This document describes a two-step surgical technique for reconstructing non-marginal full-thickness defects of the auricle. In the first step, tissue from the preauricular and retroauricular regions is used to reconstruct the anterior and posterior surfaces of the auricle defect. In the second step, performed two weeks later, the tissue pedicles are separated and adjusted. Thirteen patients underwent this procedure with excellent esthetic outcomes, low morbidity, and patient satisfaction. Vertical and horizontal dimensions of the reconstructed auricles changed minimally. The two-step technique provides an improved method for reconstructing central auricle defects.

1. SURGICAL ONCOLOGY AND RECONSTRUCTION
Two-Step Reconstruction of Non-Marginal
Auricular Defects
Maria Barbara Heinz, MD, DMD,* Hosein Ghanepur, DMD,y
and Alireza Ghassemi, MD, DMD, PhDz
Purpose: Auricular reconstruction is an extensively discussed topic in facial reconstructive surgery and
poses an immense challenge to the reconstructive surgeon. This report describes a 2-stage technique to
repair non-marginal full-thickness defects of the auricle.
Materials and Methods: Thirteen patients underwent surgery after partial to complete loss of the
auricular concha using an improved and refined method. Tissue from the pre- and retroauricular regions
was used to replace nonhelical auricular tissue loss in 2 surgical steps. All procedures were performed in
an ambulatory setting using local anesthesia.
Results: All 13 patients (age range, 37 to 82 yr; mean age, 68 yr; 4 women and 9 men) had excellent
esthetic outcomes with low surgical morbidity and were satisfied with the achieved results. No flap necro-
sis was observed. Auricular vertical and horizontal dimensions changed minimally (0 to 4 mm). A tension-
free closure of the donor-site defects could be achieved primarily.
Conclusion: The present method uses 2 separate donor sites to reconstruct centrally located
full-thickness defects of the auricle. It is straightforward to perform, minimizes the surgical steps required,
shows excellent outcomes, and allows easier closure of the donor site because of the distribution of the
harvested tissue.
Ó 2016 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg -:1-5, 2016
Defects of the auricle are often caused by trauma or
partial amputation after excision of cancerous
lesions.1
Of all carcinomas involving the ear, 45 to
55% are located on the helical rim and only few lesions
are located exclusively in the central part of
the auricle.2
As a protruded part of the facial soft tissue envelope,
the ear plays a crucial role in the overall esthetics of
the face. Even minor asymmetry in the size, shape,
color, surface, and outer contours can considerably
affect the overall appearance and bring about unpleas-
ant psychological distress in patients.3
Therefore,
ear reconstruction has always been considered a
challenging intervention, which requires knowledge
of facial esthetics and adequate surgical skills.
The method selected should be tailored to the general
medical condition of the patient and the patient’s
esthetic goal. Moreover, the proposed operative steps
should be thoroughly planned with utmost regard to
the local and regional anatomy and accounting for
any possible complications.
Previously published reconstruction methods have
included primary closure of auricular defects and
different reconstructive procedures ranging from local
flaps in single or multiple stages, use of grafts, implant-
able materials, and an auricular prosthesis.4
In accor-
dance to the clinical abundance and distribution
of lesions across the ear, only a few reconstructive
*Resident, Department of Oral and Maxillofacial Surgery,
Bethesda Hospital M€onchengladbach, Academic Hospital of RWTH
Aachen, M€onchengladbach, Germany.
yResident, Department of Oral and Maxillofacial Surgery, Babol
University of Medical Sciences, Babol, Iran.
zConsultant, Department of Oral and Maxillofacial Surgery,
Hospital Detmold, Academic Hospital of the University of
Hannover, Detmold; Medical Faculty University RWTH Aachen,
Aachen, Germany.
Address correspondence and reprint requests to Dr Heinz:
Department of Oral and Maxillofacial Surgery, Bethesda Hospital
M€onchengladbach, Academic Hospital of RWTH Aachen, Ludwig-
Weber-Straße 15, 41061 M€onchengladbach, Germany; e-mail:
mbheinz@gmx.net
Received December 15 2015
Accepted January 15 2016
Ó 2016 American Association of Oral and Maxillofacial Surgeons
0278-2391/16/00117-8
http://dx.doi.org/10.1016/j.joms.2016.01.025
1

