ENT

1. Reconstruction of the
Auricle
Dr. Erami M.D.
ENT Resident
Department Of ENT
Shahid Sadoghi Hospital
Yazd Iran

2. • A 39-year-old male individual
was involved in a fight and
human bite

3. • Time of trauma: 3pm
• Time of refer : 6pm
• PMH :neg
• NPO time: 30min(8:30)

4. • Amputated segment

5. • Wound cleaning :
• Cleansing is best performed with:
10-mL syringe with an 18-gauge angiocatheter attached.
• isotonic sodium chloride solution
• dilute povidone-iodine (Betadine)
• dilute hydrogen peroxide
• Wound closure:
Wound closure is a source of controversy.
Head and neck wounds, being in a cosmetically sensitive area, may be closed
if they are less than 12 hours old and are not obviously infected

6. Antibiotic:
The current recommendations from the Infectious Diseases Society of
America (IDSA) in patients with an infected human bite wound:
• amoxicillin/clavulanate or ampicillin/sulbactam
• an acceptable alternative in the penicillin-allergic patient
• Trimethoprim-sulfamethoxazole or a quinolone such as levofloxacin or moxifloxacin
+in addition to +
• clindamycin

7. •Cummings 2015:
• to close simple and complex lacerations that involve cartilage
• Perichondrial and skin sutures are usually sufficient
• Occasionally, anchoring sutures through cartilage must be placed
sparingly to bring wound edges together while maintaining the original
shape and prominence.
• In older patients, the cartilage is more brittle, and it is difficult to place
sutures solely in the cartilage that do not pull through.

8. •Cummings 2015:
• Small segments of denuded cartilage
• as long as perichondrium is still present can be reliably covered with split
or full-thickness skin grafts
• defects that cannot be closed without distorting the ear, especially those
that involve the helical rim, can be dealt with in a staged manner
• A robust vascular supply frequently allows partially avulsed auricular
segments to survive

9. •Cummings 2015:
• Some authors advocate deepithelialization of the avulsed segment followed
by burial in a postauricular subcutaneous pocket
• whereas others believe that the final result of a reconstructed auricle is
more reliable with an autograft than with banked cartilage, which often
resorbs to some degree and is ultimately distorted.

10. A,. Devitalized skin has been removed to reveal a
well-preserved cartilaginous framework suitable for
reconstruction.
B, Avulsed cartilage anatomically aligned with intact
inferior framework and banked in a postauricular
scalp pocket.
Dog-bite injury resulted in composite defect of superior auricle

11. •Cummings 2015:
• A variation of the “pocket principle” described by
Baudet involve deepithelialization of
only the posterior aspect of the avulsed segment
followed by fenestration of the exposed cartilage at
1-cm intervals.
• The anterior skin edge of the avulsed segment may
then be sutured to a modest postauricular scalp flap
elevated over the mastoid to provide a vascular supply.
• The flap should be divided several weeks later and a
skin graft should be applied posteriorly on the auricle.

12. •Cummings 2015:
• Advocates of this technique cite preservation of the original cartilaginous
framework and overlying skin with reliable results.
• A temporoparietal fascia flap followed by splitthickness skin grafting also
serves to salvage an amputated auricle in an acute setting.
• In experienced hands, microvascular replantation of an avulsed segment
generally yields the best final outcome, even in cases of venous
insufficiency or inability to perform a venous anastomosis.
• Leech therapy and anticoagulation protocols are acceptable adjuncts in
these cases and often have favorable results.

13. Appearance of the composite graft on second postoperative day. Venous
congestion was relieved by leech therapy.

14. • Topographic anatomy of auricle :

16. • Arterial blood supply
to auricle :
• superficial temporal a.
• Postauricular a.

