Larger Middle Third Defects

As in the reconstruction of large upper third defects (see Fig. 10.15), a skin pocket is developed behind the ear (Fig. 10.19a). A carved piece of rib cartilage is sutured to the cartilage stump and inserted into the pocket (see Figs. 10.14-10.16). The skin is closed with 6-0 monofilament suture material and coapted with 5-0 monofilament bolster sutures (Fig. 10.19a). A suction drain is inserted for 6-7 days (see Fig. 10.16c).

Second stage: The auricle is lifted from its bed (Fig. 10.19b, c), and the defects are closed with split-thickness skin (0.32-0.40 mm). The second and third stage (if necessary) are the same as for an upper third defect (Fig. 10.17).

Fig. 10.18 Reconstruction of a large middle third auricular defect with a rotation-transposition flap (Weerda 1981). a Outline of the rotation-transposition flap. The hairless ret-roauricular transposition flap (reconstruction flap) is moved to the correct retro-auricular position by means of a hair-bearing rotation flap (transport flap). b The transposition flap is now behind the defect. The supportive cartilage graft (K: occupies the defect 3 mm smaller). The surrounding skin is mobilized. c Appearance after one-stage reconstruction of the anterior and posterior sides.

Fig. 10.19 Reconstruction of a large middle third auricular defect.

a Step 1: The stumps are freshened, and the skin surrounding the defect is mobilized. A cartilage framework is inserted (see Figs. 10.15 and 10.16) and attached to the cartilage stump. The skin is sutured to the anterior skin of the auricular stump and coapted to the framework (a large U-advance-ment flap may be required; see Figs. 10.16 and 10.17).

b Step 2: An incision is made 1-1.5 cm behind the cartilage margin, and a thick split skin flap is dissected close to the helical rim with a No. 15 blade. c The new posterior auricular surface is carefully dissected, preserving the connective-tissue layer on the cartilage framework. The split-thickness skin flap is folded over. The mastoid defect is reduced in size, and the residual defect is grafted with split-thickness skin from the scalp, groin, buttock, or old thoracic wound (see Fig. 10.31).

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