Salvage of Traumatic Ear Avulsion with a Modified Kummoona Auricular-Cervical Neck Flap

Introduction

The partial auricular defects require functional and aesthetic reconstruction with principles and techniques of surgical repair including various local flaps based on retroauricular skin [1]. The goal is to recreate an ear that is symmetric to the opposite side in orientation, size and shape and as normal as possible constructing it in three dimensions. The location, size and vascularity of the defect dictate the reconstructive plan with auricle divided into zones or subunits requiring different methods of repair.

In this case report, we present and discuss our experience with transposition flaps available from the post-auricular region used for an ear defect involving posterior-inferior helical defect under staged procedure to preserve the vascularity of the flap and support the cartilage.

Case Report

A 25-year-old male reported in Emergency of Mahatma Gandhi Hospital, Jaipur, Rajasthan, India, with complaint of pain and swelling in right side of face, and loss of ear tissue of left side after a road traffic accident as he fell from bike (Fig. 1).

Fig. 1.

Pre-operative clinical and radiological images and post-auricular defect

On evaluation, swelling and circumorbital edema was seen over right eye with the presence of an open lacerated wound on forehead along with the significant step bony deformity over right zygoma, nasal bone and difficulty on opening mouth with depressed right infraorbital rim with left ear having posterior tissue loss and posterior-inferior helical rim defect which was not in continuity with the post-auricular skin (Fig. 2a), although the cartilage being undamaged was noted. After radiologic investigation with CT scan, a diagnosis of right zygomaticomaxillary fracture, right sub-condylar fracture and naso-orbito-ethmoidal fracture with subtotal defect of ear was made, without any associated comorbidities.

Fig. 2.

Intra-operative images: a–c marking, mobilization and closure of donor site

Patient was admitted for the surgical management as ORIF along with trans-positioned retro-auricular flap of inferior base for reconstruction of the posterior ear subtotal defect after primary debridement and through cleansing of the ear wound and antiseptic dressing were performed.

Flap Design

After 7 days of injury, to manage the defect of approximately 40 × 30-mm dimensions, a single transposition-rotational platysma musculocutaneous flap was used.

Two parallel incisions extending inferiorly from mastoid region down to cervical area extending anteriorly to anterior surface of sternocleidomastoid muscle of about 15 cm length, both connected by a transverse incision, were made. The flap was dissected from lower part as full thickness of skin, fascia and superficial muscle fibres, rotated 120′ angle using posterior pedicle as pivot and containing posterior auricular and occipital superficial perforator branches to reconstruct the defect with anterior surface of the flap covering the auricular defect at antihelix and the posterior margin covering outer part of the posterior ear defect, this way, we obtained complete posterior skin cover without any skin grafts (Fig. 2b).

The donor site was undermined and closed with a Penrose drain in situ (Fig. 2c).

The modification of original Kummoona auricular-cervical flap (Fig. 3) used in our case, viz. extension of flap anteriorly and larger in size, makes it resemble more to original Kummoona lateral cervical flap used for reconstruction of the tongue, floor of mouth, or cheek after tunnelling under the angle of the mandible into the mouth using two vertical incisions which extend up to the clavicle, joined by a transverse incision on the superior border. The modification of flap was incorporated to cover the larger size of defect and a tension-free closure using more obtuse angle of rotation then original while providing optimal bulk of donor tissue with tubing of flap to reconstruct the defect as a whole.

Fig. 3.

Design of Kummoona Auricular-Cervical flap. Image source: [2]

On 5-day follow-up, the drain was removed after the flap was found healthy with integrity of vascular and nervous supply maintaining the sensation in auricular region.

After 3 weeks, the post-auricular tubular flap was transected and achievement of significantly aesthetic appearance with great patient satisfaction was found at 3-month and 6-month follow-up (Fig. 4).

Fig. 4.

Post-operative images: a 10 days, b–d post-transection of flap, at 3 weeks, c 3 month, d, e 6-month follow-up, f post-operative radiograph

Discussion

Reconstruction of partial defects is a particularly challenging, given the complex three-dimensional architecture of the auricular pavilion, associated with high expectations of patients after loss of original structure by causes as trauma, cancer ablation, congenital malformations, keloids or burns and because of its thickness and its fat content [4]. Several methods of ear lobe reconstruction have been described previously in the literature with most of the techniques using one or two local flaps of the pre- or post-auricular region, with or without the use of a graft cartilage [5]. The longevity of the initial result obtained can be compromised by tissue contraction and scarring of donor flaps. The use of skin grafts, on the other hand, for the posterior surface of the lobe repair makes the lobe thinner and, in our opinion, gives it a poor appearance.

For defects not involving the helical rim and those of the full-thickness defects, a post-auricular subcutaneous pedicled advancement flaps involving branches of the post-auricular artery and it perforators are being extensively used. This flap is good for superior and central defects and also allows for incorporation of cartilage between the flap for better strength and fullness. The flap is elevated off the mastoid bone, with post-auricular sulcus providing sufficient laxity and mobilized in a posterior to anterior direction to cover the defect [5].

Defects can also be closed using bipedicled tubed flaps which utilize pre- or post-auricular skin for coverage. In the first step, a vertical strip of skin is tubed upon itself and pedicled. Three weeks later, the pedicle is divided and the flap sewn to the helical rim closing the donor site primarily [3].

Conclusion

In summary, our technique is a combination of those of Kummoona Auricular-Cervical flap, 2017 and lateral neck stem flap, providing the necessary thickness to preclude support by a cartilage graft as the goal is to recreate an ear symmetric to the opposite side, which restores form and function, in only one stage and with no skin grafting and in achieving a prominence. This flap is easy to design and safe although some thinning and trimming may be necessary to ensure good contour of the retrieved flap [6, 7].

Funding

Not applicable.

Availability of Data and Material

Data were collected from the patient source.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Code Availability

not applicable.