Auricular Reconstruction Following Total Amputation

(Fig. 10.30; Weerda 1983 c, 1987, 1997, Weerda and Siegert 1998)

When the entire auricle has been lost as a result of accidental trauma or tumor surgery, generally there is enough skin left to proceed with reconstruction. Otherwise the available skin should be expanded by implanting a 20-35-mL tissue expander for approximately 8 weeks (Siegert and Weerda 1994; see Figs. 4.5 and 5.53).

First stage: First a pattern is traced from the opposite, normal ear onto a sheet of radiographic film or other transparent material (see Figs. 3.8 and 10.14). The pattern is reversed, the position of the new auricle is precisely determined (Fig. 10.30a), and a skin pocket is developed past the hairline (Fig. 10. 30b). The skin should be dissected thin enough to conform well to the underlying framework but thick enough to preserve an adequate blood supply. After the rib cartilage has been harvested (see Fig. 11.1), a cartilage framework is carved from the synchondrosis of the ipsi-lateral or contralateral sixth and seventh ribs. The framework should be 3-4 mm smaller in all dimensions than the proposed auricle (see Fig. 11.3).

Total Auricular Reconstruction

Fig. 10.31 Second stage of auricular reconstruction about 6 weeks later.

a An incision is made 1-1.5 cm above and behind the rim of the framework. A full-thickness skin flap is dissected with a No. 15 scalpel above the level of the hair bulbs, developing to flap close to the framework (P = limit of the dissection). The framework itself should not be exposed.* b The cartilage framework is dissected from its bed, preserving the connective-tissue layer (B) over the frame. A galea-fascia-muscle flap (G) of adequate size is then outlined and raised on the mastoid. c A crescent-shaped cartilage graft (K) measuring approximately 35-40 mm x 10 mm x 12 mm (height) is inserted and sutured into place. The graft functions as a spacer to maintain the auriculocephalic angle.*

Fig. 10.31 Second stage of auricular reconstruction about 6 weeks later.

a An incision is made 1-1.5 cm above and behind the rim of the framework. A full-thickness skin flap is dissected with a No. 15 scalpel above the level of the hair bulbs, developing to flap close to the framework (P = limit of the dissection). The framework itself should not be exposed.* b The cartilage framework is dissected from its bed, preserving the connective-tissue layer (B) over the frame. A galea-fascia-muscle flap (G) of adequate size is then outlined and raised on the mastoid. c A crescent-shaped cartilage graft (K) measuring approximately 35-40 mm x 10 mm x 12 mm (height) is inserted and sutured into place. The graft functions as a spacer to maintain the auriculocephalic angle.*

d The cartilage graft is covered with the galea-fascia-muscle flap (G), which is secured with sutures and fibrin glue (Baxter, Heidelberg, Germany). The raw surface on the mastoid is reduced in size.* e Two split-thickness skin grafts (Sp) are glued and sutured into the defects. A tie-over Vaseline gauze bolster is secured with adhesive tape to create a light pressure dressing. f Sectional view of the individual layers I = Incision P = Limit of dissection Sp = Split-thickness skin graft G = Galea-fascia-muscle flap K = Cartilage graft B = Granulation and connective tissue

Generally the eighth rib is used to reconstruct the helix; it should be at least 8-10 cm long (see Fig. 11.3). Rib cartilage remnants are reimplanted subcu-taneously in the thoracic wound for the second stage of the operation. The cartilage framework is inserted into the pocket (Fig. 10.30), and one or two continuous suction drains and bolster sutures coapt the skin to the frame. The bolster sutures are left in place for about 8 days (Fig. 10.30c). The suction drains are not removed before the sixth or seventh day. Second stage (Brent 1992, Weerda 1996, Weerda et al. 1996; Fig. 10.31): About 8-12 weeks latera curved incision is made about 1-1.5 cm above and behind the rim of the implanted framework, and a thick split skin flap is sharply dissected to the rim on a shallow plane using a No. 15 blade (Fig. 10.31a, see Fig. 10.19 and pp. 33). The framework itself is not exposed, and care is taken to leave ample connective tissue on the back of the framework to ensure cartilage nutrition (Fig. 10.31b, B; see also Fig. 10.19). A crescent-shaped cartilage graft 35-40 mm long, 1012 mm high, and about 8 mm thick is carved from the rib cartilage that was banked in the thoracic pocket during the first operation (Fig. 10.31c). The cartilage graft is mobilized until it can be separated from the head by about 25 mm (distance from superior helical rim to mastoid) without tension (Fig. 10.31a-d). The crescent-shaped cartilage graft (K) is positioned under the new anthelix to function as a spacer (Fig. 10.31c) and is fixed to the anthelix with two sutures. An anteriorly based galea-fascia-muscle flap (G) is folded over the cartilage graft (Fig. 10.31b-d, f) and secured to the connective tissue with absorbable sutures and fibrin glue (Immuno, Vienna, Austria) (Fig. 10.31d, G). Perichondrium is left attached to the mastoid plane. The surrounding skin is mobilized and advanced behind the auricle. A Burow's triangle is excised, and the wound is closed in two layers (Fig. 10.31d). If there is adequate separation of the auricle from the mastoid (ideally about 2.0 cm to the upper helical rim), the remaining defects can be grafted with split-thickness skin from the groin or buttock (Fig. 10.31e, f). This graft is covered with a light pressure dressing (Fig. 10.31e), and the first ear bandage is not applied before day 6. The split-thickness skin graft can also be obtained from the head, keeping above the plane of the hair follicles in the scalp to permit rapid re-epithelialization and normal hair growth that will conceal the donor site. Additional touch-ups can be performed later. Figure 10.31f shows the individual layers in cross section.

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