SAN DIEGO – In the clinical experience of Dr. Michael A. Keefe, 70%-80% of ear defects from auricular cancer treatment can be easily remedied with skin flaps.
The most common locations of auricular cancer are the helix, the posterior auricle skin, and the antihelix, Dr. Keefe said at a meeting on superficial anatomy and cutaneous surgery.
Dr. Michael A. Keefe
"More than 70% of lesions are smaller than 3 cm in size, and auricular lesions make up an estimated 8% of all skin cancers," said Dr. Keefe, a plastic surgeon with the division of head and neck surgery at Sharp Rees-Stealy Medical Group in San Diego. "The defects are unique, and the underlying cartilage structure makes it all the more interesting."
And challenging – defects may be located on the skin of the ear only, on the lateral side, or on the posterior side, or they may involve a combination of skin and cartilage. Healing by secondary intention is effective for concave defects, but the size of the defect drives the reconstruction options. "If there is no perichondrium, punch holes through cartilage with a 2-3 mm punch to allow granulation tissue to grow through, and then use a skin graft or allow it to heal with secondary intention," he said. "Keep the area moist with antibiotic ointment."
Options for reconstruction of defects in the middle one-third of the ear include primary closure, full-thickness skin grafts (FTSGs), the helical advancement flap, and the retroauricular composite advancement flap, while options for defects in the lower one-third of the ear include primary closure and the preauricular tubed flap. Options for reconstruction of defects in the upper one-third of the ear include primary closure, FTSGs, the helical advancement flap, the retroauricular and preauricular tubed flaps, and constructing an autogenous cartilage framework with FTSGs.
Dr. Keefe said that most small helical rim defects limited to the skin can be closed primarily. "There might be slight rim asymmetry [after closure]," he said at the meeting, which was sponsored by the University of California, San Diego, School of Medicine and the Scripps Clinic. "Some patients might not care [about this], but you have to advise them of that," he added.
A bilobed advancement flap is another option for helical rim defects limited to the skin. This flap "works well for cutaneous defects 2 cm or smaller in the helical rim or the posterior auricle," he said. "The other thing you can do with these bilobed flaps is advance them over the edge to correct helical rim defects."
The banner flap is another effective flap for helical rim defects, especially those located on the superior helix. It does not replace cartilage, but it conceals the incision well. For small composite helix and anterior defects, Dr. Keefe favors the chondrocutaneous advancement flap.
He said that he favors using FTSGs on the anterior surface of the helix for skin defects whenever possible. "You can use a composite skin graft as well, especially to replace cartilage or skin defects that are smaller than 1 cm in size," he said. "A FTSG is easy to harvest and has minimal contraction. Common donor sites include the preauricular, postauricular, supraclavicular, and clavicular regions. Make sure you trim off the fat." For posterior surface defects, the bilobe or advancement flaps work well.
Grafts must be placed on tissue with an adequate blood supply. Effective grafts establish imbibition in the first 24 hours, inosculation within 48-72 hours, and restoration of circulation within 4-7 days.
Dr. Keefe said that he had no relevant financial conflicts to disclose.