10.14639/0392-100X-N2036
Anterior auricular concha reconstruction has always been a challenge for the plastic surgeon. The goal of optimal reconstruction is to achieve a natural aesthetic outcome taking care to avoid meatal stenosis and distortion. We present a new technique for reconstruction of large anterior conchal defects with meatal involvement using a perforator flap harvested from the superior auricular region. All patients undergoing post-oncological reconstruction with superior temporo-auricular perforator flap were retrospectively analysed. A handheld Doppler evaluation was performed prior to surgery. Follow-up at 1, 3, 6 and 12 months was carried out. Nine patients were evaluated. No partial or total vascular complications were observed. No relapse of the tumour and meatal stenosis developed. Eight patients were very satisfied with the aesthetic outcome. Only one patient was not completely satisfied due to the presence of hair at the level of reconstructed site. The superior temporo-auricular flap is a good alternative to flaps harvested from the retroauricular region and should be considered as a primary choice for reconstruction of extensive defects of the conchal and external meatus area.
text/xml
1827-675X
2036
en
Valeria Navach
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
propeller flap
Superior temporo-auricular perforator flap for reconstruction of extensive conchal defects
Text.Serial.Journal
https://www.actaitalica.it/
42
Clinical techniques and technologies
2022-09-30
2022-02-10
2022-10-12
2022-10-12
395-399
1
Valeria Navach
2022/09/30
10.14639/0392-100X-N2036
395
AUSL Piacenza, UO of Plastic Surgery, Piacenza, Italy
1827-675X
propeller flap
en
399
Superior temporo-auricular perforator flap for reconstruction of extensive conchal defects
https://www.actaitalica.it/article/download/2036/859
42
ACTA OTORHINOLARYNGOLOGICA ITALICA 2022;42:395-399; doi: 10.14639/0392-100X-N2036




Clinical techniques and technologies


Superior temporo-auricular perforator flap
for reconstruction of extensive conchal defects
Il lembo perforante temporo-auricolare superiore per la ricostruzione dei difetti estesi
della conca
Paola Parisi1, Mohssen Ansarin2, Elisabetta Pennacchioli3, Filippo Di Meglio1, Diego Ribuffo1, Valeria Navach4
1
  Sapienza University of Rome, Department of Surgery “P. Valdoni”, UOC of Plastic Reconstructive Surgery, Rome, Italy; 2 European
Institute of Oncology, Head and Neck Unit, Milan, Italy; 3 European Institute of Oncology, Sarcoma and Melanoma Unit, Milan, Italy;
4
  AUSL Piacenza, UO of Plastic Surgery, Piacenza, Italy


