placed. The tie-over bolus sutures are
now used to hold the dressing in place (Fig.9.7a–f, g–i). The sutures and pack are
removed in 7–10days time.
Tips: For 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 (See also Fig.9.14e–i). Full-thickness grafts are preferred to split
skin grafts.
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