We describe refinements to the original chondrocutane- ous advancement flap described by Antia and Buch for the reconstruction of the upper to mid-pole of the ...
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C O A
12489
Journal Code
Manuscript No.
Dispatch: 1.7.15
CE: Nivetha
No. of pages: 3
PE: Nagappan
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TECHNICAL NOTE
1 The Antia–Buch flap revisited 1 2 2 Tay, S.,* Nikkhah, D.† & Teo, T.C.* 3 † 43 *Queen Victoria Hospital, East Grinstead, Royal Free Hospital London, London, UK Accepted for publication 3 June 2015 Clin. Otolaryngol. 2015, 00, 000–000
appropriate margins (Fig. 1). A crescent was then marked which extended superiorly and inferiorly following the contour of the antihelical rim. The rationale of taking a further crescent was to reduce the circumference of the ear and hence reduce distortion and buckling of the ear (Fig. 1). The anterior skin and cartilage were then excised and the posterior skin dissected off the posterior surface of the cartilage. It is imperative that a wide area is undermined (Fig. 2) and this allows sufficient advancement of the skin flaps and tensionless closure. In our experience, lack of undermining is the most common error when performing the Antia–Buch flap. Local anaesthetic infiltration with adrenaline in the area of dissection creates a bloodless field and facilitates easier advancement of the flap (Fig. 2). Occasionally, the tumour resection extends anteriorly and the helical root may be mobilised as part of the crescenteric excision (Fig. 1). However, the inferior flap can be mobilised much more than the superior flap (Fig. 2) and rarely is it necessary to perform a V-Y advancement from the helical root of the ear. The cartilaginous skeleton of the ear is then repaired with 6.0 MonocrylTM to minimise distortion and allow for easier closure of the skin. Finally, the edges of the defect are then mobilised towards each other and sutured with 6.0 nylonTM. The reconstructed ear is then dressed with JelonetTM and sponge (Fig. 2), and compressive Pinnaplasty type Crepe bandage is applied.
Background
About 10% of all basal and squamous cell carcinomas occur on the ear or pre-auricular area. The mainstay treatment of such lesions is surgical excision. The reconstruction of the defect that is left after complete excision remains a challenge for the surgeon due to the complex shape of the ear and thin adherent skin. The standard reconstructive options available are wedge excision with direct closure, skin grafting, local skin flaps, chondrocutaneous advancement flaps (as described by Antia and Buch)1 and multistaged reconstruction with tube pedicles. However, the sheer number of options suggests that none of these is perfect.2–4 We describe refinements to the original chondrocutaneous advancement flap described by Antia and Buch for the reconstruction of the upper to mid-pole of the external ear using a single-stage procedure that maintains both the shape and projection of the affected ear. Our primary aim in this study was to describe simple steps to help optimise reconstruction of helical rim defects by minimising cupping and distortion. Methods
Our modified technique was performed in 32 consecutive patients (36 Helices). These patients had undergone either fullthickness excision of tumour, or wider local excision of tumour when it extended close to the excision margins. The length of the resultant defect was measured as the distance between the two limbs of the excision margin at the level of the helical rim.
Results
Surgical technique
All procedures were performed under local anaesthetic with adrenaline. The great auricular nerve was blocked with 0.25% bupivicaine, and the ear itself was also injected with 2% lignocaine with 1:100 000 adrenaline, to create a bloodless field. The lesion was marked and excised with
Correspondence: D. Nikkhah, Royal Free Hospital. Pond Street, London, UK. Tel.: +00 000 000; Fax: +00 000 000; e-mail: dariushnikkhah@hotmail. com © 2015 John Wiley & Sons Ltd Clinical Otolaryngology
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The median follow-up of the 32 patients (30 Male: 2 female) was 10 months (3–18). The median age was 77 years (58–93). The mean length of the defect was 25 mm (range 20–40 mm). There were no major complications such as flap necrosis. There were only two minor complications: one with superficial infection requiring a short course of oral antibiotics and one with a stitch abscess that resolved spontaneously. Furthermore, there were no incomplete excisions. One patient reported difficulty in maintaining the position of his hearing aid after the operation due to loss of projection of the ear. In all cases, a natural looking external ear with no cupping or distortion was achieved. 1
