AURICULAR RECONSTRUCTION AFTER

ONCOLOGICAL RESECTION
BARRY L. EPPLEY, MD, DMD

A variety of ear defects can occur after resection of malignant tumors, which presents the option for a diverse array
of surgical techniques for their reconstruction. Because the functional demands of the ear are few and the opposite
ear is usually unaffected, reconstruction should focus on the position, size, and contour of the resected ear. In
skin-only defects, secondary healing, skin grafts, and direct closure are effective options. In smaller partial- and
full-thickness defects, wedge closures and local chondrocutaneous flaps are effective one-stage techniques. In larger
full-thickness defects, staged local and regional flaps with cartilage grafts can recreate the shape and contour of the
ear. In total-ear defects, osseointegrated mastoid implants for prosthetic retention offer the most effective and rapid
method for ear replacement.All of these reconstructivetechniquesare outlined and the indicationsfor their use discussed.
Copyright 9 1999 by W.B.Saunders Company
KEY WORDS: ear, reconstructive surgery, grafts, flaps, implants

While congenital deformities usually present the most

difficult ear reconstructive challenges, defects from the
excision of tumors can also pose some interesting restoration problems. Oncological auricular resection usually
creates partial defects of skin a n d / o r cartilage, and one has
the advantage of beginning with a relatively normally
shaped and positioned ear. Despite these advantages, the
multiple convolutions and depressions of the ear combined with the usually firm fixation of skin to the underlying cartilage makes simple primary closure of many
excised tumors often difficult without significant esthetic
distortion of the ear.
The goals of oncological auricular reconstruction would
seem to be preservation or restoration of the preoperative
ear, including symmetry with the opposite ear. However,
given that both ears are rarely viewed simultaneously in
any facial view and may be partially or completely covered
by hair, the size, position, and orientation of the ear to the
scalp and anterior face may be more important than an
absolute recreation of the architecture of the opposite ear.
Often, given the older age of most patients with auricular
pathologies, eyeglass support by the helical root or enough
lobule for earring wear may be the only functional concern.
From a structural standpoint, the ear is often described
as a step-wise progression of layers beginning inferiorly at
the conchal floor and progressing upward to the scaphahelix and helix. To the casual eye, this framework essentially creates an outline of three curved lines: an outer
elongated C-shape beginning from the helical root to the
lobule; a central near-parallel curvilinear line from the
crura to the antitragus; and an opposing distorted Ushaped line from the antitragus to the tragus 1 (Fig 1). Thus,
From the Division of Plastic Surgery, Indiana University School of
Medicine, Indianapolis, IN.
Address reprint requests to Barry L. Eppley, MD, Indiana University
School of Medicine, 702 Barnhill Drive, #3540, Indianapolis, IN 46202.
Copyright 9 1999 by W.B. Saunders Company
1071-0949/99/0604-0007510.00/0

the pertinent skin-cartilage components that are necessary

to make a recognizable ear are the helix, tragus, antitragus,
and concha as is well demonstrated from congenital
microtia repair (Fig 2).

AURICULAR PATHOLOGY
Overwhelmingly, tumors of skin origin comprise almost all
of the auricular pathologies, with squamous cell carcinomas being the most common (>50%), followed by basal
cell carcinomas (30% t o 40%), and less frequently, melanomas (5%). 2'3 The presentation of basal and squamous cell
carcinomas on the helical rim and antihelix is common
given their unprotected position on the ear with continuous exposure to the sun and other elements. The absence of
subcutaneous tissue in the ear allows for the potential of
early perichondrial involvement. However, the perichondrium usually acts as a barrier against direct invasion into
the cartilage and often directs tumor spread laterally.
Cervical lymph node involvement is very rare in basal
carcinoma. However, a thorough examination of the neck
should be done in squamous cell and melanoma, because
up to one third of patients will have nodal spread. 6

RECONSTRUCTION
Reconstructive options can be categorized by either the
characteristics and location of the ear defect (eg, partial or
full-thickness or upper, middle, or lower third of the
auricle) or the type of surgical technique employed. Either
approach is a valid method for selecting the type of
reconstruction, but to avoid duplicity in their description,
surgical techniques will be reviewed from the simplest to
the most extensive ablative ear defect.