19. • Auricular Reconstruction Based on Anatomic Location:
• Defects of Conchal Bowl and Root of Helix
• Defects of Superior Third of Auricle
• Defects of Middle Third of Auricle
• Defects of Inferior Third of Auricle

20. • Defects of Middle Third of Auricle :
• Small defects (<1.5 cm) may be closed by converting the defect into a
wedge-shaped excision, although this approach will have a direct impact on
the vertical height of the ear.
• Full-thickness helical defects less than 2.5 cm are amenable to helical
chondrocutaneous advancement flaps.
• Defects that are larger than 2.5 cm in width and confined to the helical rim
may be repaired with an interpolated cutaneous tube flap.
• Large defects of the central third of the auricle involving the helix and
antihelix require cartilage grafting to achieve the necessary structural
support.

21. • Two-stage postauricular advancement flap for repair of defect of central
third of auricle.
• A, Traumatic auricular defect

22. • B, Design of postauricular
advancement flap.

23. • C, Stages of reconstruction

24. • D, First stage completed

25. • E, Second stage.
• Release of flap from posterior
attachment and incorporation of
supporting septal cartilage graft.
Graft, shown outside of flap, was
inserted beneath flap to provide
framework for constructed helix

26. • F, Postoperative result at
• 6 months.

28. • The first stage involves :
• creating a cutaneous advancement flap based posteriorly on the scalp.
• The width of the flap is equal to the height of the defect, and the flap is
elevated from the skin of the medial aspect of the remaining auricle and
from the postauricular sulcus skin immediately adjacent to the defect.

29. • The first stage involves :
• The flap is advanced over the lateral aspect of the defect.
• The medial aspect of the auricular cartilage is exposed :
• as a result of dissecting the skin away from it in the process of creating
the flap.
• The exposed cartilage is attached to and nourished by the denuded
postauricular soft tissue.

30. • The first stage involves :
• During the first stage, septal or conchal cartilage is implanted beneath the
advancement flap to replace missing portions of the auricular cartilage.
• The cartilage graft is sutured directly to the borders of the auricular
cartilage defect.
• The advancement flap provides soft tissue coverage for the cartilage graft
and replaces the missing skin of the lateral ear.

31. • The second surgical stage:
• performed 3 weeks later
• involves :
• detachment of the advancement flap from the scalp.
• The flap is then folded on itself as a hinge flap to cover the medial aspect of
the cartilage graft.
• For this to occur, the medial aspect of the cartilage graft and the auricular
cartilage attached to the postauricular denuded soft tissue during the first
surgical stage are released from their attachments to the postauricular soft
tissue.

33. • The second surgical stage:
• Flap inset must provide adequate skin coverage of the cartilage graft and
prevent exposure of any auricular cartilage medially.
• A full-thickness skin graft is used to close the postauricular donor area
if it cannot be closed primarily.
In cases of extensive cartilage loss in the central third of the ear:
• a more complex framework using the sixth to eighth ribs is carved and
tailored to the missing segment of auricular cartilage.
• The framework is then covered by a postauricular skin advancement flap

34. • Reconstruction of central and inferior auricular defect with costal cartilage
framework.
• A, Defect resulting from motor
• vehicle accident.

35. • B, Drawings showing stages
of reconstruction.

36. • C, Costal cartilage graft tailored to
replace missing cartilaginous segment.

37. • D, Framework implanted beneath
postauricular skin.

38. • E, Postoperative result 4 months after
framework elevation with overlying Skin
and full-thickness skin grafting of medial
surface of constructed area.

39. • Another approach to reconstruction:
• Another approach to reconstruction of the middle third of the helix
when the skin of the medial aspect of the concha and the postauricular
sulcus are intact is :
• to use a postauricular interpolated advancement flap in two surgical stages.