SUMMARY
Anterior auricular concha reconstruction has always been a challenge for the plastic sur-
geon. The goal of optimal reconstruction is to achieve a natural aesthetic outcome taking
care to avoid meatal stenosis and distortion. We present a new technique for reconstruction
of large anterior conchal defects with meatal involvement using a perforator flap harvested
from the superior auricular region. All patients undergoing post-oncological reconstruction
with superior temporo-auricular perforator flap were retrospectively analysed. A handheld
Doppler evaluation was performed prior to surgery. Follow-up at 1, 3, 6 and 12 months was
carried out. Nine patients were evaluated. No partial or total vascular complications were
observed. No relapse of the tumour and meatal stenosis developed. Eight patients were very
satisfied with the aesthetic outcome. Only one patient was not completely satisfied due to
the presence of hair at the level of reconstructed site.
The superior temporo-auricular flap is a good alternative to flaps harvested from the retro-
auricular region and should be considered as a primary choice for reconstruction of exten-
sive defects of the conchal and external meatus area.
KEY WORDS: concha reconstruction, perforator flap, temporal superficial artery, propeller flap   Received: February 10, 2022
                                                                                                 Accepted: April, 21, 2022
RIASSUNTO
                                                                                                 Correspondence
La ricostruzione dei difetti della conca è da sempre stata una sfida per il chirurgo plastico.
                                                                                                 Paola Parisi
L’obiettivo di una ricostruzione ottimale è di ottenere un risultato estetico naturale senza     Sapienza University of Rome, Department of Sur-
creare distorsioni o stenosi del meato esterno.                                                  gery “P. Valdoni”, UOC of Plastic Reconstructive
I pazienti sottoposti a ricostruzione con il lembo perforante temporo-auricolare superiore       Surgery, viale del Policlinico 155, 00616 Rome,
sono stati analizzati retrospettivamente. Tutti i pazienti hanno eseguito un esame doppler       Italy
preoperativamente. I pazienti hanno seguito un follow-up a 1-3-6 e 12 mesi.                      E-mail: paola.parisi@uniroma1.it
In totale nove pazienti sono stati valutati. Non è stata evidenziata nessuna complicanza
vascolare parziale o totale del lembo. Otto pazienti sono risultati molto soddisfatti del          How to cite this article: Parisi P, Ansarin
risultato estetico. Solo un paziente non è risultato completamente soddisfatto a causa della       M, Pennacchioli E, et al. Superior temporo-
presenza di capelli a livello del lembo.                                                           auricular perforator flap for reconstruction
Il lembo perforante sopra-auricolare è una buona alternativa ai lembi allestiti dalla re-          of extensive conchal defects. Acta Otorhi-
gione retroauricolare e dovrebbe essere considerato come prima opzione chirurgica nella            nolaryngol Ital 2022;42:395-399. https://doi.
ricostruzione dei grandi difetti della conca.                                                      org/10.14639/0392-100X-N2036

PAROLE CHIAVE: ricostruzione della conca, lembo perforante, arteria temporale                    © Società Italiana di Otorinolaringoiatria
superficiale, lembo propeller                                                                    e Chirurgia Cervico-Facciale


                                                                                                                OPEN ACCESS
Introduction                                                                                     This is an open access article distributed in accordance with
                                                                                                 the CC-BY-NC-ND (Creative Commons Attribution-Non-
The auricular conchal cavity is the shallow central structure of the external ear.               Commercial-NoDerivatives 4.0 International) license. The
This anatomical region is extremely important in maintaining the anatomical                      article can be used by giving appropriate credit and mentio-
                                                                                                 ning the license, but only for non-commercial purposes and
structure of the external ear and to conduct sound waves to the external audi-                   only in the original version. For further information: https://
tory canal. Skin cancer localisation at the level of the concha is not uncommon                  creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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P. Parisi et al.