SECONDARY HEALING
Because of the excellent vascularity of the head and neck
region and its high resistance to infection, almost all facial

Operative Techniques in Plastic and Reconstructive Surge~ Vol 6, No 4 (November), 1999: pp 275-283

275

there is relatively little tendency for contracture even with

large resections (Fig 4). Combined with the absence of any
significant fat between the dermis and perichondrium, this
allows an ear reconstruction that is not depressed and is
confluent with the surrounding skin. For best match of
color and texture, skin grafts should be full-thickness,
non-hair-bearing, and harvested from either the posterior
surface of the ear, postauricular sulcus, or lateral neck.
When cartilage is exposed without perichondrium, a
skin graft may take if the amount of cartilage exposure is
limited and adequate soft tissue contact is available such as
in small excisions. An alternative strategy is to delay skin
graft reconstruction until sufficient granulation tissue develops. However, a preferable approach would be to electively remove cartilage to expose the raw surface of the
dermis on the opposite side of the ear. This is best done in
concave areas such as the concha or triangular fossa, which
are nothing more than simple hollows. This technique can
also be performed on the helical rim, but there will be a
resultant notch deformity.

COMPOSITE GRAFTING

Fig 1. The three outlines of the cartilage framework make an

ear recognizable.

wounds including those of the ear will heal by secondary

intention as was initially described by the work of Mohs. 4
This process obviously takes longer than surgical reconstructions and exacts a price of eventual scar contracture.
The amount of scar contracture, however, varies according
to the anatomical region of the ear involved and the
characteristics of the excised w o u n d bed. Small superficial
resections will heal with minimal to no esthetic distortion
in almost all ear areas. The larger (>1 cm) and deeper the
excision, the greater the contraction will be, particularly if
there is loss of cartilagenous support. Generally, wounds
on c o n c a v e ear surfaces will heal better and more esthetically acceptable than those on c o n v e x surfaces. 5 Given the
relative simplicity of many surgical closures, however,
secondary healing is limited to those patients who are
unable to tolerate or do not desire any form of further
surgery. When cartilage is exposed, granulation tissue is
slow to develop, and with the risk of cartilage infection or
necrosis, surgical reconstruction is indicated.

SKIN GRAFTING
Skin grafts have great versatility in ear reconstruction.
Because they are adaptable to even very concave or
convoluted surfaces, they work very effectively in those
superficial excisions that leave perichondrium (Fig 3).
Because of the strong support of the underlying cartilage,
276

Like the nose, composite grafts of skin and cartilage can be

used to restore small defects of the ear. The best selection
for this technique are defects of the helical rim that are 1.5
cm or less in width to optimize take and prevent secondary
atrophy of the central regions of the transplanted graft. 6
The graft is harvested from the scapha or helix of the
opposite ear, and the excised defect is converted to a
through-and-through wedge by removing the underlying
skin and cartilage. The graft is then inset with maximal
contact to vascularized skin on both edges. In defects of
this size, however, other methods of direct closure may be
simpler and eliminate the need for manipulation of the
opposite unaffected ear. One of the advantages of composite grafting would be to allow adjustment of the height of
both ears. By a well-measured graft harvest, the resected
ear can be restored (with a slight reduction in height from
normal), while the donor ear can be slightly reduced to
match the opposite side. Most patients, however, are not
that discriminating to demand absolute symmetry of both
auricular heights.
Larger defects may be reconstructed with this technique
by reducing the bulk of one surface of the composite graft.
The posterior skin and cartilage are removed from the graft
medial to the new helix and inset into the defect. Vascular
ingrowth is achieved by either having a defect that has
preserved the postauricular skin or advancing a postauricular skin flap in full-thickness defects to serve as the
recipient bed for the remaining anterolateral portion of the
composite graft. 12

DIRECT CLOSURE
The tight adherence of the skin to the underlying cartilage
limits the ability to directly approximate many ear defects.
If the defect is small and the excision lies parallel along the
helical rim, the surrounding skin may be approximated
with only slight flattening of the rim contour. For larger
defects along the helical rim that are full-thickness, the ear
segments may be brought together in a classic V-shaped or
BARRY L. EPPLEY

'Y~r:

~,r

Fig 2. Congenital microtia repair (A = preop at age 6; B = postop at age 8 after a four-stage reconstruction).

