Reconstruction of the ear using silicone fiber

Received on: 27/02/2011
Approved on: 18/06/2011

This study was carried out at the Instituto
Lauro de Souza Lima – São Paulo (SP), Brazil.

Conflicts of interests: none
Financial support: none

Abstract

Reconstructions of the auricular pavilion are complex, especially when there is a loss of cartilaginous support. A case of chondrocutaneous defect reconstruction, after the exeresis of a basal cell carcinoma in the upper third of the auricular pavilion, is reported. Silicone fiber was used to model and provide support for the ear. The technique of using cartilage or compound grafts in the auricular pavilion is described.

Keywords: EAR CARTILAGES, SURGERY, PLASTIC, EAR DEFORMITIES, ACQUIRED, EAR, PROSTHESES AND IMPLANTS

INTRODUCTION

Auricular pavilion reconstructions are complex due to the anatomic peculiarity of the region. Congenital and acquired deformations have stimulated the development of new tech- niques for centuries. Due to the risks and complexity of per- forming cartilaginous grafts, auricular molds made of synthetic materials (silicone, polyethylene, nylon mesh and Teflon, among others) were used in the 1960s and 1970s. 1 We report a case in which silicone fiber, often used in orthopedic surgeries, was used to mold and temporarily support the upper third of the ear.

METHODS

A 68-year-old healthy female patient presented with a 1.5 cm lesion, infiltrated and adhered to the cartilaginous plan in the upper third of the left helix, which was diagnosed as a basal cell carcinoma (Figure 1). The exeresis of the lesion and corre- sponding cartilaginous structure was able to preserve only the posterior face of the auricular pavilion (Figure 2) – which lost its support completely. Due to the size of the defect, and with the goal of preserving the original curvature and creating sup- port for the reconstruction, a decision was made to use the type of flexible silicone fiber that is used in orthopedic surgeries. (Oval tendon spacer, Medicone, Cachoeirinha – RS, Brazil) (Figure 3). After implanting the silicone fiber up to the edge of the surgical defect, the area was covered again with a wide trans- position flap originating from the preauricular region (Figures 4 and 5). The separation of the flap took place in a second surgery, four weeks later, when the wound opened and the implant became visible (Figures 6 and 7). An infection developed at the site of the dehiscence, which did not respond to topical or sys- temic antibiotic therapy. The proximal portion of the fiber extruded and was removed after eight weeks; the infection healed and the aesthetic results were satisfactory (Figure 8).

DISCUSSION

Defects in the auricular pavilion can be classified accord- ing to their location (upper, middle and lower third) and thick- ness: total (loss of the cartilage) or partial (only the skin). 1 A great number of reconstruction techniques have been described in the literature, with appropriate grafts or flaps for each area, which yield good aesthetic results. 1,2

Small chondrocutaneous defects can be resolved with direct suture, 1,3 however large total thickness defects are difficult to repair due to a lack of cartilaginous support. When the pavil- ion''''''''s contour is not affected, healing by second intention for small lesions or a simple graft for larger lesions ensure excellent reconstruction results. 2 In cases where the outer support is affected, complex techniques involving compound or cartilage grafts (costal, ipsi or contralateral auricular pavilion covered by local flaps, are necessary. Compound grafts taken from the oppo- site ear are useful for defects of up to 1.5 cm. However, the risks of necrosis of the graft and sequela in the donor ear reduce their acceptance and applicability. 1,2 The costal cartilage was initially used for the reconstruction of congenital deformations of the auricular pavilion, 1 supplying cartilage pieces that must be molded as required. The techniques for obtaining it demand experience on the part of the surgeon, and complications, such as chronic residual pain and pneumothorax, can occur. 1,3

Auricular cartilage from the opposite ear is currently the most frequently used in reconstructions of acquired lesions of total thickness, for it allows a more delicate and flexible support, in addition to a more straightforward removal and a minor residual scar. 1,2

In an attempt to avoid wide incisions in both ears, and based on recent reports in the literature, 3 a decision was made to use the thin and flexible silicone fiber that is used in tendon reconstructions in hand surgeries. 4 That material generates little inflammatory response and helped support and maintain the auricular pavilion''''''''s shape, making it possible to cover the whole defect and the fiber with a preauricular transposition flap, result- ing in a very satisfactory aesthetic result.

The main risks associated with the use of synthetic mate- rials are infection and the extrusion of the product 1,2 – which have historically discouraged their use. 1 In this case, these events occurred two months after the procedure, probably due to the dehiscence that occurred in the flap''''''''s suture. After that period, even with the removal of the implant, the fibrosis generated in the healing site of the flap on the posterior face of the ear was enough to maintain the support and shape of the auricular pavilion. This technique is a viable alternative to the use of car- tilage or compound grafts in the auricular pavilion.

References

1 . Brent B.Recontrucción de la oreja. In:MacCarthy JG,Cirurgía plástica- La Cara.Montevideo: Editora Medica Panamericana; 1990. p 1197-1254.

2 . Mellete, JR. Reconstruction of the Ear. In: Lask GP,Moy RL, Principles and Techniques of cutaneous surgery.New York.McGraw Hill;1996.p 363-80.

3 . Cardoso JC, Vieira R, Freitas JD, Figueiredo A. Reconstruction of a chondrocutaneous auricular defect using a kirschner wire. Dermatol Surg 2009; 35(6): 1001-04

4 . Tarar B.Flexor tendor Injury. In:Boyer,Taras,Kaufman,Green`s Operative Hand Surgery- fifth edition.New York: Elsevier; 2005. p 258-9.