Acquired Defects

BURNS

Regardless of the agent responsible for burning the auricular region (fire, acid, or electrocution), we have observed several similarities. Understanding these particular features may influence surgical planning.

Appearance of the Remnants

The antihelix is often preserved in burn patients, whereas the helical rim is often missing. It is essential to analyze the antihelix for deformity and to determine whether the height of the posterior wall of the concha has been preserved. These observations will indicate the type of framework required to complete the reconstruction.

The first of the following three cases will require excision of the deformed antihelix and reconstruction with a TYPE III framework. The second case shows a more complete antihelix, but the posterior wall of the concha has decreased height; therefore it must also be excised and reconstructed as an entire subunit of a TYPE III framework. The third case shows a normal antihelix and posterior conchal wall. A partial reconstruction will be performed using costal cartilage to reproduce the scapha, helix, and lobule.

Inflammation and infection of the auricular fibrocartilage always result in resorption and deformity of the shape of the ear. The skin is very often healthy despite the presence of the infection and can be relied on to maintain its elasticity after the deformed cartilage is excised. In rare cases it may even be possible to meticulously dissect the chondritic skin and use the existing skin pocket to complete the reconstruction in one stage (type 3a).

Bilateral Auricular Injury

Patients with extensive burns of the face and neck often have bilateral auricular damage.

The ears may be reconstructed simultaneously, particularly if indirect expansion is indicated, because this will markedly reduce the time for the additional expansion phase.

Another advantage of reconstructing both ears simultaneously is that a smaller amount of projection can be selected; therefore less cartilage stock is used in projecting the ears.

This burn patient had already undergone multiple surgeries for facial, neck, and hand sequelae. The operative plan was to reconstruct both ears in one stage and to reconstruct the sulcus in a second stage, only if the patient desired this. A type 3b skin approach (skin-only incision) was used to create a skin pocket that would cover a well-projected TYPE III framework. Cartilage was harvested from both sides of the thorax.

The projection of the ears was symmetrical after the first stage, and we agreed to forego the second stage.

When a large surface of scalp has been burned and grafted, including the temporal area, dissecting the graft free from the underlying temporal fascia may seem hazardous. Despite the theoretical risks for the vascularity of the fascia and skin flaps, we have found that this can be done safely in carefully selected cases. It may be possible to perform such a reconstruction, and if problems are encountered, we have the option of a prosthesis as a lifeboat.

Doppler ultrasound showed an intact superficial temporal artery under the grafted temporal area, but of short length. An atypical skin approach was planned. A bipedicled skin flap was used to cover the upper part of the ear reconstruction, and skin graft was applied to the secondary donor site. This approach removed tension and allowed adaptation of the flap to the underlying contours of the framework.

In this case, most of the scalp had been skin grafted. On the right side, the temporal area was unharmed. On the left side, no superficial temporal artery was present.

On the right side, a temporal fascial flap was used. On the left side, a random-pattern fascial flap with skin graft on its superficial surface was rotated to cover the framework, and the secondary defect was skin grafted.

These images show the final result after a bilateral type D elevation (tunnel technique) was performed in a single stage, with a simultaneous touch-up of the left tragus.

Surgical Amputation

Skin cancer of the ear is the cause of most acquired ear defects after surgery. Severe widespread neoplasms may require complete amputation of the ear and drilling of the temporal bone. Frequently, this type of excision is followed by free flap reconstruction. Radiotherapy also complicates reconstructive options in the auricular area. A prosthesis is often the solution in this challenging patient group.

Giant Melanocytic Nevus

When a nevus is excised from the ear, it is usually for aesthetic concerns; therefore it is usually possible to retain the perichondrium covering the fibrocartilage and cover the area with a skin graft. However, in cases of suspected malignant change, wide local excision is warranted requiring an ear reconstruction.