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Modified Antia–Buch flap for the reconstruction of helical rim defects
Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) 67, 1659e1662
Modified AntiaeBuch flap for the reconstruction of helical rim defects* Warren Noel a, Patrick Leyder a, Julien Quilichini a,b,* a b
Department of Plastic Surgery, Robert Ballanger Hospital, 93602 Aulnay sous Bois, France Department of Surgery, Jean Verdier/Avicenne Hospital, Paris Nord University, 93000 Bobigny, France
Received 9 June 2014; accepted 5 August 2014
KEYWORDS Ear reconstruction; Chondrocutaneous flap; AntiaeBuch flap; Skin cancer
Summary Background: The AntiaeBuch flap is a sophisticated one-stage procedure using two chondrocutaneous flaps to reconstruct the ear helix. Because tissue laxity is largely conferred by the inferior flap, relative to the less mobile superior flap, chondrocutaneous resection of scapha is required for closure. This results in loss of ear height and limits morphologic outcome. We describe a modification of the AntiaeBuch flap, which may avoid such drawbacks. Patients and method: We conducted a retrospective review of patients (n Z 15), each undergoing our modified AntiaeBuch flap between 2010 and 2014. All procedures were performed under local anesthesia as outpatient procedures. Data on magnitude of resections, procedure durations, related complications, and aesthetic outcomes were collected. Results: The mean size of resection was 25 mm (range, 20e30 mm). The modification improved the mobility of the upper chondrocutaneous flap, eliminating the need to resect the scapha. All wounds healed uneventfully, with no skin necrosis. The morphologic outcome was satisfactory or very satisfactory in all patients, preserving the shape, height, and width of the ear. Conclusions: Our modification changes the upper flap from an advancement flap to a transposition flap, enhancing its mobility and preempting the resection of the scapha. Thus, anatomic landmarks, aesthetic subunits of the pinna, and ear height are maintained for highly satisfactory morphologic results. Level of evidence: 4. ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
*
Presented at the French Society of Plastic, Reconstructive and Aesthetic Surgery, 29th March 2014, Paris, France. * Corresponding author. Department of Plastic Surgery, Robert Ballanger Hospital, 93602 Aulnay sous Bois, France. Tel.: þ33 1 49 36 71 02; fax: þ33 1 49 36 72 79. E-mail address: [email protected] (J. Quilichini). http://dx.doi.org/10.1016/j.bjps.2014.08.008 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
1660
W. Noel et al.
Introduction Given its three-dimensional shape, complex contours, and aesthetic importance, reconstruction of the ear may pose a challenge for reconstructive surgeons. Furthermore, the pinna of the ear is a common site of cutaneous malignancies due to sun exposure, particularly squamous or basal cell carcinomas involving the often vulnerable helical rim.1 Currently, many techniques exist for reconstructing fullthickness helical rim defects, including skin, chondrocutaneous, or tubed mastoid flaps and composite grafts. The choice of procedure typically is dictated by the dimension and site of the defect and the level of the dermatologic surgeon’s skill. Although the chondrocutaneous advancement flap of Antia and Buch, first described in 1967,2 is not a favorite in routine practice, it is a versatile and cosmetically sound one-stage alternative in this setting. Its primary disadvantages are the loss in dimensions of pinna that result and the degree of surgical complexity.
Figure 1
Herein, we describe a modification of the AntiaeBuch flap for use in small-to-moderate defects of helical rim. Our method is intended to remedy the diminution of pinna, which is otherwise expected with this approach.
Patients and method Between November 2010 and March 2014, all patients undergoing modified AntiaeBuch flaps for ear reconstruction at our institution were included in this retrospective study.
Surgical procedure The procedure is performed under local anesthesia, infiltrating the posterior aspect of the ear pinna with xylocaine 1% plus epinephrine 1:100,000. Epinephrine is not used on the anterior aspect of the pinna to avoid skin necrosis, but xylocaine 1% is infiltrated as needed.
The vertical back cut enhances the mobility of the upper chondrocutaneous flap.
