Surgical management of skin cancer and ... - Wiley Online Library

Minireview Submitted: 18.9.2017 Accepted: 1.12.2017

DOI: 10.1111/ddg.13544

Conflict of interest None.

Surgical management of skin cancer and trauma involving the middle third of the auricle

Diana Crisan1, Lars Alexander Schneider2, Sabine Kastler 1, Karin Scharffetter-Kochanek1, Maria Crisan3, Johannes Alexander Veit 4 (1) Department of Dermatology and Allergic Diseases, University Medical Center Ulm, Germany (2) Department of Dermatology and Dermatosurgery, Helios Clinic, Rottweil, Germany (3) Department of Dermatology, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania (4) Department of Otorhinolaryngology, Head and Neck Surgery, University Medical Center Ulm, Germany

Summary The main causes of acquired auricular defects are surgical treatment of skin tumors and trauma. Due to the complex anatomy of the external ear, surgical reconstruction of defects in this area is challenging for surgeons, especially in case of midhelix-antihelix involvement with significant loss of soft tissue and cartilage. Our purpose is to illustrate the main reconstructive techniques of large midhelix and antihelix defects, as well as the advantages or disadvantages associated with each surgical procedure. Primary closure/wedge technique is mainly used in elderly, multimorbid subjects where single-stage procedures are desirable, but several complex chondrocutaneous, retroauricular, temporoparietal full-thickness flap procedures can also be used to recreate an ear with normal appearance. Auricular reconstruction of large midhelix-antihelix defects requires a good knowledge of auricular anatomy and the various surgical procedures available for such defects.

Introduction The human ear is characterized by its complex cartilaginous anatomy; it is therefore essential to maintain or restore the shape and contour of the helix and antihelix when recreating an ear with normal appearance [1]. Lifelong exposure of the auricles to ultraviolet radiation means that this area is susceptible to skin cancer. Since surgical resection is still the gold standard for treatment, local auricular reconstruction is necessary. A wide variety of reconstructive procedures is currently available for auricular defects, depending on anatomical location, size, shape and depth [2]. However, micrographic surgery of this region often results in extensive multi-layered defects, where standard reconstruction techniques no longer apply. In this setting, limited reconstruction techniques are

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described, which allow the preservation or reconstruction of auricular anatomy [3, 4]. This comprehensive article describes the most common procedures used for reconstructing defects of the midhelix and antihelix, and summarizes the advantages and disadvantages of each reconstruction type. The choice of defect reconstruction should always be made according to age, comorbidities and defect size as well as the surgeon’s skills and the patient’s expectations.

Auricular anatomy and vascularization The auricle consists largely of a cartilaginous framework; the lobule is the only anatomical structure not supported by cartilage. The helix arises from the helical root, curves down

© 2018 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2018/1606

Minireview Reconstruction techniques of midhelix-antihelix defects

Simple single-step techniques

Figure 1 Anatomy of the external ear.

and connects to the lobule, and is responsible for the overall shape of the auricle (Figure 1). According to Steele et al., even slight changes in the size of the helix, concha and lobule alter the aesthetic appearance of the ear [5]. Surgical reconstruction of auricular defects is therefore a challenge for surgeons, since inappropriate reconstructions may lead to significant functional and aesthetic impairment. The arterial supply of the auricle from branches of the posterior auricular artery (PAA) and the superficial temporal artery is the anatomical basis for auricular reconstructive procedures [6 ]. The presence of several vascular anastomoses, such as the helical arcade (Erdman) and the arterial helical rim arcade (Zilinksi-Cotofana), connecting the superior and inferior branch of the superficial temporal artery, allow the preparation of a wide variety of auricular flaps [7 ]. Furthermore, the blood supply of the retroauricular skin and fascia (from the posterior auricular artery) involves an area (angiosome) extending between the helical insertion, external auditory canal and mastoid process that allows safe preparation of PAA-based fasciocutaneous flaps in this area [8].

Approaches to reconstruction of midhelix and antihelix defects Secondary intention healing Secondary intention healing can be successful with small auricular defects in maintaining normal function and minimizing anatomic and cosmetic deficiencies. It involves simple wound management and avoids complex reconstructive procedures and potential complications. In contrast to immediate closure, it is a time-consuming process that lasts for several weeks, and the cosmetic result depends on the location of the defect [9].

