Ear Reconstruction: Preservation of perforator vessels on the pedicle to improve results

Abstract

Introduction My new concepts on abdominoplasty have been an important knowledge to improve ear reconstruction on congenital and acquired deformities. In my anatomical research performing dissections on cadaver looking for new surgical operations to perform safe abdominoplasty, it was evident to me that those surgical principles were also correlated with ear reconstruction procedures. As far as normal auricles present important anatomical structures for their support on the lateral sides of the head, when ear reconstruction is done, I was deeply concerned that it is mandatory to create a main pedicle for the new auricle. Meantime, I identified narrow technical knowledge to create a new auricle which stimulated me to devote much effort to find new procedures to improve surgical results in order to achieve well balance to facial contour. Even creation of the temporoparietal fascial flaps is a useful step forward to identify a vascular pedicle to provide adequate blood supply to the reconstructed ear which is similar to the preservation of perforator vessels on new concepts on abdominolipoplasty. When a person presents normal auricles, another one may not see them on each side of the head. However, any alterations on size, shape, position, and location of one or two pinnas will be noticed by most people even from a distance. Technique The success of ear reconstruction on congenital abnormalities and after traumatic amputation is mandatory to create two anatomical elements: (a) cutaneous covering and (b) new auricular framework which is performed in two surgical stages. During the first stage the cutaneous covering is created on mastoid region since it is the closest one, even presenting hairless skin. On the other hand, the future auricular skeleton is provided by sculpture with meticulous excavation on rib cartilage. Creation of the cutaneous covering I have described that the skin of the mastoid region must be undermined only on the area of the future helix and antihelix creating a subcutaneous tunnel. Thus, the future conchal cavity will be the fundamental pedicle of the ear which presents same surgical principles as to preserve the perforator vessels on my new concepts of abdominoplasty. Also cutaneous dissection of the future helix and antihelix is performed under the same surgical principle of the abdominoplasty since the vessels come from the depth passing close to the anterior border of the mastoid bone which must be entirely preserved. Even this pedicle is also a neurovascular one (similar with perforator vessels with sensate nerve) since there is a branch of sensitive nerve which will provide sensibility to the reconstructed auricle. The operation is performed under general anesthesia. The ninth rib cartilage is removed where the new auricular framework is sculptured by meticulous excavation which is introduced subcutaneously through the tunnel already created on the mastoid area. On congenital abnormalities, the lobule is created by rotation back- and downward of the lower segment of the cutaneous fold of the deformity. The remnant cartilage tissue must be removed in order to create the new auditory canal and conchal cavity as well. The second stage of reconstruction is performed 6 months after the first one by cutaneous incisions following the posterior border of the new auricle. Afterward, the new ear is lifted by dissection below the fascial flap which covers the entire posterior aspect of the auricle. At this point, it is fundamental to create the main pedicle of the future auricle. Follow the operation skin graft removed by knife from the scalp or any other region of the patient is done. A careful dressing is performed and must be kept for 1 week, and when it is removed, apply another one for 1 month. The final result gives harmonious facial contour. Reconstruction of the ear after traumatic amputation under same surgical principles which concerns creating the main neurovascular pedicle is employed, since the future conchal cavity is not undermined. The second stage is also performed 6 months later following similar surgical step as on congenital anomalies.