2. methods have been described for the surgical recon-
struction of centrally located non-marginal defects of
the auricle.5,6
Even fewer reports have evaluated the
treatment of full-thickness defects of this region. In
consequence, reconstruction of these infrequent
defects is very important.
The anterior pedicled retroauricular flap (APRF)
was first described in 2012.7,8
In 2015, the authors
introduced the APRF for the repair of centrally
located perforating defects. The described method
needed 3 surgical stages.9
Since then, the method
has been refined for centrally located perforating
defects and the APRF was combined with a flap from
the preauricular region, the cranial pedicled preauric-
ular flap (CPPF). The present report describes the
technique of 2-step reconstruction and the complica-
tions, changes in auricular size, esthetic outcome,
and patient satisfaction.
Materials and Methods
Thirteenpatientswithcentrallylocatedfull-thickness
auricle defects were treated. Defect size ranged from 10
to 40 mm in diameter. Vertical and transversal dimen-
sions were measured pre- and postoperatively. The
reconstruction procedures were performed in 2 steps
in ambulatory settings using local anesthesia. A CPPF
was used to cover the anterior surface and an APRF
was used for the posterior defect site.
Surgical interventions were carried out in compli-
ance with the World Medical Association Declaration
of Helsinki on medical research protocols and ethics.
SURGICAL PROCEDURE
A precisely defined donor-site area, mirroring the
size of the existing defect, is outlined on the preauric-
ular and retroauricular skin (Figs 1A, 2A). First, the
FIGURE 1. Illustrations of the reconstruction procedure after full-thickness excision of the central part of the auricle. A, Designing the flaps in
the pre- and retroauricular regions. B, Harvesting and transposition of the anterior pedicled retroauricular flap into the defect area to reconstruct
the dorsal surface of the auricle. C, Incision and transposition of the cranial pedicled preauricular flap to reconstruct the anterior surface of the
auricle. The donor sites are closed primarily. D, Separation of the 2 pedicles and adaptation of the flaps in the second step.
Heinz, Ghanepur, and Ghassemi. Reconstruction of Auricular Defects. J Oral Maxillofac Surg 2016.
2 RECONSTRUCTION OF AURICULAR DEFECTS

3. dorsal incision is performed to elevate an APRF from
the retroauricular region. Then, the posterior tip of
the flap is folded into the anterior edge of the dorsal
defect to replace the dorsal surface (Fig 1B). As a
result, the subcutaneous part of the APRF is seen ante-
riorly. Second, the skin of the preauricular region is
incised with the pedicle based cranially. The skin is
used to reconstruct the anterior surface of the ear
(Fig 1C). The pre- and retroauricular donor sites are
closed primarily without tension (Fig 2B). After
2 weeks, the pedicles of the 2 flaps can be separated
surgically and adjusted accordingly (Fig 1D).
Results
Tissue from the pre- and retroauricular regions was
used to reconstruct full-thickness conchal defects in
13 patients (age range, 37 to 82 yr; mean age, 68 yr;
4 women and 9men). Postoperatively, vertical and hor-
izontal decreases in auricle size were 0 to 4 mm
(Table 1). Flap necrosis or flap loss, clinically notice-
able hematoma, or wound infection were not
observed. Scars were placed in hidden regions and
were barely visible. Skin color, texture, and thickness
of the reconstructed part matched well with the sur-
rounding tissue (Figs 2C, D). Tension-free wound
closure of the donor sites was achieved by the distribu-
tion of the needed skin into 2 separate regions. All 13
reconstructive treatments could be performed in 2 sur-
gical steps. Esthetic results were excellent and all pa-
tients were pleased with the outcome.
Discussion
The authors have presented a method to recon-
struct auricular conchal defects using the APRF
combined with a CPPF. Their aim was to maintain
the original size of the ear, achieve an optimal esthetic
outcome, distribute the donor-site defect wound, and
shorten the treatment time needed for reconstruction
FIGURE 2. Photographs of an 82-year-old patient after excision of a basal cell carcinoma of the central part of the left ear. A, Full-thickness
defect of the antihelix (diameter, 3.5 Â 3.0 cm) (posterior view). B, The anterior pedicled retroauricular and cranial pedicled preauricular flaps
are adapted. The 2 donor sites are closed primarily. (Fig 2 continued on next page.)
Heinz, Ghanepur, and Ghassemi. Reconstruction of Auricular Defects. J Oral Maxillofac Surg 2016.
HEINZ, GHANEPUR, AND GHASSEMI 3

