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auric-recon-slides-070516 - Auricular Reconstruction...

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Unformatted text preview: Auricular Reconstruction Auricular Reconstruction Grand Rounds Presentation University of Texas Medical Branch Garrett Hauptman MD David Teller MD May 16, 2007 Overview Overview Etiology Goals Relevance Anatomy Patient evaluation Surgical techniques Complications Etiology Etiology Goals of Auricular Goals of Auricular Reconstruction Primary Wound healing Function: patent auditory canal Secondary Topographic preservation & restoration Camouflage scar Maintain ear size Maintain anterior profile Maintain lateral profile Brodland, DG. Dermatol Clin 2005 Challenging Aspects Challenging Aspects Skin:cartilage ratio high Complex 3D structure Psychosocial Impact of Auricular Psychosocial Impact of Auricular Deformity C Retrospective review­ surgically corrected auricular deformities Significant psychosocial morbidity: reduced self­confidence Main motivation for surgery Children = teasing Adults = appearance dissatisfaction Surgical intervention improved self­ confidence Horlock N, et al. Ann Plast Surg 2005. Auricular Deformity Due to Auricular Deformity Due to Psychosocial Issues Anatomy Anatomy Embryology Embryology Composition Composition Lobule Areolar tissue Fat Skin Auricle (excluding lobule) Elastic fibrocartilage Subcutaneous tissue (minimal) Skin Loosely adherent posteriorly Tightly adherent anteriorly Surface Anatomy Surface Anatomy Cartilage Anatomy Cartilage Anatomy Ligaments and Musculature Ligaments and Musculature Intrinsic Connects cartilage to itself and to external auditory meatus Extrinsic Connects auricle to side of head Associated Muscles Associated Muscles Vascular Supply Vascular Supply External carotid branches Superficial temporal artery (anterior) Occipital artery Gives off posterior auricular artery (posterior) Vascular Supply Vascular Supply Innervation Innervation Sensory Auriculotemporal branch of V3 Great auricular nerve Lesser occipital nerve Facial nerve Innervation Innervation Lymphatic Drainage Lymphatic Drainage Parotid nodes Superficial cervical nodes Retroauricular nodes (mastoid) Lymphatic Drainage Lymphatic Drainage Preoperative Evaluation Preoperative Evaluation Preoperative Evaluation Preoperative Evaluation Compare auricles to each other Overall symmetry Projection Proportion to facial features Surface landmarks Postauricular skin redundancy Cartilage thickness and stiffness Preoperative Evaluation Preoperative Evaluation Measurements Height and width Axis Angular relationship (projection) Idealized Auricular Dimensions Idealized Auricular Dimensions Male 63.5mm X 35.3mm Female 59.0mm X 32.5mm Auricular measurements according Auricular measurements according to guidelines of anthropometry Kompatscher, P. et al. Aesthetic Plast Surg. 2003 Auricular Protrusion Auricular Protrusion Helical rim 1cm to 2cm from mastoid skin Auriculomastoid angle between 15° to 30° Cephaloauricular Angle Cephaloauricular Angle Normally < 45° > 20mm protrusion excessive Photodocumentation Photodocumentation Preoperative and Postoperative Anterior Posterior Oblique (bilaterally) Lateral (bilaterally) Close­up Auricular Reconstruction: Auricular Reconstruction: Traumatic Injury Auricular Hematoma Auricular Hematoma Etiology: blunt auricular trauma Potential sequelae Infection Cartilage necrosis Contracture Neocartilage: cauliflower ear Treatment Small & acute = needle aspiration + bolster Large = open approach ± drain Aggressive debridement Ghanem T, et al. Laryngoscope 2005 Auricular Hematoma Auricular Hematoma Human Bites Human Bites C Head & neck = 20% Ear = 67% Treatment goals Infection prevention Healing + good cosmesis Recommendations ≥ 48 hours IV antibiotics Delayed surgical closure: > 24 hours Stierman KL, et al. Otolaryngol Head Neck Surg 20 Human Bites Human Bites