Ear reconstruction

Anatomy

The auricle has an elastic cartilage framework with thin adherent anterior skin and looser posterior skin. Blood supply: superficial temporal artery (anterior), posterior auricular artery (posterior); rich anastomoses make most flaps reliable.

Sub-sites: helix, antihelix, scapha, triangular fossa, conchal bowl (cymba and cavum), antitragus, tragus, lobule.

Helical rim

Wedge excision

Star-wedge excision for defects up to ~1.5 cm helical width. Close cartilage and skin in layers, taking care to avoid cupping deformity.

Antia-Buch chondrocutaneous advancement

Bilateral chondrocutaneous helical advancement based on superior and inferior pedicles for defects up to ~3 cm (approximately 1/3 of helical length). Preserves shape; minor reduction in ear height.

Conchal bowl

• Secondary intention — workhorse; concave site granulates and contracts well over weeks.
• Full-thickness skin graft from postauricular sulcus or supraclavicular skin; needs preserved perichondrium or cartilage fenestration.
• Postauricular revolving-door (transpositional) flap — passes through a window in the conchal cartilage to cover anterior defects.
• Postauricular tube pedicle — staged for larger defects.

Lobule

• Wedge excision and primary closure for partial defects.
• Posterior auricular advancement flap or trefoil flap for total lobule loss.
• Cosmetic prosthesis for patients declining surgery.

Through-and-through defects

• Tube pedicle posterior auricular flap with secondary cartilage grafting (multi-stage).
• Removal and prosthesis (osseointegrated implants) — especially in elderly or after radiation.
• Subtotal / total auriculectomy for advanced cSCC — partial coverage and prosthesis.

Pitfalls

• Cartilage exposure without perichondrium → graft failure.
• Cupping deformity from large wedge excision without modification.
• Failure to recognise high cSCC metastatic risk on the ear → inadequate primary excision.
• Smokers / irradiated tissue / vascular disease → composite graft failure.