Upper Third Defects

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If insufficient skin is available above the avulsion or defect, the skin should be expanded over a 6-8-week period using a 10-mL tissue expander (see also Figs. 4.5, 5.53 and Fig. 10.16). Generally, however, there will be sufficient local skin for the reconstruction. First stage: A transparent film pattern is traced from the opposite, normal ear (Fig. 10.13). Then rib car

Fig. 10.11 Small defects of the upper helix. a Small inferiorly based (1) or superiorly based (2) transposition flap (the latter from the retroauricular sulcus) is used to reconstruct the upper helix. b The flap is inset, giving it a "fish mouth" configuration along the helix.

c Use of a preauricular flap (K: cartilage strut from the concha. I: skin incision in the concha at the border of the anthelix).

< Fig. 10.12 Reconstruction of a long helical defect with a bipedicle flap.

a Cartilage (K) from the concha, accessed through the donor defect for the bipedicle flap in the sulcus. b After the cartilage strut is sewn into place, the bipedicle flap is inset into the defect, whose edges have been freshened. c Three weeks later the flap is divided and the tips are inset into the helical defects. The bipedicle flap is inset into the sulcus in the mastoid area. d Appearance on completion of the second stage.

tilage is harvested from the ipsilateral or contralateral side (see Figs. 11.1 and 11.3), and a delicate auricular framework is carved from the autogenous material (Figs. 10.14 and 11.3). The framework should be 3 mm smaller in all dimensions than the traced pattern. It is stitched to the auricular stump with 4-0 or 5-0 Vicryl sutures and implanted into the prepared subcutaneous pocket, which should be approximately 1 cm larger than the height of the framework (Fig. 10.15a). The skin of the pocket is stitched to the anterior skin of the auricular stump (freshened) with interrupted 6-0 or 7-0 monofilament sutures. The helix is shaped with bolster sutures (Fig. 10.15b), and a suction drain is inserted (for about 6-7 days) to promote skin coaption to the frame.

Fig. 10.13 A pattern is traced from the normal ear on a sheet of transparent material (e.g., radiographic film), which is held against the orbital margin. The auricle is traced, and the scapha, triangular fossa, and concha are cut out.

Fig. 10.15 Partial avulsion of the upper auricle.

a A retroauricular incision is made at, or preferably just below, the level of the auricular stump. A subcutaneous pocket is developed; it should be about 1 cm larger than is necessary to accommodate the cartilage framework. The framework may consist of native auricular cartilage cleared of skin (after an avulsion) or a framework carved from autogenous rib cartilage (see Figs. 10.13 and 10.14). The framework is inserted into the pocket and attached to the cartilage of the stump.

b The skin on the back of the stump is sutured to the lower, retroauricular wound margin. The upper wound margin of the pocket is sutured to the anterior side of the stump (with 6-0 monofilament). Bolster sutures and a suction drain coapt the skin to the underlying framework.

c The auricle is lifted from its bed 6-8 weeks later, and the split-thickness skin previously obtained from the buttock or thorax scar is stitched and glued to the raw surfaces on the back of the ear and the mastoid (skin grafts should be 0.350.40 mm thick).

< Fig. 10.14 A delicate cartilage framework is carved using the film pattern as a guide (sixth, seventh, or eighth rib). The pattern is reversed to carve the cartilage framework (K) for the opposite ear.

Second stage: The auricular skin is incised 6-8 weeks later and the framework is elevated from the mastoid (see Fig. 10.31a, b), taking care to preserve a good connective-tissue layer on the cartilage. The resulting defects are covered with thick split or full-thickness skin obtained from the thoracic donor site, groin, or buttock (Fig. 10.15c). Reconstruction with an anteriorly based flap employs a similar technique (Fig. 10.16).

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