Stierman KL, et al. Otolaryngol Head Neck Surg Replantation Timeline Replantation Timeline 1971­ Mladick et al: retroauricular pocket 1972­ Baudet et al: postauricular skin flap 1980­ Pennington et al: microvascular anastamosis Mladick Technique Mladick Technique First stage Amputated auricle part deepithelialized Anatomic cartilage reattachment Retroauricular pocket burial Second stage Cartilage elevation STSG Kyrmizakis DE, et al. Head Face Med 2006 Baudet Technique Baudet Technique First stage Amputated auricle posterior surface deepithelialized Cartilage fenestrated­ improves vascular bed access to anterior pinna skin Postauricular skin flap elevated Anterior pinna skin sutured Attached anterior skin Postauricular flap Second stage Ear elevation STSG Kyrmizakis DE, et al. Head Face Med 2006 Baudet Technique Baudet Technique Kyrmizakis DE, et al. Head Face Med 2006 Microvascular Replantation Microvascular Replantation Arterial ± venous re­anastomosis Arteries Superficial temporal Posterior auricular Best cosmetic reconstructive option Single procedure Small vessel caliber makes challenging Yong L, et al. Acta Otolaryngol 2004 Microvascular Replantation Microvascular Replantation Prerequisites Short ischemic interval Appropriately preserved amputated part Saline gauze wrapped on ice Compliant patient Preserve secondary reconstruction options Postauricular skin Temporoparietal fascia flap Proximal superficial temporal artery Schonauer F, et al.. Scand J Plast Reconstr Surg Hand Surg 2004 Microvascular Replantation Microvascular Replantation Best results: arterial + venous anastomosis Venous anastomosis Difficult Necessity questioned Venous connections in 1 week­ neovascularization Venous anastomosis alternatives Meticulous debridement Wider contact area Akyurek M, et al. Ann Plast Surg 2001 Auricular Reattachment Review Auricular Reattachment Review C Literature review: acute ear trauma between 1980­2004 Categorized Damage Reattachment technique Final outcome 56 publication: 74 cases Steffen, A et al. Plast Reconstr Surg 2006 Auricular Reattachment Review Auricular Reattachment Review Steffen, A et al. Plast Reconstr Surg 2006 Auricular Reattachment Review Auricular Reattachment Review Steffen, A et al. Plast Reconstr Surg 2006 Auricular Reattachment Review Auricular Reattachment Review Techniques Microsurgical replantation Pocket methods Periauricular tissue flaps Composite grafts Conclusion Microsurgical replantation is best Failed replantaion does not hinder later reconstruction Pocket method & periauricular flaps should be abandoned Steffen, A et al. Plast Reconstr Surg 200 Microvascular Replantation Microvascular Replantation Microvascular Replantation Microvascular Replantation Venous Congestion Venous Congestion Auricular replantation problem without venous anastomosis Treatment options Leeches Skin puncture Venous Congestion: Leeches Venous Congestion: Leeches First recorded use: 200BC Microvascular tissue transfer caused reemergence Salivary anticoagulant: Hirudin ↓ venous engorgement → ↓ capillary pressure → ↑ tissue perfusion Therapy duration based upon clinical appearance Precautions Broad spectrum antibiotics + Aeromonas hydrophilia prophylaxis Monitor hematocrit Frodel JL, et al. OtolaryngolHead Neck Surg 2004 Venous Congestion: Leeches Venous Congestion: Leeches Antithrombotic Agents Antithrombotic Agents Dextran Heparin Alters platelet activity & fibrin network formation Relatively lower post­op bleeding/hematoma risk No clinical efficacy evidence after free tissue transfer Acts at multiple sites in coagulation cascade Aspirin Irreversibly inhibits platelet aggregation Ridha H, et al. J Plast Reconstr Aesthet Surg 2006 Biomaterials: Alloplastic Implants Biomaterials: Alloplastic Implants Advantages Widespread availibility Consistent shape ↓ OR time Disadvantages Infection­ ↑ risk Extrusion Biocompatibility Long­term durability Shieh SJ, et al.. Biomaterials 