4. (from 3 to 2 surgical steps). The CPPF was used to
cover the anterior surface of the defect. Because of
the similarity in texture, this tissue replaced the ante-
rior surface more adequately. The posterior surface
was reconstructed by the APRF, which consists of
thicker skin from the retroauricular region and offers
greater stability. In contrast to the previous technique,
there was no need for dividing any transitional part of
the APRF after passing the edge of the cartilaginous
framework, which would require another step.9
Because the tissue needed originated from 2 separate
regions, the size of the resulting defect of each donor
site was decreased and could be closed primarily and
without tension. The resultant scars were located in
invisible areas.
The goal of reconstructive surgery of the auricle is
to achieve morphologically acceptable auricular size
and shape and proportionally integrated anatomic
landmarks. Moreover, the proposed reconstructive
procedure should consider the patient’s existing
medical condition and should aim for a positive image
by achieving an adequate esthetic outcome. The first
reported method used a composite graft from the
contralateral ear.10
Since then, different methods
have been developed. Many reported technical
methods involve reconstruction of the helical rim,11-
17
because it is the prominent part of the ear and
most neoplastic lesions are found in this region.
Although some investigators have suggested
reconstructive techniques of central nonperforating
defects of the ear,4,18-21
only a few methods have
described full-thickness reconstruction of this region.
Nevertheless, most of these described methods result
in visible deformities and a smaller ear overall.22
In summary, there is a lack in the literature of tech-
nical reconstruction methods to close full-thickness
nonhelical defects of the ear in a convenient way
without changing the size. In their previous report,
the authors introduced a reconstruction technique
using the APRF, which required 3 steps. To decrease
the stages, the authors refined their technique and
used tissue from 2 separate pre- and retroauricular
donor sites for reconstruction. Because of the distribu-
tion of the donor-site defect, the present technique
allowed tension-free wound closure of the 2 donor
regions. In addition, sufficient tissue was available to
FIGURE 2 (cont’d). C, Frontal view of the patient 7 months postoperatively. D, Posterior aspect of the patient during follow-up period. Overall
size and shape of the reconstructed ear matches the contralateral side.
Heinz, Ghanepur, and Ghassemi. Reconstruction of Auricular Defects. J Oral Maxillofac Surg 2016.
4 RECONSTRUCTION OF AURICULAR DEFECTS

5. reconstruct the complete non-marginal part of the
auricle easily without obvious decrease of auricular
size. Although the method required 2 surgical steps,
it was reliable for flap survival. Esthetic outcome
was excellent because of the similarity of tissue
texture between the preauricular region and the
anterior surface of the auricle. Moreover, the thick
skin from the retroauricular region offered sufficient
stability and there was no need for cartilage grafting.
The new method was associated with improved
patient satisfaction because of fewer surgical steps
and shorter reconstruction time.
Combining flaps from pre- and retroauricular
regions simplified the full-thickness reconstruction
of non-marginal auricular defects, resulting in minimal
horizontal and vertical size changes. Because of the
distribution of required tissue into 2 anatomically
separate regions, primary wound closure was easier
to achieve. However, 2 surgical steps were required.
Acknowledgment
The authors thank Mr Wolfgang Graulich, from the Institute of
Anatomy, RWTH Aachen, for his contribution in creating and permit-
ting the use of his illustrations.
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Table 1. AURICULAR DEFECT SIZE COMPARED WITH
POSTOPERATIVE DECREASE OF VERTICAL AND
HORIZONTAL AURICULAR DIMENSIONS
Patient
Number
Defect
Size (mm)
Postoperative Decrease (mm)
Vertical Horizontal
1 18 3 2
2 25 2 2
3 40 4 3
4 32 3 3
5 23 3 3
6 35 4 3
7 10 1 0
8 28 2 1
9 36 4 1
10 20 2 1
11 30 3 4
12 24 4 3
13 26 2 2
Heinz, Ghanepur, and Ghassemi. Reconstruction of Auricular De-
fects. J Oral Maxillofac Surg 2016.
HEINZ, GHANEPUR, AND GHASSEMI 5