Modified Antia–Buch flap for helical rim defect The procedure begins with tumor resection, marking the lesion and gauging margins accordingly. The excisional defect is converted to a rectangular shape, circumscribed at the helical rim, with reconstruction performed immediately thereafter (see video footage). The procedure begins as a standard AntiaeBuch flap. Anterior chondrocutaneous incisions are made on both sides of the defect along the helical sulcus, preserving posterior skin. The posterior skin and ear cartilage are separated up to the posterior sulcus of the ear. Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.bjps.2014.08.008. The helical root is ultimately isolated from the temporal skin, and a 2-cm vertical back cut is made on the temporal scalp. Finally, the helical root is rotated and advanced to close the defect. The vertical back cut may be extended as needed to achieve closure, but no scaphal resection is performed. The helical root defect is closed in a V-to-Y fashion with a 6/0 nylon suture. A dressing with petroleum gauze is applied and removed the day after the operation. Usually, no further dressings are needed. Sutures may be removed in 7e10 days (Figure 1 and video footage).
Results A total of 15 consecutive patients (mean age, 74 years; range, 37e89 years) were qualified for study. The mean size of defects was 25 mm (range, 20e30 mm). In 14 patients, flaps were required after skin cancer excisions (basal cell carcinomas, eight; squamous cell carcinomas, four). In one patient, reconstruction followed traumatic amputation of the helical rim. All procedures were performed as outpatient procedures under local anesthesia. Antiplatelet or anticoagulant treatment was ongoing in eight patients and continued
1661 without suspension. The mean duration of procedure, including tumor resection, was 50 min (range, 40e120 min). Neither necrosis of chondrocutaneous flaps nor other significant adverse events were reported. All wounds healed successfully, without chondritis or infection. All patients experienced mild edema of the ear, which regularly resolved in <10 days. None of the patients complained of pain after the first week. In all instances, morphologic outcomes were reasonably or highly satisfactory (Figure 2). Despite visibility of three notches on the helical rim scars, no revisions were requested by patients, and no malignancies have recurred to date.
Discussion Various techniques have been described for reconstructing helical rim defects. Wedge resection, as the standard approach for small-to-moderate sized defects, is simple and straightforward. However, microtia, webbing, cupping, and butterfly deformity3 are problematic. Other methods, such as flaps harvested from pre- or postauricular skin, generally are complex, multistage procedures, which are time consuming and may not be appropriate for elderly patients presenting with skin cancers. The AntiaeBuch flap is a simple yet sophisticated onestage procedure offering very good morphologic outcomes. Tissue laxity is largely conferred by the inferior chondrocutaneous flap, so large ear lobes are advantageous. The pivot point of the less movable superior chondrocutaneous flap is at the helical root (on preauricular skin). Consequently, closure requires chondrocutaneous resection of the scapha, which diminishes ear height and morphologic outcome. Few modifications and refinements of the AntiaeBuch flap have been reported, most of which are for scaphaloriented4 or large-sized defects.5,6 Such modifications
Figure 2 Left: Preoperative view of a squamous cell carcinoma in a 75-year-old man (Size of the defect: 25 mm). Right: Result after 3 months.
1662 routinely entail additional resections of the scapha or concha to ease flaps for mobilization and closure, which lead to microtia. Our modification is aimed at enhancing mobilization of the superior chondrocutaneous flap. It consists of changing the upper flap from an advancement flap e the ear being sacrificed to facilitate closure e to a transposition flap. The preauricular helical root is completely detached to form a random anterior extension of the superior chondrocutaneous flap. A vertical back cut in the scalp then moves the pivot point of the flap posteriorly and superiorly, placing it closer to the defect and enabling mobilization along the external border of the antihelix. The range of flap mobility is thereby greatly improved, with upper and lower chondrocutaneous flaps contributing equally to closure. Consequently, no resection of the scapha is needed. Because less skin is mobilized from the lobule, the height of the pinna is maintained. Of note, pre- and supra-auricular back cuts do not jeopardize blood supply to the chondrocutaneous flaps. Although one or two branch vessels of the superficial temporal artery were sacrificed, none of our patients displayed any flap necrosis. The anastomotic network of the face is well developed, especially in the ear area, so randompattern flaps are quite reliable. Moreover, important perforators arising from the posterior auricular artery may be preserved through less vigorous dissection at the retroauricular sulcus.7 At a minimum, however, we advise a 15mm-wide cutaneous pedicle for the superior flap. The incisions made eventually are concealed in natural creases, making helical root displacement (superiorly and posteriorly) inconspicuous. Hence, relationships between aesthetic subunits of the ear are unchanged, and the external aspect of the pinna stays natural. All suturing is tension free as well, to avoid the development of webbing and notching. In our experience, our modification is applicable to defects up to 3 cm, without the need for scaphal resection. Although more advanced than wedge resection, this modified AntiaeBuch flap is easy to perform under local anesthesia and is not painful, making it an attractive alternative in elderly patients. The procedure is usually completed in <1 h, including the time allotted for anesthesia and tumor resection, and patients are discharged the same day.