wedge closure (Fig 5). Because of the stiffness of ear

cartilage, closure of larger wedges will distort the ear by
pulling it forward around the defect, creating an iatrogenic
cup-ear deformity. This is particularly manifest in the
upper half of the ear, which has more inherent curvature.
This can be reduced by extending the full-thickness excision deeper into the ear, often crossing the antihelix into
the concha, to close down the angle of closure. Another
technique for closure of wedge excisions is to selectively
remove additional triangles of tissue along either one or
both limbs of the excision. This is done either along the
antihelical rim or concha and alleviates some of the tension
of closure at the price of an overall smaller, but normally
appearing, ear. The design and location of these triangular
excisions is up to the tailoring of the surgeon and will vary
somewhat depending on which area of the ear is involved.

Numerous local flaps have been described for ear reconstruction that are based either on tissue within the existing
ear structure or adjacent non-hair-bearing skin from the
postauricular sulcus, mastoid, or upper cervical regions.
These are almost always random skin or skin-cartilage
flaps that can be advanced, rotated, or rolled to restore the
missing ear part. The following basic flaps are the most
commonly used but are not inclusive of all methods.

based on the original description of Antia and Buch 1~is an

extremely reliable method with numerous variants. While
originally described for upper-third ear defects as an
inferiorly based advancement flap, it works equally well, if
not better, for more inferior helical rim defects. For middlethird defects 2.5 cm or less in size, the remaining lower
portion of the helix, antihelix, and lobule is transferred
superiorly based on the vascular supply from the posterior
skin (Fig 6). This technique takes advantage of the helical
mobility obtained after its release from the scapha. An
anterior cut is made through skin and cartilage along the
helical rim or within the scaphoid fossa but not through the
posterior ear skin. Incisional release is carried into the ear
lobule as necessary for the amount of advancement needed.
This maneuver is very effective, because the lobule lacks
cartilage, which allows a large amount of stretch and
adapts well to a reduction in size. u
When used for inferior transfer of the residual helix and
antihelix for more superior helical defects, incisions must
be carried around the apex of the anterior helical crus,
creating a V-pattern of skin and cartilage. Again, the
posterior skin remains intact, although a portion of it can
be excised for even greater mobility of the flap. This allows
closure in a V-Y advancement pattern. In larger defects,
opposing superiorly and inferiorly based helical advancements can be done, which lessens the esthetic distortion
that may occur when either flap is used alone. 12

Helical Advancement

Postauricular Flaps

For defects of the lateral or helical portion of the ear, the

well-known and described helical advancement technique

Postauricular skin, based either superiorly or inferiorly,

can be transferred to resurface or reconstruct ear defects. In

LOCAL

FLAPS

AURICULAR RECONSTRUCTION

277

Fig 3. Skin grafting of ear defects. Excellent results are obtained on all ear surfaces with cartilage and perichondrial support
with little risk of contracture.

its simplest form, postauricular skin fashioned into a rolled

tube can be advanced to restore a helical rim. 12,13 In a
staged procedure, the lateral margins of the ear defect are
initially sewn into the postauricular skin. At a second
stage, the posterior edge of the postauricular skin with the
desired amount of skin needed to create the helical rim is
released and the postauricular defect either primarily
closed or skin grafted (Fig 7). When the excised defect
extends beyond the helical rim, a larger postauricular skin
flap is needed with a broader base and the need for a
cartilage strut incorporated as part of the flap inset to resist
collapse and secondary ear distortion. In a more eloquent
use of this concept as a transposition flap, a cutaneous
tube, or flap can also be created with an axial blood supply
based on the postauricular vessels. In one or two subsequent stages, the skin is transposed into the helical defect
with an initial superior attachment, followed by an inferior
release and inset. 14,15
An island of postauriuclar skin can be transferred into
the concha when both skin and cartilage have been
removed. An island of skin is outlined around the postauricular sulcus, partly on the mastoid area and partly on the
postauricular region. Skin incisions are then made entirely
around the outline of the flap, preserving a vertical band of
subcutaneous tissue at the ear-mastoid groove. This becomes the vascular pedicle and allows the skin island to be
passed onto the anterior surface of the ear for reconstruc-

278

tion of the conchal defect (Fig 8). The donor defect is closed
primarily.

