Particular Cases

SECONDARY CASES

Most often we see patients treated elsewhere who have had reconstruction of partial defects using only skin flaps or inadequate cartilage graft. The previous surgery has created scars, making the local skin unsafe to use for coverage of the cartilage graft. In some patients, although a partial defect is present, the use of a fascial flap may be necessary. In many of these cases, a one-stage reconstruction is possible.

This patient had two-stage reconstruction of an upper-third defect with a skin-only flap performed elsewhere. The skin has retracted without a support, and a reconstruction using local skin is not possible because of posterior scars. A temporal fascia was used to cover both the anterior and posterior surface of a costal cartilage graft to reproduce the missing part of the ear. The reconstruction was performed in one stage.

In this case an inadequate costal cartilage graft was inserted under the postauricular skin, and a second stage was performed, leaving scars posteriorly. A temporal fascia was brought behind the ear through a postauricular skin approach. A costal cartilage graft was used to reconstruct the defect, and a split-skin graft was harvested from the scalp to allow a reconstruction in one stage.

We have found a laser to be efficient at removing small areas of hair in particular situations.

This 62-year-old patient had a partial amputation to treat melanoma. The use of a temporoparietal fascial flap could have been considered. Because of his poor medical condition and the availability of some local skin, a simpler procedure was chosen. His costal cartilage was not ossified, so the framework was carved without difficulty. Three laser treatments were very efficient at removing hair around the ear, allowing the use of the previous hair-bearing flap to cover the framework. The reconstructed part of the ear was elevated with the patient under local anesthesia using a full-thickness skin graft from the contralateral retroauricular sulcus.

Keloids occur more commonly in predisposed patients and in those of particular ethnicities. It is difficult to decide if a reconstruction should be performed in such patients, given the risk of keloids on the thorax and the ear. This question remains unanswered, because we do not know what exactly causes keloid scarring. The following case shows that aggressive management of keloids can have long-lasting results.