Conclusion The chondrocutaneous advancement flap is an elegant technique for reconstructing full-thickness helical defects.
W. Noel et al. Our modification of the AntiaeBuch flap improves mobility of the superior flap, making scaphal resection unnecessary. Anatomic landmarks, aesthetic subunits of the pinna, and ear height are, thereby, preserved for highly satisfactory morphologic results. This simple and reliable technique is particularly suitable for elderly patients.
Ethical approval N/A.
Funding None.
Author contribution Dr Julien Quilichini: original idea, study design, data collection, revision of the manuscript and its final approval. Dr Warren Noel: data collection, artwork, revision of the manuscript and its final approval. Dr Patrick Leyder: revision of the manuscript and its final approval.
Conflict of interest None.
References 1. Leferink VJ, Nicolai JP. Malignant tumors of the external ear. Ann Plast Surg 1988 Dec;21(6):550e4. 2. Antia NH, Buch VI. Chondrocutaneous advancement flap for the marginal defect. Plast Reconstr Surg May 1967;39(5):472e7. 3. Majumdar A, Townend J. Helix rim advancement for reconstruction of marginal defects of the pinna. Br J Oral Maxillofac Surg 2000 Feb;38(1):3e7. 4. Fata JJ. Composite chondrocutaneous advancement flap: a technique for the reconstruction of marginal defects of the ear. Plast Reconstr Surg 1997 Apr;99(4):1172e5. 5. Bialostocki A, Tan ST. Modified AntiaeBuch repair for fullthickness upper pole auricular defect. Plast Reconstr Surg 1999 Apr;103(5):1476e9. 6. De Schipper HJ, van Rappard JH, Dumont EA. Modified Antia Buch repair for full-thickness middle auricular defect. Dermatol Surg 2012 Jan;38(1):124e7. 7. Pinar YA, Ikiz ZA, Bilge O, et al. Arterial anatomy of the auricle: its importance for reconstructive surgery. Surg Radiol Anat 2003;25:175e9.
Modified AntiaeBuch flap for the reconstruction of helical rim defects* Warren Noel a, Patrick Leyder a, Julien Quilichini a,b,* a b
Department of Plastic Surgery, Robert Ballanger Hospital, 93602 Aulnay sous Bois, France Department of Surgery, Jean Verdier/Avicenne Hospital, Paris Nord University, 93000 Bobigny, France
Received 9 June 2014; accepted 5 August 2014
KEYWORDS Ear reconstruction; Chondrocutaneous flap; AntiaeBuch flap; Skin cancer
Summary Background: The AntiaeBuch flap is a sophisticated one-stage procedure using two chondrocutaneous flaps to reconstruct the ear helix. Because tissue laxity is largely conferred by the inferior flap, relative to the less mobile superior flap, chondrocutaneous resection of scapha is required for closure. This results in loss of ear height and limits morphologic outcome. We describe a modification of the AntiaeBuch flap, which may avoid such drawbacks. Patients and method: We conducted a retrospective review of patients (n Z 15), each undergoing our modified AntiaeBuch flap between 2010 and 2014. All procedures were performed under local anesthesia as outpatient procedures. Data on magnitude of resections, procedure durations, related complications, and aesthetic outcomes were collected. Results: The mean size of resection was 25 mm (range, 20e30 mm). The modification improved the mobility of the upper chondrocutaneous flap, eliminating the need to resect the scapha. All wounds healed uneventfully, with no skin necrosis. The morphologic outcome was satisfactory or very satisfactory in all patients, preserving the shape, height, and width of the ear. Conclusions: Our modification changes the upper flap from an advancement flap to a transposition flap, enhancing its mobility and preempting the resection of the scapha. Thus, anatomic landmarks, aesthetic subunits of the pinna, and ear height are maintained for highly satisfactory morphologic results. Level of evidence: 4. ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
*
Presented at the French Society of Plastic, Reconstructive and Aesthetic Surgery, 29th March 2014, Paris, France. * Corresponding author. Department of Plastic Surgery, Robert Ballanger Hospital, 93602 Aulnay sous Bois, France. Tel.: þ33 1 49 36 71 02; fax: þ33 1 49 36 72 79. E-mail address: [email protected] (J. Quilichini). http://dx.doi.org/10.1016/j.bjps.2014.08.008 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