Infra-auricular/Cervical Flaps
A variety of defects of the lower one third of the ear
including the lobule can be satisfactorily reconstructed by
adjacent skin flaps. The laxity of the upper neck skin, especially
in the older patient, compared with the postauricular skin over
the mastoid, makes flap transfer slightly easier. The trade-off
for easier skin movement of upper neck skin is that scars
and skin grafts of the donor sites are more visible. Small
wedge excisions or a reduction in the size of the lobule is
esthetically well tolerated as long as enough lobule remains to create a clear separation from the antitragus and
hangs below the lower border of the concha cavum.
While replacement of the lobule can be done by a
one-stage transfer of a superiorly based (auricular) skin
flap, most excisional defects have a free-standing edge
rather than the defect already scarred to the neck. 12
Therefore, a two-stage approach to transfer both skin and
cartilage is devised. Initially, a contralateral conchal cartilage graft is inserted in a soft tissue pocket beneath the
lobular defect and the superior skin edge attached to the
lower edge of the lobular defect. During the second stage,
the chondro-cutaneous unit is released and its medial
surface skin grafted 14(Fig 9).

BARRY L. EPPLEY

Fig 4. Skin graft reconstruction of the entire ear in a 64-year-old male with a history of congenital hemangioma (A --- preop; B =
postop).

Temporoparietal Flap
A fascial flap from the superior area above the ear based on
the temporal vessels is an easily raised and reliable method
of providing vascularized cover for any portion or all of
the ear. It is commonly used in combination with splitthickness skin grafts for coverage of cartilage or synthetic
frameworks in major or complete loss of the ear, when
postauricular skin is unusable due to scarring from excision or burn injuries, and as a method of salvage for
exposed frameworks. While it is a more extensive procedure with the inherent risks of a temporal scar and possible
thinning of hair over the donor area, the temporoparietal
fascial flap offers a one-stage approach to any size ear
defect. When other methods of ear reconstruction are
available, they should be used first, always reserving this
fascial flap as a potential salvage method.

TOTAL AURICULAR RECONSTRUCTION

When the entire ear is removed as a result of cancer,
autogenous treatment options are often limited due to skin
graft or flap coverage over the mastoid, as well as the
frequent use of postresection radiotherapy. The classic
technique of autologous reconstruction as is well described
for microtia usually does not apply in oncological resections because of these tissue limitations, as well as the
typical older age of the patient, who may not desire an
extensive reconstruction requiring multiple stages. Traditionally, therefore, an ear prosthesis is used and is held into

AURICULAR RECONSTRUCTION

position by a variety of skin adhesives. While the artificial

ear can be crafted as a beautiful replication of the opposite
ear (Fig 10), its retention on the side of the head is variable
and is adversely affected by wet and windy weather,
high-temperature work conditions, strenuous physical activities, patient compliance with skin hygiene, and skin
reactivity to the adhesives. Under these circumstances, the
use of an osseointegrated-retained ear prosthesis is a
preferable alternative and offers numerous advantages in
these patients, including ease of placement, predictable
retention, improved esthetics, increased life span of the
prosthesis, and elimination of continuous irritation to the
skin.7,8
Since 1979, metal implants have been placed in the
mastoid region for retention of an ear prosthesis. 9 The
success of this procedure is based on successful integration
(lack of a fibrous tissue interface) between the metal
(titanium) implant and the mastoid bone and tolerance of
the surrounding skin to the penetrating metallic fixture.
This is achieved by a two-stage procedure in which two or
three titanium implants are initially placed under lowspeed drilling to prevent bone damage. This is followed by
a 3- to 6-month healing period to allow direct bone-implant
bonding. A second stage consists of implant exposure and
the attachment of percutaneous fixtures onto which the
final ear prosthesis will be attached. If the mastoid region
around the implants has not been previously skin-grafted,
this is often clone at the same time. It is imperative that the
thickness of the skin around the implants be less than the

279

Fig 5. Primary closure of wedge excision of helical malignancy (A

B = primary closure of wedge excision).

height of the collar around the fixture to prevent hygiene

problems and chronic skin irritation. The skin flap over the
implants can also be thinned to achieve this, but a splitthickness skin graft is usually more efficacious. Once the
fixtures are exposed, the anaplastologist fabricates the final
prosthesis, which may be attached by either a snap-fit or
magnetic attachment (Fig 11). This alloplastic approach to
ear reconstruction has a significant long-term retention
rate, even in irradiated bone, with extensive experience in
Canada, Sweden, and the United States.