40. • Unlike most interpolated flaps that are transferred by pivotal movement,
this flap is transferred by advancement over the intervening skin of the
postauricular sulcus.
• In contrast to the previous discussion, in which the skin of the medial ear is
incorporated into the advancement flap, in this case the skin of the medial
aspect of the ear and of the postauricular sulcus is left undisturbed.
• The advancement flap is incised posterior to the postauricular sulcus.
• It is advanced over the skin of the postauricular sulcus and sutured to the
margins of the lateral auricular skin defect.
• This creates a skin-lined channel representing the postauricular sulcus
beneath the pedicle of the flap

41. • A, Loss of central third of helix

42. • B, First stage
• Interpolated flap
from postauricular skin attached to
lateral margin of auricular defect.
Skin of postauricular sulcus left
undisturbed.

43. • C, Hinge flap based on auricle
is designed for reconstruction of helix.

44. • The second stage is performed :
• 2 to 3 months after the first stage.
• The pedicle of the interpolated flap is divided :
• from its posterior attachment to the scalp.
• The flap is folded over like a hinge to restore the absent helix and is sutured
to the border of the skin defect of the medial aspect of the concha.
• A cartilage graft may be positioned under the flap during the second stage if
structural support is necessary.
• The donor defect resulting from flap inset is closed primarily or with a local
scalp flap.
• Detaching the pedicle of the flap restores the postauricular sulcus to its
original condition.

45. • D, Second stage
• Pedicle of interpolated flap
divided and hinge flap folded
medially and sutured to exposed
skin margin of postauricular sulcus.

46. • E, Donor defect from inset of
interpolated flap closed primarily.

47. • F, G, Four months after inset of flap

48. • The advantages:
• The advantage of using the interpolated postauricular advancement flap
compared with the technique of incorporating the postauricular skin into an
advancement flap is :
• that the medial aspect of the concha is not denuded and does not require
subsequent release from attachments to the mastoid periosteum.
• A skin graft is not required to cover the medial aspect of the reconstructed
ear and any cartilage graft that may have been used for the framework of
the ear. In addition, skin grafts are not required to restore the postauricular
sulcus because the skin of the postauricular sulcus is left in situ by the
interpolated flap technique

49. • A, Defect of inferior third of helix
and antihelix

50. • B, Interpolated flap
from postauricular skin
designed for reconstruction of ear.
• Skin of postauricular sulcus
left undisturbed.

51. • C, First stage completed.
• Interpolated flap sutured to lateral
margin of auricular defect.
• Rubber band drain placed in
postauricular sulcus beneath
pedicle of flap.

52. • D, One week after transfer of flap.

53. • E, Two months after
transfer of interpolated flap.
• Probe has been inserted beneath
pedicle of flap in postauricular sulcus.
• Hinge flap based on auricle is
designed for reconstruction of ear.

54. • Traumatic avulsion of inferior two-thirds of auricle
With loss of skin of postauricular sulcus and medial ear:
• first surgical stage:
• When the skin of the medial ear and postauricular sulcus is absent
from traumatic loss or from excision, the remaining auricle is
sutured to the postauricular skin as the first surgical stage.
• When the ear has completely healed, a second stage is performed

55. • second surgical stage:
• a hinge flap based on the auricle is designed so that the flap can be
constructed from the postauricular skin.
• Cartilage grafts are included during the second stage to provide a
framework for the constructed ear.
• The donor site of the hinge flap is covered with a full-thickness skin graft
harvested from the groin or supraclavicular fossa or closed with a scalp
advancement flap

56. • A, Skin margin of antihelix was
Sutured to postauricular skin margin.

57. • B, Hinge flap based on auricle
is designed for reconstruction of ear.

58. • C, Hinge flap dissected.
Auricular cartilage graft harvested
from contralateral ear inserted
beneath flap for framework.
Full-thickness skin graft in place to
cover donor defect of hinge flap.

59. • D, Hinge flap folded medially
over cartilage graft and sutured
to skin graft used to reconstruct
postauricular sulcus.

