Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 1145e1151

Post-traumatic ear reconstruction usingpostauricular fascial flap combined with expandedskin flap

Yu Xiaobo, Jiang Haiyue*, Zhuang Hongxing, Pan Bo, Liu Lei

Peking Union Medical College, Plastic Surgery Hospital of Chinese Academy of Medical Sciences, Beijing 100144, China

Received 9 December 2010; accepted 27 March 2011

KEYWORDSPostauricular fascialflap;Expanded skin flap;Autogenous rib-cartilage framework;Post-traumatic earreconstruction

* Corresponding author. 33 BadachuBeijing 100144, China. Tel./fax: þ86

E-mail address: jianghaiyue@yaho

1748-6815/$-seefrontmatterª2011Bridoi:10.1016/j.bjps.2011.03.040

Summary Introduction: Post-traumatic ear reconstruction still remains a great challenge forplastic surgeons. In this article, we present the technique of post-traumatic ear reconstructionusing a postauricular fascial flap combined with an expanded skin flap.

Methods: From May 2007 to June 2009, 91 cases of post-traumatic ear defect were treatedusing a postauricular fascial flap combined with an expanded skin flap. Surgical procedureincluded postauricular-skin-flap expansion, removal of tissue expander, autogenous rib-cartilage-framework implantation, postauricular-fascial-flap lifting and split-thickness free-skin grafting.

Results: With a follow-up duration of 6 months to 1 year, the described technique provideda nice final result, and the reconstructed ears showed good match in size, shape, colour andlocation to the contralateral normal ear.

Conclusion: Post-traumatic ear reconstruction using a postauricular fascial flap combinedwith an expanded skin flap is an ideal approach with good final results.ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

Satisfactory treatment of severe post-traumatic ear defectstill remains a great challenge for plastic surgeons. The eardefects can result in significant physical and psychologicalissues including depression, loss of confidence, anxiety andpoor social interaction. Based on our former technique ofusing an expanded skin flap with a postauricular fascial flapin microtia reconstruction,1,2 we modified the technique

Road, Shijingshan District,(0) 10 88772133.o.cn (J. Haiyue).

tishAssociationofPlastic,Reconstruc

into a two-stage method and found it suitable for recon-struction of post-traumatic auricular defects. A lowcomplication rate and high patient satisfaction were noted.

Patients and methods

Patients

This project was assessed and approved by the Ethics andResearch Committee and informed consent was signed byall patients. All patients were treated in the Auricular

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Table 1 Location of Auricular Defects.

Location of Defect

Upper 2/3 35Upper 1/3 31Middle 1/3 9Lower 2/3 11Total loss 5Total 91

1146 Y. Xiaobo et al.

Department of Plastic Surgery Hospital of Chinese Academyof Medical Sciences. Of these patients, 77 were male and 14female. The average age of the patients at the time of theinitial surgery was 21.3 years (range Z 9e45 years). Thelocation of defects is categorised in Table 1. One year afterear reconstruction was accomplished, an aesthetic assess-ment of the reconstructed ears was carried out by anattending doctor and patients (parents when the patient’sage was under 18 years). Five groups of parameters(aspects) were scored: (1) location and size; (2) projectionof symmetry (compared with opposite normal ear); (3)appearance of helix, antihelix, triangular fossa, earlobe,concha and tragus; (4) convolution, thickness and colourmatch; and (5) stability and endurance. Each group ofparameters was graded on a 10-point scale. Final resultswere graded as excellent when each aspect was marked noless than 8, good when one or more aspect was marked 7,fair when one or more aspect was marked 6 and poor whenone or more aspect was marked 5 or less.

Surgical procedure

The surgical procedure is divided into two stages: (1)implantation of a properly sized tissue expander at themastoid region and postauricular skin expansion; and (2)expanded skin flap and postauricular-fascial-flap dissectionafter removal of the expander, implantation of the rib-cartilage framework and split-thickness free-skin grafting.

Figure 1 Expander was dissected along the surface of the capsuflap was finally harvested.

First stage: tissue-expander implantation followedby skin expansion

In this stage, a kidney-shaped skin expander, with a 50e80-ml potential volume, was implanted, as we demonstratedin previous publications.3,4 The final inflation volume of theexpander usually reached 60e90 ml; then, the staticexpansion phase followed for another month before thesecond-stage operation.

