Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, e615ee618

CASE REPORT

Infratemporal fossa reconstruction following totalauriculectomy: An alternative flap option

David T. Pointer Jr a, Paul L. Friedlander b, Ronald G. Amedee b,Perry H. Liu a, Ernest S. Chiu a,*

a Tulane School of Medicine, Division of Plastic Surgery, 1430 Tulane Avenue SL-22, New Orleans, LA 70112, USAb Tulane School of Medicine, Division of Otolaryngology, 1430 Tulane Avenue SL-22, New Orleans, LA 70112, USA

Received 10 November 2009; accepted 22 January 2010

KEYWORDSSupraclavicular arteryflap;Auriculectomy;Lateral skull basedreconstruction;Infratemporal;Pedicled myocutaneousflaps;Tunnelledsupraclavicular arteryisland flap

* Corresponding author. Tel.: þ1 504E-mail address: eschiu@gmail.com

1748-6815/$-seefrontmatterª2010Britdoi:10.1016/j.bjps.2010.01.027

Summary Reconstruction following oncologic resection in the head and neck is complex dueto large surgical defects left after removal of skin, subcutaneous, and skeletal structures. It isessential to adequately fill the defect as well as provide an acceptable tissue match in terms oftone, texture, thickness and contour. A 55-year-old male presented with an advanced mela-noma in the right pre-tragal area. Surgical resection was performed including a total auricu-lectomy. A tunnelled right supraclavicular artery island (SAI) flap was used to repair thesurgical defect. A Doppler probe ensured adequate circulation within the flap, especially inthe distal tip. Reconstruction using the SAI flap after oncologic ear resection reduced operatingroom time, required less technical expertise, and provided excellent tissue match compared tomore traditional methods of surgical defect reconstruction including free flaps, local flaps, andpedicled myocutaneous flaps. Successful use of the SAI flap in this case further expands theflaps versatility. We recommend that the reconstructive surgeon consider the SAI flap whenpresented with challenging infratemporal fossa and lateral skull base cases.ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

Reconstructive options in the head and neck, followingoncologic resection, are numerous and strive to provideoptimal defect closure and cosmetic outcomes. Treatmentof lateral skull based tumours often involves large tissueresections requiring removal of skin, subcutaneous

988 5500; fax: þ1 504 988 3740(E.S. Chiu).

ishAssociationofPlastic,Reconstruc

structures (auricle, parotid gland, infratemporal contents),and skeletal structures.1 The preferred procedure is a wideen bloc resection of the tumour with free surgical margins.2

Successful reconstruction of these defects must adequatelyfill their complex shape and provide an acceptable match

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tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

e616 D.T. Pointer Jr et al.

regarding contour, texture, thickness, and skin tone toadjacent local tissue.3,4 In the past, local tissue flaps, freetissue flaps and pedicled myocutaneous flaps were used toreconstruct lateral skull based defects involving theauricle. However, many of these options resulted in a sub-optimal outcome for the patient. Regional myocutaneousflaps such as the trapezius flap or the deltopectoral flapleave patients disfigured with significant functionalmorbidities. Free tissue transfers avoid the morbidities ofthe regional flaps but require technical expertise andincreased operative time. These methods also fail toprovide adequate tissue match for the reconstructed area.5

The supraclavicular artery island (SAI) flap provides anideal local fasciocutaneous flap alternative to the freetissue and regional flaps described above. Based on thesupraclavicular vessels arising from the thyrocervical trunk,the supraclavicular artery flap is a pedicled flap that maybe tunnelled to avoid visible scarring on the neck.5,3 Theflap is demarcated by the posterior border of the sterno-cleidomastoid, the clavicle and the external jugular vein.This technique provides superior tissue colour and texturematch compared to traditional flap options. In addition,when compared to free flap reconstruction, utilisation ofthe SAI flap decreases operative time and does not requiresophisticated microvascular techniques.5

In this report, we present a case using supraclavicularartery island flap to reconstruct a lateral skull base defectfollowing ablative surgery for a melanoma of the auriclewith extension into the infratemporal fossa.

Case report

A 55-year-old Caucasian man presented with an advancedmelanoma located in the right pre-tragal area (Figure 1).The patient was noted to have a congenital nevus whichhad undergone increased growth during the last six or sevenyears. The patient sought medical treatment when hedeveloped a large swelling in the right parotid area. Biopsyof the auricle and subsequent imaging (CT/PET) revealeda T4aN2M0 melanoma of the ear metastatic to the rightparotid and neck.

Figure 1 Preoperative presentation with advancedmelanoma in the right pre-tragal area.

The patient was seen by the Tulane Health SciencesCentre Head and Neck multidisciplinary team, and surgicalextirpation was recommended. A total auriculectomy, widelocal excision of the cheek, supraomohyoid neck dissection,lateral temporal bone resection, and infratemporal fossaresection were performed by the head/neck surgicaloncologists. A large common cavity, including the externalauditory canal and the mastoid cavity, was created asa result of the resection. There was no attempt to re-createan external ear canal. The opening to the eustachian tubewas occluded with Gelfoam and bone wax to prevent re-pneumatization of the post-op cavity Figure 2.