1660
W. Noel et al.
Introduction Given its three-dimensional shape, complex contours, and aesthetic importance, reconstruction of the ear may pose a challenge for reconstructive surgeons. Furthermore, the pinna of the ear is a common site of cutaneous malignancies due to sun exposure, particularly squamous or basal cell carcinomas involving the often vulnerable helical rim.1 Currently, many techniques exist for reconstructing fullthickness helical rim defects, including skin, chondrocutaneous, or tubed mastoid flaps and composite grafts. The choice of procedure typically is dictated by the dimension and site of the defect and the level of the dermatologic surgeon’s skill. Although the chondrocutaneous advancement flap of Antia and Buch, first described in 1967,2 is not a favorite in routine practice, it is a versatile and cosmetically sound one-stage alternative in this setting. Its primary disadvantages are the loss in dimensions of pinna that result and the degree of surgical complexity.
Figure 1
Herein, we describe a modification of the AntiaeBuch flap for use in small-to-moderate defects of helical rim. Our method is intended to remedy the diminution of pinna, which is otherwise expected with this approach.
Patients and method Between November 2010 and March 2014, all patients undergoing modified AntiaeBuch flaps for ear reconstruction at our institution were included in this retrospective study.
Surgical procedure The procedure is performed under local anesthesia, infiltrating the posterior aspect of the ear pinna with xylocaine 1% plus epinephrine 1:100,000. Epinephrine is not used on the anterior aspect of the pinna to avoid skin necrosis, but xylocaine 1% is infiltrated as needed.
The vertical back cut enhances the mobility of the upper chondrocutaneous flap.
Modified Antia–Buch flap for helical rim defect The procedure begins with tumor resection, marking the lesion and gauging margins accordingly. The excisional defect is converted to a rectangular shape, circumscribed at the helical rim, with reconstruction performed immediately thereafter (see video footage). The procedure begins as a standard AntiaeBuch flap. Anterior chondrocutaneous incisions are made on both sides of the defect along the helical sulcus, preserving posterior skin. The posterior skin and ear cartilage are separated up to the posterior sulcus of the ear. Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.bjps.2014.08.008. The helical root is ultimately isolated from the temporal skin, and a 2-cm vertical back cut is made on the temporal scalp. Finally, the helical root is rotated and advanced to close the defect. The vertical back cut may be extended as needed to achieve closure, but no scaphal resection is performed. The helical root defect is closed in a V-to-Y fashion with a 6/0 nylon suture. A dressing with petroleum gauze is applied and removed the day after the operation. Usually, no further dressings are needed. Sutures may be removed in 7e10 days (Figure 1 and video footage).
Results A total of 15 consecutive patients (mean age, 74 years; range, 37e89 years) were qualified for study. The mean size of defects was 25 mm (range, 20e30 mm). In 14 patients, flaps were required after skin cancer excisions (basal cell carcinomas, eight; squamous cell carcinomas, four). In one patient, reconstruction followed traumatic amputation of the helical rim. All procedures were performed as outpatient procedures under local anesthesia. Antiplatelet or anticoagulant treatment was ongoing in eight patients and continued
1661 without suspension. The mean duration of procedure, including tumor resection, was 50 min (range, 40e120 min). Neither necrosis of chondrocutaneous flaps nor other significant adverse events were reported. All wounds healed successfully, without chondritis or infection. All patients experienced mild edema of the ear, which regularly resolved in <10 days. None of the patients complained of pain after the first week. In all instances, morphologic outcomes were reasonably or highly satisfactory (Figure 2). Despite visibility of three notches on the helical rim scars, no revisions were requested by patients, and no malignancies have recurred to date.
Discussion Various techniques have been described for reconstructing helical rim defects. Wedge resection, as the standard approach for small-to-moderate sized defects, is simple and straightforward. However, microtia, webbing, cupping, and butterfly deformity3 are problematic. Other methods, such as flaps harvested from pre- or postauricular skin, generally are complex, multistage procedures, which are time consuming and may not be appropriate for elderly patients presenting with skin cancers. The AntiaeBuch flap is a simple yet sophisticated onestage procedure offering very good morphologic outcomes. Tissue laxity is largely conferred by the inferior chondrocutaneous flap, so large ear lobes are advantageous. The pivot point of the less movable superior chondrocutaneous flap is at the helical root (on preauricular skin). Consequently, closure requires chondrocutaneous resection of the scapha, which diminishes ear height and morphologic outcome. Few modifications and refinements of the AntiaeBuch flap have been reported, most of which are for scaphaloriented4 or large-sized defects.5,6 Such modifications
Figure 2 Left: Preoperative view of a squamous cell carcinoma in a 75-year-old man (Size of the defect: 25 mm). Right: Result after 3 months.