60. • E, Postoperative result at 1 year.
• No revision surgery performed

62. • Advantage of local flaps to skin grafts:
• good color and texture match of the reconstructed auricle
Even if direct suturing is possible, care is needed to prevent distortion.
(mobility of auricular skin is poor because its thin subcutaneous tissue)
• The auricle can be divided into three parts in consideration of
reconstruction methods:
1. Concha
2. Helix
3. Ear lobe

63. • Strategy for partial auricular reconstruction:
• Concha : retroauricular flap
• Helix
• Cartilage defect(-) :
• Cartilage defect(+)
• Defect less than 1.5cm :
• Defect from 1.5cm to 3cm :
• Defect about 1/3 of the helix :
• Defect over 1/3 of the helix :
• Ear lobe : retroauricular chondrocutaneous flap

64. • A defect from 1.5 cm to 3.0 cm:
• A composite graft from the contralateral auricle is useful
• for using a composite graft the maximum size of a defect is 3 cm
(because a defect of the donor site of more than 1.5 cm can not be directly sutured).
• in order to obtain sufficient blood supply:
• The skin of the composite graft should be sutured to the skin of recipient
site (blood supply can usually be observed one day after the operation).
• Congestion may occur, but it usually improves after about 5 days.

65. • A defect about one-third of the helix:
• There are some reports of reconstruction using only a local flap without
cartilaginous reconstruction, but post-operative deformity due to scar
contracture may occur.
• Park reported a one-stage reconstruction method using
• free cartilage graft
• local flap
• skin graft
but this method is slightly complicated.
• Reconstruction methods using a conchal chondrocutaneous flap are useful.
• Cartilaginous reconstruction is necessary for such reconstruction.

66. • A defect of the upper one-third of the helix:
• Donelan reported a useful conchal chondrocutaneous flap:
designed on the concha and elevated with conchal cartilage. Then the flap is
rotated to the upper part of the helix.
(blood supply from the helical crus as a pedicle)
• The skin defect of the donor site of Donelan’s flap is covered with a skin
graft.
• Yotsuyanagi covered a conchal skin defect with a retroauricular flap.
• The posterior surface of the reconstructed upper helix is covered with a
retroauricular local flap.

67. • A defect of the middle one-third of the helix :
• Several reconstruction methods using chondrocutaneous flaps have bee reported.
• Millard reported a two-stage reconstruction method :
• using a conchal chondrocutaneous flap and local flaps.
• Yotsuyanagi and Selçuk reported a one-stage reconstruction method.
• Yostuyanagi elevates the conchal chodrocutaneous flap as a subcutaneous
flap and transfers it to the middle part of the helix. The conchal skin defect is
covered with a retroauricular flap. The retroauricular skin defect is directly
sutured if possible or covered with a local flap or skin graft.
• Selçuk reported a retroauricular chondrocutaneous transposition flap. The
cartilage of the flap is revolved about 90 degrees in order to fit to the helical
cartilaginous defect and covered with a skin flap.
• We usually use Yotsuyanagi’s method for a defect of the middle one-third of the
helix because more cartilage can be transferred than that by Selcuk’s method,
which is important for structural strength.

71. • A defect of more than one-third of the helix:
• It is difficult to reconstruct with local flaps only.
• In such cases, a costal cartilage graft is necessary to maintain the size and
form of the auricle.
• The grafted costal cartilage should be covered with a vascularized flap as a
temporoparietal fascial flap, and its surface is covered with a skin graft.
• It is important to make a cartilage frame that has a high helix and deep
scapha to make a fine threedimensional structure.

72. • Strategy for partial auricular reconstruction:
• Concha : retroauricular flap
• Helix
• Cartilage defect(-) : local flaps
• Cartilage defect(+)
• Defect less than 1.5cm : direct suture
• Defect from 1.5cm to 3cm : composite graft
• Defect about 1/3 of the helix : conchal chondrocutaneous flap + local flaps
• Defect over 1/3 of the helix : costal cartilage graft + TPF + skin graft
• Ear lobe : retroauricular chondrocutaneous flap
(TPF : temporoparietal fascial flap )