Modified Antia-Buch Flap Incorporating an Extended Temporal Scalp Incision

Background:

The Antia-Buch flap is a popular reconstructive method for full-thickness ear defects involving the helical rim. However, scaphal or conchal resection is often required to prevent ear distortion. Noel et al described a modified technique to the Antia-Buch flap, which includes an incision in the temporal scalp and complete detachment of the preauricular helical root to increase mobility of the flap. Since then, no studies have reported on the use of this modification. We report our experience in implementing Noel et al’s modification of the Antia-Buch flap for helical rim defects.

Methods:

The modified technique differs from the original Antia-Buch flap by completely detaching the root of the helix and adding a vertical incision to the temporal scalp to increase mobility of the flap. No scaphal resection is necessary. After complete elevation of the flaps, the flaps are advanced and inset toward each other followed by closure.

Results:

In our practice, 10 patients have been treated with Noel et al’s modification to the Antia-Buch flap. In each of these patients, acceptable reconstruction of the helical rim was able to be achieved. All the patients were pleased with their reconstructive outcome and ear anatomy was able to be successfully maintained.

Conclusions:

The modified Antia-Buch flap has shown to be an excellent method for large, helical rim defects, creating versatility by adding the temporal scalp incision. Our outcomes with Noel et al’s modification to the original Antia-Buch flap support this method as a versatile technique for wide full-thickness helical rim defects.

Takeaways

Question: Is the modification of the Antia-Buch flap presented by Noel et al sufficient to repair large helical rim defects?

Findings: In 10 patients with helical rim defects, successful reconstruction was able to be achieved, ear anatomy was preserved, and all patients were satisfied with their reconstructive outcome.

Meaning: The modified Antia-Buch flap has shown to be an excellent method for large, helical rim defects, creating versatility by adding the temporal scalp incision.

INTRODUCTION

Defects of the helical rim may result from trauma, congenital abnormalities, or surgical excision. The choice of reconstruction often depends on the size of the defect. Large defects 2 cm or greater often require extensive dissection and multiple stages, whereas smaller defects can typically be repaired in a single stage. Wedge resection is the procedure of choice for deficits up to 1.5 cm. With this treatment modality, microtia, webbing, or cupping deformity can be seen despite meticulous surgical technique.¹ For significant full-thickness defects of the helical rim, the Antia-Buch flap provides adequate advancement for defects up to 2 cm. The Antia-Buch flap is a single-stage, helical advancement flap based on a postauricular skin pedicle, and is a common method of repair for helical rim defects (Fig. 1A–C).² This technique, however, can be associated with loss of ear height and unsatisfactory aesthetics. Modifications to the original technique have been created, including the addition of crescentic scaphal excision, Burrow’s triangle, transposition flaps, and retroauricular advancement flaps with improved cosmetic outcomes.^3,4,5,6

Fig. 1.

Schematic of the operative steps of the original Antia-Buch ear flap. A, Preoperative markings. B, Incisions and elevation of the chondrocutaneous flaps. C, Inset of the flap with final appearance of reconstruction.

Noel et al first presented a modified Antia-Buch flap that incorporated a temporal scalp incision to increase mobility to the anterior chondrocutaneous flap.⁵ Their original intent was to avoid scaphal resection, which is known to decrease ear height, while increasing mobility of the flap. By incorporating this modification, they reported that defects up to 3 cm could be closed in a single stage with pleasing cosmetic outcomes and no reported complications.⁵ Since then, no studies have confirmed their method. It is our aim to present our technique and experience with this modified Antia-Buch flap.

METHODS

As in the original Antia-Buch flap description, chondrocutaneous flaps are marked, and incisions are performed on both sides of the defect along the helical sulcus, sparing the postauricular skin. The posterior auricular skin is elevated off the auricular cartilage down to the posterior sulcus of the ear. The anterior chondrocutaneous flap, based on the superficial temporal artery, includes the root of the helix, and is mobilized by performing a 3-cm vertical incision in the temporal scalp. Care is taken not to injure the superficial temporal artery. No scaphal resection is performed. The root of the helix, cartilage, and the skin are elevated (Fig. 2A). A second flap is designed posteriorly based on the posterior auricular artery. The remaining helical area is incised into the lobule. The entire postauricular skin is elevated from the ear’s cartilaginous framework, allowing the flap to be translated superiorly and anteriorly. The two chondrocutaneous flaps are then advanced and inset toward each other and secured at the level of the cartilage with 5-0 PDS suture (Fig. 2B). The flaps are secured to the remaining portion of the ear with interrupted and running fast-absorbing gut sutures. The helical root defect is closed in a V-Y fashion (Fig. 2C). If excess retroauricular skin is present, it is excised to prevent the formation of a dog ear.

Fig. 2.

Schematic of the operative steps of Noel et al’s modified Antia-Buch ear flap. A, Temporal releasing incision. B, Incisions and elevation of the chondrocutaneous flaps. C, Inset of the flap with final appearance of reconstruction.