1662 routinely entail additional resections of the scapha or concha to ease flaps for mobilization and closure, which lead to microtia. Our modification is aimed at enhancing mobilization of the superior chondrocutaneous flap. It consists of changing the upper flap from an advancement flap e the ear being sacrificed to facilitate closure e to a transposition flap. The preauricular helical root is completely detached to form a random anterior extension of the superior chondrocutaneous flap. A vertical back cut in the scalp then moves the pivot point of the flap posteriorly and superiorly, placing it closer to the defect and enabling mobilization along the external border of the antihelix. The range of flap mobility is thereby greatly improved, with upper and lower chondrocutaneous flaps contributing equally to closure. Consequently, no resection of the scapha is needed. Because less skin is mobilized from the lobule, the height of the pinna is maintained. Of note, pre- and supra-auricular back cuts do not jeopardize blood supply to the chondrocutaneous flaps. Although one or two branch vessels of the superficial temporal artery were sacrificed, none of our patients displayed any flap necrosis. The anastomotic network of the face is well developed, especially in the ear area, so randompattern flaps are quite reliable. Moreover, important perforators arising from the posterior auricular artery may be preserved through less vigorous dissection at the retroauricular sulcus.7 At a minimum, however, we advise a 15mm-wide cutaneous pedicle for the superior flap. The incisions made eventually are concealed in natural creases, making helical root displacement (superiorly and posteriorly) inconspicuous. Hence, relationships between aesthetic subunits of the ear are unchanged, and the external aspect of the pinna stays natural. All suturing is tension free as well, to avoid the development of webbing and notching. In our experience, our modification is applicable to defects up to 3 cm, without the need for scaphal resection. Although more advanced than wedge resection, this modified AntiaeBuch flap is easy to perform under local anesthesia and is not painful, making it an attractive alternative in elderly patients. The procedure is usually completed in <1 h, including the time allotted for anesthesia and tumor resection, and patients are discharged the same day.
Conclusion The chondrocutaneous advancement flap is an elegant technique for reconstructing full-thickness helical defects.
W. Noel et al. Our modification of the AntiaeBuch flap improves mobility of the superior flap, making scaphal resection unnecessary. Anatomic landmarks, aesthetic subunits of the pinna, and ear height are, thereby, preserved for highly satisfactory morphologic results. This simple and reliable technique is particularly suitable for elderly patients.
Ethical approval N/A.
Funding None.
Author contribution Dr Julien Quilichini: original idea, study design, data collection, revision of the manuscript and its final approval. Dr Warren Noel: data collection, artwork, revision of the manuscript and its final approval. Dr Patrick Leyder: revision of the manuscript and its final approval.
Conflict of interest None.
References 1. Leferink VJ, Nicolai JP. Malignant tumors of the external ear. Ann Plast Surg 1988 Dec;21(6):550e4. 2. Antia NH, Buch VI. Chondrocutaneous advancement flap for the marginal defect. Plast Reconstr Surg May 1967;39(5):472e7. 3. Majumdar A, Townend J. Helix rim advancement for reconstruction of marginal defects of the pinna. Br J Oral Maxillofac Surg 2000 Feb;38(1):3e7. 4. Fata JJ. Composite chondrocutaneous advancement flap: a technique for the reconstruction of marginal defects of the ear. Plast Reconstr Surg 1997 Apr;99(4):1172e5. 5. Bialostocki A, Tan ST. Modified AntiaeBuch repair for fullthickness upper pole auricular defect. Plast Reconstr Surg 1999 Apr;103(5):1476e9. 6. De Schipper HJ, van Rappard JH, Dumont EA. Modified Antia Buch repair for full-thickness middle auricular defect. Dermatol Surg 2012 Jan;38(1):124e7. 7. Pinar YA, Ikiz ZA, Bilge O, et al. Arterial anatomy of the auricle: its importance for reconstructive surgery. Surg Radiol Anat 2003;25:175e9.