Closure of smaller defects can either be primary or by conversion of the defect into a wedge with subsequent primary closure [3, 10, 11]. Primary closure is mainly used for small tumors or in older subjects whose condition precludes a complicated reconstruction. After tumor removal, the exposed cartilage can usually be trimmed, followed by primary closure after undermining the adjacent posterior and anterior skin tissue (Figure 2a). However, the width of the helix is significantly narrowed postoperatively and the helical rim contour is disturbed. In some cases, the length of the defect must be increased in order to taper the narrowing helix width [4]. Wedge excision: Small midhelix-antihelix defects (< 1 cm) can be repaired by performing a triangular full-thickness excision of the tumor with subsequent primary closure (Figure 2b). After wedge excision, the remaining cartilage is sutured together with subcutaneous sutures in order to decrease wound tension and better approximate the wound margins. Since part of the helix rim is also removed, vertical mattress sutures can be placed at rim level to evert defect margins [12]. After realignment of the skin surface, the defect is closed primarily. Wedge excisions lead to shortening of the auricle, but maintain its normal contour [13]. Disadvantages of wedge excisions include the appearance of ‘telephone ear’ deformity, rim notching or protrusion of the ear from the scalp (> 30 degrees); these can be avoided by release incisions, everted sutures or Z-plasties [14, 15]. Cartilage sutures may also lead to suture extrusion, granuloma formation or appearance of chondrodermatitis over time. An interesting technique for the closure of large midhelix-antihelix defects in patients requesting a single-step procedure is partial wedge resection and subsequent coverage of the remaining defect with the resected wedge tissue, used as a skin graft [16 ]. Skin grafting: A full-thickness skin graft can be performed for two-layered auricular defects of the midhelix-antihelix, but the results are not satisfactory due to loss of auricular form and stability [17 ]. Reconstruction can be challenging for helical and non-helical defects, since full-thickness grafts are too thick for the non-helical area and may not survive. Split-thickness skin graft repair can be successful in such cases [18, 19]. In case of preserved cartilage, skin punch fenestration can be used prior to grafting to stimulate granulation tissue in areas without perichondrium [20]. Local advancement fl aps: Larger defects of the midhelix-antihelix region with cartilage involvement require the use of composite chondrocutaneous and full-thickness advancement flaps. In other cases, even if the posterior skin layer is preserved following tumor resection with cartilage involvement, complete full-thickness resection allows a better auricular reconstruction


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Figure 2 a: Primary linear repair of midhelix and antihelix defects. Surgical site prior to surgery, showing an ulcerated, bleeding exophytic squamous cell carcinoma involving the helix and antihelix (a). Surgical site after surgical resection and defect closure by primary repair (b). Schematic representation of spindle-shaped excision (c). b: Primary linear repair after wedge excision of a malignant melanoma of the midhelix and posterior part of the antihelix. Surgical site prior to surgery showing a well-demarcated dark brown-black plaque with central hemorrhagic crust; the continuous lines indicate the incision lines (a). Surgical site after surgical wedge resection to achieve clear margins and defect closure by primary repair (b). Schematic representation of wedge excision (c).

[21]. After full-thickness resection, a cranial Antia-Buch flap is designed: an incision is made through the skin and cartilage of the anterior helical sulcus on the cranial side of the defect [22, 23]. The retroauricular skin flap, supplied by the posterior auricular artery, is dissected from the upper cartilage and 3–4 mm of the anterior scaphal skin and cartilage is then excised, reducing the length of the cranial helical rim [24]. A full-thickness flap from the earlobe is prepared by incising through the anterior helical sulcus into the earlobe, generating an ear-lobe-based advancement flap (ELBAF) [25]. The cranial chondrocutaneous flap is advanced medially to the remaining mid-antihelix border and sutured. The caudal full-thickness antihelix area is also advanced cranially and medially, and sutured to the antihelix border and the cranial chondrocutaneous flap. Finally, the helical rim and the ELBAF flap are advanced and sutured. With this reconstruction, scars are hidden at junction sites of auricular aesthetic subunits; this results in a slightly smaller ear but with normal appearance, and avoids more extensive surgery such as cartilage grafting (Figure 3a) [10].

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Local advancement/rotational fl aps: Full-thickness defects of the midhelix-antihelix can also be closed by combining advancement and rotation flaps. A full-thickness rotation flap can be prepared from the ear lobe (ELBAF flap) and sutured to a cranial chondrocutaneous flap (Antia-Buch) and to the resulting posterior helical rim (also rotated into the defect) (Figure 3b). This technique is used successfully in patients with abundant lobular tissue, where the lobular flap only leads to a minimal, sometimes unnoticeable auricular deformity [26 ]. The drawback is the decreased lobular size and reduced vertical height of the auricle [27 ]. In some cases, the helical sulcus (a critical reconstruction region) loses its shape following this approach; a local gauze can be sutured to reestablish a normal-looking helical rim [28]. The Antia-Buch chondrocutaneous flap has been adapted by several surgeons for reconstruction of larger defects that involve more than the helical rim. Several other modifications/adaptations of this flap are mentioned in Table 1.



