Salvage of Ear Framework Exposure Following Autologous Microtia Reconstruction: Repair Strategy for Each Location of Exposure

Abstract

One of the most common complications of total auricular reconstruction is exposure of the ear framework. Various reconstruction methods have been reported depending on the location and size of exposed cartilage. This report describes a safe reconstruction method for each exposed part of the grafted ear framework. From January 2019 to August 2021, 2 cases (4 areas) of framework exposure were observed following autologous microtia reconstruction. The first case developed 2 small areas of skin necrosis on the anterior helix and lower antihelix to concha. The former was reconstructed with a temporal fascia flap and the latter with a local transposition flap. The second case also developed 2 small areas of skin necrosis on the posterior helix and lower antihelix to concha. The former was sutured directly and the latter with a local transposition flap. However, both wounds recurred due to flap necrosis and the cartilage was exposed again. The 3rd operation was performed by covering both wounds with a posterior auricular turnover flap and skin graft. In both cases, the exposed framework was completely covered with the flaps, and the reconstructed ears showed well-defined convolutions. Covering exposed cartilage with a local flap with a random pattern of blood circulation is convenient because no additional skin grafts are required. However, the blood circulation of the flaps is inadequate when an elongated flap is required; consequently, flap necrosis may occur. On the other hand, a temporal fascia flap and posterior auricular flap, which have axillary pattern blood circulation, are considered to be safer. We believe that it is safe to use a temporal fascia flap for cartilage exposure in the upper half of the auricle, and a posterior auricular turnover flap for the lower half.

Salvage of Extensive Skin Graft Necrosis After Auricle Reconstruction by Using Modified Nagata Method

“…Split-thickness skin grafting is a proven method for flap/graft salvage but is rarely used in reconstructed ear salvage surgery. [9][10][11] The primary concern is the occurrence of unsatisfactory survival of the secondary skin graft due to inadequate blood supply. A TPFF is reliable with its rich vascularity, and is the most commonly used method before.…”

“…9 Initially, they were proposed only for mild malocclusions, 10 and the range of malocclusions being treated with clear aligner therapy (CAT) has continued to expand, with some involving extractions or orthognathic surgery. 11,12 However, treating tooth extraction patients with CAs is difficult because their biomechanical effects are more complicated than those of traditional appliances. 13,14 We speculate that in cases with skeletal class III deformity that require extraction of maxillary premolars to decompensate, maxillary Le Fort I segmental osteotomy is applied to close part of the extraction space and correct the maxillary incisor axis, which not only saves preoperative orthodontic time but also avoids possible periodontal risks of the maxillary anterior teeth.…”

“…8 Multiple salvage method could be used in limited skin graft necrosis with cartilage exposure, such as TPFF with skin grafting, 9 preauricular perforator cutaneous flap, 10 and poste-rior auricular turnover flap. 11 Salvage of extensive skin graft necrosis ( > 20%) is rarely reported. From January 2016 to January 2023, 4 patients suffered extensive skin graft necrosis after ear elevation surgery.…”

“…Partial skin graft necrosis was reported to occur in 2.9% of patients 8 . Multiple salvage method could be used in limited skin graft necrosis with cartilage exposure, such as TPFF with skin grafting, 9 preauricular perforator cutaneous flap, 10 and posterior auricular turnover flap 11 . Salvage of extensive skin graft necrosis (>20%) is rarely reported.…”

Update on Total Auricular Construction

“…The authors recommend immediate closure with either a local skin or fascial flap in the operating room. 37 Some surgeons prefer to wait and allow the wound to heal spontaneously if the size of the skin defect is less than 1 cm. Kim et al analyzed 101 cases of PPE framework reconstruction, and 11 patients had framework exposure but no loss.…”