Revisiting Gavello’s procedure for single-stage reconstruction of the earlobe: The vascular basis, technique and clinical uses

Abstract

BACKGROUND:

Deformities or loss of the earlobe may be congenital, or acquired due to trauma, bites, burns or tumour excision. A variety of single-stage and two-stage procedures have been described for earlobe reconstruction, of which Gavello’s procedure was one of the earliest.

OBJECTIVE:

To revisit Gavello’s procedure with reference to the vascular supply of the flap, and discuss the relevance of the technique in current practice.

METHODS:

The authors discuss the vascular basis of Gavello’s flap, and describe the clinical application of the single-stage Gavello’s procedure in diverse clinical situations, including congenital absence of earlobe, post-burn earlobe deformity and traumatic amputation of the earlobe.

RESULTS:

Excellent cosmetic results have been achieved in all different clinical situations in the authors’ experience, with preservation of earlobe shape and volume, good colour match and a well-concealed scar in the donor area.

DISCUSSION:

Gavello’s procedure is a simple, one-stage procedure that relies entirely on local tissue for earlobe reconstruction; the flap has a predictable vascular supply, skin grafting is not required and the procedure can be used for large defects. An intact donor area over the postauricular mastoid region is a prerequisite.

CONCLUSION:

The simple, century-old Gavello’s procedure is still of great value for reconstruction of earlobe defects of diverse etiology.

Deformities of the earlobe may be congenital, or acquired as a consequence of trauma, human or animal bites, burns or tumour excision. A variety of procedures for earlobe reconstruction, both one-stage and two-stage, have been described. The technique described by Gavello (quoted by Nélaton and Ombrédanne, 1907 [1]) is one of the earliest and simplest and, in our opinion, this century-old technique merits revisiting for evaluation of its application in contemporary reconstructive surgery.

Gavello’s procedure consists of outlining a horizontal bilobed skin flap in the postauricular mastoid region. The posterior flap is folded under the anterior flap, thus forming the posterior lining of the new earlobe. The resulting skin defect is closed by direct approximation (2). In the present article, we describe the Gavello procedure in detail, including its vascular basis and demonstrate excellent outcomes in three patients with earlobe deformity/loss due to diverse etiologies.

THE VASCULAR BASIS OF GAVELLO’S FLAP

The posterior auricular artery arises in the neck from the external carotid artery, and ascends between the auricle and mastoid process. It supplies the cranial surface of the auricle via its auricular branch, and the occipital belly of occipitofrontalis and the scalp behind and above the auricle via its occipital branch (3). Our observation of digital subtraction angiography (DSA) images of different individuals undergoing DSA for unrelated causes revealed that the occipital branch of the posterior auricular artery that runs horizontally behind the ear is a constant vessel in the area where Gavello’s flap is raised (Figure 1).

Figure 1).

Digital subtraction angiography image demonstrating the occipital branch of posterior auricular artery

Description of the procedure: Figures 2A and 2B

Figure 2).

Design of the bilobed Gavello flap. A schematic drawing. B Preoperative marking

A straight line (A–B) is drawn on the postauricular mastoid skin, along the cut margin of the earlobe. This line is further extended posteriorly to a point C, so that AB = BC. A point D is marked approximately 1 cm vertically below the point A. From point D, a double-curved line (D-E-C) is drawn, joining points D and C. The bilobed flap thus formed is raised by subcutaneous dissection with caution to avoid injury to the posterior auricular artery, which runs at the base (A–D) of the flap. The cut margin of the earlobe is paired and freshened. The bilobed flap is folded on itself along B–E. AB and BC are sutured with the anterior and posterior paired margins of the earlobe, respectively. The lower curved borders of the bilobed flap are sutured with one another to form the free margin of the new earlobe. The donor site defect is closed primarily after wide undermining. Sutures are removed after two weeks.

Clinical application and results

Case 1:

A 19-year-old woman underwent earlobe reconstruction for congenital absence of left earlobe (Figure 3A) using the technique described above. The postoperative result is shown in Figure 3B.

Figure 3).

Results of Gavello’s procedure in congenital absence of earlobe. A Preoperative photograph. B Postoperative outcome

Case 2:

A 33-year-old man presented with postburn deformity of his right earlobe (Figure 4A). The deformed and extremely scarred earlobe was excised and a new earlobe reconstructed using the method described (Figure 4B).

Figure 4).

Results of Gavello’s procedure in postburn earlobe deformity. A Preoperative photograph. B Postoperative outcome

Case 3:

A 40-year-old woman experienced near total amputation of her left earlobe as a result of sharp-cut injury (Figure 5A). Reconstruction by Gavello flap yielded a satisfying result (Figure 5B).

Figure 5).

Results of Gavello’s procedure in traumatic amputation of earlobe. A Preoperative photograph. B Postoperative outcome

DISCUSSION

The earlobe is a small but aesthetically crucial structure. The challenge in earlobe reconstruction surgery is to obtain a natural-appearing structure with a durable outcome. The technique should be simple, preferably performed in one stage, suitable for earlobe defects of all sizes and volume, and yield acceptable cosmetic results.

A variety of single-stage and two-stage reconstructive techniques have been described for earlobe reconstruction. These techniques mainly use local skin flaps from the preauricular, infra-auricular, retroauricular, retromandibular areas or the auricular surface, depending on the flap design: doubled-over single or bilobed flaps (1,2,4–10), superimposition of two opposing or paired flaps (11–14) or double-crossed flaps (15) may be used; some techniques require a skin graft in addition to the flap (6,16,17). Some of the procedures involve the incorporation of a cartilage graft into the reconstructed earlobe to maintain shape (18–20).

The advantages of the Gavello technique are as follows: it is a simple, one-stage procedure; it is suitable for both immediate and delayed reconstruction; it relies entirely on local tissue for reconstruction; the flap has a predictable vascular supply; skin grafting is not required; it yields excellent cosmetic results with preservation of earlobe shape and volume; excellent colour match; the donor site scar is well-concealed; and the procedure can be used for large defects or even total loss of earlobe, as shown in case 3 of the present series. The limitation of the procedure is the requirement of an intact donor area over the postauricular mastoid region.

CONCLUSION

In the present article, we revisited Gavello’s procedure of earlobe reconstruction with an attempt to understand the vascular basis of the procedure, and demonstrated the excellent results that can be achieved with this century-old technique for earlobe defects of diverse etiology. Thus, it can be concluded that such ‘old’, simple flaps are still of great value.