Figure 3 a: Repair of midhelix and antihelix defects using composite chondrocutaneous and full-thickness advancement flaps. Surgical site showing the defect after clear margin resection of the lentigo maligna melanoma. Continuous lines indicate the resection site with a safety margin of 1 cm; dotted lines indicate the incision sites for reconstruction (a). Surgical site after surgery (b). Surgical site five days after surgery (c). Surgical site five months after surgery (d). Schematic representation of flap design (e). Step-by-step design of the composite flaps (f). b: Repair of midhelix and antihelix defects using a modified combined caudal ear lobe rotation flap and cranial helical rim advancement flap. Surgical site after resection of melanoma including a safety margin. Lines indicate the resection area with 1 cm safety margins as well as the incision sites for reconstruction (a). Surgical site seven days after surgery (b). Surgical site three months after surgery (c). Schematic representation of flap design (d). Step-bystep design of the composite flaps (f).


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Table 1 Adaptations of the Antia-Buch chondrocutaneous flap for reconstruction of larger mid-helical defects. Publication

Author

Indication

Method

“Through and Through Defect on the Helix and Antihelix” [43]

Willey A

Large full-thickness defects of the midhelix and antihelix

– Chondrocutaneous incision along the antihelix/conchal border, leaving the posterior skin intact – Removal of narrow cartilage strut along the antihelix/conchal border together with two Burow triangles at the cranial and caudal poles of the concha – Incorporation of cartilage strut into the lobule to recreate the helical rim structure of cranial and caudal flaps

“Composite Chondrocutaneous Advancement Flap: A Technique for the Reconstruction of Marginal Defects of the Ear” [44]

Fata JJ

Defect involving helix, scapha, antihelix

– Incision through skin and cartilage inside the antihelix level, leaving posterior skin intact, reduction of concha through wedge excisions at superior and inferior pole of concha – Mobilization of flaps and defect closure

“Modified Antia Buch Repair for Full-Thickness Middle Auricular Defects” [45]

Bialostocki A, Tan ST

Full-thickness middle auricular defects

– Mobilization of cranial helical rim from postauricular skin flap, up to the concha and scapha – Cranial transposition of helix, according to Antia-Buch method, and rotation around the remaining scapha and concha – Adjustment of helical border to the defect, after removal of Burow triangle at earlobe level – Mobilization of helical root and closure with VY advancement

“The Modified Chondrocutaneous Advancement Flap for the Reconstruction of Helical Defects of the Ear” [46]

Skaria AM.

Helical defects of rim

– Preparation of triangular flap from postauricular skin, including the helical rim below defect; dissection of posteromedial skin from auricular cartilage – Flap pedicle in the myocutaneous layer of posterior part of ear – Rotation and suture of flap at defect level – Covering of posterior exposed cartilage with skin graft

Postauricular rotation/advancement flaps with conchal cartilage grafting A flap with a narrow pedicle is prepared in the retroauricular area, posterior to the mastoid region and providing a wide rotation arc. A longitudinal conchal cartilage graft is included in the midline of the flap, with a length equal to that of the defect. The flap is then elevated, rotated and incorporated into the surgical defect, with the cartilage now placed at the level of the helical rim. The flap donor area can be either closed primarily or with skin grafts [29].

Multi-step procedures Two-step locoregional advancement fl aps: Wide defects with cartilage preservation can be closed with postauricular advancement flaps in order to cover autologous cartilage (Figure 4a) [30, 31].

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After the design, preparation and suture of the retroauricular flap into the defect, the ear is pinned back to avoid damage of the flap by tension/traction. Four weeks later, after weekly conditioning of the flap pedicle, the pedicle is divided and the ear is detached from the retroauricular skin. This avoids auricular miniaturization, which occurs with other reconstruction techniques [32]. Furthermore, the resulting scar is easily concealed behind the ear and the skin color and texture are a good match [33]. One disadvantage is that it is a two-step procedure; another disadvantage is that such flaps, even if they do not contract, may not solve the issue of auricular instability of the cartilaginous framework [34]. Complex two-step partial auricular repair without cartilage: Very large defects of the midhelix-antihelix region sometimes require partial auricular reconstruction using a pedicled flap of temporal fascia (supplied by the superficial temporal artery and vein) and a split-thickness skin graft (Figure 4b) [35].