Each patient was seen 6 weeks postoperatively for follow-up and only by request afterward. At their final follow-up, each patient was asked if they had any concerns and if they were pleased with their outcome. Aesthetic outcomes were determined by a panel of three independent reviewers. The preoperative and postoperative (6 weeks) photographs of each surgery were shown to the three reviewers. The reviewers were asked to rate the aesthetic postoperative results using a five-point Likert scale: 1, poor; 2, fair; 3, acceptable; 4, good; and 5, excellent. Demographic data and injury characteristics were obtained through a retrospective chart review. Ear height was measured preoperatively and postoperatively, and the difference was determined for each case. All data are reported in Table 1.

Table 1.

Complete Demographic Data and Injury Characteristics of the Cohort

	Patient 1	Patient 2	Patient 3	Patient 4	Patient 5	Patient 6	Patient 7	Patient 8	Patient 9	Patient 10	Mean
Age (y)	24	16	50	40	6	36	65	50	23	18	32.8
Sex	Male	Male	Male	Male	Male	Male	Male	Male	Male	Male
Race*	W	A	W	W	W	W	W	W	W	W
Diabetes	No	No	No	No	No	No	No	No	No	No
HTN	No	No	No	No	No	No	No	No	No	No
Other comorbidity			Hypothyroidism				Hepatitis 2/2 Gilbert’s disease
Tobacco	Yes; half pack a day	No	Former smoker	No	No	No	No	No	No	No
Cause of defect	Trauma; human bite	Trauma; mutilation	Melanoma	Melanoma	Melanoma	Trauma; dog bite 12 years before	Melanoma	Melanoma	Trauma; car accident	Trauma; ATV accident
Size of defect	2.5 cm	3 cm, helical rim, partial scapha missing	2 cm, sharp dissection	2.8 cm, sharp dissection	3 cm	Complete helix missing	3 cm, partial scapha missing	3 cm	3 cm	2.5 cm	2.9 cm
Original ear height	6 cm	6.35 cm	7.4 cm	5.2 cm	5.1 c m	5 cm	5.7 cm	6.1 cm	6.5 cm	6.1 cm	5.9 cm
Postoperative ear height	5.5 cm	6 cm	6.8 cm	4.8 cm	4.7 cm	4.7 cm	5.4 cm	5.5 cm	6.1 cm	5.8 cm	5.5 cm
Pre/postoperative difference	0.5 cm	0.35 cm	0.6 cm	0.4 cm	0.4 cm	0.3 cm	0.3 cm	0.6 cm	0.4 cm	0.3 cm	0.4 cm
Aesthetic rating	4.6	4.3	4.6	4	3.3	1.3	5	4.3	3.3	4	3.9 (4.2 excluding necrotic ear)

^*W, White; A, African.

RESULTS

Since employing this technique, 10 patients have been treated with Noel et al’s modification to the Antia-Buch flap. All patients treated with the technique were male with an average age of 32.8 years, ranging from 6 to 65 years. Only two patients had a comorbidity: one with hypothyroidism and another with hepatitis secondary to Gilbert disease. One patient smoked half a pack of cigarettes per day, and two were former smokers. The cause of injury was trauma for five patients and surgical excision for five patients. The average ear defect size was 2.9 cm with a range of 2–4 cm, and the average difference in ear height from pre- to postoperation was 0.4 cm with a range of 0.3–0.6 cm. Using a five-point Likert scale, the mean aesthetic rating of the panel of reviewers was 3.9 with a range of 1.3–5, but when excluding the patient whose ear flap necrosed, the mean rating was 4.2 with a range of 3.3–5.

All cases were performed under general anesthesia in an outpatient setting. Their postoperative courses were uneventful, and only one case of skin necrosis was noted. This case was in a patient that received a dog bite a few years prior with significant mangling and secondary epithelialization of the tissues. (See figure, Supplemental Digital Content 1, which shows a preoperative photo of a patient that previously experienced a dog bite to the ear with the complete helical rim and scapha missing, http://links.lww.com/PRSGO/C375.) (See figure, Supplemental Digital Content 2, which shows an immediate postoperative photograph already showing some early signs of necrosis, http://links.lww.com/PRSGO/C376.) (See figure, Supplemental Digital Content 3, which shows a patient on postoperation day 13 showing necrosis of the helical rim flap, which was subsequently taken down, http://links.lww.com/PRSGO/C377.) This patient’s ear flap was subsequently taken down and allowed to heal. We offered additional reconstructive options, but the patient declined, citing that he could not afford to miss any more work. In each of the other patients, acceptable reconstruction of the helical rim was able to be achieved. The youngest patient treated was 6 years old, and though we recommended two-stage reconstruction because of the large defect, the parents insisted on only one operation. (See figure, Supplemental Digital Content 4, which shows a preoperative photograph of 6-year-old patient demonstrating significant loss of the helical rim, http://links.lww.com/PRSGO/C378.) (See figure, Supplemental Digital Content 5, which shows an intraoperative photograph showing elevation of the ear and temporal scalp flap, http://links.lww.com/PRSGO/C379.) (See figure, Supplemental Digital Content 6, which shows an inset and closure of the flaps using the modified Antia-Buch flap technique, http://links.lww.com/PRSGO/C380.) All the patients were pleased with their reconstructive outcome and complete ear functionality was able to be successfully maintained. (See figure, Supplemental Digital Content 7, which shows a large, superior helical rim defect with the auricular cartilage intact, http://links.lww.com/PRSGO/C381.) (See figure, Supplemental Digital Content 8, which shows an inset and closure of the flaps using the modified Antia-Buch flap technique, http://links.lww.com/PRSGO/C382.) (See figure, Supplemental Digital Content 9, which shows a 6-week postoperative result from the index operation, http://links.lww.com/PRSGO/C383.)