and advanced parotid cancer can also affect this region.          temporo-auricolar perforator (STAP) flap was intraopera-
Surgical access to the anterior auricular concha is quite         tively checked again with a handheld doppler. A flap was
difficult due to its concavity and partially hidden location.     designed around an eccentric perforator as in propeller
Due to this peculiar anatomical conformation, diagnosis of        flaps in the superior and retro-auricular area. Surgery was
concha skin tumour is difficult and often delayed. Local to-      performed under magnification with 3.5X surgical loops.
pography of the auricular area, with its irregular contours,      Perforator vessels were examined through an exploratory
complicates exploration and treatment. For these reasons,         incision made along the margin of the flap outline. A skin
the concha is a high risk area, and follow-up may be more         island was incised and dissection performed in a subfascial
difficult than in other anatomical locations. Complete tu-        plane. Care was taken to preserve the fat tissue surrounding
mour excision at the first intervention is warranted.             the perforator to the temporalis vessels. Dissection was per-
Many reconstructive methods for anterior conchal defects          formed until the superficial temporalis artery was reached;
following tumour excision have been described depend-             when a longer pedicle was needed, the terminal branches
ing on the size and depth of the excision 1. Small defects        of temporalis vessels were closed and the dissection per-
with intact perichondral layer can heal by secondary inten-       formed further along temporalis vessels to gain movement
tion or reconstructed with split or full-thickness skin grafts    and reduce the risk of kinking. To decide the 180° rotation
(FTSGs). In cases of perichondral layer involvement and           direction of the flap, a gentle rotation of the flap was per-
for larger defects, it is necessary to use a local flap usually   formed counter-clockwise and clockwise to evaluate flap
harvested from the post-auricular region. FTFGs can used          perfusion before the definitive in-setting. Next, the flap was
only after completely removing the cartilaginous layer            passed through a subcutaneous tunnel under preauricular
weakening the structural firmness of the ear. The revolving-      skin.
door (RD) flap, described by Masson 2, is a post-auricular        All patients with meatus demolition superior to 180° main-
island pedicle type that provides skin from the ipsilateral       tained a removable stent for one month.
post-auricular mastoid region an it is one of the most wide-      Follow-up was carried out at 1, 3, 6 and 12 months. A
ly used flaps.                                                    Visual Analogue Scale from 0 (worst result) and 10 (better
For larger defects extending to the external meatus, it is        result) to evaluate cosmetic outcomes was administered to
necessary to use the post-auricular flap. Neither the RD nor      patients at 12 months.
the post-auricular flap can be used for very large defect that    A total of 9 conchal reconstructions with temporo-auricular
completely involves the concha area and meatus, especially        flap were performed; 8 patients had immediate reconstruc-
if this is involved circumferentially at 360°.                    tion (Tab. I). One patient received reconstruction one year
The aim of this article is to present a novel technique for re-   after tumour excision due to a complete meatal stenosis and
construction of auricular conchal and meatus defects using        ear acquired deformation (Fig. 1).
a local perforator flap from the superior auricular region.       There was 1 woman and 8 men. Mean age was 62 years
                                                                  (range from 58 to 70). All patients required reconstruction
Description of surgical technique                                 after tumour removal for oncological purposes. The mean
                                                                  dimension of the excision was 1.8 cm x 2 cm (range 1.5 x 2
and medical management                                            to 2 x 2 cm).
A retrospective study analysing all patients undergoing           The diagnoses were: one case of adenoidocystic cancer
conchal immediate or delayed reconstruction after tumour          (ACC) of the parotid gland affecting concha and external
resection with superior temporo-auricularis perforator            meatus; four cases of squamocellular carcinoma (SSC)
(STAP) flap from January 2017 to June 2021 at the Eu-             of the concha involving cartilage and partially the exter-
ropean Institute of Oncology (IEO), Milan, Italy was per-         nal meatus; three cases of invasive basocellular carcinoma
formed.                                                           (BCC) of the skin and cartilage. The patient who under-
All patients undergoing this type of reconstruction were          went delayed post-oncological reconstruction was negative
preoperatively analysed by a handheld Doppler to mark the         for a neoplastic lesion and histopathologic exam of the scar
superior perforator of the superficial temporal artery, which     revealed a chronic inflammatory lesion.
is the principal pedicle of the temporo-auricular flap.           In all cases the affected conchal cartilage was removed.
First, the tumour was excised with removal of the affected        In the cases of ACC of the parotid gland, ear demolition
conchal cartilage. Definitive histological examination was        was conducted together with nerve sparing total parotidec-
always performed. Intraoperative examination of the skin          tomy and a 360° meatal reconstruction was performed us-
limits was always done.                                           ing the superior temporo-auricular perforator flap (Fig. 2).
After removal of the tumour, the perforator of the superior       In 3 cases (2 SCC and 1 BCC), a 200° meatal reconstruc-



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                                                                                                                  A new technique for ear conchal defect reconstruction




Table I. Characteristic of the case series.
 Patient              Gender              Age                      Lesion diameter                          Histological                   Meatal involvement
                                                                        (cm)                                    type                            (grade)
 1                         M                  58                       1.5 X 1.8                               BCC                                  no
 2                         M                  59                        1.8 X 2                                Scar                                180°
 3                         M                  61                        1.8 X 2                                SCC                                 200°
 4                         M                  64                       1.6 X 1.8                               SCC                                  no
 5                         F                  62                        1.8 X 2                                BCC                                  no
 6                         M                  59                        1.7 X 2                                SCC                                  no
 7                         M                  70                         2X2                                   BCC                                 200°
 8                         M                  63                         2X2                                ACC parotid                            360°
 9                         M                  62                         2X2                                   SCC                                 200°
Note: M: male; F: female; BCC: basocellular carcinoma; SCC: squamocellular carcinoma; ACC: adenoidocystic carcinoma.



