DEFECT BASED RECONSTRUCTION : EAR

Dr. Ajay ManickamJunior Resident ENT & Head neck surgeryR. G. Kar Medical College

The Auricle

The complex 3 dimensional shapes of any human appendages – skin & cartilage

Emotional & psychological distress

The auricle

Cosmetically important structure

History

Susruta reconstructed ear lobules using local flaps 600BC

Autogenous costal cartilages – modern era – Harold Gillies 1920

Ranford Tanzer 1950 laid foundation for current ear technique.

Anatomy

Blood supply (1) posterior branch of superficial temporal artery & (2) posterior auricular artery

Anatomy of periauricular area – most important

Anatomic axis of the ear

Ear anomalies

Congenital Acquired

Congenital ear anomalies

Tanzer’s classification

Cosman’s classification

Anotia Complete hypoplasia Hypoplasia of middle

third of auricle Hypoplasia of superior

third of auricle Prominent ears

Lidding Smaller ear Low ear position

Reconstruction of ear

Stick on ear prosthesis Osseo integerated ear prosthesis Use of synthetic auricular frames Total autologous reconstruction

Stick on ear prosthesis

Prosthetic pieces attached using skin adhesives

Limitations – may not attach strongly in mean time, skin reaction

Osseontegerated ear prosthesis Pliable silicone –

shaped & colour matched with opposite ear

Anchorage by bone anchored osseointegerated titanium plates

Limitations – daily cleaning, risk of local tissue unflamation

Synthetic auricular frames Synthetic frame used to recreate shape of ear Frames burried in subcutaneous pocket or

covered with superficial temporal fascia Silicone or PTFE Better success with temporalis fascia flap Significant risk of infection

Total autologous reconstruction

Ear frames from autologous costal cartilage

Burried in subcutaneous pocket or temporalis fascial flap

Popular methods are BRENT and NAGATA

Microtia

Nagata’s classification

Lobule type Concha type Small concha

type Anotia Atypical

microtia

Microtia repair

Brent technique Nagata technique 5 years of age Four stages 6th, 7th, 8th, costal

cartilages harvested Nylon sutures Auricular projection

involves only skin graft

10 – 12 years of age Two stages 6th, 7th, 8th, costal

cartilages harvested Stainless steel sutures Auricular projection

involves cartilage wedge sup temporal artery flap

Acquired ear defects

Partial defects – direct closure, local tissues, autologous reconstruction

Total defects – congenital total defect Skin only defects – full thickness skin

flap, local flaps

Reconstructive options

Upper third – local flaps – VY technique . Post auricular flap defects involving helical rims

Middle third – Antia Buch reconstruction & dieffenbach flap

Lower third – lobule. Local flaps are used

Defects of the concha – trapdoor flaps

Defects upto 1.5cm wide can be excised as a wedge and closed directly

Upper third local flaps

VY flaps – helical rims or marginal reconstruction defectPedicled flap based on post auricular artery

Middle third

We can use post auricular artery based flapsDieffenbach flap – staged reconstruction of pinnaAntia buch advancement flap – incorporates chondrocutaneous segment – but smaller ear

Lower third

Local flaps are used one or two stage procedure Often Non anatomical cartilage graft can give support for reconstructed ear lobule

Defects of concha

Trapdoor flaps are used for this purpose

Flap is inset after tunnelling through post part of the auricular defect

Partial ear defects

Local flaps , skin only flaps may not deliver best results

Bespoke cartilage frames are increasingly used in reconstruction.

Cartilage framework for pinna reconstruction upper 1/3

Middle third recontruction

Conclusion

There is yet no ideal alloplastic implant

Scalp skin grafts provide best texture and colour match

Costal cartilage provide best framework reconstruction

Thank you