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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. 9.9 (continued)
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9 Auricular Reconstruction
Fig. 9.9 (continued)
Subunits andAnatomical Considerations
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Fig. 9.9 (continued)
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9 Auricular Reconstruction
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Fig. 9.9 (continued)
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Subunits andAnatomical Considerations
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Fig. 9.9 (continued)
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Fig. 9.9 (continued)
9 Auricular Reconstruction
Subunits andAnatomical Considerations
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Modified Rim Advancement Flap
Indications: Medium-sized full-thickness defects, helix, antihelix, scapha.
Technique: The lesion is excised with adequate margins and the defect modied
to a rectangle. An incision is from the base of the defect superiorly and inferiorly
through the anterior skin and cartilage, taking care not to damage the posterior skin.
Back cuts are made along the superior end to cross the triangular fossa and inferiorly extended to the antitragus. The posterior skin is dissected of the cartilage from
the medial margin of the ap, till adequate mobilisation is achieved. The resultant
rim, pedicled on the posterior skin is rotated superiorly to close the defect. It is often
necessary to remove additional cartilage and skin from the medial aspect to prevent
distortion and “cupping” during ap inset. The cartilage removal can be as an additional rim along the medial margin, The wound is closed in three layers (anterior
skin, cartilage, posterior skin) (Fig.9.10a–f, g–j).
Tips: Rim advancement ap results in a decrease in the height of the pinna, but
prevents cupping and makes the reconstructed ear less obvious. Accurate approximation of the helical rim and cartilage is essential to prevent notching and distortion. Dog ears often have to be corrected on the posterior surface of the pinna to
accommodate the ap.
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9 Auricular Reconstruction
Fig. 9.10 Modied rim advancement ap. (a) Markings for excision and ap, (b) Excision defect
and ap raised, (c) Rim advancement and closure of original defect; excess medial skin and cartilage to be excised highlighted, (d) Final closure - anterior view, (e) Final closure - posterior view,
(f) Markings for excision and ap, (g) Excision defect and ap raised, (i) Closure of rim defect;
excess skin cartilage highlighted, (j) Final closure
Subunits andAnatomical Considerations
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Fig. 9.10 (continued)
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9 Auricular Reconstruction
Two-stage Post-auricular Flap (Superiorly Based)
Indications: Medium-sized helical rim, helical rim + antihelix defects.
Technique: The lesion is excised with adequate margins and the defect modied
to a rectangle or square with parallel superior and inferior edges. A superiorly based
post-auricular ap is marked overlying the mastoid skin, at least 1cm away from the
auriculocephalic sulcus. The dimensions and reach of the ap are tested prior to any
incisions. The margins of the ap are incised and the ap elevated on the surface of
the sternomastoid muscle inferiorly and in the supra-periosteal plane overlying the
mastoid. The mobilised ap is sutured into the defect on the anterior, inferior and
superior margins. The pedicle will traverse over the intact skin in the auriculocephalic
sulcus and is covered by Vaseline gauze. The donor defect is closed by undermining
the wound margins (Fig.9.11a–f).
The second stage is carried out 4weeks later. The bridge is excised, and the distal
end inset into the posterior margin of the pinna defect. The base of the ap is excised
and inset into the remaining donor site (Fig.9.11g).
Tips: The ap is useful for long defects, where a rim advancement ap is likely
to result in signicant shortening of the height of the ear. The ap can be inset across
or along the defect, depending on the length of the defect. Interpositional cartilage
grafts are benecial in large defects to provide additional support. This can be
inserted during the rst or second stage. Additional contouring, if required can be
undertaken as a third-stage procedure.
An inferiorly based post-auricular ap can also be used for similar defects. The
choice between an inferiorly or superiorly based ap will depend on the position of
the superior and inferior margins of the defect. A “low” inferior margin is better
reconstructed with a superiorly based ap and vice versa, a “high” superior margin
by an inferiorly based ap.
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