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V-Y Flap in Second Stage Release for the Lower Pole Following Autologous Ear Reconstruction

V-Y Flap in Second Stage Release for the Lower Pole Following Autologous Ear Reconstruction The second stage release of an ear reconstructed with autologous rib cartilage presents a challenge to surgeons who specialize in this field. There are many techniques ranging from a simple skin graft to insertion of a retro-auricular cartilage block covered by various types of fascial flaps and a skin graft.1,2 Tissue expansion prior to reconstruction to enable a one-stage operation has also been described.3 All techniques have advantages and disadvantages related to healing, contraction, sulcus formation, and projection. Application of a skin graft with advancement of mastoid skin is commonly used because of its simplicity and predictability. Graft take is excellent with this technique, as the ear can be generally released with sufficient vascularized fascia on its posterior surface. This, however, can be problematic when the lobule has been completely reconstructed with rib cartilage, such as in congenital anotia or traumatic ear loss. The fascia at the site of the lobule is adherent to the parotid fascia, and it is not always possible to raise a healthy vascularized layer on the posterior aspect of the reconstructed lobule. This may result in an unstable surface with possible rib cartilage exposure. A local skin flap rotated to cover a cartilage block positioned behind the released ear has been described.4 With this concept in mind we devised a local skin flap with a V-Y mobilization that provides vascularized skin cover to the reconstructed lobule during the second-stage release. The case described here involves a 28-year-old man who suffered traumatic partial amputation of his ear involving the lower two thirds and first presented to our service in April 2014 (Figure 1A). The patient subsequently underwent first-stage autologous costal cartilage reconstruction, and his 6-month postoperative result is shown in Figure 1B. Figure 1C demonstrates the skin markings for a small V-Y flap incorporated into the second-stage release. A V-shaped flap of skin from the mastoid area was raised (Figure 1D), undermined, and advanced in a V to Y fashion to cover the posterior lobule and part of the sulcus. As well as providing good quality vascularized skin behind the lobule, it also enabled the lower pole to be fully released, helping to improve the sulcus and projection. Figure 1. View largeDownload slide The patient is a 28-year-old man. (A) Shown here are the pre-first-stage autologous reconstruction, (B) 6-month postoperative result following first-stage reconstruction, (C) marking of the V-Y flap, (D) raised V-Y flap, (E) 6-week postoperative result, and (F) detail of the postauricular space at 6 weeks postoperative. Figure 1. View largeDownload slide The patient is a 28-year-old man. (A) Shown here are the pre-first-stage autologous reconstruction, (B) 6-month postoperative result following first-stage reconstruction, (C) marking of the V-Y flap, (D) raised V-Y flap, (E) 6-week postoperative result, and (F) detail of the postauricular space at 6 weeks postoperative. The donor site was closed directly. Simultaneously, the upper part of the reconstructed ear was also released and resurfaced with a full-thickness skin graft (not shown). The 6-week postoperative result is shown in Figures 1E and 1F with the latter showing a posterior view of the lower lobe in more detail. Unfortunately, we do not have further postoperative photos, as the patient returned to his home country. There are several advantages of this technique over simple application of a skin graft. These include preventing the risk of cartilage exposure, better cosmetic appearance and texture of the newly released lower pole, and less contraction and adherence of the lobule. We believe that this simple flap provides good results and should be considered when releasing a lobule that has been reconstructed with costal cartilage. We recommend, as with any ear release procedure, regular stretching exercises in the postoperative period to prevent stiffness and contraction of the sulcus. We have used this technique on numerous occasions with a successful outcome. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Brent B . Earlobe construction with an auriculo-mastoid flap . Plast Reconstr Surg . 1976 ; 57 ( 3 ): 389 - 391 . Google Scholar CrossRef Search ADS PubMed 2. Nagata S . A new method of total reconstruction of the auricle for microtia . Plast Reconstr Surg . 1993 ; 92 ( 2 ): 187 - 201 . Google Scholar CrossRef Search ADS PubMed 3. Inbal A , Lemelman BT , Millet E , Greensmith A . Tissue expansion using hyaluronic acid filler for single-stage ear reconstruction: a novel concept for difficult areas . Aesthet Surg J . 2017 ; 37 ( 10 ): 1085 - 1097 . Google Scholar CrossRef Search ADS PubMed 4. Cox A , Sabbagh W , Gault D . Costal cartilage or conchal cartilage for aesthetic and structural reconstruction of lower pole ear defects . Aesthet Surg J . 2012 ; 32 ( 3 ): 271 - 274 . Google Scholar CrossRef Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

V-Y Flap in Second Stage Release for the Lower Pole Following Autologous Ear Reconstruction

