Thinking outside the box and inside the affected area: Combined local flaps for auricular reconstruction after partial amputation.

Reconstruction of the auricle is a challenging problem. Here we describe a case of auricular reconstruction following partial ear amputation, including the helix and
antihelix up to the concha. The patient requested a reconstructive option using only tissue from around the affected ear.
MATERIALS AND METHODS: To meet her request, we decided to combine three previously published local flaps, a combination that, to our knowledge, had not been
described before:
-Posterior conchal chondrocutaneous flap, designed as an inferiorly based transposition flap of the same width as the defect, to support and cover the new antihelix posteriorly (1).
-Preauricular dermocutaneous flap, inferiorly based, to provide skin coverage to the anterior surface of the new antihelix, tunnelled through the earlobe to reach the defect (2).
-Post-auricular bipedicled interpolated tubular flap, designed to reconstruct the helix (3).
The procedures were performed in three stages, under local anaesthesia and on an outpatient basis.
RESULTS: Auricular reconstruction using the described technique allowed adequate restoration of anatomical structures.
CONCLUSIONS: When the defect is extensive, most auricular reconstruction techniques require the use of rib cartilage grafts, approaching the reconstruction as a total ear defect. However, techniques have been described to avoid the morbidity associated with the use of costal cartilage graft by combining multiple flaps. Most of them use chondrocutaneous flaps as described by Antia and Buch (4) and modifications of them, such as the one described by Yotsuyanagi et al (1). Based on this concept, we decided to add as well the tubular bipedicled flap to improve the helix reconstruction, and we preferred the preauricular skin flap for its greater versatility. The need for three surgical steps could be considered a disadvantage in comparison with other techniques, but we believe that it is fully justified by the quality of the helix reconstruction obtained. Other techniques using advancement flaps can hardly produce enough tissue to reconstruct a well-defined helix, which is a fundamental aesthetic feature. The main advantages of the combination of the three techniques described above are the possibility of performing it under local anaesthesia, the fact that it does not require the use of donor areas other than the affected ear, and its reliability. We believe that the need for three operations is justified by the superior aesthetic results that can be achieved.

References.
1. Yotsuyanagi T, Watanabe Y, Yamashita K, et al. Reconstruction of defects involving the middle third of the auricle with a full thickness conchal chondrocutaneous flap. Plast Reconstr Surg 2002;109:1366-71.
2. Braga AR, Pereira LC, Grave M, et al. Tunneled inferiorly based preauricular flap repair of antitragus and concha after basal cell carcinoma excision: case report. J Plast Reconstr Aesthetic Surg. 2011;64:e73–e75.
3. Hadlock TA, Cheney ML and Quatela VC. Local Flaps in Facial Reconstruction. Chapter 22, 583-624.e1 ISBN-10 0323683908 ISBN-13 978-0323683906 Edición 4ª Editorial Elsevier.
4. Antia NH and Buch VI. Chondrocutaneous advancement flap for the marginal defect of the ear. Plast Reconstr Surg 1967;39(5):472-477.doi: 10.1097/00006534-196705000-00006.

Reconstructive

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