2004 Biomaterials: Alloplastic Implants Biomaterials: Alloplastic Implants Shieh SJ, et al.. Biomaterials Biomaterials: Tissue Engineering Biomaterials: Tissue Engineering Research involving biodegradable polymers and cell isolates In vitro In vivo Advantages ↓ donor site morbidity Precise structure creation Donor & recipient tissue identical Potential for implant growth Shieh SJ, et al.. Biomaterials 2004 Biomaterials: Tissue Engineering Biomaterials: Tissue Engineering Auricular Reconstruction: Auricular Reconstruction: Surgical Defect Auricular Cancer Auricular Cancer Most common locations Helix Posterior auricle skin Antihelix Presentation size > 70% area < 3cm Silapunt, S et al. Dermatol Surg 2005 Australian Moh’s Database Australian Moh’s Database = 8% Leibovitch, I et al.Dermatol Surg. 2006 Types of Defects Types of Defects Cutaneous Lateral surface Rarely close primarily Granulation FTSG on intact perichondrium Medial surface Primary closure Cutaneous­ cartilagenous Alters auricular shape May be full­thickness or have preserved skin < 1.5 mm defect Wedge excise & primary closure Many reconstructive options General Principles General Principles Defects unique Many reconstructive options Primary closure Secondary epithelization Skin graft/composite graft Flap Considerations Size & depth Location Esthetic concerns Medical history/smoking history Reddy, LV et al.. J Oral Maxillofac Surg 2004 Reconstruction Based on Defect Reconstruction Based on Defect Location Conchal Bowl Preserved perichondrium: FTSG Island transposition flap Helical Root Helical advancement flap Reconstruction Based on Defect Reconstruction Based on Defect Location Upper 1/3 Primary closure FTSG Helical advancement flap Retroauricular & preauricular tubed flaps Autogenous cartilage framework with FTSG – vs­ TPFF + STSG Reconstruction Based on Defect Reconstruction Based on Defect Location Middle 1/3 Primary closure FTSG Helical advancement flap Retroauricular composite advancement flap Lower 1/3 Primary closure Preauricular tubed flap Reconstruction Based on Defect Reconstruction Based on Defect Location Preauricular Primary closure Advancement flap Transposition flap Large Defects exceeding 1/3 of auricle require multiple techniques Bilobed Advancement Flap Bilobed Advancement Flap Cutaneous defects ≤ 2cm helical rim length ≤ 2cm posterior auricle skin Flap design Primary lobe equivalent size to defect Smaller secondary lobe Larger & less rotated than nasal bilobe Alam, M et al. Dermatol Surg 2003 Bilobed Advancement Flap Bilobed Advancement Flap Alam, M et al. Dermatol Surg Bi­Pedicle Post­Auricular Tube Flap Bi­Pedicle Post­Auricular Tube Flap Cutaneous & cartilagenous helical rim ± lobule defect 2­stage procedure Post­auricular tubed pedicle created & attached to auricle Division with inset after 3 weeks Flap design Defect edge to proposed helical rim edge X 2 Defect length + several mm Close donor primarily Ellabban, MG, et al. Br J Plast Surg 2003 Bi­Pedicle Post­Auricular Tube Flap Bi­Pedicle Post­Auricular Tube Flap Ellabban, MG, et al. Br J Plast Surg 2003 Chondrocutaneous Rotation Flap Chondrocutaneous Rotation Flap Defects Scapha, antihelix, triangular fossa ≤ 2cm Flap design Create wedge­shaped cutaneo­cartilaginous defect Incise scapha Elevate cutaneo­ cartilaginous flaps superiorly & inferiorly Ladocsi, L. Plast Reconstr Surg 200 Chondrocutaneous Rotation Flap Chondrocutaneous Rotation Flap Ladocsi, L. Plast Reconstr Surg 200 Postauricular Island Pedicle Flap Postauricular Island Pedicle Flap Defects Conchal skin defect ± caritlage Flap design Postauricular skin & subcutaneous tissue Incise flap periphery Inset­ “revolving door” Redondo, P et al. J Cutan Med Surg 2003 Postauricular Island Pedicle Flap Postauricular Island Pedicle Flap Redondo, P et al. J Cutan Med Surg Peninsular Conchal Axial Flap Peninsular Conchal Axial Flap Defects Upper 1/3 of auricle Middle 1/3 of