Second stage: expander removal, expandedpostauricular skin flap and postauricular fascial flapformation, rib-cartilage framework implantationand split-thickness free-skin grafting

Expander removal, expanded postauricular skin flap andpostauricular fascial flap formationAllocation of expanded skin and fascial flap is determinedby the remaining ear size and defect position. A curvilinearskin incision at the most posterior aspect of the expandedskin was performed. Then, the expander was dissectedalong the surface of the capsule around it, and an anteri-orly pedicled expanded skin flap was finally harvested(Figure 1). It is necessary to appropriately remove thecapsule to get a thinner skin envelope, which can drapeeasily around the details of the new ear. However, careshould be taken to avoid injuring the vessels of theexpanded skin flap. For the upper-part ear defect or totalear loss, the expanded skin is not enough to cover thethree-dimensional (3D) framework; another incision 2e4-cm in length vertical to the temporal hairline is made forthe exposure and harvesting of the postauricular fascialflap. The fascial flap was about 7e9 cm and designed tocover the margin of cartilage framework totally. Both thepostauricular fascial flap and the expanded skin flap wereanteriorly pedicled when the postauricular fascial flap waselevated; then, a two-flap structure like a sandwich wasprepared for wrapping the rib-cartilage framework(Figure 2). For the lower-part ear defect, the expanded skinflap can usually wrap the whole framework without thefascial flap (Figure 3).

le around the expander, an anteriorly pedicled expanded skin

Figure 2 During the second operation, after the expander was removed, an anteriorly based expanded skin flap was shaped anda postauricular fascial flap was harvested to wrap the cartilage framework.

Post-traumatic ear reconstruction using postauricular fascial flap combined with expanded skin flap 1147

Rib-cartilage framework implantation and split-thicknessfree skin graftingBased on the amount of the defect of auricle and thedevelopment of the chest, rib cartilages were harvestedfrom the sixth to the eighth ribs. The cartilage frameworkwas fabricated using 5/0 steel or titanium wires following anear template. The ear template was produced according tothe contralateral normal ear size on a transparent filmbefore operation. Subsequently, the cartilage frameworkwas inserted and fixed at the desired position and projectionbetween the fascial flap and the expanded skin flap. Thefascial flap was reversed and sutured onto the helix of theframework. The expanded skin envelope was draped overthe anterior part of the framework and helix, and a smallround suction drain was placed along the inside rim of thehelix. As negative pressure was applied, the convoluted, 3Dcontour of the auricle framework appeared. Finally, if theear defect was total ear loss and the expanded skin was notbig enough to cover the framework, then, the postauricularraw areawas surfaced by a thick fusiform split-thickness skinharvested at the thoracic incision site. The skin graft wassutured to themastoid region andwrapped in a dressing. Thesuction drains and the sutures were removed 5 and 10 days,respectively, after the operation.

Figure 3 Lower part reconstruction using tissue expansio

Results

As many as 91 cases of ear reconstruction were performedin the period from May 2007 to June 2009. The patientswere all followed up in our department regularly since thefirst surgery, and the postoperative follow-up time rangedfrom 6 to 12 months. After the first stage, haematoma wasobserved in one patient, in which case evacuation wasperformed and expansion continued without other compli-cations. There were no cases of exposure or extrusion ofthe auricular framework, chest-wall deformities, partialnecrosis of the expanded skin flap or cartilage infection inany of the 91 cases. Severe postoperative oedema wasnoted in eight cases but gradually vanished 1 month post-operatively (Table 2). All patients were involved in the finalaesthetic assessment: 28 ears showed excellent result and46 ears showed good result, and 81.3% of patients weresatisfied with their new ear (Table 5). The expanded skinand fascial flaps were thin enough to show the subtledetails of the reconstructed ears when the oedema van-ished gradually from 3 to 6 months postoperatively. Thenew ear had a stable shape and its skin colour and textureshowed good match to the normal surrounding skin (Figures4 and 5) (Table 3 and Table 4).

n without fascial flap and split-thickness skin grafting.

Table 2 Postoperative Complications.