The patient was reconstructed using a tunnelled rightsupraclavicular artery island flap to cover the exposedtemporal bone and infratemporal fossa. The pedicle wasidentified intraoperatively using an 8 MHz Koven Doppler. Itwas located in the anatomical triangle bordered by thesternocleidomastoid, the clavicular bone, and the trapezius.A 6� 20 cm dimension flap was marked over the ipsilateralshoulder utilising the Doppler signal auscultated proximally.Skin incisions were made and the flap was dissected ina distal to proximal subfascial plane using electrocautery. Asdissection neared the pedicle, bipolar forceps were used formore precise dissection. After islanding the flap, a Dopplersignal was appreciated on the skin paddle. Dissectionstopped once enough tissue was acquired to reach thedefect without tension, pedicle length was about 3 cm.Anatomical variations that can exist6 in the vasculature ofthis flap were taken into consideration during dissection.The pedicle was not skeletonised completely to avoid injury.The flap was then rotated 180 degrees to cover the defect.Harvest was completed in 45 minutes and the tip demon-strated excellent bleeding. The proximal and distal flap skinwas de-epithelialized and tunnelled under the intact suppleneck skin. There was a strong Doppler signal in the middle ofthe flap. The shoulder donor site was closed primarilywithout significant functional donor site morbidity(Figure 4a). Final pathology revealed a multinodular

Figure 2 Intraoperative surgical defect and mapped SAI flap.

Figure 3 6-month postoperative view.

Infratemporal fossa reconstruction following total auriculectomy e617

melanoma arising from a congenital nevus (2.5 cm in depth)with extension into the adipose tissue. There was no sign ofnodal disease and margins were negative. The final stagewas a T4N0M0 melanoma.

Six month follow-up demonstrates normal facial nerveand donor site shoulder function. No additional surgicalrevisions were required. Patient was offered ear recon-struction, but didn’t oblige. His neck and shoulderdemonstrates full range of motion Figure 3.

Discussion

Soft tissue reconstruction following auriculectomy can bechallenging. In this report, we demonstrate the use of SAIflap for coverage of this defect. Kazanjian and Conversewere first to document the clinical use of a flap from theshoulder region. 7 In 1979, Lamberty et al. 8 describedthe flap on the basis of its blood supply, now called thesupraclavicular artery. Throughout its evolution, thesupraclavicular artery flap has been the subject of contro-versy, predominantly criticised due to a high incidence ofdistal tip necrosis.9 After some modification the flap wasutilised for new indications, i.e. reconstruction following

Figure 4 9-month postoperative view: (a) SAI flap donor s

the resection of burn scars.3 The supraclavicular artery flapthus was re-discovered as a dependable reconstructiveoption, and confirmed by others for reconstructing facialand chest defects.4

In the past, the predominant reconstructive optionsfollowing oncologic temporal bone resection have been localskin flaps, pedicled myocutaneous flaps, and free tissueflaps. Local flaps are not ideal due to their limits in size andlack or versatility.10 Regional pedicled myocutaneous flaps,such as the pectoralis major flap and trapezius flap, arebulky and have length limitations.11 Free tissue transfer hasbeen the choice reconstructive option of late for lateral skullbased tumour resections. More specifically, these flapsinclude the radial forearm flap, anterolateral thigh flap,rectus abdominus flap, and latissimus dorsi flap.10,11

Though free flaps have numerous beneficial qualities,they require a high level of technical skill, specific opera-tive equipment and longer operative time.5 Moncreiffet al.10 documented a 90 minute increase in operative timewhen using a free flap compared to a pedicled flap. Thetunnelled supraclavicular artery island flap is a pedicledflap and offers many of the same benefits of fasciocuta-neous free flaps. For these reasons, the tunnelled SAI flapwas chosen to reconstruct the lateral skull based defectpresented in this case.

A pedicled flap based on the supraclavicular vessels, theSAI flap is initially mapped preoperatively using a DopplerProbe.3 The flap has become more popular over the pastdecade and is now tout as a reliable and versatile methodthat can be used in place of free flaps, local tissue flaps orregional flaps in facial reconstruction. The advantages of thesupraclavicular island flap are 1) simplicity, 2) reduced donorsite defect and 3) excellent skin match in terms of colour,texture and thickness.3 Also, the pliable hairless surface ofthe SAI flap yields excellent facial tissue match. Further-more, the SAI flap may be tunnelled - reducing unsightlyincisions and resulting in an improved aesthetic outcome.4

The supraclavicular artery flap was successfully per-formed to restore soft tissue after oncologic ear resection,thus expanding the versatility of this flap. We recommendthat the supraclavicular artery island flap be considered bythe reconstructive surgeon when encountering this chal-lenging problem.

ite; (b) full range of motion demonstrated in both arms.

e618 D.T. Pointer Jr et al.

Conflict of interest statement

This work has not been submitted for publication, and noneof the authors have conflict of interest using any of theproducts.

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