C ROSSELLO: MORPHOLOGICAL CLASSIFICATION CRITERIA FOR EAR RECONSTRUCTION
MORPHOLOGICAL CLASSIFICATION CRITERIA FOR EAR
RECONSTRUCTION
CARLO ROSSELLO, MD
U.O. Chirurgia Plastica e Ricostruttiva, Università di Genova
IST - Istituto Nazionale per la Ricerca sul Cancro
Largo R. Benzi 10, 16132 Genova, Italy
URL: http://www.istge.it/dip_toi/ch_pl/ch_pl.htm
E-mail: [email protected]
Abstract: Owing to its especially exposed anatomical location, the external part of the ear is often involved in
burns, mechanical trauma of different nature and it is an area continually subject to solar exposure and therefore
it is a frequent site of skin tumors. In this work, we will provide classification criteria based on the
morphological characteristics of both the ear and the lesion to determine appropriate reconstruction techniques.
The focus will be on reconstructive techniques for the upper one-third of the external ear. Specifically, the
approach in the treatment of a lesion depends on the degree and type(s) of tissue involvement. The techniques
reported are intended to be used according to the type and site of the substance losses.
Keywords: External ear, Superior one-third, Perichondrium.
1. INTRODUCTION
The external ear or auricle is about 7 cm high in
the adult, projecting from 10 to 30 mm laterally.
A line, which continuing forward, projects at the
level of the eyebrow while, below, a horizontal
line, through the tip of the lobe, projects onto the
nasal spine. The external ear is supplied with a
supporting structure consisting of elastic
cartilage covered with skin. Three main parts can
be identified in the structure of the external ear:
conch, anti-helix/anti-tragus and helix/lobe. For
the purposes of reconstructive intervention
planning, it is very important to analyze the size,
proportions and symmetry of the external ear.
These, together with the characteristics of the
lesion, can be set as classification criteria for
treatment and reconstruction.
Owing to its especially exposed anatomical
location, the external part of ear is often involved
in burns, mechanical trauma of different nature
and, because of sun exposure, it is a frequent site
of skin tumors. The approach followed in the
treatment of lesions depends on the degree and
type(s) of tissue involvement. If the lesions have
only caused the exposition of the perichondrium,
the area involved will spontaneously produce
granulation and epithelium regeneration. If, on
the contrary, a full thickness lesion has deeply
involved the perichondrium with exposition of
the cartilage, then surgical debridement and
reconstruction will be necessary.
2. SURGICAL TECHNIQUES
In this work, we will analyze possible
reconstructive techniques and specify a set of
criteria for the classification of lesions in relation
to the morphological characteristics of the ear.
These criteria allow to determine the most
appropriate technique. The focus of the work is
on the upper one-third of the external ear.
Therefore, the structures interested are: helix,
antihelical fold, Darwin’s tubercle, cymba,
scaphoid fossa and root of the antihelix (Fig.1).
Let’s remember that the structures of the upper
one-third are less mobile than the structures of
the lower portion, which, thanks to non-rigid
structure of the lobe, can be used as supply
tissue.
53 ISSN 1473‐804x Online, 1473‐8031 Print IJSSST Vol. 9 No. 5, December 2008 Fig. 1
C ROSSELLO: MORPHOLOGICAL CLASSIFICATION CRITERIA FOR EAR RECONSTRUCTION
•
Advancement flaps of larger size (Fig.3) can be
obtained from the lower portion, characterized
by a notable lassitude and, therefore, allowing a
better recovery of tissue.
Fig. 3
•
•
For defects of the fold of the anterior and
superior helix, it is possible to employ retro
auricular transposition flaps with a width/length
ratio of 1:4 or 1:5.
•
In the case of a scarcity of cartilage,
chondrocutaneous flaps can be advanced
(Fig.2); for example, according to Antia and
Bulter’s technique, the flaps are supplied with
retro-auricular vascular peduncle. They are
suitable for lesions smaller than 2 cm in
diameter.
From the superior portion, it is possible to use
advancement flaps with surgical V-Y plasty
(Fig.4), which allows to reduce skin tension;
moreover, in the tissues of the treated areas, the
tension can be still reduced by decreasing the
circumference of the scapha.
Fig. 4
•
Fig. 2
Defects of more important extent, with a
diameter ranging from 2 to 4 cm, can be
treated with tabulate flaps, which have their
origin in the pre-auricular area (Fig. 5). These
flaps, at the random type, are realized in
several steps. Since this flap has no cartilagerigid structure, its use is advisable in the
reconstruction of the helix. In the wide
substance losses that do not involve the helix,
54 ISSN 1473‐804x Online, 1473‐8031 Print IJSSST Vol. 9 No. 5, December 2008 C ROSSELLO: MORPHOLOGICAL CLASSIFICATION CRITERIA FOR EAR RECONSTRUCTION
it is suitable to use retroauricular island flaps
advancement with homonymous peduncle
(Fig.6).
Fig. 5
Fig. 6
of the upper one-third, in the case of a deficit
limited to skin tissue (Fig.8).
Fig. 8
3. CONCLUSIONS
• Full thickness skin grafts (Fig.7) are useful for
primary closure in the case of limited substance
losses: about 1 cm wide and extending from the
helix to the scapha.
Fig. 7
• Cartilage grafts can be combined with temporoparietal fascia where covering is achieved by
means of skin graft.
• Skin rotation flap with random vascularization is
suitable in the reconstruction of the central portion
The paper defines a set of classification criteria
based on the morphological characteristics of the
ear for the selection of appropriate reconstruction
techniques. Different techniques are used
depending on the type and location of the lesion.
Some of these techniques assure a better
aesthetic result compared to others, which only
allow for a covering function. In fact, the use of
retro-auricular flaps achieves a better aesthetic
result, because the closure of the donor site is
located in the retro-auricular groove and,
therefore, hardly visible.
The advantage of the rotation flap in the
reconstruction of the middle portion of the
superior one-third is that the scar is located in the
scapha.
If skin flaps are used, they may be strengthened
by a cartilage graft inserted in their context with
the advantage of reconstructing the rigid
structure under the skin.
A full thickness skin graft is suitable when the
use
of
a
flap
would
require
the
removal/reallocation of such wide a portion of
tissue as to cause an excessive distortion of the
ear architecture.
REFERENCES
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