auricle Flap Design Based on Superficial temporal artery Posterior auricular artery Incise conchal skin & cartilage laterally Incise medial skin Remove medial skin Rotate/transpose flap Skin graft Dagregorio, G et al. Dermatol Surg 2005 Peninsular Conchal Axial Flap Peninsular Conchal Axial Flap Dagregorio, G et al. Dermatol Surg 2005 Crusotomy Crusotomy Defects Superior conchal lesion Technique 2 incisions Crus along tragal meeting point & extend superiorly Inferior crus attachment to cavum Banar, M et al. Dermatol Surg 2003 Retroauricular Advancement Retroauricular Advancement Flap Defects Large Flap design First stage Often combine contralateral conchal cartilage Retroauricular skin elevation & advancement Second stage 2­4 weeks Division & inset flap Butler, CE. Ann Plast SurgI 2002 Retroauricular Advancement Flap: Retroauricular Advancement Flap: Stage 1 Butler, CE. Ann Plast SurgI 2002 Retroauricular Advancement Flap: Retroauricular Advancement Flap: Stage 1 Butler, CE. Ann Plast SurgI 2002 Retroauricular Advancement Flap: Retroauricular Advancement Flap: Stage 2 Butler, CE. Ann Plast SurgI 2002 Retroauricular Advancement Flap: Retroauricular Advancement Flap: Results Butler, CE. Ann Plast SurgI 2002 Perichondritis and Chondritis Perichondritis and Chondritis Perichondrium or cartilage inflammation post­injury predisposes to tissue ischemia Pseudomonas infection may ensue May cause liquefactive necrosis Prevention Careful cartilage manipulation Sterile technique Prophylatic antibiotics: anti­Psuedamonal Kaplan, AL et al. Dermatol Surg 2004 Fundamental Tools Fundamental Tools Temporoparietal Fascia Flap Temporoparietal Fascia Flap Temporoparietal fascia Most superficial layer beneath temporal subcutaneous fat Continous with Galea superiorly SMAS inferiorly Blood supply = superficial temporal artery Dimensions 2­4mm thick 14 X 17cm area Salem DK, Cheney ML. Arch Otolaryngol Head Neck Surg. 1995 Temporoparietal Fascia Flap Temporoparietal Fascia Flap Harvest Preauricular facelift incision extended temporally Dissect subcutaneous plane over temporoparietal fascia to zygomatic arch and frontal branch (CNVII) Incise periphery­ defect size Pearls Maintain fat layer on skin side­ avoids hair loss Remain posterolateral to frontal branch (CN VII) Do not harvest beyond temporal line­ avoids distal necrosis Dolan R. Dermatol Surg 2000 Temporoparietal Fascia Flap Temporoparietal Fascia Flap Skin Grafting Skin Grafting Fundamental reconstruction option Cutaneous free tissue transfer Separate from donor site Transplant to recipient site Secondary intention & primary closure not possible Adams, D et al. Dermatol Surg 2005 Skin Grafting Skin Grafting Survival dependent upon blood supply establishment 1st 24 hours 48 – 72 hours Imbibition: absorbs transudate Inosculation: vascular anastamoses 4 – 7 days Circulation restoration Adams, D et al. Dermatol Surg 2005 Skin Grafting Skin Grafting 3 primary types Full­thickness skin graft (FTSG) Epidermis + dermis ± subcutaneous tissue Split­thickness skin graft (STSG) Epidermis + variable thickness of dermis 0.005 – 0.028 inches Composite skin graft 2 or more germ layers tissue Adams, D et al. Dermatol Surg 2005 FTSG FTSG Easy harvest Minimal contraction Necrosis more common than STSG Common donor sites for facial defects Preauricular Postauricular Supraclavicular Clavicular Adams, D et al. Dermatol Surg 200 STSG STSG Nutritional requirements ↓ : ↑ survival Mesh ↑ surface area Last resort for cosmesis Contraction Donor site Size Wound care Activity Cosmesis Adams, D et al. Dermatol Surg 2005 Complications Complications Infection Hematoma Perichondritis & chondritis Failure Poor cosmesis Conclusion Conclusion Maintain function, then cosmesis Careful patient assessment Consideration of multiple techniques Informed consent Bibliography Bibliography Adams, D et al. Grafts in dermatologic surgery: review and update on full­ and split­thickness