                                                                                         tion was performed (Fig. 3). Two patients with SCC and
                                                                                         two with BCC did not require meatal reconstruction. The
                                                                                         patient who performed delayed reconstruction required a
                                                                                         180° meatal reconstruction (Fig. 1). Eight patients were
                                                                                         discharged from hospital the day after intervention; the pa-
                                                                                         tient who required parotidectomy was discharged after 72
                                                                                         hours. All patients were administered antibiotics for 6 days
                                                                                         post-operatively. No complication such as venous conges-
                                                                                         tion, partial/total ischaemic bleeding, haematoma, or infec-
                                                                                         tion were observed.
                                                                                         A total of 4 patients maintained a removable stent for one
                                                                                         month.
                                                                                         Two patients received radiotherapy after surgery. Due to
                                                                                         the thickness of the flap, cartilage reconstruction was not
                                                                                         needed in any case. No patient had meatus stenosis at 12
                                                                                         months. No local cancer recurrence was detected during
                                                                                         follow-up.
Figure 1. Delayed reconstruction in a patient with acquired ear deformity
and meatal stenosis. (A) preoperative appearance and flap marking; (B) recon-            Cosmetic results were judged very satisfactory (10) by 8
struction with STAP flap with a 180° meatal reconstruction.                              patients; one patient judged it as sufficient (5). This patient




Figure 2. Ear demolition in patient with adenoidocystic tumour of the parotid gland and reconstruction with STAP flap. (A) intraoperative image after ear demo-
lition and STAP flap; (B) in-setting of the flap with a 360° meatal reconstruction; (C) post-operative appearance after 12 months follow-up.



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P. Parisi et al.




Figure 3. Ear demolition and reconstruction with STAP flap in a patient with basocellular carcinoma; (A) preoperative image of BCC with meatal involvement;
(B) intraoperative harvesting of STAP flap with 200° meatal reconstruction; (C) post-operative appearance at 3 month follow-up.