Complication No. Patients Management Outcome

Haematoma 1 evacuation was performedand expansion continued

Cartilageexposure

0

Chest walldeformities

0

Postoperativeedema

8 Improved 3 monthspostoperatively

Hypertrophicscarring

2 Improved with localsteroid injection

Total 11

1148 Y. Xiaobo et al.

Discussion

Ear reconstruction using autogenous rib-cartilage frame-works has become the standard technique for microtiapatients. Skin expansion has been suggested as an ancillarytechnique for patients with tight skin or an inadequateamount of skin.5 However, over the past 10 years, tissueexpansion has gradually become accepted as a usefuladjunct to ear reconstruction with an autologous frame-work.6,7 The advantage of expanded tissue in these cases

Figure 4 Patient: preoperative and

has been the addition of more tissue with similar colour,texture and sensation. In our traumatic cases, the creationof well-vascularised tissue allows an improved anteriordraping of skin over the cartilaginous framework andproduction of a well-defined posterior sulcus. Encroach-ment of hair onto the reconstructed ear is minimisedbecause of the extra tissue produced by expansion. Underfavourable conditions, tissue expansion is an acceptableand reliable method for partial or total ear reconstruction.

The soft-tissue coverage traditionally used is a local skinflap or superficial temporal fascial flaps and skin graftcombinations.6,8 However, with respect to superficialtemporal fascial flaps for coverage of the auricular frame-work, complications related to the harvesting of superficialtemporal fascial flaps must be mentioned. Visible donorscars and alopecia in male patients were common compli-cations. Ideal auriculocephalic angle did not appear afterthe cartilage framework was planted in the subcutaneouspocket. To avoid these complications and considering thedemanding skills needed to harvest the superficial temporalfascial flaps, a postauricular fascial flap and an expandedpostauricular skin flap were used in our auricular centre.

The postauricular fascial flap is a neurovascular flap,which corresponds cephalad to the superficial temporalfascia. It is primarily supplied by the stylomastoid branch ofthe posterior auricular artery and can be elevated as ananteroinferiorly based flap. This fascia is also supplied by

postoperative results at 6 months.

Figure 5 Patient: preoperative and postoperative results at 12 months.

Post-traumatic ear reconstruction using postauricular fascial flap combined with expanded skin flap 1149

(1) the posterior branch of the superficial temporal arteryand/or the superior auricular artery and (2) the occipitalartery. Thus, the postauricular fascial flap can be elevatedin three directions: as an anteroinferiorly based flap (usingthe posterior auricular artery), a posteroinferiorly basedflap (using the occipital artery) or a superiorly based flap(using the superficial temporal artery).9 With these nutrientvessels, all these three pedicles have sufficient bloodsupplies to each direction. Based on the posterior auricularartery, we designed a fan-shaped postauricular fascial flap,which can totally embrace the cartilage framework. Thepostauricular fascial flap provides reliable soft-tissue coverand reduces the risk of flap necrosis secondary to tension.Compared with the temporoparietal fascial flap, elevating

Table 3 Results of aesthetic assessment（scored by patients o

Result(Location of Defect) Upper 2/3

location, size 8.5 � 1.1projection of symmetry (comparedwith opposite normal ear)

8.2 � 1.2

appearance of helix, antihelix,triangular fossa, earlobe, concha and tragus

8.5 � 0.5

convolution, thickness and colour match 8.4 � 1.3stability and endurance 8.2 � 1.1

the postauricular fascial flap to wrap the cartilage frame-work is simple and straightforward. Anatomical details ofthe framework completely showed in the follow-up 3months postoperatively. It also provides an excellent rescueoption for salvage of exposure of framework using theremnant temporoparietal fascial flap.

Recently, using an expanded postauricular skin flap hasbeen proved successful for microtia ear reconstruction inour centre.3 In our experience, it is also useful for trau-matic ear reconstruction. Compared with Park,7 weembedded the expander subcutaneously and attained thinpostauricular skin after expansion, and both the post-auricular fascial flap and the expanded postauricular skinflap formed a two-layer coverage to cover the framework.

r parents）(x�s).

