Ear Reconstruction: Tridimensionality and Deception.

Sir

Scaphoid fossa and antihelix regions of the ear are often the sites of squamous cell carcinomas. A good reconstruction of these regions has to take into account tridimensionality of both cartilaginous frame and skin covering. The gold standard for reconstruction of these structures involves harvesting of a cartilage graft (usually from posterior concha) and turning over of a skin flap to cover the structures.[1-3] If cartilage is not involved, the use of skin grafts alone is adequate.[4,5]

Whenever an important reconstruction is not operable because of patient’s general condition, fiction and optical illusion can come to our aid.

The case reported here is that of a patient with squamous cell carcinoma occupying almost the entire antihelix (crura) and triangular fossa. The patient had previously received surgical superficial excision and reconstruction with skin graft. Histologic examination showed the tumor had infiltrated the bed of the lesion (cartilage) and a margin, resulting in enlargement and hence resulting in almost complete destruction of the pinna. Surgical excision resulted in destruction of the upper area of antihelix (crura) and total triangular fossa. However, a sizable part of the helix was preserved even after the removal of the portion of insertion on the crus of helix.

After this, the aim was to enhance every single remaining structure and use mastoid area to mime ear pinna.

First, the remaining part of the concha was sutured with the skin over mastoid area. After this, a round skin incision running along the same area was made up to the persistent part of the crus of helix. Subsequently, margins of the circular incision were sutured with those of the residual helix (Fig. 1).

Fig. 1.

Intraoperative time. A, Ear after demolition surgical time. B, The remaining part of the concha sutured with the skin over mastoid area. C, Round skin incision running along mastoid area up to the crus of helix. D, Margins of the circular incision sutured with residual helix. E, Lateral projection at the end of surgery. F, Posterior projection at the end of surgery.

As previously explained, this technique allowed us to create a fake ear, retaining, at first glance, the same structures (helix, hollow, triangular fossa) of original one. At the same time, this technique allowed us to make an aesthetically acceptable reconstruction in 15 minutes in a patient who could not stand a longer or more complex surgery. Complete healing occurred in 14 days without complications and with complete patient satisfaction.

In conclusion, although the basic principle of plastic surgery that must lead in reconstruction should always remain Millard’s maxim “like with like,” in some uncommon situations, we can follow the forma mentis “reconstruct, fooling the eye, with what is available.”