presented hair very close to the ear, so that hairy skin was                    parotid gland in the preauricular region and runs superfi-
included in the conchal reconstruction requiring definitive                     cially underneath the skin and superficial temporal fascia.
hair removal with laser.                                                        It gives off between one and three branches to supply the
                                                                                root of the helix and the upper two-thirds of the helical
Discussion                                                                      rim. These branches from the superficial temporal artery
                                                                                also provide blood to the hairless supra-auricular and retro-
Reconstruction of ear defects has always been a challenge                       auricular area which can be included when designing the
to the plastic surgeon given the complex three-dimensional                      temporo-auricular flap.
conformation of this anatomic area.                                             The majority of flaps described in the literature have used
Good reconstruction should aim to correct the deformity                         the postauricular skin area due to its rich vascularisation,
with minimum morbidity and to achieve the utmost natu-                          skin laxity and skin colour, ease of surgical access and re-
ral aesthetic outcome; thus, care should be taken to avoid                      duced donor site morbidity. The post-auricular flap tech-
meatal stenosis, distortion of the concha, or significant aes-                  nique has been thoroughly described for reconstruction of
thetic change as much as possible. Reconstruction of de-                        various ear defects, including those of the anterior surface.
fects of the auricular concha is difficult because the skin in                  Preauricular flaps for anterior ear reconstruction have also
this region is closely adhered to the underlying cartilage.                     been described 4. Field described a 2-stage approach using
Skin grafting is still widely used by many surgeons for re-                     a preauricular flap inferiorly (IBPA) and superiorly (SBPA)
pair of defects in this region. However, skin grafts can lead                   based for anterior ear reconstruction. A two-stage IBPA for
to development of complications such as delayed wound                           closure of a defect, which extended from the inner rim of
healing, pigmentation, and centripetal contraction, with                        the superior helix to the inferior crus of the antihelix, was
meatal stenosis in cases of involvement of this area. Fur-                      described by Suchin et al. 5 Wang et al. 6 described a tun-
thermore, for defects that are not supported by nearby car-                     neled preauricular island flap for an earlobe defect. Pereira
tilage, wound contraction and irregularities of contour will                    et al. 7 described a tunneled preauricular superiorly based
lead to a less than optimal aesthetic outcome. For these rea-                   flap in a single stage operation for closure of an auricular
sons, local flaps become the leading reconstructive option.                     defect in the scapha. Sorkin et al. 8 presented a case series
Houseman et al. 3 demonstrated that the blood supply of the                     of 11 patients with anterior ear defect reconstructed with
external ear consists of two angiosome territories, the su-                     an IBPA. Braga et al. 9 presented a case report of a single-
perficial temporal and the posterior auricular artery, which                    stage tunneled, IBPA flap procedure for reconstruction of
supply the anterior and posterior surfaces of the ear, respec-                  antitragus and concha. Recently, Binhimd et al. described
tively.                                                                         a superficial temporal artery capillary perforator-based is-
The posterior auricular artery ascends behind the ear in the                    land flap for conchal bowl and external auditory canal with
auriculo-cephalic sulcus and branches into 3 to 5 sizable                       good results and without need for surgical revision 10.
vessels providing blood supply to the lower, middle, and                        According to our knowledge, one-stage perforator flaps
upper posterior auricle.                                                        from the superior region based on perforator of the super-
The superficial temporal artery emerges from within the                         ficial temporal artery have not been described for conchal



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                                                                                       A new technique for ear conchal defect reconstruction




and meatal reconstruction. This is the first case series de-   Author contributions
scribing the use of a superior temporo-auricular perfora-      VN conceived and performed the analysis; PP collected
tor flap from the superior auricular region to reconstruct     data; MA and EP contributed to data analysis; PP, FDM
extensive defects from the concha and meatus in a single       and DR wrote the paper.
stage operation.
The advantages of this perforator/propeller flap, despite a    Ethical consideration
pedicled cutaneous/subcutaneous/island flap, are: the pos-     No Ethical Committee approval was required for this study.
sibility to gain major mobilisation of the flap for coverage   The research was conducted ethically, with all study pro-
of larger and more distant defects; mobilisation can be im-    cedures being performed in accordance with the require-
proved by increasing the pedicle dissection when neces-        ments of the World Medical Association’s Declaration of
sary. Our outcomes and results demonstrate that the STAP       Helsinki.
flap is an effective and safe flap for one stage reconstruc-   Written informed consent was obtained from each partici-
tion of an extensive conchal defect with meatal involve-       pant/patient for study participation and data publication.
ment. We did not observe difficulties during dissection or
vascular postoperative complications: the harvesting pro-      References
cedure is simple, and the flap has a rich blood supply with    1
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                                                                    tions, Plast Reconstr Surg 2000;105:2287-2313. https://doi.
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We acknowledge that the sample of patients described           5
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technique. Nonetheless, we consider that this flap is a good        flap for an earlobe defect. Dermatol Surg 2007;33:835-837. https://
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                                                                    Pereira N, Brinca A, Vieira R, et al. Tunnelized preauricular transpo-
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chal and external meatus area.                                 8
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                                                                    Braga AR, Pereira LC, Grave M, et al. Tunnelised inferiorly based
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                                                               10
                                                                    Binhimd U, Alkaabi SA, Alsabri GA, et al. Superficial temporal artery
                                                                    capillary perforator-based island flap for conchalbowl and external
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