Figure 4 a: Repair of helix and antihelix defects using a retroauricular cutaneous advancement flap Surgical site after wound conditioning after traumatic amputation by human bite (a). Surgical site after preparing the retroauricular flap (b). Surgical field showing the retroauricular flap placed and sewn into defect (c). Surgical site after division of pedicle three months postoperatively (d). Schematic representation of flap design. f). Step-by step design of the retroauricular flap (e). b: Repair of midhelix and antihelix defects using a pedicled flap of temporal fascia and a split-thickness skin graft. Surgical site prior to surgery showing the lentigo maligna melanoma involving helix and antihelix (a). Surgical site after surgical resection and temporary coverage with an alloplastic material (b). Elevation of the fascial flap. The fascial flap is tunneled through the cavum conchae into the defect (c). Split-thickness skin graft placed and sutured over the fascial flap (d). Follow-up result six months after surgery (e). Schematic representation of flap design (f). Step-by-step design of the pedicled flap of temporal fascia (g).


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After sonographic identification of the superficial temporal artery and its branches, a zigzag incision is performed from the preauricular area towards the superior temporal line and the superficial temporal fascia is dissected. After exposure, the flap is elevated from the deep temporal fascia and tunneled through the helical root to cover the auricular cartilage. Finally, the flap is covered with a split-thickness skin graft. Flap loss may occur as a result of inappropriate surgical technique, previous local surgery or carotid occlusion [36]. Another critical complication is injury to the frontal branch of the facial nerve. This flap is thin, pliable and very well vascularized, allowing both sides to be covered with skin grafts; it provides thin coverage of large auricular defects, while leaving a minimal donor site scar that is usually hidden by hair. It represents a good (but complex) reconstructive alternative for auricular defects caused by trauma, tumor resection or congenital deformities due to its anatomical proximity and its coverage of exposed bone or cartilage [37 ]. Complex two-step partial auricular repair with cartilage: Auricular stability may be endangered in cases with cartilage loss. Reconstructions therefore aim at replacing missing cartilage with cartilage grafts (rib, conchal cavum, nasal septum) or tissue-engineered cartilage and covering them with superficial temporoparietal fascial flaps and retroauricular skin grafts in order to provide local stability [38]. Studies have shown that auricular cartilage has a homogeneous structure and morphology, but various biomechanical properties. When using cartilage replacements, it is important that the mechanical properties are appropriate in order to prevent tissue or shape deformation [39]. After prelevation and reshaping of cartilage to provide structural support, the graft is inserted into the defect and sutured to the existing cartilage (Figure 4b). Next, a superficial temporoparietal fascial flap is prepared, elevated from the deep temporal fascia at the level of the loose, areolar plane over the skull and temporalis muscle fascia, and fi nally draped and sutured over the cartilage. This flap carries the blood supply to the underlying cartilage graft. A retroauricular full-thickness skin graft is then prepared and subsequently placed and sutured over the temporoparietal fascial flap. With this method, the helical rim and antihelix are reconstructed and the structure, skin texture and size of the ear are maintained. The contour of the helical rim sulcus is diminished following surgery and excessive hair may grow at the skin grafting site [40]. This can be corrected with laser treatment six months after surgery or by initial transplantation of a split-thickness skin graft without hair follicles [41]. Tissue expanders: Tissue expanders are used in the retroauricular region to gain tissue for defect coverage in combination with a graft. However, this procedure requires multiple stages and the patient’s cooperation, and complication rates are significantly higher. The tissue expander is usually placed subcutaneously in the retroauricular region, and its volume is then serially expanded; the expander is left in place

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for several months and then removed. After removal, the expanded skin provides sufficient tissue for skin flaps [42].

Conclusions Auricular reconstruction of midhelix-antihelix defects requires an appropriate knowledge of auricular anatomy as well as surgical experience, since the ear must be reconstructed in three dimensions. The reconstructive method for midhelix-antihelix defects depends on location, tissue components and defect size, as well as the medical condition and the aesthetic outcome desired by the patient. When performing partial auricular reconstruction, attention must also be paid to the contralateral ear, since the reconstructed ear should maintain its original shape and size if possible. Simple reconstructive surgery such as primary closure/wedge excision is indicated with thin, vertical auricular defects. Composite flaps and various adaptations of the well-known Antia-Buch flap are very useful for the repair of full-thickness defects of the midhelix and antihelix, especially when a cartilaginous framework is required and a single stage repair is desired. Complex reconstruction options with cartilage grafting and fascial flaps are also possible, and provide good aesthetic outcomes. To our knowledge, this is one of the few reviews summarizing the most important reconstruction options for large and complex defects involving the midhelix/antihelix region of the auricle, and should facilitate rapid decision-making for surgeons according to the nature of the respective defect. Correspondence to Diana Crisan, MD Clinic for Dermatology and Allergology University Clinic Ulm Albert Einstein Allee 23 89075 Ulm, Germany E-mail: [email protected]

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