Upper 1/3 Middle 1/3 Lower 2/3 Total loss

8.3 � 0.7 8.6 � 0.8 8.5 � 0.6 8.3 � 0.88.9 � 0.7 8.5 � 0.8 8.7 � 0.6 8.4 � 0.8

8.5 � 1.3 8.5 � 1.1 8.4 � 0.6 8.5 � 0.8

8.5 � 0.3 8.7 � 0.8 8.5 � 0.7 8.6 � 0.88.3 � 0.7 8.2 � 0.8 8.3 � 0.2 8.4 � 0.8

Table 4 Results of aesthetic assessment（scored by doctors）(x�s).

Result(Location of Defect) Upper 2/3 Upper 1/3 Middle 1/3 Lower 2/3 Total loss

location, size 8.5 � 1.1 8.5 � 0.7 8.5 � 0.5 8.5 � 0.6 8.8 � 0.3projection of symmetry(compared with oppositenormal ear)

8.4 � 1.1 8.5 � 0.7 8.8 � 0.7 8.5 � 0.6 8.6 � 0.5

appearance of helix, antihelix,triangular fossa, earlobe,conchal and tragus

8.6 � 0.1 8.7 � 0.7 8.5 � 0.8 8.6 � 0.6 8.7 � 0.8

convolution, thickness andcolour match

8.4 � 1.2 8.6 � 0.7 8.4 � 0.7 8.5 � 0.5 8.5 � 1.1

stability and endurance 8.5 � 1.1 8.4 � 0.7 8.5 � 0.2 8.3 � 0.6 8.6 � 0.8

1150 Y. Xiaobo et al.

The time of expanding was much shorter. Embeddingexpander subcutaneously was also easier than embeddingexpander subfascially and not demanding. The expandedpostauricular skin flap was thin, conforming, well-vascularised, hairless, sensitive, easily available and well-matched to the colour of the other ear. Moreover, as theprojection was often required, traditionally, the methodneeds another stage operation using a piece of the har-vested cartilage to insert into the postauricular area toform the auriculocephalic angle. A superficial tempor-oparietal fascial flap and a split-thickness graft were alsoneeded,6,10 increasing the patients’ expense and time cost.In our method, the expanded postauricular skin flapprovides enough skin without hair for wrapping the carti-lage framework. It could meet the need of projection justin one single stage.

Large composite defects involving the upper-third of theear or total ear loss are usually reconstructed witha combination of costal cartilage graft, fascial flap fornutrient support and full-thickness skin graft for cutaneouscoverage. The principle and most results are similar tomicrotia reconstruction. However, in the seminal article byWilkes et al., absent lower half of the ear is one of theindications for prosthetic reconstruction.11 Gault et al.6

reported using a local skin flap to reconstruct an ampu-tated ear lobe. The postauricular skin has the advantage ofbeing thin and non-hair bearing and good colour andtexture match; we used tissue expansion for extra post-auricular skin and found the fascial flap and skin graftingwere not needed in these case. Once the capsule wasremoved, the skin was thinner and the details of the newear were more easily seen; skin shrinkage was not notedpostoperatively in our cases.

Table 5 Results of the graded aesthetic assessment.

Result Case（scored bypatients orparents）

% Case（scored bydoctors）

%

Excellent 28 30.8 25 27.5Good 46 50.5 48 52.7Fair 15 16.5 13 14.3Poor 2 2.2 5 5.5Total 91 100 91 100

The patients’ satisfaction was followed-up in our centrevia a questionnaire regarding the results at latest follow-up. All patients were involved in the final aestheticassessment; 28 ears showed excellent result and 46 earsshowed good result, and 81.3% of patients were satisfiedwith their new ear (Table 5). Three patients were notsatisfied with the texture of the reconstructed part of ear,and two patients opined the reconstructed ear was notsymmetric to the other side. Overall, patients were satis-fied with the reconstructed ear.

Conclusions

The technique of enveloping a rib-cartilage framework witha combination of a postauricular fascial flap and anexpanded mastoid skin flap can meet the need for coverageof different size and height of cartilage ear framework inone single surgical stage. The details of the reconstructedtraumatic ear appeared completely in the follow-up 6months postoperatively. The results are promising and werecommend this technique as an ideal method for post-traumatic ear reconstruction.

Conflict of interest/funding

None.

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