Aesthetic Surgery Journal , Volume 38 (9) – Sep 1, 2018
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Publisher
Oxford University Press
Copyright
© 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
ISSN
1090-820X
eISSN
1527-330X
DOI
10.1093/asj/sjy139
Publisher site
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Abstract

The second stage release of an ear reconstructed with autologous rib cartilage presents a challenge to surgeons who specialize in this field. There are many techniques ranging from a simple skin graft to insertion of a retro-auricular cartilage block covered by various types of fascial flaps and a skin graft.1,2 Tissue expansion prior to reconstruction to enable a one-stage operation has also been described.3 All techniques have advantages and disadvantages related to healing, contraction, sulcus formation, and projection. Application of a skin graft with advancement of mastoid skin is commonly used because of its simplicity and predictability. Graft take is excellent with this technique, as the ear can be generally released with sufficient vascularized fascia on its posterior surface. This, however, can be problematic when the lobule has been completely reconstructed with rib cartilage, such as in congenital anotia or traumatic ear loss. The fascia at the site of the lobule is adherent to the parotid fascia, and it is not always possible to raise a healthy vascularized layer on the posterior aspect of the reconstructed lobule. This may result in an unstable surface with possible rib cartilage exposure. A local skin flap rotated to cover a cartilage block positioned behind the released ear has been described.4 With this concept in mind we devised a local skin flap with a V-Y mobilization that provides vascularized skin cover to the reconstructed lobule during the second-stage release. The case described here involves a 28-year-old man who suffered traumatic partial amputation of his ear involving the lower two thirds and first presented to our service in April 2014 (Figure 1A). The patient subsequently underwent first-stage autologous costal cartilage reconstruction, and his 6-month postoperative result is shown in Figure 1B. Figure 1C demonstrates the skin markings for a small V-Y flap incorporated into the second-stage release. A V-shaped flap of skin from the mastoid area was raised (Figure 1D), undermined, and advanced in a V to Y fashion to cover the posterior lobule and part of the sulcus. As well as providing good quality vascularized skin behind the lobule, it also enabled the lower pole to be fully released, helping to improve the sulcus and projection. Figure 1. View largeDownload slide The patient is a 28-year-old man. (A) Shown here are the pre-first-stage autologous reconstruction, (B) 6-month postoperative result following first-stage reconstruction, (C) marking of the V-Y flap, (D) raised V-Y flap, (E) 6-week postoperative result, and (F) detail of the postauricular space at 6 weeks postoperative. Figure 1. View largeDownload slide The patient is a 28-year-old man. (A) Shown here are the pre-first-stage autologous reconstruction, (B) 6-month postoperative result following first-stage reconstruction, (C) marking of the V-Y flap, (D) raised V-Y flap, (E) 6-week postoperative result, and (F) detail of the postauricular space at 6 weeks postoperative. The donor site was closed directly. Simultaneously, the upper part of the reconstructed ear was also released and resurfaced with a full-thickness skin graft (not shown). The 6-week postoperative result is shown in Figures 1E and 1F with the latter showing a posterior view of the lower lobe in more detail. Unfortunately, we do not have further postoperative photos, as the patient returned to his home country. There are several advantages of this technique over simple application of a skin graft. These include preventing the risk of cartilage exposure, better cosmetic appearance and texture of the newly released lower pole, and less contraction and adherence of the lobule. We believe that this simple flap provides good results and should be considered when releasing a lobule that has been reconstructed with costal cartilage. We recommend, as with any ear release procedure, regular stretching exercises in the postoperative period to prevent stiffness and contraction of the sulcus. We have used this technique on numerous occasions with a successful outcome. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Brent B . Earlobe construction with an auriculo-mastoid flap . Plast Reconstr Surg . 1976 ; 57 ( 3 ): 389 - 391 . Google Scholar CrossRef Search ADS PubMed 2. Nagata S . A new method of total reconstruction of the auricle for microtia . Plast Reconstr Surg . 1993 ; 92 ( 2 ): 187 - 201 . Google Scholar CrossRef Search ADS PubMed 3. Inbal A , Lemelman BT , Millet E , Greensmith A . Tissue expansion using hyaluronic acid filler for single-stage ear reconstruction: a novel concept for difficult areas . Aesthet Surg J . 2017 ; 37 ( 10 ): 1085 - 1097 . Google Scholar CrossRef Search ADS PubMed 4. Cox A , Sabbagh W , Gault D . Costal cartilage or conchal cartilage for aesthetic and structural reconstruction of lower pole ear defects . Aesthet Surg J . 2012 ; 32 ( 3 ): 271 - 274 . Google Scholar CrossRef Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Journal

Aesthetic Surgery Journal – Oxford University Press

Published: Sep 1, 2018

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