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COLOR
COLOR
2 S. Tay et al.
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(a)
(b)
(c)
(d)
Fig. 1. (a–d) Preoperative markings anterior (a) and posterior (b) with injection sites over great auricular nerve, conchal bowl and superior aspect of ear (a). If the ear is closed as a simple wedge significant cupping and distortion can occur (c), distortion and buckling is further reduced by removing a crescent of cartilage (d).
(a)
(b)
(c)
(d)
Fig. 2. (a–d) Significant undermining of the posterior skin of the ear from the cartilage is necessary to allow the significant advancement of the inferior chondrocutaneous flap (a, b). Final result with postoperative dressing application of foam and Jelonet (c, d).
Discussion
The ideal reconstruction should be simple, safe, and single staged and leave a cosmetically pleasing unit with minimal cupping. None of the commonly used techniques meet all these requirements. Direct closure
following resection is possible following wedge excisions of the lesion around the lobule where there is sufficient laxity to allow minimal deformity of the ear contour. However, in the upper pole, this method almost always cups the ear with increased projection, thus making it more noticeable (Fig. 1). © 2015 John Wiley & Sons Ltd Clinical Otolaryngology
Antia–Buch flap revisited
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Skin grafting is a simple and acceptable option where the tumour has not invaded the perichondrium or where the tumour is in the concha where defects in structure-giving cartilage will not be noticeable. It is seldom suitable for the reconstruction of a defect in the helical rim. Tubed pedicles provide good cosmesis; however, it is a multistage process. The latter may not be ideal for tumour reconstruction especially as this group of patients is generally older and may have other significant comorbidities. The chondrocutaneous advancement flap described by Antia and Buch is a good method of reconstructing defects of the helix; however, where the defect is large (more than 1.5 cm), significant cupping occurs. Unlike Antia and Buch’s original description, we include removal of a crescent of cartilage and emphasise the accurate suturing of the underlying cartilage. These modifications have allowed us to comfortably reconstruct the ear with defects of up to 40 mm with minimal change in projection. The scarring is also well hidden within the contours of the ear. Furthermore using the surgical steps described, it is rarely necessary to mobilise the helical root of the ear.5 The disadvantage of the technique is that the vertical height of the ear is reduced due to the crescenteric excision at the expense of cupping. However, as both ears are rarely viewed simultaneously in any facial view, this is not usually a problem. Keypoints
•
The authors describe the use of a modified Antia–Buch flap for middle and upper third defects of the helical rim.
© 2015 John Wiley & Sons Ltd Clinical Otolaryngology
• •
3
They describe technical steps to minimise cupping and contour irregularities in a series of 32 patients. These easily reproducible modifications can comfortably reconstruct the ear with defects of up to 40 mm with minimal change in projection.
Conflict of interests
None. References 1 Antia NH & Buch VI (1967) Chondrocutaneous advancement flap for the marginal defect of the ear. Plast. Reconstr. Surg. 39, 472–477 2 Butler CE (2003) Reconstruction of marginal ear defects with modified chondrocutaneous helical rim advancement flaps. Plast. Reconstr. Surg. 111, 2009–2013 3 Bialostocki A & Tan ST (1999) Modified Antia-Buch repair for fullthickness upper pole auricular defects. Plast. Reconstr. Surg. 103, 1476–1479 4 Low DW (1998) Modified chondrocutaneous advancement flap for ear reconstruction. Plast. Reconstr. Surg. 102, 174–177 5 Noel WLP & Quilichini J (2014) Modified Antia-Buch for the reconstruction of helical rim defects. J. Plast. Reconstr. Aesthet. Surg. 9 ????, ????–????
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COA
Article:
12489
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