Case Presentation

A 50-year-old man presented to the clinic after resection of a lesion on his left ear. The patient had a 3-cm full-thickness defect involving the superior pole of the ear with the helix and upper scapha missing (Fig. 3). The patient underwent reconstruction of his left ear using the modified Antia-Buch flap utilizing a 3-cm temporal scalp incision (Figs. 45,67). The ear healed without complication while maintaining natural anatomical landmarks with satisfactory aesthetics (Fig. 8).

Fig. 3.

Three-centimeter full-thickness defect involving the superior pole of the ear with the helix and upper scapha missing.

Fig. 4.

Incisions and elevation of the chondrocutaneous flaps. White arrow pointing to the incision from the sentinel lymph node biopsy this patient had previously.

Fig. 7.

Postoperative result following inset and closure of the flaps.

Fig. 8.

Six weeks postoperative result from the index operation.

Fig. 5.

The posterior auricular skin is elevated off the auricular cartilage down to the posterior sulcus of the ear. White arrow pointing to the elevated postauricular skin (not an additional incision).

Fig. 6.

Temporal releasing incision and elevation of the temporal scalp flap.

CONCLUSIONS

Ear reconstruction is often challenging given the ear’s complex three-dimensional shape and aesthetic importance as a prominent feature of the face. Various techniques exist to address defects of the ear, but many are difficult and require multiple stages under general anesthesia.³ The Antia-Buch flap has remained a popular reconstructive technique because of its relative simplicity and acceptable cosmetic outcomes. However, scaphal resection is required of the traditional Antia-Buch flap to increase mobility, and ear distortion is common with scaphal or conchal resection. The limited mobility of the original Antia-Buch flap is caused by pivot point of the anterior chondrocutaneous being located at the helical root.^2,5 The modification described by Noel et al vertically incises the temporal scalp to completely detach the preauricular helical root and increase mobility, allowing reconstruction of the helical rim without scaphal resection.⁵

In our experience, this flap has proven to be an excellent method for helical rim defects up to 3 cm wide. It creates versatility by adding the temporal scalp incision. Care should be taken when dealing with posttraumatic wounds that involve significant devitalization of tissues to prevent flap necrosis. In cases of trauma involving significant auricular and periauricular involvement with secondary epithelialization, caution should be employed with elevation of such flaps. In contrast, for instances of sharp traumatic amputation or post-oncologic resection of the helical rim, the flaps can be raised safely. The most common problem we noticed on postoperative physical examination is minimal notching where the flaps meet at the helical rim, but this was not considered significant by any of the patients. Asymmetry is minimized with this technique, as ear height and anatomy are largely maintained by sparing scaphal resection.

Of note, all these procedures can be performed under local anesthesia in an outpatient setting, which makes this technique suitable for older patients with wide helical rim defects. However, all our cases were performed under general anesthesia because we operate at an academic institution where almost every case is performed this way. Nonetheless, local anesthesia could have been performed had this been the standard practice. We believe this ear reconstruction method is versatile and should be part of the armamentarium of ear reconstructive surgeons. Our outcomes with Noel et al’s modified Antia-Buch flap support this method as a useful technique for wide full-thickness helical rim defects.

PATIENT CONSENT

Informed consent was obtained from all patients included in the study. Additional informed consent was obtained from all patients for whom identifying information is included in this article.

HELSINKI DECLARATION

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5).

Supplementary Material

gox-11-e4797-s001.pdf ^{(5.5MB, pdf)}

gox-11-e4797-s002.pdf ^{(4.4MB, pdf)}

gox-11-e4797-s003.pdf ^{(4.5MB, pdf)}

gox-11-e4797-s004.pdf ^{(7.4MB, pdf)}

gox-11-e4797-s005.pdf ^{(8.2MB, pdf)}

gox-11-e4797-s006.pdf ^{(15.3MB, pdf)}

gox-11-e4797-s007.pdf ^{(3.2MB, pdf)}

gox-11-e4797-s008.pdf ^{(8.1MB, pdf)}

gox-11-e4797-s009.pdf ^{(2.2MB, pdf)}