Length of time the lesion has been present

Associated symptoms: pain, itching, bleeding, and hyperkeratosis

History of sun exposure

Personal and family history of skin cancer

Thorough examination of the ear, including size and shape of lesion

Characterize findings associated with skin lesion (if present): Size, color, shape of lesion, skin irregularity, and hyperkeratosis

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  Depth of lesion and likelihood for cartilaginous or full-thickness involvement.

Lymph node examination

Full body integument examination

If patient presents initially without resection, a biopsy should be performed at the time of evaluation to establish a diagnosis.

Full-thickness incisional versus excisional biopsies may be performed. Avoid shave biopsies.

When the likelihood of cancer is high, as in this case, take multiple biopsies along the periphery.

Primary closure +/– Tanzer’s excision patterns (Fig. 11-1)

Wedge resection: Defect <1.5cm

Skin grafts may be used for superficial defects

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  Usually harvested from contralateral posterior auricular ear

  
  
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  Skin graft cannot be placed on raw cartilage without overlying perichondrium

  
  
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  Exposed raw cartilage must be covered by flap or debrided

Helical rim advancement (Fig. 11-2)

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  Useful for defects of helical rim

  
  
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  Chondrocutaneous flaps are advanced into the defect

Antia-Buch flap (Fig. 11-3)

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  Useful for upper 1/3 helical defects

  
  
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  The base of the helix is advanced in V-Y fashion and coupled with helical rim advancement from below

  
  
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  May result in decrease in height of ear

Posterior auricular flap: Large flap of skin from behind the ear can be advanced to cover the posterior ear

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  Typically used in a staged fashion for initial coverage followed by additional release and further reconstruction, possibly with skin graft

Tubed pedicle flap from postauricular skin

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  Useful to reconstruct longer sections of missing helical rim

  
  
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  Must be divided in second stage

Banner flap: Skin flap based on anterosuperior auriculocephalic sulcus

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  Combine with contralateral auricular cartilage graft for larger (>2cm) defects

Chondrocutaneous transposition flaps: Often require grafting of donor site

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  Converse flap: Contralateral auricular cartilage graft tunneled under skin flap from mastoid, requires second stage (3 weeks) for division and inset

  
  
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  Orticochea procedure: Based laterally on helix

  
  
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  Davis flap: Based anteriorly on crus helicis, from conchal bowl

Temporoparietal fascia (TPF) flap

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  Thin flap of TPF may be harvested from scalp based on superficial temporal artery

  
  
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  Large flap (10×12 cm) may be elevated for complete coverage of the ear, if necessary

Total ear reconstruction (see Chapter 20)

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  Autologous rib cartilage framework covered with posterior auricular skin or TPF flap and skin graft

  
  
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  Medpor construct covered with TPF flap and skin graft

Complete amputation/avulsion: Replantation if viable blood supply is available (e.g., superficial temporal or posterior auricular artery)

External auditory canal

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  Maintenance of patency more important than choice of coverage

  
  
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  May use skin graft over vascularized bed

  
  
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  Requires use of stent or splint for 6 months