Antia-Buch Flaps for Ear Reconstruction

Amir M. Ghaznavi

Brian R. Gastman

ANATOMY

The ear is made up of delicate skin and soft tissues covering a cartilaginous framework and underlying muscles.
- The cartilaginous portion of the ear includes the conchal bowl, antihelix, and helix.
- The surrounding muscles of the ear can be divided into intrinsic muscles (muscles that originate and insert on the ear) and extrinsic muscles (muscles that originate in other regions of the skull and insert onto the ear).
The intrinsic muscles include the helicis major, helicis minor, tragicus, antitragicus, transverse, and oblique muscles.
The extrinsic muscles include the anterior, superior, and posterior auricular muscles.
The arterial supply of the ear is derived from the posterior auricular artery and perforators arising from the superficial temporal artery.
Venous drainage is provided by the posterior auricular veins that drain into the external jugular system as well as the superficial temporal and retromandibular veins.
Lymphatic drainage of the ear is to the parotid, infraclavicular, mastoid, and infraauricular cervical nodes.
Sensory innervation of the ear is provided by:
- Great auricular nerve (C2-C3)
  - Auriculotemporal nerve (V3)
  - Lesser occipital nerve
  - Auricular branch of the vagus nerve (Arnold nerve)

PATIENT HISTORY AND PHYSICAL FINDINGS

A complete history and physical exam of the head and neck should be performed to document the exact location of the defect within the ear (superior third, middle third, and lower third portions) and involvement of cartilage if present.
The patient should also be examined for evidence of nodal metastases and secondary lesions in the head and neck region. Attention should be paid to the lymph node basins in the parotid and cervical areas.
Comorbidities that can increase the risk of postoperative wound healing and bleeding complications should be evaluated and optimized if possible.

IMAGING

No imaging is required for Antia-Buch flaps; however, imaging of the head and neck region may be necessary to evaluate tumor metastasis.

NONOPERATIVE MANAGEMENT

Isolated skin defects of the helical rim with intact underlying cartilage and perichondrium can heal by secondary intention or full-thickness skin grafting.
Full-thickness skin grafts can result in excellent outcomes in patients with preserved cartilaginous support. However, healing by secondary intention or skin grafting of more complex lesions that include full-thickness excision of the underlying cartilage may result in contour abnormalities and require more complex reconstructions.

SURGICAL MANAGEMENT

Preoperative Planning

The contours of the ear are marked preferably before skin prep to avoid washing off.
Patients who have large defects of the ear should be counseled that they may require contralateral reduction by wedge resection and/or setback of the unaffected ear at a later time to obtain symmetry.

Positioning

The patient is placed in a supine position with the entire ear exposed including the hairline.
The bed is turned 180 degrees to allow unimpeded approach to the head and neck area.
The contralateral ear may be exposed if planning on contralateral procedure and to evaluate symmetry.

Approach

Several surgical approaches have been described for Antia-Buch flaps including those for “classic” helix-only defects that are less than 25% of the total length of the helix, as well as modifications for longer defects and defects that include loss of the helix, scapha, and antihelix.
Prophylactic antibiotics are administered by most surgeons particularly if the cartilage or perichondrium has been removed.
Coverage with fluoroquinolones provides excellent cartilage penetration and provides coverage of common organisms that can cause infections of the ear (eg, Pseudomonas aeruginosa).
Prolonged antibiotic treatment is usually not necessary unless the wound is contaminated or the patient is otherwise at risk for postoperative infections.