Total Ear Reconstruction with Prelaminated Radial Forearm Flap

Total reconstruction of the auricle in traumatic ear loss requires a different approach than that of congenital microtia. Selection of proper flap coverage is important in this situation, in order to achieve good skin cover of the area and, at the same time, to reconstruct the detailed convolutions of the underlying cartilage framework.

The contralateral temporoparietal fascial free flap, the antebrachial fascia free flap, and the omentum have been employed in these situation, but they require the addition of skin grafts that may fail, retract, or pigment. In addition, the interface between the graft and fascia and the interface between the fascia and cartilage represent two layers of interposed scar over the ear framework. The objective of this presentation was to evaluate the total ear reconstruction using a prelaminated radial forearm flap.

A prelaminated radial forearm flap was performed with success on 9 patients who presented with a devascularized or scarred temporoparietal region. The main indication for this technique was unavailability of the contralateral temporoparietal fascia or extensive scarring of the temporal region. The technique consists of two surgical steps. A rib cartilaginous framework is inserted under the antebrachial skin over the superficial fascia in the first step. After 2 to 3 month, the second step, free microsurgical transfer of the prefabricated flap, is done. Between the first and second steps, a compression garment is used over the forearm in order to immobilize and model the ear. In two cases, the oldest aged patients with heavy calcified cartilage ribs, an artificial ear framework was used (Porex (r)). In one patient, an extended antebrachial flap was used in order to substitute for the scarred skin in the temporal area.

There were no microvascular failures in the procedures conducted. Two patients presented small areas of skin necrosis over the edge of the reconstructed helix during the period of external compression due probably to excessive pressure. The necrotic skin and a small amount of cartilage exposed were excised under local anesthesia and they healed uneventfully, although an aesthetic compromise was demonstrated. Five patients required minor surgical procedures under local anesthesia to refine the final result. Three had a retro–auricular skin graft to release the ear, and two required modeling of the ear lobe.

The average follow–up period was 5.1 (10–3) years. Final aesthetic results were graded as satisfactory in 7 patients and poor in 2 patients. The authors think this may be a good solution to reconstruct complex defects in the temporal region that include the ear. Possible drawbacks of this possibility of total ear reconstruction are the scar at an exposed portion of the body and the sacrifice of an important artery.