skin grafts, free cartilage grafts, and composite grafts. Dermatol Surg 2005; 31: 1055­1067. Akyurek M, et al. Microsurgical ear replantation without venous repair: failure of development of venous channels despite patency of arterial anastomosis for 14 days. Ann Plast Surg 2001; 46: 439­443. Alam, M et al. Two­lobed advancement flap for cutaneous helical rim defects. Dermatol Surg 2003; 29: 1044­1049. Banar, M et al. Crusotomy: a safe, simple surgical technique to facilitate resection and reconstruction of poorly accessible auricular tumors. Dermatol Surg 2003; 29: 1217­1221. Brodland, DG. Auricular reconstruction. Dermatol Clin 2005; 23: 23­41. Butler, CE. Extended retroauricular advancement flap reconstruction of a full­thickness auricular defect including posteromedial and retroauricular skin. Ann Plast SurgI 2002; 49: 317­321. Dagregorio, G et al. Peninsular conchal axial flap to reconstruct the upper or middle third of the auricle. Dermatol Surg 2005; 31: 350­355. Dolan R. Resurfacing extensive malar and preauricular cutaneous defects with pedicled temporoparietal fascia. Dermatol Surg 2000; 10: 949­954. Ellabban, MG, et al. The bi­pedicle post­auricular tube flap for reconstruction of partial ear defects. Br J Plast Surg 2003; 56: 593­598. Frodel JL, et al. Salvage of partial facial soft tissue avulsions with medicinal leeches. OtolaryngolHead Neck Surg 2004; 131: 934­939. Ghanem T, et al. Rethinking auricular trauma. Laryngoscope 2005; 115: 1251­1255. Hendi, A et al. Split­thickness skin graft in nonhelical ear reconstruction. Dermatol Surg 2006; 32: 1171­1173. Horlock N, et al. Psychosocial outcome of patients after ear reconstruction. Ann Plast Surg 2005; 54: 517­524. Kaplan, AL et al. The incidences of chondritis and perichondritis associated with the surgical manipulation of auricular cartilage. Dermatol Surg 2004; 30: 58­62. Kyrmizakis DE, et al. Nonmicrosurgical reconstruction of the auricle after traumatic amputation due to human bite. Head Face Med 2006 1; 2: 45. Ladocsi, L. Perforator­preserving chondrocutaneous rotation flap reconstruction of auricular defects. Plast Reconstr Surg 2003; 112: 1566­1572. Leibovitch, I et al. The Australian Moh’s database: short­term recipient­site complications in full­thickness skin grafts. Dermatol Surg. 2006; 32: 1364­1368. Ozturk S, et al. Reconstruction of acquired partial auricular defects by porous polyethylene implant and superficial temporoparietal fascia flap in adult patients. Plast Reconstr Surg 2006; 118: 1349­1357. Reddy, LV et al. Reconstruction of skin cancer defects of the auricle. J Oral Maxillofac Surg 2004; 62: 1457­1471. Redondo, P et al. Aggressive tumors of the concha: treatment with postauricular island pedicle flap. J Cutan Med Surg 2003; 339­343. Ridha H, et al. The use of dextran post free tissue transfer. J Plast Reconstr Aesthet Surg 2006; 59: 951­954. Salem DK, Cheney ML. An anatomic study of the temporoparietal fascial flap. Arch Otolaryngol Head Neck Surg. 1995;121:1153­1156. [Description of flap taken directly from article] Schonauer F, et al. Three cases of successful microvascular ear replantation after bite avulsion injury. Scand J Plast Reconstr Surg Hand Surg 2004; 38: 177­182. Shieh SJ, et al. Tissue engineering auricular reconstruction: in vitro and in vivo studies. Biomaterials 2004; 25: 1545­1557. Silapunt, S et al. Squamous cell carcinoma of the auricle and Mohs Micrographic Surgery. Dermatol Surg 2005; 31: 1423­1427. Steffen, A et al. A comparison of ear reattachment methods: a review of 25 years since Pennington. Plast Reconstr Surg 2006; 118: 1358­1364. Stierman KL, et al. Treatment and outcome of human bites in the head and neck. Otolaryngol Head Neck Surg 2003; 128: 795­801. Yong L, et al. Successful auricle replantation via microvascular anastamosis 10h after complete avulsion. Acta Otolaryngol 2004; 124: 645­648. ...
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