excision of melanoma of helix and preauricular lesions;

GENERAL RECONSTRUCTIVE PRINCIPLES

Amidst the variety of ear-reconstruction techniques presented, certain conceptual and technical principles are
worth following, including:
1. In reconstruction of an ear defect, the fundamental approach
is either reduction or replacement.
In assessing any ear defect, think of whether a smaller
but normaMooking ear is acceptable or whether replace-

. Fig 6. Classic depiction of Antia-Buch's helical advancement technique.

280

BARRY L. EPPLEY

A
/,

I:
i

',

lb
;

Fig 7. (A) Postauricular skin flap advancement for helical rim

restoration (anteriorly-based). (B) Outer ear loss secondary
to horse bite. (C) Postauricular skin advancement after tissue
expansion (posteriorly-based).

ment of the missing parts is better. While a reductive

approach can be achieved in one stage and is simpler,
tissue replacement usually requires multiple stages and
is more complex.
2. Preservation or restoration of the postauricular sulcus and
external auditory canal are major functional areas of reconstruction.

The ability to gather and transmit sound to the tympanic membrane and provide support for visual or
recreational eyeglass wear are the only significant functional objectives of ear reconstruction. The majority of
the intricacies of the ear framework including the lobule
are decorative. In general, do not sacrifice tissue or
induce scarring from the postauricular sulcus or concha

P4;n

Fig 8. Postauricular island flap for conchal reconstruction.

AURICULAR RECONSTRUCTION

281

~!Lll~,,~::, ,

.
i!iiiiii!

.:.... ,...;
......
~ ....i i

~"~;'~
"

Fig 9. Lobule reconstruction by infra-auricular/cervical flap transfer, which

can be used with a cartipostoperativelags
graft to eliminatecontrac.
ture.

-.',.,,,,,
\,,,, .- -..'.
-.. ",",:~

: ' i ~U, ~

Fig 10. Prosthetic ear fabrication produces a beautiful replica

of the normal or opposite ear.

Fig 11. (A) Osseointegrated titanium implants secured to mastoid after removal of entire ear secondary to melanoma. (B) Total
ear prosthesis held in place by magnetic attachments to titanium implants.
282

BARRY L. EPPLEY

s y m b a for reconstructing other ear regions unless a

m e t h o d is p r o v i d e d for simultaneously reconstructing
these areas as well.

3. Restoration of ear cartilage support after resection is usually

not necessary in concave hollows.
Cartilage s u p p o r t of the shape and position of the ear is
maintained primarily b y the shape and length of the
helical rim and antihelix. Concave hollows such as the
concha and triangular fossa a d d interesting architecture
to the ear b u t little to structural support. They, therefore,
m a y be replaced b y soft tissue only.

4. Ear cartilage repair should be approximated by sutures.

The elastic cartilage of the ea,." does not heal with
cartilagenous i n g r o w t h but by the d e v e l o p m e n t of
fibrous scar between the cut cartilage edges. Therefore,
cartilage edges should be sutured with an u n d y e d
slowly resorbing or clear p e r m a n e n t suture for a more
secure closure.

5. Full-thickness skin grafts are preferred over split-thickness

grafts.
Because of the paucity of subcutaneous fat on the
anterior surface of the ear, a g o o d thickness m a t c h is
obtained with full-thickness skin, thus avoiding contour
depression of the reconstructed area.

SUMMARY
The goals of auricular reconstruction after t u m o r excision
are to obtain a functioning a p p e n d a g e on the side of the
head that is as n o r m a l as possible in position, size, and
contour, in decreasing order of importance. A variety of
basic techniques to achieve these goals has been described
including secondary healing, skin grafts, direct closure,

AURICULAR RECONSTRUCTION

local flaps, and alloplastic reconstruction d e p e n d i n g on the

location and size of the excised ear segment. W h e n p r o p erly selected, these techniques have been p r o v e n to achieve
successful ear-reconstruction results with limited complications.

REFERENCES
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9. Tjellstrom A: Osseointegrated implants for replacement of absent or
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